Opinions on corrective refractive surgery

Helen Chung, MD, Emi Sanders, BSc, Jamie Bhamra, MD

ABSTRACT ●
Objective: To investigate public perception that ophthalmologists are hesitant to undergo refractive surgery by determining the
personal opinions of ophthalmologists on different surgical options.
Design: Prospective cross-sectional survey.
Participants: Members of the American Society of Cataract and Refractive Surgery electronic mailing list.
Methods: An online survey administered from July to August 2014.
Results: There were 396 (5.7%) respondents: 204 (51.5%) would undergo laser refractive surgery (LRS) and 192 (48.5%) would
not. Of the 228 (57.6%) with refractive error, 121 (53.1%) would have LRS, with 83 (36.4%) already having had the procedure
done. Top reasons against LRS include existing contraindications, worry about intolerable side effects, and worry about
complications. 179 (45.3%) would undergo lenticular refractive surgery (lenRS), with 22 (12.3%) having already had this done.
Among those who said yes, most preferred a monofocal intraocular lens (IOL; 59 [33.0%]), whereas those who said no thought
Toric IOLs to be superior (82 [38.0%]). 184 (46.6%) would undergo femtosecond laser–assisted cataract surgery (FLACS); the
main reason against FLACS was concern regarding efficacy, followed by safety. Pearson χ2 analysis found that younger age and
higher number of LRS procedures performed were associated with increased willingness to undergo LRS. Furthermore,
willingness to undergo LRS was positively correlated with willingness to undergo lenRS.
Conclusions: Ophthalmologists indeed are willing to undergo corrective refractive procedures. There is an approximately 50–50
divide on whether or not they would undergo LRS. Slightly less than half of ophthalmologists would personally undergo lenticular
surgery, which includes cataract refractive surgery and FLACS.

Refractive error is the leading cause of visual impairment
and the second leading cause of blindness in the world.1
Modern corrective surgical techniques include laser refrac-
tive surgery (LRS) and lenticular refractive surgery
(lenRS), such as phakic intraocular lens (IOL) insertion,
refractive lens exchange (RLE), and cataract refractive
surgery (CRS).
LASIK is the most popular form of LRS, even among
ophthalmologists. A systematic review examining patient
satisfaction after LASIK surgery revealed a satisfaction rate
of 95.4%, making LASIK one of the most successful
elective procedures performed.2 The most recent U.S.
Trends in Refractive Surgery Survey showed a 30% to
33% penetration of modern refractive surgery among
refractive surgeons, which is 3–4 times that in the general
population.3 Kezirian et al. conducted a survey determining
the prevalence of laser vision correction among ophthalmol-
ogists performing refractive surgery and found that among
self-reported candidates for LRS, prevalence was 62.6%.4
Despite these reports, public belief is that ophthalmologists
prefer wearing glasses or contact lenses over refractive
surgery. A surgical candidate may hesitate if the refractive
ophthalmologist is eligible but has not had the procedure
personally. As such, it is important to evaluate why some
ophthalmologists may choose to forgo refractive surgery.
Previous U.S. Trends surveys have also investigated
which IOL ophthalmologists prefer to use in various
clinical situations, but there has been little follow-up on
why these choices are made. Our survey examines which
type of IOLs ophthalmologists choose to have implanted
and why, to compare if these findings are consistent with
previous trends and evidence-based practices.
Femtosecond laser–assisted cataract surgery (FLACS) is
becoming more popular, rising in popularity by 10%
between 2014 and 2015.3 This relatively new approach
has potential benefits, including more precise capsulotomy
and decreased corneal endothelial cell reduction; however,
potential drawbacks also exist, such as a higher rate of
posterior capsular tears.5 Further rigorous studies are
needed to establish the long-term safety, efficacy, and
cost-effectiveness of this procedure.6 In our survey, we
determine whether respondents would be willing to
undergo FLACS and their reasons for these choices.
METHODS
An online survey was created in English and reviewed
by the American Society of Cataract and Refractive
Surgery (ASCRS) Refractive Clinical Committee. Ethics
approval was prospectively granted through the Conjoint
Health Research Ethics Board at the University of Calgary.
This survey was forwarded to the ASCRS mailing list,
consisting of approximately 7800 individuals. Participants
had between July and August 2014 to submit responses.

