Biosensor technology is an active field of research and development presenting rapid progress in recent decades, and the subfield of optical biosensors based on refractometric sensing schemes has developed dramatically during this time. This review focuses on advances in the refractometric sensing-based guided-wave optical biosensors particularly in the last two decades. It starts with a concise discussion on the underlying principles of label-free refractometric biosensor. Subsequently, advances in biosensor design, especially the transducer configuration and the integration of the sensing device are reviewed, highlighting the challenges and efforts dedicated to improving this technology. Various surface functionalization strategies designed to produce well-defined and reproducible surface properties are introduced for evaluation. Refractometric sensing scheme-based optical biosensors have found versatile applications varying from environmental monitoring and food safety to clinical diagnostics, together with advances in these applications and others are described. This paper concludes with a brief discussion on the outlook for integrating biosensors with emerging technologies.