Refractive surgery: current events and perspectives

What are the advantages/disadvantages of the various types of Phakic IOLs?
There are three types of phakic IOLs, one posterior chamber and two anterior chamber, one with angular support and another with iris enclavation. Many refractive surgeons and patients are satisfied with this surgery because it allows good correction of high ametropias.
For the use of these IOLs, a study and perfect knowledge of the entire anterior segment complex of the eye is essential.
In addition to the study of the cornea, it becomes essential to know the depth of the anterior chamber, pupillometry, posterior chamber, etc., then use complete diagnostics with endothelial cell count, tomography, gonioscopy, etc.
These IOLs, however, occupy free intraocular spaces, therefore, disadvantages may arise from the pathophysiological changes caused by the occupation of these spaces or contact with adjacent structures.

Give us some data on the numbers of 'cataract-refractive' IOLs, meaning IOLs that aim to correct the axial, toric and presbyopic defect.
Unfortunately, even today this remains a niche surgery, in fact the data in the reports of recent congresses give premium IOL utilisation rates of around 3%, but above all, the surgeons who use them are not many. This is a major limitation in achieving the visual quality we all strive for for our patients. In my opinion, there are two reasons for this limitation: one is patient selection, which is a very demanding procedure, and secondly the cost of this technology, which unfortunately our National Health Service does not want to face today.
Let me explain: it is certainly true that these prostheses cost more than the standard provided, but if one were to factor in the costs of corrective glasses, work performance, quality of life, the possibility of cost-sharing on the part of the patient (who is already demanding it strongly) would largely solve the problem.

The Femto-Laser is changing the refractive world, are there other technologies on the way?
The Femto is a working tool that will become established in our profession. One technology being studied that could be its evolution is the Nanosecond Laser, which using a much smaller spot and much lower energy than that used by the Femto could make more precise cuts and reduced thickness flaps.
In fact, by now the Femto technology, which is available today, is also working on cataract surgery with what I consider to be advanced experimentation. It is now clear that the path is laid by the Femto-Cataract and I believe that in a few years time this will be the surgery that will surpass phacoemulsification.

You are known as an expert in vitreo-retinal surgery: Have you ever had to perform refractive surgery on a previously retina-operated patient with residual ametropia?
This is a very interesting question because it may dispel the taboo some people think, namely that retina operated patients are not refractive operable.
Often postoperative retinal surgery results in anisometropias that are difficult to manage, increased myopia in patients previously treated refractionally, patients who have recovered good visus and ask to remove their glasses; in these cases I have tackled monocular or binocular ametropias with surface treatments (PRK), because in my opinion the only risk, apart from those of normal refraction, is the high pressure that is generated at the time of suction with both the microkeratome and the Femto. In fact, the results have been very satisfactory for the patients and this confirms the centrality of the refractive surgeon in all fields of ophthalmology.