& 2017 Canadian Ophthalmological Society.

Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcjo.2017.09.012
ISSN 0008-4182/17

CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017 1

Opinions on corrective refractive surgery—Chung et al.

Respondent location data were collected as zip codes and Table 1—Demographic features of survey respondents
postal codes. For values that had more than one associated Number of Percentage of
location, given that the survey was sent through ASCRS, it Respondents Respondents
Total 396 100.0
was assumed to be in the United States. Furthermore, when Age group (y)
data were exported from survey responses, leading zeroes 26–30 6 1.5
disappeared. Again, in these cases, assumption was made to 31–40 75 18.9
41–50 98 24.7
a location in the United States. 51–60 129 32.6
Quantitative analysis was completed on the data collected 61 and older 85 21.5
Missing 3 0.8
using SPSS version 19 (IBM Corp., Armonk, N.Y.). Pearson Total 396 100.0
χ2 analysis was performed to determine if there was any Gender
significant association between factors such as age, gender, Male 336 84.8
Female 53 13.4
length of practice, location of training, location of practice, and Other 1 0.3
willingness to participate in refractive eye surgery and FLACS. Missing 6 1.5
Total 396 100.0
Years in practice (y)
Still in training 10 2.5
RESULTS Less than 5 41 10.4
In total, 396 (5.7%) responses were received. Demo- 6–15 81 20.5
16 and above 264 66.7
graphics of respondents are summarized in Table 1. Total 396 100.0
Location of training
United States 213 53.8
Laser Refractive Surgery Canada 18 4.5
International 61 15.4
Most respondents performed between 1 and 20 LRS Undecipherable 20 5.1
procedures per month. When asked whether they would Missing 84 21.2
undergo LRS, 204 (51.5%) responded yes (Figure 1). Total 396 100.0
Location of practice
Among those who would consider LRS, 83 (40.7%) had United States 246 62.1
already undergone LRS, with LASIK being most common. Canada 22 5.6
International 60 15.2
Of the respondents, 228 (57.6%) had refractive error. Of
Undecipherable 16 4.0
those, 121 (53.1%) would have LRS, with 83 (36.4%) Missing 52 13.1
already having had the procedure done. Total 396 100.0
Specialties
Those who have not yet undergone or would not Anterior segment 247 62.4
undergo LRS were asked why. The top response revealed Comprehensive 194 49.0
Cornea 147 37.1
that visual acuity did not require correction, followed by
Glaucoma 65 16.4
existing contraindications to LRS, worry about intolerable Medical retina 30 7.6
side effects, and worry about complications. A summary of Oculoplastics 23 5.8
Uveitis 11 2.8
the most common responses in each of these categories is Pediatrics 10 2.5
given in Table 2. Surgical retina 8 2.0
χ2 Tests of independence found 2 variables to be Neuro-ophthalmology 6 1.5
Oculopathology 5 1.3
significantly associated with willingness to undergo LRS. Ocular oncology 3 0.8
Age was significant, with younger ophthalmologists being Other 36 9.1
Total 396 100.0
more willing to consider LRS than their older counterparts
[χ2(7, n ¼ 393) ¼ 17.89, p ¼ 0.01]. The number of LRS Respondents were able to select more than one specialty.

