Refractive surgery has a long history in Italy, dating back as early as the use of phakic implants in the 1950s. Once neglected by the majority of ophthalmologists, refractive surgery gained popularity due to the activity of a few pioneers including Fabio Dossi, MD, of Turin, Italy; Lucio Buratto, MD, of Milan, Italy; and Umberto Merlin, MD, of Rovigo, Italy. Approximately 20 years ago, they founded the first refractive surgery society, currently the Italian Association of Cataract and Refractive Surgery (AICCER).

Many ophthalmic surgeons perform refractive surgery that is mainly based on laser procedures. At the 1988 AICCER meeting in Sirmione, Italy, Marguerite McDonald, MD, of New York, gave the first lecture in Italy about the excimer laser. Since then, a huge refractive interest has been devoted to PRK. Two surgical centers were established, one in Milan and the other in Rome, where surgeons could learn the procedure, perform their first procedures with assistance, and use the facility thereafter. This process proved effective, and it contributed to the diffusion of PRK without giving rise to significant problems.

The number of lasers rapidly increased in the 1990s, and more procedures were performed with great success, great patient satisfaction, and some disappointments. Haze was a concern with the first lasers, but the high number of lasers available helped in exchanging information of how to prevent and to treat it.

LITTLE NEED TO CHANGE
Although a few surgeons devoted their professional career to refractive surgery, the majority kept it as a part of their surgical armamentarium and felt little need to change their preferred technique when LASIK arrived. After Massimo Camellin, MD, invented LASEK, though, many tried—and converted—to this protected surface procedure. Currently, PRK is still the preferred technique, followed by LASEK and LASIK in Italy. High-volume surgeons prefer LASIK, whereas low-volume surgeons favor PRK. The Technolas 217z100 (Bausch & Lomb, Rochester, New York) is the laser used most often, and the Hansatome (Bausch & Lomb) is the most used microkeratome. Many centers implemented wavefront-guided ablations in their procedures.

Approximately 100,000 laser procedures are performed annually in Italy, but few surgeons perform more than 1,000. The majority perform approximately 100 to 300 procedures per year. Myopia is the most addressed visual defect, followed by astigmatism and hyperopia. Few centers address presbyopia. More than 300 lasers are currently active. Instead of a few big facilities, a lot of small refractive centers are spread across the nation.

In the near future, an increase in the number of femtosecond lasers is expected, and maybe this will draw greater attention to LASIK. At the moment, only three are installed, but every ophthalmologist is aware of their potential for corneal surgery. Additionally, patients are finding relevant information on the Internet, and they are beginning to insist on creating flaps with the femtosecond laser. Funding problems will arise, as the current law regulations allow refractive surgery only on a private basis (ie, the patient must pay). All the remaining ophthalmic care is almost free of charge for everybody.

NO CHARGE TO THE NONLASER PATIENT
Intraocular surgery may be performed in public hospitals. For instance, we may perform phakic IOL implantation and refractive lens exchange at no charge to the patient, however, only monofocal IOLs can be implanted. This surgery is devoted to a small number of patients; no more than 2,500 phakic IOLs are implanted annually. There is no reliable information on the number of (almost) clear lens extractions, however, we do not expect it to increase substantially, as there are anatomical limitations and complications.

As for presbyopia, which is the current hot topic, many patients who are asking for solutions will not accept monovision, and many complain about their driving ability with multifocal IOLs. Therefore, multifocal IOLs are mainly proposed for high hyperopic patients. We believe that lifestyle differences (eg, driving, walking through traffic) could account for the lack of popularity of these solutions in Italy.

FUTURE OF REFRACTIVE SURGERY
So, what is the future of laser refractive surgery in Italy? The answer must take into account the situation of ophthalmology in our country. In the past—and until 1991—university ophthalmic schools were not compelled to teach surgery, due to government rules and other problems. Now, many ophthalmologists who are unable to perform many types of surgery are trained to perform PRK. They use the excimer laser centers (previously mentioned) to perform PRK. They are not, however, skilled to do LASIK. PRK is an easy procedure, as no complication is encountered during surgery. Italian patients are aware that they will experience pain for 2 days to 3 days. Frequently, they are told that LASIK is a dangerous procedure indicated only for special cases.

Since 1995, a new generation of ophthalmologists has been born—a smaller number than the previous generation—who worked hard in hospitals before starting private practice, are able to perform surgery, and are prepared to perform refractive surgery including LASIK. Therefore, future refractive surgery in Italy will be characterized more by the correct indication for LASIK or PRK.

Another problem is that, in Italy, refractive surgery is completely paid for by the patient, and most private insurances companies do not offer reimbursement. With the arrival of European financial problems that some patients experience, certain banks will now finance refractive surgery with a low-cost financial loan. This may be a nice option for the future of refractive surgery in Italy.

Roberto Bellucci, MD, is Chief of the Hospital Ophthalmic Unit, Hospital and University of Verona, in Italy. Dr. Bellucci states that he has no financial interest in the products or companies mentioned. He may be reached at roberto.
bellucci@azosp.vr.it.

Simonetta Morselli, MD, practices at the Hospital Ophthalmic Unit, Hospital and University of Verona, in Italy. Dr. Morselli states that she has no financial interest in the products or companies mentioned. She is a member of the CRST Europe Editorial Board. Dr. Morselli may be reached at fax: +39 045 8122289; morsell@tiscali.it.