Refractive surgery You can find the eye laser operations designed to reduce their dependence on a lens in correction glasses or contact lenses. It allows to correct permanently the vision of patients whose eye present an optical defect (ametropia) causing a permanent visual blurring. The ametropia which are accessible to refractive surgery include: myopia, hyperopia, astigmatism, presbyopia. These optical defects reflect the fact that the captured light rays don't are not or not all focused in the retinal plane (see:) eye and mind, introduction). After surgery, the patient becomes emmetropic: it boasts increased or even total independence to its correction in glasses or lenses.
The LASIK and techniques of surface laser (PKR) is the most practical actions to correct the vision, and they represent the most popular ophthalmic procedures and even the most popular in the surgery world, across all specialties.
Sight refractive eye surgery is performed under local anesthesia in outpatient (no hospitalisation) and often bilaterally (in excimer laser refractive surgery, both eyes are made the same day in the vast majority of cases). When the indication is well put, it's very safe surgery. Estimated 16 million the number of intervention LASIK performed in the USA in recent years. The Food and Drug Administration (FDA) recently concluded in theeffectiveness and safety of LASIK for the correction of myopia, hyperopia, astigmatism.
Sight refractive eye operations demand a pre-surgery careful, accurate and modern surgical correction technique. A clear, fair and objective information must be delivered to the patient by the surgeon, in accordance with the ethics rules. All eyes are not operable, and the results of the surgery depend not only on the technical quality of the performed Act, but also of the choice of the surgical indication.
Many pages of this site are devoted to the description of refractive surgery techniques and their indications, which must take account of the characteristics of the human vision. The most fundamental aspects, such as the study of lasers excimer or femtosecond, as well as the profiles of ablation excimer lasers are discussed in the section «» Research and Education« . You will find detailed explanations of the technologies and principles that govern the refractive surgery.
Why refractive surgery?
Patients who consult for refractive surgery do so for various reasons, the first of which the desire to no longer wear glasses or lenses (2). Other motives combine a business need (uncorrected Visual acuity minimum threshold: mounted police, firefighters, etc.), the practice of some sports, intolerance to contact lenses, the existence of an asymmetry between the correction of an eye and the other... Of course, the aesthetic dimension is often present, many patients considered unsightly glasses, at least for themselves. Patients with strong ametropia (ex; high myopia, hyperopia strong) are feeling be achieved a real "handicap", and angoissent to the idea of losing their glasses, or not being able to bear the port of contact lenses.
For these patients, it is not a comfort, but truly a response surgery to change their life. Refractive surgery is a growing interest, but also a certain number of frequently asked questions.
In all cases, the desire for a refractive surgery must come from the patient. This wish can give following an intervention, provided that the pre-surgery is favourable and that the patient's expectations are consistent with the planned results.'
History of refractive surgery
The history of refractive surgery is truly born in the 20th century, with the technique of radiaire keratotomii, whose principles were described with experimental rigor by Leedert Jan Lans in 1898: the incision of the cornea according to some traces induces central flattening, and thus a reduction of the optical power of the cornea. Myopia, which corresponds to an excess of power perspective (with respect to the axial length of the eyeball) could thus be corrected by judiciously placed incisions (1). The Japanese Sato was the pioneer of the technique of radiaire keratotomii (2), but it was the subject of a large distribution in the former Soviet Union through a Russian surgeon named Fyodorov (3): the latter is probably the first to popularize the refractive surgery in the 1970s, by trivializing the surgical correction of myopia with simple corneal incisions. During the 50's and 60's, a Colombian surgeon called Barraquer had laid the Foundation for the "keratomileusis", IE the "sculpture of the cornea", to change the optical power. The laser did not yet exist, and the technique of sculpture required cut then freeze a slide of cornea, to prune it to the desired shape before stitching it over the cornea. Technical constraints could be circumvented by the ingenuity of anywhere, which developed many instruments, some of which are still used today. The myopic keratomileusis without freezing was used until the early 1990s. The introduction of the excimer corneal surgery laser, which was at the origin of a revolution at the end of the 1980s, as it became possible with the technique of PKR (procedures to refractive aiming) to sculpt the cornea with an accuracy of the order of a micron. This precision made obsolete the previous techniques, such as the radiaire keratotomii and the keratomileusis without laser. LASIK (acronym for "Laser Assisted in-situ Keratomileusis"-that can be translated by 'Sculpture within the cornea laser-assisted') is the culmination of the work of Barraquer, and feats recognized of the 20th century whose laser is emblematic.