procedures performed per month was also significant

[χ2(4, n ¼ 393) ¼ 53.15, p o 0.001], with more prolific
ophthalmologists being willing to personally undergo LRS.
No significant relationships were found between gender
[χ2(6, n ¼ 396) ¼ 6.72, p ¼ 0.35], location of training [χ2(6,
n ¼ 396) ¼ 5.28, p ¼ 0.51], location of practice [χ2(4, n ¼
396) ¼ 4.22, p ¼ 0.38], and performance of LRS [χ2(2, n ¼
395) ¼ 4.44, p ¼ 0.11] and willingness to personally undergo
LRS.
Regardless of a patient’s relationship to the ophthalmol-
ogist or his or her current occupation, most ophthalmol-
ogists would recommend LRS, as summarized in Table 3.
Lenticular Refractive Surgery
Types of lenRS and IOLs respondents offered to
patients are summarized in Table 4. When asked whether
they would undergo lenRS, 179 (45.3%) responded yes
(Figure 1), with 148 (82.7%) saying that they would
consider CRS. Of those who would consider lenRS, 22
(12.3%) have already had this completed.
χ2 Test of independence revealed that age [χ2(7, n ¼
395) ¼ 1.87, p ¼ 0.97], gender [χ2(3, n ¼ 395) ¼ 4.35, p
¼ 0.23], location of training [χ2(4, n ¼ 395) ¼ 4.47,
p ¼ 0.35], and location of practice [χ2(4, n ¼ 395) ¼ 5.52,
p ¼ 0.24] were not significantly associated with willingness
to undergo lenRS. Whether an ophthalmologist offered
RLE [χ2(1, n ¼ 365) ¼ 15.30, p o 0.001] or phakic
IOL was significant [χ2(1, n ¼ 365) ¼ 13.72, p o 0.001]
for a greater willingness to undergo lenRS. A significant

2 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017

 Opinions on corrective refractive surgery—Chung et al.

