refractive surgery survey 2004

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special report Refractive Surgery Survey 2004 Helga P. Sandoval, MD, Luis E. Ferna ´ndez de Castro, MD, David T. Vroman, MD, Kerry D. Solomon, MD To determine the refractive surgery (RS) preferences of ophthalmologists worldwide, questionnaires were sent to 8897 members of the American Society of Cataract and Refractive Surgery. A total of 1053 questionnaires were returned by the deadline. The practice distribution included 29.5% cataract surgeons, 48.8% comprehensive ophthalmologists, 11.6% RS specialists, 5.1% cornea and external disease specialists, 1.9% glaucoma specialists, 1.1% retina specialists, and !1.0% oculoplastics/pediatrics/researchers/retired. Results were compared with those in the 2003 survey and demonstrate that refractive surgery continues to develop and change. J Cataract Refract Surg 2005; 31:221–233 ª 2005 ASCRS and ESCRS T he Magill Research Center for Vision Correction in association with the American Society of Cataract and Refractive Surgery (ASCRS) conducted the fourth refractive surgery (RS) survey evaluating RS techniques and preferences worldwide. As in previous surveys, 1,2 the focus was primarily on laser in situ keratomileusis (LASIK), laser-assisted subpithelial ker- atectomy/photorefractive keratectomy (LASEK/PRK), and phakic intraocular lenses (IOLs). However, de- tailed questions about LASIK wavefront-guided abla- tion were included. Materials and Methods In November 2003, a questionnaire highlighting demo- graphics, practice plans, and surgical techniques; instrumen- tation and equipment; and complication rates and clinical scenarios were mailed to 8897 ASCRS members worldwide. Respondents were asked to mail completed questionnaires to the Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. Surveys received before April 2, 2004, were scanned and tabulated using Microsoft Access 2003 and analyzed using Microsoft Excel 2003. The results reported here are based on the number of surgeons responding to each survey question, queried with those surgeons performing RS, unless stated otherwise. Multiple responses or no response to any single question were not included in the question’s tally. Results and Discussion Demographics The overall response rate was 11.8% (1053 of 8897 mailed questionnaires). By geographic area, the responses were as follows: Canada 10.6%, United States 13.5%, Oceania 16.5%, Europe 8.2%, Latin America 4.7%, Asia 5.7%, and Africa 4.7%. Accepted for publication August 31, 2004. From Magill Research Center for Vision Correction, Storm Eye In- stitute, Medical University of South Carolina, Charleston, South Caro- lina, USA. Presented in part at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, May 2004. Supported in part by the American Society of Cataract and Refractive Surgery, Fairfax, Virginia; NIH EYO14793; and an unrestricted grant to MUSC-SEI from Research to Prevent Blindness, New York, New York, USA. None of the authors has a financial or proprietary interest in any product mentioned. James P. Byrnes provided IT services and Oday Al Sarraf helped prepare the manuscript. Reprint requests to Helga P. Sandoval, MD, Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, 167 Ashley Avenue, Charleston, South Carolina 29425, USA. E-mail: [email protected]. ª 2005 ASCRS and ESCRS 0886-3350/05/$-see front matter Published by Elsevier Inc. doi:10.1016/j.jcrs.2004.08.047

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s p e c i a l r e p o r t

Refractive Surgery Survey 2004

Helga P. Sandoval, MD, Luis E. Fernandez de Castro, MD, David T. Vroman, MD,Kerry D. Solomon, MD

To determine the refractive surgery (RS) preferences of ophthalmologistsworldwide, questionnaires were sent to 8897 members of the American Society ofCataract and Refractive Surgery. A total of 1053 questionnaires were returned bythe deadline. The practice distribution included 29.5% cataract surgeons, 48.8%comprehensive ophthalmologists, 11.6% RS specialists, 5.1% cornea and externaldisease specialists, 1.9% glaucoma specialists, 1.1% retina specialists, and!1.0% oculoplastics/pediatrics/researchers/retired. Results were compared withthose in the 2003 survey and demonstrate that refractive surgery continues todevelop and change.

J Cataract Refract Surg 2005; 31:221–233 ª 2005 ASCRS and ESCRS

The Magill Research Center for Vision Correction

in association with the American Society of

Cataract and Refractive Surgery (ASCRS) conducted

the fourth refractive surgery (RS) survey evaluating RS

techniques and preferences worldwide. As in previous

surveys,1,2 the focus was primarily on laser in situ

keratomileusis (LASIK), laser-assisted subpithelial ker-

atectomy/photorefractive keratectomy (LASEK/PRK),

Accepted for publication August 31, 2004.

From Magill Research Center for Vision Correction, Storm Eye In-stitute, Medical University of South Carolina, Charleston, South Caro-lina, USA.

