Refractive surgery today: is there innovation or stagnation?

Refractive surgery, both corneal and intraocular, has undergone an explosive evolution during the last 25 years. The first excimer laser surgery performed now already over 25 years ago is a historical landmark which started the scientific age of corneal refractive surgery. Before that momentous occasion, refractive surgery was a buccaneer procedure that lacked consistent scientific knowledge about the long-term outcomes of the procedures that were practiced (mainly radial and astigmatic keratotomy). In other words, there was a complete lack of objective outcome analysis coupled with almost no perspective on what the future development of this subspecialty was going to hold [1]. A classic example of this is Radial Keratotomy, which was extensively performed in Europe, the US and Latin America at the end of the 80’s and early 90’s. Only the PERK study was able to detect and announce the trend towards hyperopic flattening of these corneas years later when they approached the technique in a systematic way by studying a relatively small number of cases [2-4]. The introduction of excimer laser in the practice of refractive surgery was an exciting innovation. Large investments from the industry and even from doctors and hospitals created a huge demand for adequate information on outcomes as the possibilities of largescale application of this technology were immediately seen. This challenge forced the companies involved in the ophthalmic development of the excimer laser technology to immediately perform clinical studies or refractive corneal surgery, which reached its peak in the first and second decades after its introduction in Europe. Almost everything that could be known about efficacy, predictability and stability, complications, technological development and innovation was then reported and accomplished in these two decades [5,6]. Currently, corneal refractive surgery performed by excimer laser has matured considerably and is able to cover from +6 to −12 diopters of