Table 2—Summary of selected reasons for not undergoing (36.1%) selecting monofocal IOLs. Individuals selecting
laser refractive surgery, yet or at all
monofocal IOLs as their preferred IOL indicated that
Reasons for Not Undergoing Laser Number of Percentage of patient satisfaction with the lens, quality of vision, and
Refractive Surgery Respondents Respondents
Visual acuity does not require correction 182 59.9
cost were top reasons for this choice. Individuals selecting
Contraindication(s) exist 69 22.7 toric IOLs indicated that top reasons were patient sat-
Dry eyes 27 8.9 isfaction with the lens, quality of vision, and evidence-
Cornea too thin 23 7.6
High refractive error 18 5.9 based efficacy of the lens. Top reasons for particular lens
Worry over intolerable side effect(s) 44 14.5 choices did not differ between individuals who would and
Dry eyes 29 9.5
Glare/halo 24 7.9
would not undergo lenRS.
Poor night vision 23 7.6
Worry over complications 38 12.5
Corneal inflammation 27 8.9 FLACS
Infection 20 6.6 Of the respondents, 211 (53.4%) answered that they
Retinal detachment 12 3.9
Happy with glasses/contact lenses 25 8.2
would not personally undergo FLACS at the time of the
Waiting for better technology 16 5.3 survey (Figure 1). Reasons given by respondents regarding
Prefer intraocular approach 15 4.9 why they would not undergo FLACS included not enough
Total 304 100.0
evidence for efficacy (n ¼ 150 [67.9%]), safety concerns
Respondents could select more than one reason. Only the top 3 responses in each
subcategory are shown.
(n ¼ 106 [48.0%]), and associated cost (n ¼ 91 [41.2%]).
χ2 Test of independence revealed that age [χ2(14, n ¼
396) ¼ 8.87, p ¼ 0.84], gender [χ2(6, n ¼ 396) ¼ 2.42,
p ¼ 0.88], location of training [χ2(8, n ¼ 396) ¼ 12.14,
association between willingness to undergo LRS and will- p ¼ 0.15], and location of practice [χ2(10, n ¼ 395) ¼
ingness to undergo lenRS [χ2(1, n ¼ 392) ¼ 42.92, p o 15.11, p ¼ 0.13] did not have a significant relationship
0.001] existed, with a very strong positive correlation with willingness to personally undergo FLACS. Willing-
between these variables as well (r ¼ 0.33, n ¼ 392, p o ness to undergo LRS [χ2(1, n ¼ 392) ¼ 2.43, p ¼ 0.12]
0.001). This demonstrates that if an ophthalmologist were and lenRS [χ2(1, n ¼ 392) ¼ 0.99, p ¼ 0.32] also was not
willing to undergo LRS, it was very likely that he or she significantly associated with willingness to undergo
would be willing to undergo lenRS, and vice versa. FLACS Fig. 1.
Conversely, this also indicates that if an ophthalmologist
were unwilling to undergo LRS, he or she was likely
unwilling to undergo lenRS, and vice versa. DISCUSSION
Of the respondents considering lenRS, 59 (33.0%) It is important to patients that physicians “practice what
selected monofocal IOLs as their lens of choice, with the they preach,” as reported by Puhl et al.,7 who found that
next most popular being multifocal IOLs, selected by 35 patients were less likely to follow medical advice from and
(19.6%). Those not considering lenRS were asked which more likely to mistrust an overweight or obese doctor.
type of IOL they believed was superior, and 82 (38.0%) of Extrapolating the same principle to refractive surgery, one
these individuals chose toric IOLs, followed by 78 might see why a patient would be more sceptical about
having a refractive consult from a surgeon who is unwilling
Table 3—Respondents’ willingness to recommend laser to personally undergo the procedure.
refractive surgery to eligible surgical candidates of different Results from our survey reinforce the concept that
relationships and occupations
ophthalmologists indeed consider and personally undergo
To Whom Would You Recommend Number of Percentage of refractive surgery, with a reported 36.4% penetrance of
Laser Refractive Surgery? Respondents Respondents
previous LRS among respondents with refractive error.
Friend 347 87.6
Spouse 298 75.3 This number matches previously published rates, which
Sibling 209 52.8 are above the average rate among the general popula-
Daughter/son
Parent
288
231
72.7
58.3
tion.3,4 Most respondents were also willing to recommend
Medical physician 326 82.3 LRS to individuals of all backgrounds, from relatives to
Surgeon 287 72.5 fellow ophthalmologists to airline pilots, which reinforces
Ophthalmologist 281 71.0
Teacher 339 85.6 the appearance of confidence in these procedures.
Proathlete 330 83.3 Why, then, does the notion persist that ophthalmolo-
Musician 317 80.1
Construction worker 316 79.8
gists do not undergo refractive surgery? Perhaps this
Taxi driver 306 77.3 misconception is created by higher rates of refractive error
Bus driver 302 76.3 among ophthalmologists. As demonstrated in the Guten-
Computer programmer 294 74.2
Accountant 291 73.5
berg Health Study, myopia is associated with higher levels
Engineer 268 67.7 of education: 53% prevalence among university graduates
Airline pilot 253 63.9
compared to 26.9% of those who never graduated from
Total 396 100.0
secondary school.8 These numbers hold true for

CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017 3

Opinions on corrective refractive surgery—Chung et al.

Table 4—Intraocular lens options offered by respondents and respondents’ personal preference for lenses

IOL(s) Offered IOL Preferred for Self IOL Felt Superior

Number of Percentage of Number of Percentage of Number of Percentage of

Respondents Respondents Respondents Respondents Respondents Respondents
Monofocal 356 94.9 59 33.0 78 36.1
Toric 336 89.6 33 18.4 82 38.0
Multifocal 293 78.1 35 19.6 14 6.5
Multifocal/toric 132 35.2 22 12.3 16 7.4
Accommodative 88 23.5 19 10.6 9 4.2
Other 8 2.1 12 6.7 12 5.6
Total 375 100.0 179 100.0 216 100.0