Presented in part at the ASCRS Symposium on Cataract, IOL andRefractive Surgery, San Diego, California, USA, May 2004.

Supported in part by the American Society of Cataract and RefractiveSurgery, Fairfax, Virginia; NIH EYO14793; and an unrestrictedgrant to MUSC-SEI from Research to Prevent Blindness, New York,New York, USA.

None of the authors has a financial or proprietary interest in anyproduct mentioned.

James P. Byrnes provided IT services and Oday Al Sarraf helpedprepare the manuscript.

Reprint requests to Helga P. Sandoval, MD, Magill Research Centerfor Vision Correction, Storm Eye Institute, Medical University ofSouth Carolina, 167 Ashley Avenue, Charleston, South Carolina29425, USA. E-mail: [email protected].

ª 2005 ASCRS and ESCRS

Published by Elsevier Inc.

and phakic intraocular lenses (IOLs). However, de-

tailed questions about LASIK wavefront-guided abla-

tion were included.

Materials and MethodsIn November 2003, a questionnaire highlighting demo-

graphics, practice plans, and surgical techniques; instrumen-tation and equipment; and complication rates and clinicalscenarios were mailed to 8897 ASCRS members worldwide.Respondents were asked to mail completed questionnaires tothe Magill Research Center for Vision Correction, StormEye Institute, Medical University of South Carolina,Charleston, South Carolina, USA. Surveys received beforeApril 2, 2004, were scanned and tabulated using MicrosoftAccess 2003 and analyzed using Microsoft Excel 2003. Theresults reported here are based on the number of surgeonsresponding to each survey question, queried with thosesurgeons performing RS, unless stated otherwise. Multipleresponses or no response to any single question were notincluded in the question’s tally.

Results and Discussion

DemographicsThe overall response rate was 11.8% (1053 of

8897 mailed questionnaires). By geographic area, the

responses were as follows: Canada 10.6%, United

States 13.5%, Oceania 16.5%, Europe 8.2%, Latin

America 4.7%, Asia 5.7%, and Africa 4.7%.

0886-3350/05/$-see front matter

doi:10.1016/j.jcrs.2004.08.047

SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Figure 1. Percentage of respondents

who performed RS procedures for 1 or

more years in the 2003 (nZ 793) and

2004 (614) surveys.

Most respondents (47.9%) were 40 to 54 years

of age; 20.1% were 39 years and younger and 32.0%,

55 years and older. The clinical practices were based on

the following subspecialties: cataract surgeons (29.5%),

comprehensive ophthalmologists (48.8%), RS special-

ists (11.6%), cornea and external disease specialists

(5.1%), glaucoma specialists (1.9%), and retina special-

ists (1.1%); fewer than 1% each were oculoplastic,

pediatric, and research specialists.

Refractive Surgeons and Refractive SurgeryFigure 1 shows the number of years of RS expe-

rience of 2003 and 2004 respondents. The respon-

dents’ future practice plans for 2004 compared with

those for 2003 showed they expected an increase in

corneal RS volume with conventional LASIK (29.1%),

PRK (10.6%), and LASEK (12.2%). Some respond-

ents indicated they did not and would not perform

certain procedures including implantable corneal seg-

ments (Intacs) (20.3%), laser thermal keratoplasty

(LTK) (20.0%), and surgical reversal of presbyopia

(15.2%). When asked about their plans for LASIK

222 J CATARACT REFRACT SURG

wavefront-guided ablation, 27.0% expected to increase

their volume and 17.3% had not done the procedure

but were planning to do it. Only 2.1% reported they

would try it once it is approved.

Of the 1042 respondents who answered the per-

sonal RS question, 17.6% had had RS at some point

in the past; 14.4% of them had the surgery in 2003.

Of the 15 respondents who had RS in 2003, 53.3%

had LASIK, 13.3% LASEK, and 33.4% other

procedures. No respondents had PRK, LTK, refractive

lens exchange (RLE), phakic IOLs, or Intacs in 2003.

Of the 178 respondents who had had an RS

procedure, 84.8% performed refractive surgery. The

results indicate that surgeons who have had RS are

more likely to perform it and those who have not had

it are less likely to perform it, as in 2003 (Figure 2).

Of the 415 respondents not performing RS, 9.4%

discontinued it in 2003, 25.8% discontinued it more

than a year ago, and 64.8% never performed it.

Clinical Practice ComanagementIn 2003, 55.5% of respondents comanaged pa-

tients (ie, shared care of a patient with 1 or more

Figure 2. Refractive surgery practice

patterns of respondents who had had

(nZ 178) or had not had (nZ 832) RS.