Development of refractive surgery
Refractive surgery is an activity growing since the 1990s. This expansion is contemporary with the rise of the technology excimer, and is now maintained by the provision of the femtosecond laser to complete the achievement of certain stages in corneal refractive surgery. Laser techniques have caused a real technological rupture, and replaced in a few years the incisionnelles techniques, which were to make incisions in the corneal tissue, to change the optical power: the technique of radiaire keratotomii has been abandoned at the end of the 1990s. THEdevelopment of LASIK is the result of the convergence of corneal reshaping techniques, to which excimer laser brought unmatched precision. The development of ocular exploration as the corneal topography techniques, the OPD, make refractive surgery even more efficient and safe.
Already, in 2003, more than 55% of American surgeons had performed the LASIK technique (5). A relatively small proportion of French ophthalmologists regularly practice refractive surgery, due to the cost of investing in material, and the expertise necessary to practice this activity with high result requirement. In France, the number of laser refractive surgery performed annually is estimated at about 200 000. The number of proposed surgical techniques tends to increase, but LASIK and PKR remain largely at the top of the practice. These techniques are intended for the majority of patients who consult for advice, and their results provide a very high level of satisfaction (see next paragraph). The Smile technique, introduced a decade ago and presented Intialement as an advantageous alternative to LASIK has not been imposed because of certain technical limitations, a range of more limited indications, and a difficult management of alterations Early or late.
Satisfaction and quality of life after refractive surgery
The results of refractive surgery on patient satisfaction are very high. A 2001 study had shown that refractive surgery of myopia provided a satisfaction rate of more than 85% (percentage of patients declaring themselves "very satisfied" with their intervention), and that 97% would do the surgery if it were to be redone (6). More recently, a meta-analysis conducted from 309 scientifically validated data published between 1988 and 2008 showed that the average satisfaction rate after LASIK surgery was 95.4% (this rate was between 87.2% and 100% depending on the studies) (7). These results make LASIK the most rewarding "comfort" surgical Procedure for patients: satisfaction rates are far superior to those of cosmetic surgery such as lifting, rhinoplasty, ... (8).
In 2012, a (9) the use of a questionnaire-based study showed that among the various techniques of Visual correction (glasses, lenses, Orthokeratology, refractive LASIK surgery), LASIK was the technique that gave a sense of quality of life the more comparable to those of the normal sighted patients (who haven't needed optical correction). A study published in 2013 (10) shows that the rate of satisfaction after LASIK in terms of perceived quality is average of 86 out of 100.
Getting a good result in refractive surgery is also based on the respect of the treatment and precautions to be taken in post operative. The quality of the result depends on the choice of the good indication of a perfect performance intervention, and respect for the treatment and the post-operative instructions.
Trends in refractive surgery
If we consider the issue related to the reduction of the dependence on glasses, the refractive surgery is mainly carried on two elements: the cornea (laser techniques dominate the scene: PKR, LASIK), but also the lens)cataract surgerythe clear lens surgery).
Advances in surgical lasers technology allows to offer an effective solution to most of the optical defects. We thus distinguish the techniques proposed in surgery for myopia, hyperopia surgery, astigmatism surgery. LASIK is the most convenient Act of refractive surgery; the PKR is also a commonly performed technique, especially in patients whose corneas are fine. The use of the femtosecond laser for the realization of the flap of LASIK is a significant contribution in terms of safety and quality of the results. Important advances have also been achieved with the guidance systems, alignment and centering of the lasers firing. All these improvements allow refractive surgery to conquer an increasing amount of information; the correction of high myopia and the astigmatismes pronounced benefits for example of these advances. The presbyopia is a particular fault, which is most often an extra dimension taken into account for the choice of the most effective remediation strategy (see:) myopia and presbyopia, hyperopia and presbyopia). The presbyopia surgery includes various techniques, some of which are specific, others rather considered variants of techniques for the correction of myopia or hyperopia.
