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Special challenges are presented by the replacement or repair of highly specialized but scarce tissue within the constraints of transparency, tissue shape and alignment, tissue borders and pressure maintenance. Many, mostly destructive, surgical procedures were developed prior to an understanding of underlying pathophysiology. For a number of conditions, both reconstructive and destructive procedures co\u2010exist, yet there are few guidelines as to the better approach. Because the consequences of these procedures may take many years to surface (consistent with a stem cell role in long\u2010term tissue maintenance), guidance may be provided by the elucidation of underlying principles from these approaches. Illustrative examples from clinical, basic research and biotechnology, particularly relating to pterygium, ocular surface squamous neoplasia, dry\u2010eye syndrome, corneal rehabilitation and replacement, cataract surgery, strabismus surgery and bionic eye research, are described. An unexpected consequence of bionic device development has been an appreciation of the sophistication of tissues being replaced, given the limitations of available biomaterials. Examples of how this has provided insights into ocular disease will be illustrated. Stem cell and biomaterial technologies are starting to impact at a time when cost\u2010effectiveness is under scrutiny. Both efficacy and cost will need to be considered as these interventions are introduced. It appears that the paradigm shift rate is accelerating and there is evidence of this in ophthalmology. Lessons learned from the areas of destructive versus reconstructive surgery and the limitations of development of bionic replacements will be used to illustrate how new procedures and technologies can be developed.<\/jats:p>","DOI":"10.1111\/ceo.13023","type":"journal-article","created":{"date-parts":[[2017,7,17]],"date-time":"2017-07-17T22:06:37Z","timestamp":1500329197000},"page":"280-297","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Paradigm shifts, peregrinations and pixies in ophthalmology"],"prefix":"10.1111","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3061-2011","authenticated-orcid":false,"given":"Minas T","family":"Coroneo","sequence":"first","affiliation":[{"name":"Department of Ophthalmology University of New South Wales at Prince of Wales Hospital  Sydney Australia"},{"name":"Ophthalmic Surgeons  Sydney Australia"},{"name":"East Sydney Private Hospital  Sydney Australia"},{"name":"Look for Life Foundation  Sydney Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2017,8,25]]},"reference":[{"volume-title":"The Chase: An Autobiography","year":"1986","author":"Mann I","key":"e_1_2_10_2_1"},{"volume-title":"Ida and the Eye: A Woman in British Ophthalmology","year":"1996","author":"Buckley EI","key":"e_1_2_10_3_1"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1442-9071.1986.tb00019.x"},{"volume-title":"The Development of the Human Eye","year":"1964","author":"Mann I","key":"e_1_2_10_5_1"},{"volume-title":"Developmental Abnormalities of the Eye","year":"1957","author":"Mann I","key":"e_1_2_10_6_1"},{"key":"e_1_2_10_7_1","article-title":"An experimental and clinical study of the reaction of the anterior segment of the eye to chemical injury, with special reference to chemical warfare agents","volume":"1","author":"Mann I","year":"1948","journal-title":"British Journal of Ophthalmology"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1442-9071.1989.tb00494.x"},{"key":"e_1_2_10_9_1","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9394(46)92159-9"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.1136\/bjo.29.7.333"},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.1136\/bjo.30.1.8"},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.1136\/bjo.30.3.134"},{"key":"e_1_2_10_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9394(47)91183-5"},{"key":"e_1_2_10_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9394(46)91629-7"},{"key":"e_1_2_10_15_1","first-page":"109","article-title":"History of contact lenses","volume":"58","author":"Mann I","year":"1938","journal-title":"Trans Ophthalmol Soc UK"},{"key":"e_1_2_10_16_1","doi-asserted-by":"publisher","DOI":"10.1136\/bjo.31.9.565"},{"key":"e_1_2_10_17_1","first-page":"107","article-title":"Brief review of contact lens work","volume":"1","author":"Mann I","year":"1939","journal-title":"Trans Ophthalmol Soc Aust"},{"key":"e_1_2_10_18_1","first-page":"169","article-title":"Ophthalmology in the factory","volume":"2","author":"Mann I","year":"1945","journal-title":"Br J Ind Med"},{"key":"e_1_2_10_19_1","first-page":"174","article-title":"Some ophthalmic problems in war\u2010time","volume":"144","author":"Mann I","year":"1940","journal-title":"Practitioner"},{"key":"e_1_2_10_20_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1445-2197.1951.tb03770.x"},{"volume-title":"Culture, Race Climate and Eye Disease. 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