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SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Figure 3. Comanaged cases in the

U.S. and Canada that followed (nZ 256)

or did not follow (n Z 67) AAO/ASCRS

comanagement guidelines.

practitioners [ie, ophthalmologist or optometrist] per-

forming the preoperative and/or postoperative care and

a surgeon performing the surgical procedure), similar

to 59.2% in 2002. When the comanagement responses

were limited to the U.S. and Canada and queried with

the responses regarding guideline use, 79.3% of the

comanagement respondents indicated they followed

the guidelines of the American Academy of Ophthal-

mology (AAO) and ASCRS, similar to the response in

2003. Figure 3 shows the distribution of comanaged

patients in the U.S. and Canada, the use of AAO/

ASCRS guidelines, and the percentage distribution of

patient comanagement within the practices. Figure 4

shows the responses of surgeons following or not fol-

lowing the AAO/ASCRS comanagement guidelines in

North America in 2003 and 2004 and if not following,

the reasons for this.

J CATARACT REFRACT SURG

Laser in Situ KeratomileusisTechnology. In the 2004 survey, the Visx S2/S3

excimer laser continued to be the most commonly used

worldwide (57.6%), followed by the Alcon Autono-

mous LADARVision (17.2%). The Visx laser was used

by 68.2% of respondents in the U.S. and 36.8% in

Canada. The LADARVision was used by 20.5% in the

U.S. and 10.4% in Europe. The Bausch & Lomb

Technolas 217 laser was the laser of choice of respon-

dents in Oceania (83.3%), Asia (35.7%), and Europe

(35.4%) and the Nidek EZ-5000 laser, of respondents

in Asia and Canada (21.1% each) and Latin America

(15.8%).

The Bausch & Lomb Hansatome was the most

commonly used microkeratome worldwide (44.7%),

followed by the Advanced Medical Optics Amadeus

(12.8%) and the Moria Carriazo-Barraquer (11.2%)

Figure 4. Respondents in the 2003

survey (n Z 419, Canada and U.S.) and

2004 survey (nZ 392, Canada and U.S.)

who followed or did not follow AAO/

ASCRS comanagement guidelines and

the reasons they did not.

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SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Figure 5. Cost of LASIK (U.S. dollars)

per continent or country during 2003

(Africa, nZ 2; Asia, nZ 28; Canada,

nZ 13; Europe, nZ 50; Latin America,

nZ 20; Oceania, nZ 12; U.S., nZ 439).

microkeratomes. From 2002 to 2003, worldwide use

of the IntraLase keratome increased the most among

respondents (from 2.3% to 5.1%), followed by the BD

microkeratome (from 1.8% to 3.1%).

Cost. Most LASIK respondents worldwide (67.4%)

planned to maintain their prices for the next 6 months;

21.5% and 2.1% planned to increase prices and

decrease prices, respectively; the remaining 9.0% were

undecided. Figure 5 shows the reported LASIK prices

by continents and countries. Respondents in Oceania,

the U.S., and Europe (66.7%, 48.7%, and 40.0%,

respectively) reported the highest prices, which ranged

from US$1500 to US$2000 per eye. Respondents in

Asia and Latin America (14.3% and 25%, respectively)

reported the lowest prices, less than US$500. Figure 6

224 J CATARACT REFRACT SUR

compares the 2004 expected changes in the price of

LASIK based on current prices of U.S. respondents to

those of the remainder of worldwide respondents.

Most respondents (67.6%) expected LASIK prices to

stay the same in their geographic area within the next

6 months; 23.5% of worldwide respondents, princi-

pally in the U.S. and Latin America (27.2% and

22.2%, respectively), expected LASIK prices to increase

in their regions. Only 8.9% of respondents expected

a decrease in LASIK prices in their geographic areas,

mainly Asia (25.0%) and Europe (18.0%). A compar-

ison of LASIK prices per eye is shown in Figure 7.

Volume. More than half the respondents (53.0%)

performed 20 or fewer procedures per month; 19.6%

performed fewer than 5 and the remainder (47.0%),

Figure 6. Single-eye cost of LASIK

(U.S. dollars) in U.S. (n Z 406) and other

regions (n Z 152) cross-accessed with

respondents who planned cost changes

during the first half of 2004.

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SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Figure 7. Single-eye LASIK cost in

the 2003 (nZ 733) and 2004 (nZ 564)

surveys.

more than 20. These percentages are the same as in

2003. The number of respondents who performed

wavefront-guided LASIK, 60.1%, was larger than in

2003, 13.3%. Of those who performed the procedure,

60.1% performed 10 or fewer per month and 5.5%

performed more than 70.

Respondents who had had RS were more likely to

perform a larger volume of LASIK than those who had

not (Figure 8). This tendency was similar to that in the

2003 survey.

Practice Patterns. Table 1 shows the surgical items

used by respondents during LASIK. The items are

similar to those reported in the 2003 survey.

