he term “refractive eye surgery” may be unfamiliar to some of you, but you'll be hearing it more and more in the future. It's a new kind of eye surgery that has given relief and freedom to thousands of myopia, hyperopia, and astigmatism victims; rendering eyeglasses obsolete in many cases. However, you may not need or want this surgery at all if glasses and or contact lenses are fulfilling your needs.

The following page is excerpted from the introduction to my textbook: Refractive Eye Surgery —

“It has long been an axiom of mine that the little things are infinitely the most important”.

Sir Arthur Conan Doyle

This work is about a new type of eye surgery — refractive eye surgery — designed primarily to remove the visual handicap of ametropia, chiefly myopia. To be sure, hyperopia and astigmatism take their toll in diminished vision. However, it is myopia that is, by far, the greatest scourge and toward which the majority of our energies have been focused. This treatise is designed to prepare the beginning refractive surgeon for this adventure by providing a firm grounding in basic fundamentals and techniques and to assist the general ophthalmologist in understanding these methodologies. The experienced refractive surgeon will find much that is of value within these pages as well. All aspects of the problem including hyperopia and astigmatism are included and practical tips and methods of surgical treatment are detailed.

This work is not, however, encyclopedic nor does it attempt to be. The author has found through experience that eclecticism has no place in refractive surgery. If ever the old saw — “Too many cooks spoil the broth” — were true it is surely here. All too often instruction courses are given whose many guest speakers present so many differing points of view, undoubtedly in the spirit of non-bias, that the erstwhile refractive surgeon goes away more confused and bewildered than before. It is just not possible, however, to “mix-and-match” with this surgery. The beginning refractive surgeon cannot be eclectic in his/her surgical approach and expect it to be effective. Nor are they in any position to decide what to choose and what to discard. They must first adopt the surgical method of a particular, experienced, surgeon and follow his/her method assiduously until such time that the they have become absolutely confident in their understanding of all the nuances of the surgery. Then and only then will it be possible for the surgeon to “vary the theme” and strike off on his/her own. Thus this present work emerges as the point of view of one individual — with a little help from friends — admixed with a tincture of philosophy to give it some spice.

Refractive eye surgery is defined as that surgery upon the eye which acts to change the light bending characteristics of that eye. This definition could include such things as cataract surgery — with or without the implantation of an intraocular lens. This discussion will, however, confine itself to surgery performed upon the cornea, sclera, or lens of the eye specifically for modifying its refractive characteristics. Hence corneal transplants and cataract surgery are not refractive surgical procedures, whereas removal of a clear lens for the express purpose of reducing the patient's myopia is.

In 1708, Hermann Boerhaave, suggested that high myopia could perhaps be treated by couching the clear lens in such patients. Von Haller, in 1746, may well have tried it but it was not until 1894 that Fukala published his first reports on the technique of clear lens extraction for myopia. In 1869, Snellen, in an article published in the German literature — discussed the possibilities of correcting corneal astigmatism, possibly drawing on the attempts of Von Galezowski to achieve the same purpose through resection of a crescentic piece from the cornea. Bates , in 1894, described a surgical technique for such modification and reported a number of cases, as did Lans in 1898. Thus the search for effective surgical means to modify ametropia began.

The evolution of such surgical techniques resembles, in many ways, the development of manned flight. As experience and technical skills improve, early and more primitive efforts give way to more advanced ideas and methods. Sometimes, ideas that were previously discarded or not implemented because of technical deficiencies are revived at a later time when they are capable of being used or their worth fully recognized.

Parallel to these and other technological advances have come changes in the psycho-social makeup of human society. In the “early days”, the battle against disease was black and white. Disease was once thought of as God's punishment to the ungodly and meddling with its progress sinful. As medicine advanced, the subject of “preventative medicine” began to play a more important role. Today there is more emphasis on the quality of life and the human condition than ever before and procedures designed to modify human existence, such as genetic engineering, plastic reconstructive surgery, and refractive surgery of the eye are being employed.

Throughout such evolution, however, the innovator must battle not only those specific problems that accompany the treatment itself, but must also confront and surmount those generated by the actions and attitudes of his contemporaries and colleagues. Such circumstances are, of course, not new and given the nature of man — very likely to continue.

There are currently five methods of surgically modifying the corneal curvature presently in general usage. These are:

1. mechanical modulation of corneal shape — keratomileusis
2. relaxing incisions — radial keratotomy
3. corneal onlays — epikeratophakia
4. corneal inlays — keratophakia
5. tissue replacement — keratoplasty

Of these five, the latter — keratoplasty, does not always have as its primary goal (except in cases of keratoconus) the modification of the corneal curvature and so will be discussed only incidentally. Additionally, clear lens extraction or IOL implantation can be employed to reduce high myopia and scleral reinforcement can shorten axial length and prevent further elongation of the globe. Such approaches to the problem, once considered bizarre and risky, are now being more seriously entertained as primary or alternative treatment of ametropia.