Respondents who would consider lenticular refractive surgery, such as refractive lens exchange, selected the intraocular lens (IOL) preferred for self. Respondents who would not consider
lenticular refractive surgery selected the IOL they felt was superior.

ophthalmologists, with 53.4% of respondents of a recent
survey self-reporting myopia, toward a total of 69.4%
reporting refractive errors not including presbyopia.4
Previous retrospective studies examining reasons for not
performing LRS on patients seeking surgery have reported
16.1%,9 20.0%,10 and 25.4%11 of patients as being
unsuitable for surgery due to ocular and systemic contra-
indications not including age. Common contraindications
reported were high refractive error, thin central corneal
thickness, and keratoconus.9–11 In our survey, the top
reason reported for not performing LRS in someone with
refractive error was an existing contraindication to the
procedure, such as dry eyes, thin central corneal thickness,
and high refractive error.
Willingness to undergo LRS was significantly affected
by age, with younger ophthalmologists being more likely
to undergo LRS. This is consistent with a steady decline in
risk taking, in the health domain, that comes with
increasing age.12 Another factor may be development of
presbyopia and cataracts with greater age, which may
influence consideration of a lenticular procedure or
another presbyopic procedure, such as corneal inlay, over
LRS. A factor could be that an older individual may have
already undergone cataract extraction and thus no longer
would require LRS. It is important to note that whether
one performed LRS did not affect whether one would
undergo LRS. However, those performing a higher
monthly quota of LRS were more willing to undergo
LRS. The literature on cataract surgery has shown higher
procedural volume to be associated with lower complica-
tion rates.13 Thus, a higher-volume LRS provider may see
a lower rate of complications, giving the ophthalmologist
greater confidence in the procedure.
Of the respondents, 179 (45.3%) would consider
lenRS, which includes RLE, phakic IOL implantation,
and CRS. Willingness to undergo lenRS was not
affected by age, gender, location of training, or location
of practice. There was a greater willingness to undergo
LRS among those who offered RLE or phakic IOL to their
patients.
Previous systematic reviews and meta-analyses have
compared toric,14 multifocal,15 and accommodative16
lenses against monofocal IOLs. Toric IOLs have been
shown to provide better uncorrected distance visual acuity
and greater spectacle independence.14 Multifocal IOLs
provide improved near vision, but adverse effects such as
haloes and reduced contrast sensitivity need to be taken
into consideration.15 With accommodative IOLs, moder-
ate evidence showed improvement of near vision at
6 months but possible decreased distance vision at
12 months due to posterior capsular opacification.16 Our
survey findings appear congruous with these reviews, as

Fig. 1 — Summary of survey responses to the following questions: (left) willingness to undergo laser refractive surgery, n ¼ 396;
(middle) willingness to undergo lenticular refractive surgery, n ¼ 395; (right) willingness to undergo femtosecond laser-assisted
cataract surgery, n ¼ 393.