In the preoperative examination of LASIK pa-

tients, most respondents (93.0%) performed corneal

topography. Pupil size in dim light was measured

J CATARACT REFRACT SUR

directly by 89.3% of respondents and using infrared

pupillometry by 44.1%. Only 34.5% performed a tear-

secretion (Schirmer) test. These percentages are similar

to those in the 2003 survey. The use of preoperative

wavefront measurements increased from 23.2% of

respondents in the 2003 survey to 52.6% in the 2004

survey.

In myopic patients, 35.2% of respondents pre-

ferred a 9.5 mm flap and 35.9% an 8.5 mm flap,

comparable to the preferences in the 2003 survey. In

hyperopic patients, 82.4% preferred a 9.5 mm flap and

14.0% preferred a 9.0 mm flap, also comparable to the

preferences in 2003.

The flattest central corneal measurement that

respondents would plan for a myopic patient is shown

in Figure 9 per respondent country or continent, and

Figure 8. The number of monthly

LASIK procedures reported by respond-

ents during 2003 cross-accessed with

those who had had RS (n Z 147) and

those who had not (nZ 451).

225G—VOL 31, JANUARY 2005

SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Table 1. Comparison of surgical items used by respondents worldwide for LASIK procedures.*

Country/Continent Mask

SterileGloves

NonsterileGloves

SterileDrape

NonsterileDrape

ScrubHat

SurgicalGown

SurgicalScrubs

Africa 100.0 0 0 50.0 50.0 100.0 50.0 0

Asia 89.3 60.7 3.6 75.0 3.6 82.1 53.6 67.9

Canada 71.4 50.0 7.1 35.7 14.3 50.0 0 50.0

Europe 66.7 68.3 3.3 70.0 1.7 46.7 43.3 40.0

Latin America 85.7 19.0 9.5 66.7 4.8 81.0 71.4 71.4

Oceania 69.2 92.3 0 69.2 7.7 76.9 46.2 46.2

US 77.9 62.0 2.3 60.1 8.1 80.2 6.7 64.3

LASIKZ laser in situ keratomileusis; USZ United States

*Percentage of respondents

the steepest central K-reading planned for a hyperopic

patient is shown in Figure 10. The K-reading tendency

in myopic and hyperopic patients was the same as in

the 2003 survey.

Bilateral surgery was the preferred practice pattern

worldwide (Figure 11), as in the 2003 survey. Nearly

two thirds of respondents worldwide (64.9%) per-

formed monovision LASIK procedures in 1% to 24%

of patients; 8.9% did not perform monovision LASIK

procedures.

Most respondents (78.7%) changed the micro-

keratome blade between patients while 49% in Europe

and 36.4% in Oceania preferred to change the

microkeratome blade between eyes. These preferences

were similar to those in the 2003 survey. The

microkeratome blade was changed after 2 or more

patients by 11.1% of Asian respondents and 55.0% of

Latin American respondents, which was similar to the

226 J CATARACT REFRACT SUR

pattern in the 2003 survey (17.5% and 50.0%,

respectively).

Surgical Technique. Ninety-seven percent of re-

spondents would treat a pupil larger than the ablated

area in patients with low myopia (!�6.0 diopters

[D]), and 70.1% would treat a pupil larger than the

ablated area in patients with high myopia (O�6.0 D).

Figures 12 (low myopia) and 13 (mid to high myopia)

show the pupil size and optical zone size preferences of

respondents with the most commonly used lasers.

In LASIK enhancement, the option of lifting flaps

whenever possible was the preferred method of 96.6%

of respondents worldwide, which was similar to the per-

centage in the 2003 survey (94.9%). However, 2.8% of

respondents would lift the flap from 3 to 6 months

post LASIK and would recut after that. Only 1 respon-

dent (0.2%) would recut all flaps whenever possible.

Most respondents reported a 1% to 10% enhancement

Figure 9. The flattest predicted central

K-reading that respondents would plan

for a myopic patient by continent or

country (Africa, nZ 2; Asia, nZ 27;

Canada, nZ 13; Europe, nZ 50; Latin

America, nZ 19; Oceania, nZ 11; U.S.,

nZ 435).

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SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Figure 10. The steepest predicted

central K-reading that respondents would

plan for a hyperopic patient by continent

or country (Africa, nZ 2; Asia, nZ 25;

Canada, nZ 2; Europe, nZ 51; Latin

America, nZ 19; Oceania, nZ 11; U.S.,

nZ 427).

rate when treating low myopia (85.1%), mid to high

myopia (71.4%), and hyperopia (65.4%).

