Q&A: Advancements in laser refractive surgery

Arjan S. Hura, MD, a refractive and cataract surgeon from the Maloney-Shamie-Hura Vision Institute in Los Angeles, California, United States, discussed the significant advancements in laser vision correction in 2025. He highlighted the evolution of LASIK technology, culminating in the next-generation ray trace-enabled WaveLight Plus LASIK, which allowed patients to achieve unprecedented visual outcomes.

Note: The following conversation has been lightly edited for clarity.

Ophthalmology Times Europe: What are the latest advancements in laser refractive surgery, and how have they improved visual outcomes and safety compared to earlier technologies?

Arjan S. Hura, MD: It's been a really big year in 2025 for advancements in laser vision correction. Historically, we have seen LASIK evolve from custom LASIK to wavefront-guided to wavefront-optimized to topography-guided LASIK. In 2025 we are now able to offer patients next-generation ray trace-enabled WaveLight Plus LASIK, which the studies that have been published have shown, is allowing a level of outcomes that previously just was not possible. So we are seeing a level of 20/10 vision in many more patients than we previously did. And anecdotally, in my personal experience, I'm seeing a lot of my own patients on postop day 1 already seeing 20/10 vision. I joke with our staff, we may need to replace our visual acuity systems, because some of those charts don't go below 20/10 and so that's something I'm very excited about.

There's a key difference between 20/20 vision and 20/15 vision. And patients can discern the difference between 20/20 vision in 1 eye and 20/10 vision in the other. So the ability to get patients at 20/10, maybe even in both eyes combined, that's just incredible. I had LASIK myself 10 years ago. I'm 2015 in one eye, 2020 in the other eye. But gosh, it would be incredible if I could see 20/10 myself.

OTE: How do you determine patient eligibility for different types of laser refractive procedures, and what factors influence your choice of technique?

Hura: Determining what procedure a patient is a candidate for is a very nuanced process. There's not a one-size-fits-all approach. Really getting to know the patient, taking a very good history, understanding their personality, their lifestyle, their hobbies, their profession, their expectations for their vision after surgery, how they use their vision on a day-to-day basis, those are all things that are very, very important, almost more so than the surgery itself. The surgery itself, any refractive surgeon who is skilled, has done a lot of surgeries, they'll be experienced, they'll be able to handle any issues post operatively. But choosing the right surgery for the right patient, their eye anatomy, their unique individual case, that is so, so important, and in a lot of cases, that may mean no surgery at all. There's nothing wrong with continuing glasses and contact lenses. I turn away about 10 to 15% of patients seeking vision correction in my practice because, for 1 reason or another, they're just simply not a good candidate for surgery.

But what are sort of some broad criteria I use in general? Well, in general, if someone is a high myop, let's say they're more than a -6, more than a -8, I'm typically recommending EVO ICL surgery over laser vision correction, because it's reversible, because the quality of nighttime vision has been shown in studies to be higher, and because we don't risk, if the patient has thin corneas, dealing with issues like acoustia, exacerbating pre existing dry eye, quality of vision issues at night time. So for that population, I'm very happy to offer them EVO ICL surgery. But if a patient comes in and they're also a great candidate for LASIK or SMILE or PRK, and they want EVO ICL surgery, I'm happy to offer that to them as well. Typically, if someone is between -1, -6-ish, let's say, all else being equal, their corneas are thick. Topography looks normal. Topography looks normal. Epithelial maps look normal. If their pupil size is not tremendously huge, then those are candidates for laser vision correction. I'm happy to offer to that to them as well. Now let's say someone is a little bit older. Let's say they're not in their 20s, they're not in their 30s, they're in their mid 40s, early 50s, then we might be talking about refractive lens exchange as a procedure. So it really just all comes down again to that patient's own unique individual scenario and their eye anatomy.

OTE: What are the most common complications or challenges you encounter in laser refractive surgery, and what strategies do you recommend for optimizing patient outcomes?

Hura: I think, as a refractive surgeon, 1 of the biggest challenges is setting appropriate expectations for patients. Patients often hear, "Oh, my friend had refractive lens exchange, and they can see everything, and they're great," and they expect the exact same thing for their own eyes when they may not be a candidate for that procedure or for the lens technology that their family member or friend had when they had the surgery themselves. And so I really take a lot of time on the front end, getting to know the patient, getting to know their unique scenario, getting to know what their expectations are for their vision after surgery, so that I can custom tailor my treatment plan to them, and sometimes that means, listen, you're just not a candidate for the same procedure your friend had or that your family member had. However, we may be able to offer you a similar level of vision or outcome after surgery with a slightly different technology. And sometimes we might not be able to do that at all. And then it's more a matter of helping the patient understand, "Hey, given your unique scenario, this level of vision or range of vision just may not be possible. There may be other issues that we need to address first, or those issues may just limit you from having that level of vision or range of vision, period."

I think it's really important as a refractive surgeon to be ethical, to be honest with patients. I try not to blur the edges of what's safe or what's recommended for patients if they're not a candidate for a surgery, I have no problem telling them that what we want to do is make sure patients are if they're having surgery, that it's safe, that it's appropriate for their eyes. But again, a lot of this is also addressing the psychology beforehand and making sure their expectations are reasonable and we can meet them.