For fear of plagiarism, I have taken the freedom to write this review on current and future Norwegian refractive trends in an unorthodox manner. Much of this article is based upon my private reflections; I have no authority to write on behalf of the Norwegian refractive community.

It is well known that gathering comparative data from refractive centers is difficult, mostly because production figures pertaining to refractive surgery are a sensitive issue. Norwegian ophthalmologists are, in this respect, no different. I mailed an informal questionnaire to 20 of my colleagues. Only three responded, one of whom asked to remain anonymous. We do not presently have a separate forum or a refractive society to promote networking.

Norway is the only Scandinavian country that is not a member of the European Union. Every other Scandinavian country is associated with large companies or products. Finland has Nokia (Espoo, Finland) and of course, the sauna; Sweden has Saab (Stockholm, Sweden), Volvo (Gothenburg, Sweden), and Ericsson (Stockholm, Sweden); and Denmark has Carlsberg (Copenhagen, Denmark) and Bang & Olufsen (Struer, Denmark). What does Norway have? Aside from its petroleum industry and beautiful fjords, not a lot.

We do have a thriving fisheries industry. The value of omega-3 fatty acids is well known to the ophthalmic community. We have abundant clean hydroelectric power, but no longer the cheapest electricity rates in Europe. We administer the Nobel peace prize, but like to forget that Alfred Nobel was actually Swedish. Our country has been ranked as the world's best place to live, yet Norwegians are not the happiest people in Europe, according to a recent poll.

Is there, then, any claim that may raise the ophthalmic eyebrow? Yes, I believe there is: We have the highest density of excimer lasers per capita in Europe (sorry, Iceland). With a population of just 4.7 million sharing 380,000 km2 of high mountains, deep fjords, and thousands of islands lining a 3,000-km coastline, we are not among the most populous of countries.

TO THE PEOPLE
As a consequence, major cities are few and far between. Rather than drawing refractive candidates into these cities, industry has brought the excimer laser to the people. To my knowledge, there are 33 excimer laser clinics and three university-situated lasers in Norway, creating a laser density of 1:140,000. In greater Oslo, eight lasers create a density of approximately 1:125,000. To put these numbers into perspective, a similar density in the UK would require 420 clinics, where I believe there are fewer than 100. The majority of Norwegian refractive centers, however, are low volume. Only a handful surpass more than 1,000 eyes per year. The smallest population-based center boasts just 2,100 inhabitants, but it serves a population of 160,000 within a 2-hour driving radius.

Traditionally, there has been a high number of contact lens wearers in Norway. A reasonably affluent middle class, coupled with positive economic development, has given Norwegians the economic freedom to consider refractive options other than spectacle and contact lens wear. In 2006, it was estimated that approximately 15,000 eyes underwent laser refractive surgery in Norway. Monovision is most accepted by our younger presbyopes.

In comparison with other European countries, the Norwegian industry has received little criticism. What has been focused on, however, is the cost of surgery (approximate average, ?1,950 per eye). Although prices are as low as ?1,100 for surface ablation, they cannot compete with those offered in low-cost countries such as Turkey. Here, prospective customers are enticed by the combination of de novo vision and a holiday weekend.

Despite that no official bodies regulate private surgery in Norway, most specialty surgery is, in fact, state funded. Absence of national standards leaves much at the discretion of the individual surgeon, and most patients are oblivious to these facts. Still, litigation has not yet become a problem in Norway. I am aware of just two lawsuits following refractive surgery; both settled out of court.

STANDARD REFERRALl
Some clinics formalize contacts with high-volume optometrists who receive payment for referring patients. These optometrists fill out a standardized referral letter and provide postoperative care. The surgeon will usually follow-up with the patient on the evening of surgery or the following day. Currently, the referral fee is approximately ?600.

There are three excimer lasers affiliated to Norwegian university eye departments. Aside from providing therapeutic services, these centers offer surgery to patients whose refractive errors fall under nationally accepted guidelines for state-funded surgery. A few private clinics have also received a quota of public patients funded by the local health authority.