4 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017


toric IOLs were overall the most popular premium lens
selected. However, monofocal IOLs remained one of the
most popular IOLs overall to be selected among those who
would undergo lenRS, which is in keeping with their
status of being the tried and true standard lens to which
premium lenses must be compared.
A possible limitation in our study is that respondents
may have misunderstood the definition of CRS, which
involves implantation of a premium lens (toric, multifocal,
etc.). For individuals who have already undergone CRS,
5 of 9 stated that they had chosen monofocal IOLs. For
those who responded that they would undergo CRS but
have not had the procedure completed, 30 individuals
selected monofocal IOLs as their lens of choice. Keeping
this possible misunderstanding in mind, the number of
people who would undergo CRS may be artificially
inflated, and the popularity of monofocal IOLs for
refractive surgery may be overstated.
As for FLACS, 211 (53.4%) respondents would not
choose this procedure over conventional phacoemulsifica-
tion cataract surgery, the greatest reason being not enough
evidence for efficacy. Age, gender, and location of training
or practice did not affect willingness to undergo FLACS.
Interestingly, willingness to undergo LRS and lenRS
was positively associated, but not willingness to undergo
LRS and FLACS or lenRS and FLACS. This is keeping
with our observational trend that ophthalmologists prefer
tried and tested technologies.
Other limitations include the use of an online survey
with primarily close-ended questions. For instance,
“Parents” had the lowest rate of recommendation for
LRS. This could be due to parents being older and thus
nearer to needing or already having had cataract surgery,
or perhaps having already passed away.
Another limitation is the low response rate, leading to
possible nonresponse bias. For instance, respondents may
have wanted to show their support for refractive surgery,
leading to a higher number of individuals who would
personally undergo these procedures. Yet it is difficult to
determine the exact number of people who received the
survey; although messages were sent to 7800 email
addresses, some may have gone to inactive accounts or
directly to junk mail inboxes, as is in the nature of Listserv
send-outs. As such, our response rate may be artificially
low as we are forced to assume that all emails reached their
intended targets. Furthermore, online surveys, particularly
with physicians, are known to have low response rates.17
In a meta-analysis on web-based surveys, Cook et al.18
noted that “response representativeness is more important
than response rate in survey research.” Ultimately, we
believe that our survey is valid, as we collected responses
from a wide range of refractive surgeons with different
practices and backgrounds. We also conducted sensitivity
analyses to determine the impact of different factors on
key survey responses.
Opinions on corrective refractive surgery—Chung et al.
The structure of our questions on IOL choice may also
have been limiting. To create a “smart” survey (i.e., the
next question is dependent on your answer to the current
question), we limited options so that individuals must
choose only 1 IOL type. This led to some respondents
commenting about their preference for multiple IOL
types.
The survey was conducted in 2014. Laser techniques
such as refractive lenticule extraction (ReLEx) have since
been gaining popularity,19 new IOLs have been devel-
oped,20,21 and FLACS has been further evaluated, learned,
and grown accepted as a mainstream procedure.3 We also
did not include questions about presbyopia correction,
and now there are more options for this as well, such as
corneal inlays.22 These new advances may influence
current opinions on corrective refractive surgery.
In summary, our survey showed that ophthalmologists
with refractive errors were indeed willing to undergo LRS,
with the prevalence of those having already undergone the
procedure greater than that of the general public. There is
great value in showcasing that physicians practice what
they preach in their personal lives, as it is important for the
maintenance of our social contract. As such, plans are in
place to conduct a multinational updated survey so that
data may be compared longitudinally and between differ-
ent populations.
REFERENCES
1. Bourne R, Stevens G, White R, et al. Causes of vision loss
worldwide, 1990–2010: a systematic analysis. Lancet Glob Heal.
2013;1:e339-49.
2. Solomon K, Fernandez de Castro L, Sandoval H, et al. LASIK world
literature review: quality of life and patient satisfaction. Ophthalmol-
ogy. 2009;116:691-701.
3. Duffey R, Leaming D. ISRS 2015 U.S. Trends Survey. Available
at: http://isrs.aao.org/resources/2015-isrs-u-s-trends-survey. Accessed
October 14, 2016.
4. Kezirian G, Parkhurst G, Brinton J, Norden R. Prevalence of laser
vision correction in ophthalmologists who perform refractive sur-
gery. J Cataract Refract Surg. 2015;41:1826-32.
5. Popovic M, Campos-Moller X, Schlenker M, Ahmed I. Efficacy and
safety of femtosecond laser-assisted cataract surgery compared with
manual cataract surgery: a meta-analysis of 14 567 eyes. Ophthal-
mology. 2016;123:2113-26.
6. Day A, Gore D, Bunce C, Evans J. Laser-assisted cataract surgery
versus standard ultrasound phacoemulsification cataract surgery.
Cochrane Database Syst Rev. 2016;7:CD010735.
7. Puhl R, Gold J, Luedicke J, DePierre J. The effect of physicians’
body weight on patient attitudes: implications for physician selec-
tion, trust and adherence to medical advice. Int J Obes.
2013;37:1415-21.
8. Mirshahi A, Ponto K, Hoehn R, et al. Myopia and level of
education: results from the Gutenberg Health Study. Ophthalmology.
2014;121:2047-52.
9. Hori-Komai Y, Toda I, Asano-Kato N, Tsubota K. Reasons for not
performing refractive surgery. J Cataract Refract Surg.
2002;28:795-7.
10. Bamashmus M, Saleh M, Awadalla M. Reasons for not performing
keratorefractive surgery in patients seeking refractive surgery in a
hospital-based cohort in “Yemen.” Middle East Afr J Ophthalmol.
2010;17:349-53.
CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017 5
Opinions on corrective refractive surgery—Chung et al.