Other Refractive ProceduresLaser in situ keratomileusis remained popular

worldwide, as in the 2003 survey, but respondents

performed other RS procedures such as PRK (71.0%),

RLE (58.3%), LASEK (40.8%), and implantation of

phakic IOLs (17.4%). The number of respondents

performing these procedures was similar to the number

in the 2003 survey. Most respondents (52.6%) who

performed LASEK did so only in selected cases when

LASIK was not an option. The most commonly reported

complications of LASEK continued to be pain (96.4%),

epithelial defects (86.6%), and corneal haze (81.8%).

The pain associated with LASEK was reported as less than

or equal to that following PRK by 87.9% of respondents

and greater than that associated with LASIK by 79.9%.

J CATARACT REFRACT SUR

A minimum residual bed of 250 to 274 mm has

been the standard in LASIK (Figure 14). For primary

surface procedures such as LASEK and PRK, 15.3%

and 18.5% of respondents, respectively, would leave

a minimum residual bed of 400 mm or more and

23.9% and 26.1%, respectively, would go deeper,

leaving only 300 to 324 mm of residual tissue; these

percentages were similar to those in the 2003 survey.

The percentage of respondents who had performed

PRK over previous radial keratotomy (RK) or LASIK

was similar (24.2% and 22.7%, respectively). The

percentage of respondents who performed PRK over

previous LASIK was higher than in the 2003 survey

(16.1%). In that survey, the respondents who per-

formed PRK over RK or LASIK reported the procedure

was successful. In the 2004 survey, of those who per-

formed these procedures, 6.4% and 4.4% reported that

PRK was not successful over previous RK or LASIK,

respectively.

Figure 11. Percentage of respondents

who indicated the percentage of surgical

candidates in whom they would perform

bilateral procedures (shown on the ab-

scissa) by continent or country (Africa,

nZ 1; Asia, nZ 27; Canada, nZ 13;

Europe, nZ 40; Latin America, nZ 17;

Oceania, nZ 12; U.S., nZ 444).

227G—VOL 31, JANUARY 2005

SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Figure 12. Largest difference between

dim-light pupil size and optical zone size

(excluding the blending zone) that re-

spondents would accept in cases of low

myopia (!�6.0 D) cross-accessed with

respondents’ most frequently used laser

equipment (nZ 501).

Figure 13. Largest difference between

dim-light pupil size and optical zone size

(excluding the blending zone) that re-

spondents would accept in cases of mid

to high myopia (O�6.0 D) cross-ac-

cessed with respondents’ most frequently

used laser equipment (n Z 496).

Figure 14. The minimum residual bed

depth that respondents would accept for

primary refractive procedures (nZ 565)

and enhancements (n Z 533).

More surgeons used mitomycin-C (MMC) (58.4%)

than in 2002 (49.5%); 33.5% of respondents used

MMC for the treatment of selected primary PRK and

LASIK procedures, 27.4% for the treatment of corneal

haze, and 7.0% for all primary PRK and LASEK

procedures.

228 J CATARACT REFRACT SURG

Refractive Surgery ComplicationsSimilar to the 2003 survey responses, the most

common complication of LASIK was dry eye (95.2%),

followed by glare (80.3%), diffuse lamellar keratitis

(DLK) (66.7%), and epithelial ingrowth (60.4%).

When the monthly LASIK volumes were cross-

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SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

accessioned with LASIK complications, the high-

volume respondents (O70 procedures per month)

reported fewer complications than the low-volume

surgeons (!30 procedures per month). For example,

13.5% of high-volume respondents observed no

epithelial ingrowth compared to 47.7% of low-volume

respondents. Dry eyes were reported by similar num-

bers of high-volume and low-volume respondents,

97.8% and 94%, respectively.

As in the 2003 survey, only 5.6% of respondents

worldwide had removed or amputated at least 1 corneal

flap. Most respondents (75.0%) had removed only

1 flap; none had removed more than 3 flaps. Respon-

dents indicated a decrease from 56 to 39 in the number

of RS patients who had had corneal transplantation in

2003 compared to 2002. The most commonly reported

reasons for keratoplasty following LASIK were ectasia

(33.3%) and irregular astigmatism (23.1%).

Unlike in the 2003 survey, respondents whose

practices were based on cornea/external diseases did

not observe infections after LASIK (13.2% and 0%,

respectively). Glare and dry eyes were seen similarly in

all practices. All other complications, such as DLK,

infections, epithelial ingrowth, and slipped flaps, were

more frequently reported by RS practice respondents.

Similar to the results in the 2003 survey, 4.0% of

respondents had diagnosed infectious keratitis in their

LASIK practice and 2.0% in their PRK practice. There

was an increase in the percentage of respondents (from

0.5% to 1.1%) who reported a LASEK patient

diagnosed with infectious keratitis during the same

period. The most common infectious etiologic agents

reported worldwide (55.6%) were gram-positive bac-

teria, followed by atypical mycobacteria (19.4%) and

gram-negative bacteria (13.9%). No respondent had

seen a fungal infection. This was in contrast to the

results in the 2003 survey, in which fungi were the

third most common infectious agent (10.9%).

