2020 and beyond – Connotation for refractive surgery

The year 2020 was important for ophthalmologists as it is symbolic of “20/20 Vision” denoting normal visual acuity. Several goals were set at the turn of the century with Vision 2020 aimed at eliminating avoidable blindness by targeting leading causes of visual impairment such as cataract, trachoma, onchocerciasis, childhood blindness (including vitamin A deficiency), refractive errors and low vision, and the target year of attaining them was 2020.[1,2,3,4] The “Universal eye health” initiative was aimed at best quality eye care for all and across socioeconomic barriers with a specific target of a 25% reduction in the prevalence of avoidable visual impairment by 2019 (compared to the baseline in 2010).[5] Keeping with the theme, the beginning of this year saw many organizations planning initiatives to mark the symbolism of 2020,[6,7] and as we come to the end of a fateful year, we must look ahead to fulfill and achieve those aims of mitigating blindness.

One of the targets of Vision 2020: The Right for Sight was to reduce the burden of uncorrected refractive errors. The detection even in low-income and remote areas is now possible through telemedicine and mobile-based applications with audio and video connectivity. With unprecedented scientific and technological advances, the growing incidence of refractive errors, the higher demand for unaided 20/20 visual acuity, and the increasing affordability for surgical correction, laser-assisted corneal refractive surgery is here to stay. With more breakthroughs expected during the coming years and the wider applicability of artificial intelligence, the accuracy and predictability of outcomes are bound to increase. It may be far-fetched to contemplate extending the benefits of surgical and permanent correction of refractive errors to the entire community but it is important to consider that the prevalent conditions in many parts of the world are not conducive enough to afford spectacles or wear contact lenses long term.[8,9,10]

Given the safety of an appropriately chosen technique, refractive surgery has the potential to become primary care for vision correction. Insurance banes prevail as it is still considered a “cosmetic surgery.” The industry needs to now take into perspective an individual's improved performance and quality of life following the surgery.[11,12] This is especially true for those with very high refractive errors or for those in professions where spectacles or contact lenses can be restrictive. It is also true for sportspersons, wherein the use of prosthetics for vision correction can be cumbersome, not practical for the sporting event, a higher risk of ocular injury due to inadvertent impact or result in a reduced field of view.[13,14] On another note, presbyopia can lead to compromised productivity in working-age adults if not adequately corrected.[15] For someone who has never had spectacle correction previously, adapting to glasses after the fourth decade of life can be difficult.

Though the success and patient satisfaction rate of refractive surgery is good, the challenges are of significant concern. The age group, mindset, and demands are important considerations, especially as the number of surgeries are on the rise. As of now the investment for diagnostic and surgical equipment is high and may be out of reach for individual practices. One, therefore, needs to rely on a higher volume of procedures to recover the costs. And with more numbers, the risks proportionally increase and so do the legal liabilities. When we think of extending the benefits of refractive surgery to the community we must vary of the consequences and complications as well, be it post-surgical keratitis or ectasias.[16,17,18]

As the 2020 landmark year of the Global Initiative for the Elimination of Avoidable Blindness comes to a close, we need to take stock of what we achieved and where we fell short.[19] The consequences of the pandemic are huge, and applies to refractive surgery practice as well as most of the procedures are elective. Another impact has been on the training during this pandemic which needs appropriate measures. Nonetheless, we need to take the necessary precautions and foray ahead towards safer surgeries for our patients.[20] Renewed energies and focused care will help restore some normalcy and boost our practices. Most establishments, organizations, and institutes have rallied again despite adversity, it is a matter of time before we achieve our targets set for 2020!

About the author

Prof. Dr. Rohit Shetty DNB, FRCS, PhD (Netherlands)

Dr. Shetty is a cornea-refractive surgeon and a clinician scientist with a keen interest in keratoconus and corneal ectatic disorders. He has been practicing high volume refractive surgery for 14 years now. Dr. Shetty completed his residency in ophthalmology at the St. Johns Medical College for the Diplomate of the National Board. Dr. Shetty obtained his FRCS Glasgow, Scotland, United Kingdom in 2006 and is currently an FRCS examiner. He is the Chief Mentor for the Dual Academic Program (PhD and Clinical Fellowship) at Narayana Nethralaya Eye Institute, Bangalore and Maastricht University.

Dr Shetty has over 200 publications in peer-reviewed journals and is a reviewer for many indexed journals in the specialty. He is also on the editorial board of the Journal of Refractive surgery. Dr Shetty's work on pain management after photorefractive keratectomy, influence of stromal molecular markers on corneal ectasia and risk scoring systems to predict ectasia after refractive surgery has been well received. With a keen interest in imaging, some of his research includes - waveform analysis of deformation and deflection amplitude in keratoconus, influence of ocular spherical aberration on near and intermediate visual acuity in presbyopic eyes, biomechanics of LASIK Flap and SMILE Cap and corneal tomography in post-refractive surgery ectasia.

In the 2015 annual conference of the All India Ophthalmological Society, Dr. Shetty won the prestigious Col. Rangachari Award for the overall best paper of the conference for his work on “Is Inflammation Driving Keratoconus? A Holistic Study of Molecular Pathways”. The American Academy of Ophthalmology recently conferred an achievement award to him for the distinguished services he has rendered over the years to the programs of the society. He was awarded the Casebeer Award for outstanding contribution to refractive surgery by the ISRS in 2019. Dr. Shetty very actively contributes to IJO, being on its Editorial Board. This Refractive Surgery special issue is a result of his initiatives and efforts.