The development of so-called artificial lens implants "multifocal". and "o-rings". increases the "refractive" dimension of the cataract surgery. Extraction of the crystalline lens still "clear" and its replacement with an implant is a strategy proposed by some surgeons in patients who have reached midlife. This approach is effective, but is more invasive than the LASIK corneal refractive surgery. The diagnostic methods known as "aberrometriques")OPD) allows the ophthalmologist to finely explore the optical properties of the eye. The estimate of the light diffusion (objective scatter index) for example is an essential tool to objectify the existence of a reduction in the optical transparency of the lens: one can then affirm or disprove the diagnosis of cataract… These technologies are based on fundamental optics that are little or no taught ophthalmologists, and are still not subject to any rating Act is specific.
The border between the clear lens and cataract surgery is relatively 'fuzzy '; the delay legislative and regulatory contrasts remarkably with the expansion of diagnostic methods to establish the presence or absence of a clouding of the lens: some patients have a beginner but functionally awkward cataract (glare, sail persisting despite the absence of loss of best corrected Visual acuity tenths). Conversely, in the absence of Visual symptoms, a finding of cristalliniennes opacities is not necessarily of cataract.
In all cases, the ethics of the surgeon remains the guarantor of an informed choice of the best surgical technique for a given patient.
Cost of refractive surgery
The price of refractive surgery varies according to the centers, the surgery, the type of technical and material used. Overall it is correlated with the quality of output delivery, except for extreme cases. After cataract surgery, refractive surgery is the most convenient Act in number, all specialties: candidates are not lacking, and the centres or surgeons who practice a policy of recruitment of the patient primarily based on an advantageous tariff incentive (type 'low cost' pricing policy) usually do so to attract a clientele that would otherwise default. This is especially detrimental to the quality of the delivered deed that the technologies used in refractive surgery are very expensive: an excimer laser or a last generation femtosecond laser represents a close unit cost of EUR 500 000 (excluding maintenance). Thus, the quality at a price...
The amortization of these technologies explains why prices in centres recognized and equipped with modern equipment are higher (close to 3000 euros for both eyes in Paris) than those offered in some institutions which are not the same sophistication and are a price enticing their main argument (you can find procedures proposed less than 2000 euros for the eyes which is inconsistent with the grant of a benefit in accordance with the current standards in technology).
Refractive surgery is not just a surgical procedure: it is a full process which does not begin and doesn't end with the completion of the intervention itself. From the preoperative consultation until the completion of the postoperative follow-up, it is important to benefit from the best and the maximum guarantees and qualities in explorations, information, and delivered care.
Finally, the cost of refractive surgery can be compared to that of the correction in monthly or daily contact lenses. This calculation shall take account of the age of the patient (which determines the length of the lens port). Contact lenses for daily wear (without maintenance) have a cost higher than the monthly lenses. If the price of daily wear lenses is close to 500 euros per year on average, the cost of LASIK surgery equal to 3000 euros is amortized in 6 years. Refractive surgery is not covered by social security in France (as in all European countries except for Denmark for the high myopia). Some private insurance companies offer packages for their members.
Motivation of patients
The motivations of patients for refractive surgery are diverse and correspond to practical, functional, aesthetic and financial issues. Self-esteem is also involved in some patients, in particular achieved strong ametropia (myopia strong, etc.). The main factors put forward by the (often related) patients to justify conducting a refractive surgery are:
-intolerance to contact lenses
-the unsightly appearance of glasses
-the feeling of insecurity see handicap caused by the addiction to a lens correction (ametropia forts)
-the need to practice some sports or leisure without glasses or lenses (swimming, sailing, skiing, motorcycle, travel and stay in a natural or hostile environment, etc.)
