Zheng Wang* is Head of the Refractive Surgery Academic Committee of Aier Eye Hospital Group, General Director of Aier, Guangdong Province, and President of Guangzhou Aier Eye Hospital, China. Together with Ronald R.Krueger, he established and co-chairs Aier Global Refractive Surgery Advisory Council, a gathering of 30 top surgeons from all over the world.** Pioneering the networking of more than 800 Aier eye hospitals, he is devoted to building the highest refractive surgery standards, improving effective refractive error coverage (eREC) and driving global development.
Internationally recognized for his contributions to refractive surgery, education, and research, Prof. Wang was invited in 2023 to become a Fellow of the World College of Refractive Surgery and Visual Sciences (WCRS). Here, he sits down with The Ophthalmologist to discuss how refractive surgery is evolving in China, and why training surgeons and educating patients is equally important in this dynamic, high-volume field.
How do you see the advance of refractive surgery in China compared with the rest of the world?
China has probably the highest prevalence of myopia in the world, so the demand for refractive surgery is very high. Many people see myopia as a disease so they take it very seriously. Modern refractive surgery techniques started in China in the early 1990s. I started my first laser surgery in 1993. I was actually the first LASIK surgeon in this country. I think I’ve now done more than 100,000 procedures in total.
Seeing the progress of refractive surgery here, I think there’s a major difference with the rest of the world. The volume of surgeons in China is very high – probably 10 times higher than the rest of the world – and refractive surgeons here are very specialized; that is, they do refractive surgeries only.
Because of the high demand, many new technologies have been adopted here. Small incision lenticule extraction (SMILE), for example, was brought to China around 2011, and now accounts for more than half of the procedures. The success of SMILE was propelled by Taiwanese doctor Ray Tsai, who announced in 2012 that LASIK was not safe. This had a major impact on the world’s Chinese-speaking communities.
SMILE has a lot of advantages, but I believe it is still in its infancy in terms of development. If you look at the surface of the lenticule, it's still quite rough. As a result, patient recovery after SMILE is slower, and sometimes there are issues with visual quality. But I think the idea of lenticule extraction is a good one, and as this technology advances, we will bring this type of surgery to a new level.
What criteria do you use when determining a patient's suitability for refractive surgery?
At Aier Group, where I practice, we choose the type of surgery based on the patient's condition. We perform all types of surgeries, from photorefractive keratectomy (PRK) to implantable collamer lens (ICL) surgery, but for laser surgeries, one important factor that we consider is how irregular the cornea is. Currently, SMILE cannot offer customized treatment, so if the cornea is irregular, we tend to choose customised treatments. For example, we have done more than 8,000 procedures with Wavelight plus, and the results have turned out better than the previous technologies. But if the patient is more concerned about safety, we would still probably recommend SMILE.
Are you optimistic about the promise of AI in your particular field?
Yes, I think AI can play a big role in the future. Because now, although we know that the laser is very precise, the clinical results do not reflect its precision. At least two big factors that we cannot predict or control are corneal biomechanics and epithelial remodelling. These two things work together, and they cause a lot of refractive surprises after surgery. With AI, I think we can manage these two factors better.
What is your view on the development of femtosecond lasers in general?
In China currently, the only femtosecond laser for lenticule extraction is the ZEISS VISUMAX. But we do have some new players joining this game, such as J&J’s ELITA and the SCHWIND ATOS. I'm fortunate enough to be involved in the development of some of these products. The smoothness of the lenticule from VISUMAX is not very good, but there are newer technologies that can improve this and I think, in the future, the idea of lenticule extraction is good.
What kind of exchange of ideas is there between China and the US and Europe?
We have learned a lot from the West. Most of the technologies, the lasers, the surgical skills, come from the West. I also think Western countries are better and more strictly regulated. But China has made a lot of progress in this area recently. We have a more robust “Chinese FDA” now, the National Institutes for Food and Drug Control. Sometimes this is a double-edged sword, however, as new technologies can take a very long time to be approved.
What is the balance of public and private healthcare when it comes to refractive surgery in China?
In the past, most people wanted to go to public hospitals, and private hospitals had a very hard time. But in recent years, the situation has changed. That's why Aier Group has developed so fast in the past two decades. Nowadays, especially for refractive surgery, more and more patients are choosing private hospitals. I think that reflects a gradual change in the patient mindset. Private hospitals usually provide better service and have more advanced equipment, and patients are realizing this.
What do you see as the key challenges in your field, both within China and globally?
For me, it is how to meet patients’ rising expectations of refractive surgery. In Aier Group alone, our annual volume is over 800,000 procedures. With so many patients, there are of course some unhappy ones, but we don’t always know the exact reasons for this. Patients still have some concerns about safety, [and] they worry about going blind, of course. I think we still have to do a lot of patient education to show the real picture of refractive surgery, both good and bad.
How does Aier Group maintain surgical quality, consistency, and outcomes across such a high volume of patients?
We've been working very hard on this. We have more than 350 centres providing refractive services, and more than 600 refractive surgeons in the group. To maintain a stable quality of surgery is very tough. We try to standardize everything – patient selection, surgical skills, and peri-operational management, etc. We’ve developed a very good in-house training program for surgeons, as well as nurses, technicians, etc. We also have, not only have training programmes, we also have a system. All these people have to pass a qualification exam to do surgeries in the Aier Group. We try to standardize everything because, in China especially, all the doctors are from different backgrounds. There's a lot of diversity. For example, some of the refractive surgeons are also cataract surgeons, but most are not; they have zero experience doing intraocular surgery. So we train them to do ICL surgery. We have successfully trained more than 400 such surgeons in this.
* Professor Zheng Wang, MD, PhD, FWCRS
** Aier Global Refractive Surgery Advisory Council international members include Damien Gatinel, Arthur B. Cummings, Michael Morchen, Boris Malyugin, Cynthia J. Roberts, Ik Hee Ryu, Aylin Kilic, and Bruno M. Fontes.