Wavefront-Guided AblationSignificantly more respondents performed wave-

front-guided ablation in the 2004 survey than in the

2003 survey (71.6% and 12.1%, respectively). Specif-

ically, 33.7% of respondents treated 1% to 24% of

their patients with wavefront-guided ablation LASIK.

CustomVue was the platform most commonly used

worldwide (59.1%), followed by CustomCornea

J CATARACT REFRACT SURG

(23.4%). CustomVue was used by 69.1% of U.S. re-

spondents and 25.0% of Canadian respondents. Navex

was more commonly used by respondents in Latin

America (66.7%) and Zyoptix, by respondents in Asia

(61.5%), Europe (39.4%), and Oceania (88.9%).

When asked about pricing, 78.9% of respondents

charged more for wavefront-guided ablation; most

(28.8%) charged US$500 more than for conventional

LASIK. Moreover, 70.7% observed better results with

customized ablation and 67.7% were willing to convert

back to PRK if it showed better results than conven-

tional LASIK or wavefront-guided LASIK.

Phakic Intraocular LensesOverall, 17.4% of respondents implanted phakic

IOLs. As in the 2003 survey, the highest percentage of

these respondents was in Europe (45.9%). The percen-

tage of respondents in the U.S. increased from 6.4% to

26.5%, and the percentage in Canada and Latin

America decreased from 22.7% to 3.1% and 50.0% to

10.2%, respectively.

Respondents who performed 5 or more phakic IOL

implantations per month were more likely to use an

anterior chamber (AC) iris-claw IOL (39.0%) or

a posterior chamber (PC) Collamer IOL (33.1%) than

a PC silicone IOL (13.6%). Anterior chamber angle-

fixated poly(methyl methacrylate) (PMMA) IOLs

(9.3%) and foldable IOLs (5.1%) were less likely to be

used by these respondents. The percentage of respondents

using a PC Collamer IOL increased from 16.7% in the

2003 survey to 33.1%, while those using AC angle-

fixated PMMA IOLs and foldable IOLs decreased from

16.4% to 9.3% and 8.5% to 5.1%, respectively. The

percentage of respondents who had changed their phakic

IOL preference (10.3%) was markedly smaller than in the

2003 survey (27.7%). The most common reason for

changing phakic IOL preference was ‘‘better results’’

(44.4%), followed by other reasons (33.3%). Thirty-five

percent of respondents were willing to implant phakic

IOLs once the procedure is approved.

Figure 15 shows the respondents’ preferred method

to treat preexisting astigmatism when performing phakic

IOL implantation.

As in the 2003 survey, the most common anesthe-

sia used to implant phakic IOLs was topical (47.1%),

followed by peribulbar (25.9%). The use of topical

anesthesia increased from 37.7% to 53.7% by

229—VOL 31, JANUARY 2005

SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Table 2. Lens opacities after phakic PC IOL implantation in the 2003 and 2004 RS surveys.

2003 Survey Responses(n [ 97)

Postoperative Month

2004 Survey Responses(n[ 65)

Postoperative Month

Lens Opacities 1–6 7–12 13–24 1–6 7–12 13–24

ASC

Central 19 9 11 16 12 11

Midperiphery 11 7 7 13 7 10

Nuclear 2 0 2 1 0 9

Never observed lens opacity 52 26

Other 2 1

ASCZ anterior subcapsular; PC IOLZ posterior chamber intraocular lens

Figure 16. Percentage of respond-

ents who explanted phakic IOLs for the

indicated complications (nZ 68).

Figure 15. Preferred method to treat preexisting astigmatism when performing phakic IOL implantation in the 2004 (n Z 115) and 2003

(n Z 148) surveys.

230 J CATARACT REFRACT SURG—VOL 31, JANUARY 2005

SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Table 3. Procedures for a myopic patient with a pupil size (dim light) of 6.0 mm and a pachymetry measurement of 590 mm (healthy cornea).