-the improvement of vision
Prejudices and common mistakes with respect to refractive surgery
A certain number of (false) beliefs and prejudices exist against refractive surgery:
-refractive surgery increases the risk of being farsighted faster: this is false, because presbyopia is related to the loss of the flexibility of the lens (reduction of the accommodative function), while the refractive laser surgery is exercised on the cornea
-the extended contact lens wear may make it impossible to make a refractive surgery: fake this is also wrong in most of the common clinical situations.
-After a certain age, can no longer be operated: false: in fact, there is no age limit for refractive surgery, but the indications are based on criteria including the age of the patient
-can be operated only once: false, surgery can be repeated, even long after the completion of the initial gesture
-We can't operate the high myopia laser: false laser allows to correct high myopia (up to about 10 dioptres), provided that the thickness and regularity criteria of cornea are met; Similarly, astigmatism and hyperopia are occurring.
-for women, need surgery after having his children: false, because unlike an idea received, pregnancy does not change in vision (or then this change is transitory)
-refractive surgery makes more complicated cataract surgery; FALSE, refractive surgery induces no change in modern cataract surgery technique. Simply, we must use some precautions for the calculation of the power of the artificial lens implant that is placed over the cataract surgery.
-It is there still not enough decline to the laser eye operations: false in fact, the recoil with LASIK and the PKR is more than 20 years, and the oldest techniques (of reshaping the cornea but without the precision provided by the laser) enjoy back over 40 years. No long-term refractive surgery complication has been reported.
-doctors and ophthalmologists themselves do never operate in refractive surgery: false; to many doctors, surgeons, including ophthalmologists, benefited from a refractive surgery, and the author of this site has helped get rid of the glasses and lenses a number of them..:
We studied the satisfaction of health professionals who have benefited from refractive surgery carried out between 2012 and 2016 to the Rothschild Foundation: doctors, surgeons and nurses were able to abandon lunetttes and lenses to exercise their profession, with a satisfaction rate overall superior to 90% (see the results of this) study published in the french journal of ophthalmology in 2016).
Another study, published in March in the Journal of Cataract and Refractive Surgery 2014, reported that collected after LASIK or PKR from physicians and surgeons operated satisfaction rate was 95%, and comparable to that measured in the general population. No significant gene was reported regarding the performance of medical procedures or interventions (surgical)PASQUALI and al. JCRS 2014).
In September 2015, an American publication of the Journal of Cataract and Refractive Surgery stresses that the penetration rate of refractive surgery is more important among Refractive Surgeons themselves)Kezirian and al, JCRS 2015).
See also: refractive surgery, what's new?
For the laser refractive surgery patient information sheet
This information sheet was established by the French society of ophthalmology. It takes in a simplified way the most important information on refractive surgery when it is done by corneal photoablation, or corneal laser surgery.
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(2) Sato T. Akiyama K, Shibata H. A new surgical approach to myopia. Am J invest, 1953; 36: 823-829
(3) SN, Agranovski A.A. Fyodorov. Long term results of anterior radial keratotomy. Ocular Therapy Surg 1982; 1: 217-223
(4) Reinstein DZ, Archer TJ, Gobbe M. The history of LASIK. J Refract Surg. 2012,28 (4): 291 - 8.
(5) Leaming DV. Practices styles and preferences of ASCRS members - 2003 survey. J Cataract Refract Surg 2004; 30 (4): 892-900
(6) khan-Lim D et al. Defining the content of patient questionnaires: reasons for seeking laser in-situ keratomileusis for myopia. J Cataract Refract Surg 2002; 28 (5): 788-794
(7) Miller and al. Patient satisfaction after LASIK for myopia. OALCF J, 2001; 27 (2): 84-88
(8) Solomon KD et al. LASIK world literature review: quality of life and patient satisfaction. Ophthalmology, 2009, 116 (4): 691-701
(9) Queirós's et al. Quality of life of myopic subjects with different methods of visual correction using the NEI BBA - 42 questionnaire. Eye Contact Lens. 2012; 38 (2): 116-21
(10) Uthoff D et al. Multicentric study regarding assessment of the driving ability of LASIK and orthokeratology patients compared with conventionally corrected persons. Klin Monbl Augenheilkd. 2013; 230 (3): 255-64.