You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


![Javed Hussain Farooqui](jceh_32_105_S5_f01){#F1}

![Manisha Acharya](jceh_32_105_S5_f02){#F2}

![Mitali Kekan](jceh_32_105_S5_f03){#F3}

**We describe various surgical options for correction of myopia, the advantages and disadvantages of the procedures, current practices and emerging trends.**

![Surgeon performing LASIK surgery.](jceh_32_105_S5_f04){#F4}

Over the last few decades, refractive surgery for treatment of myopia has gained popularity as both a cosmetic procedure to avoid spectacles and as a means of complying with occupational vision standards. Refractive surgery procedures include:

-   Incisional refractive surgery

-   Excimer laser refractive surgery and

-   Intraocular surgery

Incisional refractive surgery {#s1}
=============================

The first report of using an incision to alter the shape of the human cornea was in the 19^th^ century, when Schiotz[@B1] used a limbal relaxing incision in a patient who underwent cataract surgery. In the 1980s Radial Keratotomy (RK) was used to treat thousands of patients with myopia with good predictability; however complications including infection, weakening of the cornea and night vision problems has made RK a more or less obsolete procedure for myopia management.

Excimer laser refractive surgery {#s2}
================================

-   Photorefractive keratectomy (PRK)

-   Laser subepithelial keratectomy (LASEK) and

-   Epithelial laser in situ keratomileusis (epi-LASIK, referred to as LASIK)

In PRK, the epithelium is removed either mechanically by scraping it with a blade or chemically by using a diluted solution of ethanol. In the latter approach the epithelial sheet is not repositioned after laser ablation.

In LASEK the epithelial flap is repositioned gently over the ablated tissue.

![Pentacam image of right and left eye, performed in the pre-operative workup period](jceh_32_105_S5_f05){#F5}

Comparative studies of surface ablation techniques (PRK versus LASEK) have shown similar refractive outcomes. These procedures work best for myopia up to 6.0 D (dioptres). Laser surface ablation is a better option than LASIK in patients with epithelial irregularities, dry eye syndrome, thin corneas, possible risk of post LASIK flap dislocation and possible risk of keratectasia.

LASIK is currently the most popular surgical option for myopia correction. It is superior to PRK in terms of patient comfort, visual stabilisations and stromal haze formation. It was first popularised by Pallikaris[@B2] and Buratto[@B3] as a technique of laser ablation of the corneal stroma, which involved the creation of a flap of anterior stroma including Bowman\'s and epithelium with the aid of a microkeratome. It can be used to treat up to 15.0 D of myopia, however due to risk of long-term ectasia, the recommendation has been revised to a maximum of minus 10.0 D ([Figure 1](#F4){ref-type="fig"}).

As with any other surgery, LASIK also has its own share of complications; these include free flaps, buttonhole flaps, irregular flaps and post LASIK traumatic flap displacement; epithelial ingrowth and dry eye syndrome also need to be kept in mind.

![Refractive lens exchange (RLE)](jceh_32_105_S5_f06){#F6}

![Implantation of a Phakic Intraocular Lens (pIOL)](jceh_32_105_S5_f07){#F7}

Recently, Wavefront-guided LASIK is being used to preserve the asphericity of the cornea, thus inducing less spherical aberration compared with standard LASIK ([Figure 2A](#F5){ref-type="fig"} and [B](#F5){ref-type="fig"}).

Intraocular surgery {#s3}
===================

For very high degrees of myopia (more than minus 10.0 D), LASIK is unpredictable and runs a risk of regression and ectasia. Refractive lens exchange (RLE), also known as clear lens extraction, was first described by Fukala in 1890, as one of the options to treat high myopia ([Figure 3](#F6){ref-type="fig"}).[@B4] The availability of a wide range of lens powers both for sphere and cylinder have made this approach more attractive when LASIK is contraindicated. This procedure is best suited for treating high myopia up to myopia −23 D, or in other myopes where optical correction or refractive surgery is contraindicated. Even though good refractive outcomes are reported, high myopes run a risk of retinal detachment after surgery, a complication that the patients should be counseled about. Implantation of a pIOL can also be considered ([Figure 4](#F7){ref-type="fig"}).

Recent advancements {#s4}
===================

These days, Femtosecond lasers[@B5] (IntraLase, Irvine, California, USA) have been reported to create more accurate and thinner flaps resulting in more predictable results. The flap dimension can be adjusted based on the needs of the patient and the type of excimer laser used. This also aids in faster recovery, and reduces the risk of further corneal problems.

The most recent addition to this list is that of Small incision lenticule extraction (ReLEx® SMILE) which is a minimally invasive procedure, and combines the advantage of both PRK and LASIK that is flapless and fast recovery.[@B6] During this procedure, an intrastromal lenticule is created, and is removed from a small tunnel incision. Since 2011, when the procedure started in Europe, China and India, it has proved to be ideal.

Surgical options for refractive errors have come a long way since 1990. In a field like ophthalmology, which is dependent on technology, we can only expect that treatment options will become more sophisticated and patient-friendly in the coming years.