ESCRS Refractive Surgery Guidelines a Work in Progress

The ESCRS work to achieve a consensus on guidelines on corneal refractive surgery is ongoing, but there are still many challenges to face, according to Jesper Hjortdal MD, PhD.

The last 30 years have marked a real revolution in refractive surgery, full of many breakthrough inventions. Surgeons now have a lot of procedures available when it comes to refractive surgery. So, many questions come to mind. “Which procedure should we perform? Which variation should we select to obtain the best and safest outcome in each individual patient?” Professor Hjortdal asked.

In this regard, common guidelines are the best strategy to answer all these questions, but a thorough evaluation must be put in place considering different aspects such as patient selection, contraindications, efficacy, safety, predictability, and stability.

He explained that guidelines are designed following the PICO (Patient, Investigative condition, Comparison condition, Outcome) process, used in evidence-based practice to frame a clinical or healthcare-related question. Also, evidence is commonly classified according to an ‘evidence pyramid,’ where systematic reviews and meta-analyses are on top; single publications, randomised clinical trials, and cohort studies are in the middle; and finally, expert opinions and background information are below. All the evidence must be evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.

“You create the quality of evidence into high, moderate, low, and very low,” he said. “High means that there is a lot of confidence that the true effect lies to what it has been estimated, while low means there is little confidence.”

Under these premises, the ESCRS decided to develop guidelines for cataract and refractive surgery in 2020 on the initiative of Professor Rudy Nuijts. After the pandemic period, Jos Kleijnen led the Kleijnen Systemic Reviews (KSR) team in the official start of their work in 2022, finding and grading all the papers on the subject. The refractive surgery group is led by Professors Béatrice Cochener-Lamard and Thomas Kohnen, with PhD students Victoria Kauer and Joujke Wanten.

As Jesper Hjortdal recalled, the group focused on many PICO questions to address the issue, grading the existing literature.

“Many publications had quite low or very low confidence in what they reported. So, the challenge in writing evidence-based guidelines in refractive surgery is that there are many techniques and variations, and very few are addressed by randomised controlled trials,” he reported.

“Mainly, these treatments take place in private settings, or the companies support them with selected patients. Also, it is difficult to find studies on long-term stability as we tend to lose patients to follow-up after some years.”

However, while the cataract guidelines are published, the work is ongoing for the refractive ones, and the guidelines will most likely be available before the next ESCRS meeting in Copenhagen.

“Our group is confident that such guidelines will improve safety and outcomes for future patients,” Prof Hjortdal concluded. “It will be a contribution, especially for those countries that do not have their own national recommendations.”

Prof Hjortdal spoke at the 2024 ESCRS Congress in Barcelona.

Jesper Hjortdal MD, PhD is Professor of Ophthalmology at the Aarhus University Hospital, Denmark. jesper.hjortdal@clin.au.dk