To be successful as a refractive surgeon, the ophthalmologist must develop a special mind-set. He must come to terms with the fact that refractive surgery is truly micro-surgery and that microns count. He must not be swayed by the argument that because biological systems are variable in nature that precision is unnecessary in the performance of this surgery. It is vital that the surgeon make precise those things that he can control and minimize the imprecision of those things that he cannot. He must also avoid the tendency to “simplify” the surgical decision making process ad absurdum.

There is a strong tendency by the neophyte to take short cuts and because of inexperience to overlook data deemed insignificant. However, as in no other aspect of ophthalmology, the careful gathering and integration of numerous parameters to affect a desirable end result is paramount. As never before, the beginning surgeon cannot rely upon his or her “common sense” to guide him through his/her learning experience. He/she cannot “wing it”. He/she must instead rely upon the hard won experience of his brother/sister surgeons who have gone before. As John Dickinson said:

“Experience must be our only guide. Reason may mislead us.”

Because of this fact, this surgery finds no place for the instant expert and his incisional configuration of the month. Good ideas will still be good ideas six months or a year from now. Sudden flashes of inspiration are too often found to be mere glints of the egoists eye which pale when exposed to the harsh light of time and reality. Small changes in technique often made for no other reason than that “it seemed right” can produce a domino effect not apparent for some time, perhaps years.

Radial keratotomy is a case in point. This surgery is said to be simple and that it is not necessary to do “all those measurements.” If it were possible to perform this surgery optimally through the consideration of only a few parameters or by consultation of rigid tables — then those who have labored long and hard to bring this surgery about would be doing it the “simple” way.

Such “simplifications” have led, for example, to over-corrections and progression of effect after RK. It was such “innovation” that produced circular-radial keratotomy in some 30 patients with resultant increased myopia, and non- healing and marsupialization of the wounds. This was done by an “expert” some seven days after taking his first course in radial keratotomy. It was another "expert” who kept his patients on topical steroids four times daily for 6+ months to “enhance the effect” of his ineffective surgical technique and induced cataracts. It was another “expert” who over-extended his blade in the presence of a flat chamber and incised the anterior capsule of the lens. It was still another "expert” who neglected to cover his patient with antibiotics after a microperforation which eye then went on to develop endophthalmitis.

This surgery is simple to watch being done by an expert who often makes it look so easy. After all, how could it be hard to make a cut on the eye? It's done all of the time. But the incision made for a cataract extraction is not expected to produce a precisely modulated change of corneal curvature — it's expected only to provide access to the anterior chamber. This surgery is only simple to “screw up”. There are too many factors involved, all supported by clinical results over time, to take the casual approach. It is possible to guide an aircraft to a landing or simply to “arrive”. One can also “arrive” on the first floor by leaping from the tenth, but the results would not be as satisfactory as taking the elevator. Some surgeons find the elevator too slow for their tastes and insist upon “leaping” — taking the patient with them.

All of these surgeries continue to evoke controversy despite successful application of the basic principles and techniques. Some of the cautious statements that were made in the beginning were valid then but not today. Moreover, some problems previously trumpeted, have resulted from inappropriate application or execution of these procedures and are not inherent — as once believed.

These cases have served to emphasize a point often overlooked: this surgery is "microsurgery” in its strictest sense. It requires of the surgeon a particular “mind set”. He must convert from “macro” to “micro” thinking. He must think in terms of microns instead of millimeters. He must pay attention to pre-operative testing as never before. He must consider and weigh as significant, parameters which heretofore in his experience seemed “not to matter”. It should not be surprising that some surgeons fail in this conversion. A gifted cataract surgeon may not make a gifted micro-refractive surgeon. If it happens to you don't blame the surgery, some of us can't ride skate boards very well either. Kismet.

This is no place for the casual or occasional surgeon. This is no province for the surgical dilettante. None of these techniques are simple despite their appearance and some are on a par with open-heart surgery in their complexity. No general surgeon would dream of performing open-heart surgery, leaving that to specialists. So too refractive surgery. There are a myriad of small details that must be constantly considered and concentration on the case at hand is essential to success. Such necessity does not fit in well with the general practice of ophthalmology. The proper performance of this surgery is best left to specialists who have dedicated themselves to it and are prepared to continue to dedicate themselves to it. Teaching of these techniques should not be done as a matter of course in a residency program but afterwards in a program devoted to refractive surgery alone. This represents a shift in my previous position on this subject. However, continued misapplication of these techniques by general ophthalmic surgeons has made this shift in opinion necessary.

This is not a definitive text — no text on this subject could ever be — rather consider it a primer on refractive eye surgery. The type of surgery we are describing is undergoing an evolution of impressive dimension. Still the basics have not changed. The rationale behind each technique remain. It is hoped that the refractive surgeon, beginner and shellback, will find within these pages those tools necessary to take the next step whenever or where ever that might be. Thus the thrust of this text as a foundation, a sheet-anchor from whence one can cast off on the great adventure that is refractive surgery.

A list of references is available of further reading for those interested in pursuing these subjects.