Are there any traits among Norwegian refractive candidates? As blue-eyed Arabs (an anecdotal reference to our North Sea oil industry), we—and other Scandinavian countries—must contend with large pupils. Mesopic pupil diameters between 7.5 mm and 8 mm are not unusual. Transient complaints (eg, glare, halos) are more prominent when surgery is performed in the winter months, because northern Norway experiences 24 hours of darkness in mid-winter. The opposite is true during the light summer months. Seasonal variations in temperature and relative humidity affect the degree of postoperative superficial keratopathy. In my experience, the optimal time for excimer laser surgery is during the more humid summer months.

Surgically, there is no doubt that there is a definite trend toward surface ablation, be it advanced surface ablation/PRK, LASEK, or Epi-LASIK. Of the surgeons who responded to my questionnaire, two use 100% surface ablation. Mitomycin C seems to be used in approximately 20% of cases; duration of application varies from 15 seconds to 35 seconds. For those of us who primarily perform LASIK, the preferred technique is thinner flaps with stromal beds approximating 300 µm. Wavefront-generated ablative patterns vary considerably between clinics, and some clinics almost exclusively use this technology. Neither presby-LASIK or conductive keratoplasty have been performed in Norway, nor has any clinic invested in a femtosecond laser. With only a handful of clinics treating more than 1,000 eyes per annum, the femtosecond laser market is self-limiting, unless significant price reductions occur.

The number of patients opting for refractive lens exchange is rising. Last year, 650 Restor lenses (Alcon Laboratories, Inc., Fort Worth, Texas) were implanted. One clinic offers the combination ReZoom/Tecnis Multifocal (both manufactured by Advanced Medical Optics, Inc., Santa Ana, California). Of the available phakic IOLs, the STAAR ICL (Visian ICL; STAAR Surgical Company, Monrovia, California) is only the implantable contact lens that has enjoyed commercial success.

Looking toward a wider horizon, we must not forget that the most commonly performed procedure is still cataract surgery. Approximately 42,000 cataracts are operated per annum in Norway (surgical ratio, 8.9/1,000 people), half of which are performed in private clinics. Surgeons affiliated to these clinics are allocated a yearly quota—currently 500 eyes. The state will reimburse the surgeon ?730 per case. Waiting lists for cataract surgery vary from 2 weeks to 3 weeks to a maximum of 3 months to 4 months, depending on where one lives. Patients may freely choose between private clinics and public hospitals. They may also choose to upgrade from a standard monofocal IOL to a toric, diffractive, or accommodating posterior chamber IOL. The price difference is billed to the patient. To date, our politicians have not addressed the biometric errors and residual astigmatism in these custom eyes. Until we receive signals as to who shall pay for excimer laser touch-ups, I believe most private clinics will refrain from routinely using these lenses. The preoperative evaluation and counselling that these patients require is resource intensive. Logistic concerns will limit their use in high-volume surgical centers.

As for the future, a better understanding of corneal biomechanics and applying this knowledge in improved treatment algorithms will undoubtedly bring us closer to the goal of 20/10 vision by 2010. Femtosecond lasers will replace mechanical microkeratomes and will be integrated into tomorrow's lasers. Add-on technology looks promising and will provide the patient with the added security of reversibility. New IOL materials and improved design will provide us with true pseudophakic accommodation—be it implantable or injectable—without current side effects of glare, halos, and reduced contrast sensitivity.

To conclude, refractive surgery is much like the aurora borealis that is seen during winter in the northern hemisphere. Once you have seen the light, you will never forget the complex wavefront that is seen only on clear nights devoid of city light glare.

Trond Thilesen, MD, is Co-owner and Managing Director at the All Bright & Clear Synskirurgi, in Larvik, Norway. He may be reached at +47 331 22222; trond.thilesen@abc-sk.no.