Ectasia Risk Assessment Before Laser Vision Correction: The Evolving Role of Corneal Pachymetry

Background/Objectives: This study aims to review the evolution of preoperative ectasia risk assessment before laser vision correction (LVC), with particular emphasis on the changing role of corneal pachymetry and its interpretation within contemporary multimodal screening strategies. Methods: A structured narrative review of the literature was conducted to examine the historical development of ectasia screening, the incorporation of pachymetric parameters into successive risk models, and the available evidence regarding refractive outcomes in constitutionally thin corneas undergoing laser vision correction. Results: Preoperative ectasia screening has evolved from reliance on isolated clinical and topographic parameters to comprehensive multimodal assessment integrating corneal tomography, biomechanics, epithelial thickness mapping, and artificial intelligence-based indices. Although corneal pachymetry remains a key component of most contemporary risk models, increasing evidence suggests that constitutionally thin corneas with otherwise normal tomographic and biomechanical profiles can achieve favourable outcomes following surface ablation. However, the available evidence remains limited by retrospective study designs, highly selected populations, and insufficient long-term follow-up. Conclusions: Corneal thickness should no longer be interpreted as an isolated indicator of ectasia risk but rather as one component of an integrated assessment of corneal susceptibility. Contemporary preoperative screening should prioritise individualised multimodal evaluation over reliance on isolated pachymetric thresholds. At the same time, further prospective studies are needed to define the long-term safety of surface ablation in constitutionally thin corneas.