The ‘Compleat’ Refractive Surgeon

Editorial-The 'Compleat' Refractive Surgeon Refractive surgery, the emergent sub-speciality within ophthalmology, must have a distant goal of providing a permanent safe and effective surgical solution to any patient who has any significant refractive error. Today the surgical modalities that can effect refractive change are already considerable and fast evolving. Corneal re-shaping in terms of incisional methods with radial and tangential arcuate and transverse incisions is quite effective up to 6 diopters of myopia and or astigmatism. The intrastromal corneal ring is showing significant promise in its early development and this carries the unique property of revers ability. Laser ablative methods of corneal re-shaping are predictable and effective with good laser instrumentation, up to 6 or 7 diopters of myopia and also effective but with less predictability for higher levels of myopia. Toric ablations are also starting to come of age. There remain the high myopes, -10 diopters and above and the hyperopes for which the techniques are more limited. For the high myopes supplementary intraocular lenses (Baikoff style and Worst Lobster Claws style) are being evaluated in a number of centres. Full investigation of the internal collagen contact lens of Fyodorov is also being initiated. The one technique that is as safe and predictable as any of the above methods is crystalline lens surgery. With the advancement of modern small incision methods with self-sealing incisions and high quality intraocular lens implants, the prospects for clear lens extraction with lens replacement for the treatment of high myopia and hyperopia, particularly for the presbyopic population, has now to be considered seriously. The ophthalmic literature is showing a steady flow of early studies in this regard which merely extrapolate the in-depth knowledge gained from the removal of cataracts. The early studies show considerable promise in relation to the safety of the procedure but it is long term data that is essential to satisfy the surgeon and patient that they are practising a safe and sensible procedure. A multi-centre study orchestrated by the ASCRS is being initiated in the United States and there is no reason to doubt that the outcome will be predictable. Namely, that the complication rate of small incision lens extraction with 'in the bag' placement of an intraocular lens will provide a very satisfactory outcome with a small quota of complications both intraoperative and postoperative. As ever it is a question of benefits v risks. There seems to be no

greater pleasure for the ophthalmologist, let alone the patient, than the dramatic and permanent effect of emmetropia in a patient previously suffering from high degrees of ametropia. The goal is well worth seeking. If a patient is presbyopic then the concept of monovision, i.e. one eye focussed for distance and one for near vision, works well in many patients but it may not be too long before multi-focal lenses and or accommodating lenses achieve serious evaluation. The symposium on refractive surgery and discussion section published herein expand these considerations by a number of international experts. This issue is published just prior to the Congress of the ESCRS to be held in Lisbon, 18-22 September 1994. This annual major congress in the world calendar of ophthalmic events occupies an established position in the Autumn of each year. It is characterized not only by the cultural variation consequent upon the opportunity to visit different cities in different countries throughout Europe year by year but the shape and scope of the scientific programme is also increasingly comprehensive. There is certainly something in it for everyone, whatever their interest in cataract and refractive surgery, whatever their stage of education and experience and from which ever country they emanate. The pre-congress courses are increasing in number and quality and they are open to all with a new policy of a minimal subscription fee. This is a feature of the congress which will expand by demand. Major scientific symposia within the congress address current issues of interest to us all and registrants cannot fail to improve their knowledge and hence their skills and thus patient service by joining their colleagues in Lisbon. With the structure of the ESCRS they are also assured of membership, without extra payment, of the ESCRS for the coming year. We wish you a stimulating time in Lisbon. EMANUEL ROSEN

Editor

REFERENCE 1 J Colin, A Robinet. Clear lensectomy and implantation oflowpower posterior chamber intraocular lens for the correction of high myopia. Ophthalmology, 1994; 101: 107-113.

0955-3681/94/040189+01 $08.00/0 © 1994 W.B. Saunders Company Limited

Eur J Implant Ref Surg, Vol 6, August 1994