The Resurgence of Surface Ablation in Refractive Surgery: A Shift toward Flapless Keratorefractive Procedures

Abstract

For decades, laser in situ keratomileusis (LASIK) and small incision lenticule extraction dominated the refractive surgery market due to rapid visual rehabilitation and minimal patient discomfort. However, long-term concerns regarding corneal biomechanical stability, iatrogenic keratectasia, flap-related complications, and postoperative dry eye have prompted a major clinical re-evaluation. Concurrently, innovations in excimer laser technologies, such as single-step, completely noncontact transepithelial photorefractive keratectomy. Innovations such as smart pulse software algorithms, and advanced wavefront and topography guided ablation profiles have significantly mitigated the historic limitations of surface ablation. These limitations once included severe post-operative pain, delayed epithelial healing, and debilitating stromal haze. This comprehensive review outlines the structural and clinical factors driving the global resurgence of surface ablation, evaluates the technological advances optimizing modern outcomes, and details evidence-based management strategies for modern refractive surgeons.