% ResponsePatient Age 27 Years

% ResponsePatient Age 55 Years

Procedure�3.00 D(n[ 664)

�8.00 D(n[ 624)

�12.00 D(n[ 610)

�3.00 D(n[ 606)

�8.00 D(n[ 606)

�12.00 D(n [ 595)

RLE 0.2 0 5.9 2.0 16.5 41.3

Intacs 1.7 0.3 0.2 0.8 0 0.2

LASEK 5.1 4.8 2.0 5.4 2.5 1.3

LASIK 59.3 71.0 23.6 55.4 59.1 16.1

LTK 0.3 0.3 1.3 0 0.7 1.0

Phakic IOL 0.5 5.1 31.3 0.7 4.6 12.6

PRK 6.2 2.2 1.3 4.5 1.7 0.8

PRK with MMC 0 1.4 3.4 0 1.0 2.0

RK 0.2 0 0 0 0 0

Wavefront LASIK 26.7 13.1 2.0 26.9 11.1 1.8

Other 0 0.3 0.3 0.5 0.2 0.3

Would not operate 0 1.3 28.7 3.8 2.8 22.4

LASEKZ laser-assisted subepithelial keratectomy; LASIKZ laser in situ keratomileusis; LTKZ laser thermal keratoplasty; MMCZmitomy-

cin-C; PRKZ photorefractive keratectomy; RKZ radial keratotomy; RLEZ refractive lens exchange

respondents in Europe. In the U.S., the use of retro-

bulbar anesthesia decreased from 33.3% to 15.0%.

This decline correlates with the increase in the use of

peribulbar anesthesia from 23.3% to 45.0%. The use

of topical anesthesia remained the same (40.0%).

J CATARACT REFRACT SUR

Most respondents preferred an endothelial cell

count of 2000 cells/mm2 or higher before implanting

a phakic IOL (66.7% of respondents who used an AC

IOL and 51.6% of those who used a PC IOL). However,

9.5% and 16.1% of respondents said they did not count

Table 4. Procedures for a myopic patient with a pupil size (dim light) of 8.0 mm and a pachymetry measurement of 590 mm (healthy cornea).

% ResponsePatient Age 27 Years

% ResponsePatient Age 55 Years

Procedure�3.00 D(n[ 608)

�8.00 D(n[ 599)

�12.00 D(n [ 580)

�3.00 D(n[ 590)

�8.00 D(n[ 580)

�12.00 D(n [ 574)

RLE 0.3 2.2 6.7 4.2 24.0 37.8

Intacs 0.5 0.3 0.2 0.3 0.2 0.2

LASEK 5.4 3.5 1.7 4.7 2.8 0.9

LASIK 37.3 29.4 5.7 35.4 25.3 4.7

LTK 0 0.2 0.3 0 0.5 0.2

Phakic IOL 1.6 9.5 20.9 1.4 6.4 10.3

PRK 5.4 1.5 1.0 3.7 1.0 0.5

PRK with MMC 0 2.5 2.2 0 1.0 1.4

RK 0.2 0 0 0 0 0

Wavefront LASIK 34.2 14.7 2.1 32.2 11.0 1.4

Other 0.5 0.7 0.9 0.7 0.9 0.5

Would not operate 14.5 35.6 58.3 17.3 26.9 42.2

LASEKZ laser-assisted subepithelial keratectomy; LASIKZ laser in situ keratomileusis; LTKZ laser thermal keratoplasty; MMCZmitomy-

cin-C; PRKZ photorefractive keratectomy; RKZ radial keratotomy; RLEZ refractive lens exchange

231G—VOL 31, JANUARY 2005

SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

Table 5. Procedures for a myopic patient with a pupil size (dim light) of 8.0 mm and a pachymetry measurement of 490 mm (healthy cornea).

% ResponsePatient Age 27 Years

% ResponsePatient Age 55 Years

Procedure�3.00 D(n [ 605)

�8.00 D(n[ 591)

�12.00 D(n [ 586)

�3.00 D(n[ 587)

�8.00 D(n[ 585)

�12.00 D(n [ 578)

RLE 0.3 3.9 8.0 6.3 30.6 38.8

Intacs 1.2 0.2 0.2 0.5 0.3 0.2

LASEK 14.0 9.3 2.0 12.9 7.2 1.0

LASIK 24.0 4.6 0.9 22.3 2.7 0.2

LTK 0 0.2 0.5 0 0.2 0.3

Phakic IOL 2.0 15.6 23.2 1.2 8.4 9.9

PRK 19.5 7.4 1.5 15.7 5.5 1.0

PRK with MMC 1.0 12.2 2.9 1.5 8.7 2.2

RK 0 0 0 0.2 0.2 0

Wavefront LASIK 18.0 1.2 0.2 16.2 1.2 0.2

Other 0.5 0.3 0.5 0.5 0.2 0.5

Would not operate 19.5 45.2 60.1 22.7 34.9 45.7

LASEKZ laser-assisted subepithelial keratectomy; LASIKZ laser in situ keratomileusis; LTKZ laser thermal keratoplasty; MMCZmitomy-

cin-C; PRKZ photorefractive keratectomy; RKZ radial keratotomy; RLEZ refractive lens exchange

endothelial cells before AC IOL implantation and PC

IOL implantations, respectively. These were smaller

percentages than in the 2003 survey, 14.9% and 23.5%,

respectively. When queried about the difference

between pupil size and optic diameter in dim light,

232 J CATARACT REFRACT SURG

53.8% of respondents said it should not be greater than

1.4 mm.

