Refractive Surgery

Publication Date: December 19, 2022

Highlighted Findings and Recommendations for Care

  • Contraindications to refractive surgery include the following:
    • Unstable refraction
    • Abnormalities of the cornea (e.g., keratoconus or other corneal ectasias, thinning, edema, interstitial or neurotrophic keratitis, extensive vascularization)
    • Insufficient corneal thickness for the proposed ablation depth
    • Visually significant cataract
    • Uncontrolled glaucoma
    • Uncontrolled external disease (e.g., blepharitis, dry eye syndrome, atopy/allergy)
    • Uncontrolled autoimmune or other immune-mediated disease
    • Uncontrolled mental illness, including anxiety or depression
    • Unrealistic patient expectations
  • It is recommended that corneal refractive surgery patients be provided with a record listing diagnosis, preoperative keratometry readings, and refraction, as well as postoperative refraction.
  • It is recommended that the refractive surgeon maintain a record including preoperative keratometry and refraction as well as postoperative refraction and provide that data if needed for future eye care, including cataract surgery.
  • As part of the informed consent process, it is recommended that the refractive surgeon review common adverse effects such as dry eye and eventual presbyopia with patients considering corneal refractive surgery.
  • Excimer laser ablations that result in very thin residual stroma increase the risk for ectasia. For laser in situ keratomileusis (LASIK) procedures, a minimum of 250 µm is suggested as a safe residual stromal bed thickness. There is no absolute value that guarantees ectasia will not occur. Abnormal topography and percentage of tissue altered (PTA) higher or equal to 40% are also associated with higher ectasia risk.
  • Published studies have failed to demonstrate a relationship between pupil size and the quality of postop vision, minimizing the importance of pupillometry in the preoperative workup.
  • Persistent diffuse lamellar keratitis (DLK) unresponsive to corticosteroids should prompt consideration of microbial keratitis or interlamellar fluid due to increased intraocular pressure (IOP) measured peripheral to the LASIK flap, intraocular inflammation, or endothelial decompensation. For extensive DLK, the interface should be irrigated to minimize stromal loss and changes in refractive correction.
  • Surgical management of presbyopia includes keratorefractive surgery, corneal inlays, or intraocular lens implantation (multifocal, accommodative, and extended depth of focus lenses).

Recommendation Grading




Refractive Surgery

Authoring Organization

Publication Month/Year

December 19, 2022

Document Type


Country of Publication


Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, optometrist, physician, physician assistant


Treatment, Management

Diseases/Conditions (MeSH)

D054140 - Refractive Surgical Procedures


refractive surgery

Source Citation

Jacobs DS, Lee JK, Shen TT, Afshari NA, Bishop RJ, Keenan JD, Vitale S; American Academy of Ophthalmology Preferred Practice Pattern Refractive Management/Intervention Panel. Refractive Surgery Preferred Practice Pattern®. Ophthalmology. 2022 Dec 19:S0161-6420(22)00868-5. doi: 10.1016/j.ophtha.2022.10.032. Epub ahead of print. PMID: 36543604.