From numbers to meaning: Graphical reporting in refractive surgery

In the rapidly evolving field of refractive surgery, the gap between surgical innovation and outcomes analysis has long hindered clinical progress. Without standardized methods to measure and compare surgical outcomes, clinicians struggled to identify which techniques truly delivered superior results, making it difficult to adopt best practices or abandon ineffective approaches. Since George O. Waring III, MD, introduced a standardized reporting framework with 6 fundamental graphs, the ophthalmology community has recognized that precise, consistent outcome measurement is essential for advancing surgical techniques and improving patient care.^1,2 This framework, which was later expanded to 9 graphs to also address astigmatism outcomes, established the foundation for evidence-based practice in refractive surgery.

Today, many peer-reviewed ophthalmology journals either require or strongly recommend these standardized graphs for outcome reporting. Despite these standards, many studies continue to exhibit incomplete compliance, limiting comparability and reproducibility.

Existing challenges

Analytical tools previously available for refractive surgery outcome reporting were often costly, required extensive manual data entry, were prone to human error, and lacked comprehensive functionality for automated statistical analysis. These limitations restricted access to standardized outcome analysis, particularly in resource-constrained settings, and slowed the dissemination of research findings.

Filling a niche

In 2017, McGill University’s Refractive Surgery Research Unit initiated the development of a free, automated software solution (mEYEstro) to provide standardized refractive surgery outcome analysis. The software was designed to reduce manual data handling and enable reproducible statistical analyses while remaining compatible with existing clinical workflows.

Software functionality

The software generates standardized graphs across 4 categories: efficacy, safety, accuracy, and stability (Figure). These include the following:

• Cumulative uncorrected and corrected distance visual acuity
• Changes in corrected distance visual acuity
• Spherical equivalent and defocus equivalent accuracy
• Refractive astigmatism accuracy
• Target-induced vs surgically induced astigmatism
• Correction index and angle of error histograms
• Stability analyses over time

The software automatically selects appropriate statistical tests based on data characteristics, reducing the need for advanced statistical expertise. It operates as a standalone desktop application. Users select the surgical type (LASIK, photorefractive keratectomy, implantable collamer lens, refractive lens exchange, or IOL procedures), study design, and customization preferences. Data input occurs through a standardized Excel template, allowing integration with existing workflows.

From data upload to high-resolution graph generation, analyses are complete in approximately 30 seconds. Outputs are exported as publication-ready TIFF images suitable for scientific manuscripts or presentations.

Clinical applications and evidence-based practice

The software supports the transition from experience-based to evidence-based decision-making in refractive surgery. By enabling rapid and comprehensive outcome analysis, it allows practitioners to monitor quality assurance and surgical outcomes over time. Consecutive sampling enables observation of trends across multiple time points, which may inform adjustments in surgical techniques, equipment calibration, or patient selection criteria.

The software includes scattergrams comparing attempted vs achieved corrections, which can be used to refine surgical nomograms. These analyses allow surgeons to adjust surgical parameters based on observed outcomes, potentially improving the predictability of procedures.

Some clinics have incorporated mEYEstro-
generated outcome data into patient consultations, providing prospective patients with evidence-based information regarding expected surgical results.

Adoption and validation

Since its public release in 2023, the application has been accessed in over 25 countries, with more than 500 downloads. A validation study has been published in BMC Ophthalmology.³ The software builds on the developers’ prior work, including the AstigMATIC tool for standardized astigmatism vector analysis.⁴

Data security and privacy excellence

The software operates entirely on local computers without transmitting data to external servers or cloud services. The software does not require patient identifiers, ensuring compliance with data privacy standards and institutional policies.

Future developments

Planned updates include analyses for corneal cross-linking procedures, advanced nomogram features, and direct LogMAR data entry. A web-based version under development aims to provide device-independent access while maintaining local data processing. Additionally, a new tool, AstigMETRICS, will enable automated standardized vector analysis.

The mEYEstro software is freely available at www.refractivesurgery.com, with tutorials and support provided by the development team.

The mEYEstro software was developed by the authors, who are from McGill University’s Refractive Surgery Research Unit and LASIK MD/Vision Group.

The authors report no relevant financial disclosures.

References

1. Waring GO 3rd. Standard graphs for reporting refractive surgery. J Refract Surg. 2000;16(4):459-466.

2. Reinstein DZ, Waring GO III. Graphic reporting of outcomes of refractive surgery. J Refract Surg. 2009;25(11):975-978. doi:10.3928/1081597X-20091016-01

3. Gauvin M, Wallerstein A. mEYEstro software: an automatic tool for standardized refractive surgery outcomes reporting. BMC Ophthalmol. 2023;23(1):171. doi:10.1186/s12886-023-02904-6

4. Gauvin M, Wallerstein A. AstigMATIC: an automatic tool for standard astigmatism vector analysis. BMC Ophthalmol. 2018;18(1):255. doi:10.1186/s12886-018-0920-1