11. Xu K, McKee H, Jhanji V. Changing perspective of reasons for not
performing laser-assisted in situ keratomileusis among candidates in
a university eye clinic. Clin Exp Optom. 2012;96:20-4.
12. Rolison J, Hanoch Y, Wood S, Liu P. Risk-taking differences across
the adult life span: a question of age and domain. J Gerontol B
Psychol Sci Soc Sci. 2013;69:870-80.
13. Bell C, Hatch W, Cernat G, Urbach D. Surgeon volumes and
selected patient outcomes in cataract surgery: a population-based
analysis. Ophthalmology. 2007;114:405-10.
14. Kessel L, Andressen J, Tendal B, Erngaard D, Flesner P, Hiortdal J.
Toric intraocular lenses in the correction of astigmatism during
cataract surgery: a systematic review and meta-analysis. Ophthalmol-
ogy. 2016;123:275-86.
15. Calladine D, Evans J, Shah S, Levland M. Multifocal versus
monofocal intraocular lenses after cataract extraction. Cochrane
Database Syst Rev. 2012;12:CD003169.
16. Ong H, Evans J, Allan B. Accommodative intraocular lens versus
standard monofocal intraocular lens implantation in cataract surgery.
Cochrane Database Syst Rev. 2014;1:CD009667.
17. VanGeest J, Johnson T, Welch V. Methodologies for improving
response rates in surveys of physicians: a systematic review. Eval Heal
Prof. 2007;30:303-21.
18. Cook C, Heath F, Thompson R. A meta-analysis of response rates in
web- or internet-based surveys. Educ Psychol Meas. 2000;60:821-36.
19. Agca A, Demirok A, Yildirim Y, et al. Refractive lenticule extraction
(ReLEx) through a small incision (SMILE) for correction of myopia
and myopic astigmatism: current perspectives. Clin Ophthalmol.
2016;10:1905-12.
20. Mendicute J, Kapp A, Levy P, et al. Evaluation of visual
outcomes and patient satisfaction after implantation of a
diffractive trifocal intraocular lens. J Cataract Refract Surg. 2016;42:
203-10.
21. Pedrotti E, Bruni E, Bonacci E, Badalamenti R, Mastropasqua R,
Marchini G. Comparative analysis of the clinical outcomes with a
monofocal and an extended range of vision intraocular lens. J Refract
Surg. 2016;32:436-42.
22. Srinivasan S. Corneal inlays for spectacle independence: friend or
foe? J Cataract Refract Surg. 2016;42:953-4.
Footnotes and Disclosure:
The authors have no proprietary or commercial interest in any
materials discussed in this article.
From the University of Calgary, Calgary, Alta.
Originally received May. 29, 2017. Final revision Aug. 31, 2017.
Accepted Sep. 18, 2017.
Correspondence to Helen Chung, Rockyview Eye Clinic, 7007-
14 St SW, Calgary, Alta. T2T 1P9; hnchung97@gmail.com

6 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2017