Of the respondents who reported lens opacities

following phakic IOL implantation, 71.2% observed

anterior subcapsular opacities and 12.3% observed

Table 6. Procedures for a hyperopic patient with a pupil size (dim light) of 6.0 mm and a pachymetry measurement of 590 mm (healthy

cornea).

% ResponsePatient Age 27 Years

% ResponsePatient Age 55 Years

Procedure+2.00 D(n[ 609)

+5.00 D(n[ 592)

+8.00 D(n[ 593)

+2.00 D(n[ 595)

+5.00 D(n[ 596)

+8.00 D(n [ 591)

RLE 0.3 11.8 26.6 9.6 54.7 67.7

Intacs 0.3 0.2 0 0.2 0 0.2

LASEK 4.9 1.5 0.3 5.7 1.3 0.5

LASIK 73.2 28.2 2.2 70.4 17.4 1.2

LTK 0.5 0.7 0.7 1.0 0.2 0

Phakic IOL 0.7 15.0 17.5 0.5 3.9 3.4

PRK 2.5 1.5 0.2 2.2 1.2 0

PRK with MMC 0.2 0.3 0 0.2 0.2 0

RK 0 0 0 0 0 0

Other 1.0 0.8 0.7 2.5 1.0 0.8

Would not operate 12.3 38.2 51.4 3.9 19.0 25.7

LASEKZ laser-assisted subepithelial keratectomy; LASIKZ laser in situ keratomileusis; LTKZ laser thermal keratoplasty; MMCZmitomy-

cin-C; PRKZ photorefractive keratectomy; RKZ radial keratotomy; RLEZ refractive lens exchange

—VOL 31, JANUARY 2005

SPECIAL REPORT: REFRACTIVE SURGERY SURVEY 2004

nuclear opacities occurring in 1% to 20% of cases.

Table 2 compares the 2004 opacity data following

PC IOL implantation with data in the 2003 survey.

The reasons for explanting phakic IOLs are shown in

Figure 16.

Clinical ScenariosResults in 3 clinical scenarios for various degrees

of myopia and RS procedures for a 27-year-old patient

and a 55-year-old patient are summarized in Tables 3

to 5.

Another clinical scenario was that of a 35-year-old

patient who had stable residual myopia of �3.00 D and

a 160 mm flap 6 months after LASIK, leaving a residual

bed of 250 mm. Most respondents (50.8%) preferred to

recommend glasses or contact lenses. Of those willing

to operate, 27.3% would perform PRK with MMC,

16.9% would implant phakic IOLs, 12.6% would

perform PRK without MMC, 11.2% would perform

LASEK, 6.8% would implant Intacs, and 6.8% would

perform mini RK. No respondent would perform RLE.

Another case involved a 35-year-old patient who had

stable residual myopia of C2.00 D 4 months after

LASIK; the initial surgery used a superior hinge micro-

keratome and an 8.5 mm well-centered ring. The

respondents chose the following 3 options: 16.3%

would wait 2 to 3 months and then recut using

a 9.5 mm ring (same or deeper plate) or lift the flap and

retreat; 37.8% would allow peripheral pulses to be

placed outside the flap; and 23.1% would change the

optical zone with or without zone treatment to keep the

laser ablation inside the flap. These percentages were

similar to those in the 2003 survey.

J CATARACT REFRACT SUR

Table 6 shows the practice pattern in a clinical

scenario with a 27-year-old patient and a 55-year-old

patient with low hyperopia defects.

SummaryThe 2004 survey showed that LASIK is still the

RS procedure of choice and wavefront-guided abla-

tion is gaining in popularity. There was an increase in

the number of respondents who used MMC, and

most used it in selected primary PRK and LASIK

cases. Complications after LASIK remained the same;

however, the number of removed flaps or keratoplasty

procedures decreased. The most common agent caus-

ing infectious keratitis after LASIK continued to be

gram-positive organisms, but no fungi were reported.

The implantation of phakic IOLs increased in the

U.S., and the types used most were AC iris-claw and

PC Collamer. There was a decrease in the number

of respondents who had changed their preferred

phakic IOL. The use of topical anesthesia increased in

Europe.

These results show that RS continues to progress

rapidly with changes in current techniques and devel-

opment and acceptance of new procedures to improve

visual outcomes.

References1. Solomon KD, Holzer MP, Sandoval HP, et al. Refractive

Surgery Survey 2001. J Cataract Refract Surg 2002; 28:346–355

2. Solomon KD, Fernandez de Castro LE, Sandoval HP,et al. Refractive Surgery Survey 2003. J Cataract RefractSurg 2004; 30:1556–1569

233G—VOL 31, JANUARY 2005