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Subspecialties Refractive, Health Economics and Policy, Education and Training

The Refractive Principle

In the words of Martin Luther King, Jr.: “I have a dream.” Or should I say, we have a dream. “We” being the Refractive Surgery Alliance (RSA) The WHO estimates that 2.2 billion people live with some form of visual impairment and at least one billion people live with an impairment that could have been prevented, or is yet to be addressed, with refractive errors and cataracts being the leading causes (1). This one billion people includes those with moderate or severe distance vision impairment or blindness due to unaddressed refractive error (123.7 million), cataract (65.2 million), glaucoma (6.9 million), corneal opacities (4.2 million), diabetic retinopathy (3 million), and trachoma (2 million), as well as near vision impairment caused by unaddressed presbyopia (826 million). Uncorrected refractive errors dwarf the other causes of vision impairment. How can this be possible when the world has never been more prosperous, when poverty is on the decline, and when conditions are generally improving?

The truth is that refractive surgery changes lives for the better at a much younger age, with economic, health and occupational benefits that accrue over a lifetime.

In some developing countries, spectacles are simply not available or don’t work as intended (they get broken, sold, stolen, or lost). For some, contact lenses are even less suitable. This is the first part of the story: the huge burden of uncorrected refractive error.

The second major challenge is how refractive surgery is viewed within ophthalmology. Our colleagues are not always aware of the strides that refractive surgery has made; they don’t know that refractive surgery is safer than contact lens wear. Some even trivialize refractive surgery, claiming it’s “easy” – a time filler squeezed between more important jobs, a task subject to fly-by-night surgeons and medical tourism. They say it is simply not “serious surgery.”

I could not disagree more. Refractive surgery is all about performance. The rest of our foundational knowledge and practice is about diseased-based approaches. We are programmed to view avoiding minimal loss as a better choice than pursuing gain. Daniel Kahneman, the Nobel Prize-winning economist and author, has performed many behavioral economics studies that bear this out. Therefore, we have health insurance for items like cataract surgery, glaucoma treatment and diabetic retinopathy treatment. We want to minimize loss. And we as a profession have done well with this admirable and important goal. Elective vision correction surgery, however, is not covered, as it is simply deemed to be cosmetic.

The truth is that refractive surgery changes lives for the better at a much younger age, with economic, health and occupational benefits that accrue over a lifetime. It has a value that is in the trillions of dollars in the developing world. Given the monumental improvements that refractive surgery can provide those with vision impairment due to uncorrected refractive error, we now have a mission. But first, we need to raise refractive surgery to the level that is required to make our mission achievable: excellent and safe outcomes at scale. And that means more formal and thorough training for refractive surgeons.

At the end of residency, young ophthalmologists are almost as far from being refractive surgeons as they were when they started. Being able to perform a LASIK procedure every now and then does not make one a refractive surgeon. It starts with a clear mindset: pursuing gain is a valuable and noble pursuit. It continues with another mindset: pursuing gain will take more discipline and commitment to excellence than does disease-based medicine. It requires training on how to deal with self-paying (and therefore much more demanding) patients undergoing elective surgery. The field of refractive surgery requires more of the time-honored features of a great doctor-patient relationship than almost any other discipline in medicine. Is refractive surgery different enough to warrant its own College of Refractive Surgery? We think it is. And that’s step two: preparing the surgeons who will be needed to address the growing burden of refractive error.

How would such a college work? By focusing on three areas: curriculum development (and approval), accreditation, and impact assessment. The actual training would be provided by those following the approved curriculum – for example, the RSA – rather than the College itself, which would develop teaching materials and resources. The College would also oversee the surgical training with experts in the field – treating patients that otherwise couldn’t afford refractive surgery with the most up-to-date treatments available. In short, experts get to teach, fellows get to learn, and the underprivileged and underserved get to see.

In fact, we are already working with large institutions to bring the benefits of refractive surgery to the underprivileged. With increasing awareness of how refractive surgery is changing the lives of so many, we hope the perception of refractive surgery may change – and thus encourage the youngest and brightest to choose refractive surgery as a career.

The need for a College of Refractive Surgery is not a divorce from ophthalmology, rather it is a response to the unique requirements of this ever-changing field. But it takes a lot to change the world. And this movement will require legislation, strategy, financial planning, execution, but, most of all, physician leadership – and many of you reading this are those leaders.

Consider this: the brain allots 60 percent of its resources to vision. The processing speed of vision is 100 times faster than that of hearing and smell, and 10 times faster than touch. We were made to see. Some in ophthalmology have made it their mission in life to allow people to see well without prosthetic aids, helping rid the world of this congenital defect.

I see myself involved in this endeavor for the rest of my career – and I consider it an enormous privilege. I invite all those who share this mindset to join the RSA* and help make our dream a reality.

* RSA members currently come from 26 countries around the world, there are > 350 of us and it is completely funded by its members with no financial support from any other source. See to learn more.

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  1. World Health Organization, “Blindness and vision impairment” (2019). Available at: Accessed November 11, 2019.
About the Author
Arthur Cummings

“I started my career in South Africa as a retinal surgeon, and developed a special interest in the anterior segment,” says Arthur Cummings. Today based at the Wellington Eye Clinic in Dublin, Cummings is an internationally renowned expert on customized laser treatments having performed upwards of 25,000 LASIK procedures and 5,000 cataract and other IOL procedures. His research interests include refractive surgery, cataract surgery and corneal surgery for keratoconus.

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