Refractive Surgery Alliance Issues Updated Nomenclature Recommendations

• Ophthalmology Advisor Opinion: Commentary and Perspective on Medicine and Practice. This article was written by Brett Mueller, MD, and Lauren Libfraind, MD, in their capacities as members of the Refractive Surgery Alliance. The opinions expressed in this article are their own and do not necessarily reflect the views of Ophthalmology Advisor or Haymarket Media.

In the world of medicine, words hold extraordinary power. They have the ability to heal, to comfort, and to inspire. But words also carry immense responsibility, especially in the field of refractive surgery where clarity is paramount.

Precise terminology plays a crucial role in patient understanding, trust, and their decision-making process. Consistent terminology aids patients in navigating the vast amount of information available, making informed decisions about their surgical options, and eye health with greater ease. By prioritizing patient-centric language, refractive surgeons can ensure that their patients are well-informed and better equipped to participate in shared decision-making, leading to enhanced patient satisfaction and an overall positive experience. At the same time, a standardized terminology cultivates unity within the physician community, promoting effective communication, collaboration, and ongoing professional growth. 

The bottom line is: words matter. In refractive surgery, the choice of terminology is not a mere semantic exercise; it is a crucial act of communication that unites professionals within our subspecialty, and can either empower or overwhelm patients. Clear, concise, and standardized terminology can be the beacon that guides patients through the maze of surgical options, instilling confidence and trust in the process.

It is the responsibility of physicians to select appropriate terminology when discussing surgical procedures with patients. This crucial task should not be delegated to manufacturers, who often favor brand-centric terms. Recognizing this need for standardized language, the Refractive Surgery Alliance Terminology Committee (RSATC), led by Tanya Trinh, MD, gathered input from refractive surgeons worldwide to come up with the most appropriate terminology for: 

With a primary focus on patient comprehension, accuracy, and brand neutrality, the committee made the following proposals:

• Replacement of the crystalline lens for the treatment of refractive error and/or presbyopia
• Lenticule extraction procedures
• Transient hyperaesthesia with ocular surface issues after any ocular surgery

Lens Replacement (LR)

As technology has improved and the patient population has expanded, replacement of the crystalline lens for treatment of refractive error or presbyopia, or both, has increased in popularity. This procedure has been referred to by various terms, such as “refractive lens exchange” or “clear lens exchange,” as well as “laser lens upgrade” or “lifestyle lens upgrade,” and “lens implant focusing enhancement.” However, the committee favors the term “lens replacement (LR)” due to its simplicity and comprehensibility. This term naturally aligns with familiar procedures such as knee or hip replacement, which suggest the removal and replacement of a dysfunctional body part to enhance functionality and lifestyle. The adoption of the term “lens replacement” provides patients with a clear understanding of the procedure and its intended outcomes. This terminology also allows individual physicians to use descriptors like “custom,” “precision,” or “dysfunctional” as appropriate for their specific cases.  

Laser Assisted Lenticule Extraction (LALEX)

In the United States, manufacturer Carl Zeiss Vision, Inc. has trademarked the term “SMILE” (small incision lenticule extraction), to describe its procedure which uses a femtosecond laser to create a refractive lenticule inside the cornea, which is then extracted. However, other countries use alternate names, such as CLEAR (cornea lenticule extraction for advanced refractive-correction), RELEX (refractive lenticule extraction), FLEX (femtosecond lamellar extraction or femtosecond lenticule extraction), SILK (small incision lenticule keratomileusis) , and SmartSight to describe similar procedures. 

The lack of standardized terminology makes it difficult for patients to discern whether these terms refer to distinct techniques, or are simply alternative labels for similar interventions. This fragmentation of terminology creates a chaotic marketplace, lacking uniformity and clarity. Patients may struggle to convey their preferences or make informed decisions when faced with a multitude of names for the same surgical technique. The chosen term, LALEX, maintains brand neutrality, while highlighting the procedure’s distinct nature from LASIK. The German Commission on Refractive Surgery has also adopted a similar term, “laser lentikle extraktion,” fostering international continuity.

Surgical Temporary Ocular Discomfort Syndrome (STODS)

Post-surgical ocular discomfort is a common occurrence after various eye surgeries, including cataract, refractive, glaucoma, and strabismus procedures.¹ This ocular discomfort is often described by patients as dry eye symptoms; however, there is a lack of correlation between objective signs of dry eye disease and subjective symptoms.^2,3 A 2022 study specifically evaluated the subjective symptoms and objective signs of dry eye before and after Femto-LASIK surgery.⁴ It found that although patients reported increased dry eye symptoms after surgery, as measured by the Ocular Surface Disease Index (OSDI) questionnaire, objective clinical measurements such as Schirmer, fluorescein, and tear break up time did not show significant differences. The only exception was increased conjunctival staining 90 days post-surgery. The study also analyzed tear proteins and found no changes in the levels of MMP-9, IL-1β, and IL-8, although there was a reduction in CGRP 5 days post-surgery which then returned close to its initial level after 90 days. This study suggests that the symptoms experienced after femto-LASIK may have a different etiology than classic dry eye disease. It is therefore appropriate to avoid the term “LASIK induced dry eye.” This also applies to other surgical procedures. Nonsignificant changes in postoperative tear production and tear film breakup time (TBUT) have been observed in other refractive surgeries such as LALEX, photorefractive keratectomy (PRK), and cataract surgery.^5,6

There are multiple underlying causes to postoperative ocular discomfort which may include transection of corneal nerves, effects of postoperative drops on the ocular surface, inflammation, and pre-existing dry eye disease.⁷ Researchers have observed that ocular discomfort after surgical procedures is temporary, with few patients experiencing discomfort for more than a year after the procedure.^8,9 

Recognizing the crucial importance of providing patients with validation and a clear understanding of the temporary nature of discomfort during the healing process, and its distinction from dry eye disease, it becomes essential to introduce a term that encompasses these aspects. Hence, the concept of “surgery-related temporary ocular discomfort syndrome” (STODS) was developed.

By incorporating the term STODS, healthcare providers can effectively communicate with patients and provide them with a sense of validation for their post-surgery discomfort. This acknowledgment of their experience reassures patients that what they are feeling is a normal part of the healing process and not indicative of any long-term complications. 

The term STODS has been chosen to emphasize the temporary nature of the discomfort while intentionally avoiding specific associations with any particular type of surgery.

Furthermore, the simplicity and accessibility of the term STODS contribute to its effectiveness in patient communication. It can be easily understood, fostering clarity and facilitating meaningful conversations between patients and healthcare providers. This ease of comprehension ensures that patients are actively engaged in their own care, empowering them to participate in decision-making processes and manage their expectations effectively.

It is our hope that the terms “lens replacement,” “LALEX,” and “STODS” are adopted into the field of refractive surgery. This will not only facilitate standardized communication, but also enhance understanding, communication, and education for both patients and physicians.

 The RSA Terminology Committee is composed of Drs. Tanya Trinh, Balamurali Ambati, Dagny Zhu, Lance Kugler, Luke Rebenitsch, Guy Kezirian, Arthur Cummings, and Brett Mueller.