Japan resists LASIK due to cultural, economic factors

A combination of cultural convention and a weak economy has left Japan reluctant to embrace LASIK as openly as countries in the Western world, according to some Japanese surgeons.

Overall acceptance of refractive surgery in Japan has been less than favorable. This cultural mindset persists in the nation of 125 million despite the fact that it has the world’s second largest population of myopes after North America.

“The rates of LASIK surgeries in Japan pale in comparison to other industrialized countries. The rise in the actual number of cases every year is extremely low compared to the United States or Europe,” said Hiroko Bissen-Miyajima, MD, of the Tokyo Dental College, Suidobashi Hospital.

An estimated 40,000 LASIK procedures were performed in Japan in 2001. The forecast for 2002 is in excess of 50,000 surgeries.

“This growth rate is not that high when you consider the prevalence of myopes in Japan,” Dr. Bissen-Miyajima added.

More than 11 million people in Japan trust the correction of their refractive errors to contact lenses, yet these same patients are highly skeptical when it comes to undergoing LASIK.

“In other parts of the world, LASIK has been well recognized as an extremely effective procedure,” said Yuichi Ohashi, MD, of Ehime University in Shizukawa. “In Japan, people remain careful and cautious with their methods and their money.”

Part of the public’s reluctance may be because the LASIK procedure itself is not yet approved in Japan. Kensaku Miyake, MD, of the Miyake Eye Clinic in Nagoya, noted that the excimer laser has been approved to perform photorefractive and phototherapeutic keratectomy, but LASIK approval may still be a year away. At this point, surgeons who perform LASIK do so “by the physician’s personal right and decision” regarding the practice of medicine, Dr. Miyake said.

Economic downturn

According to some surgeons, the recent economic downturn in Japan has also slowed the demand for LASIK.

“Once the economy begins to prosper, we will see an increase of LASIK,” Hideharu Fukasaku, MD, of the Fukasaku Eye Center in Yokohama, told Ocular Surgery News.

“Currently we are in a so-called deflation spiral. Japan has incurred a huge amount of financial debt,” said Okihiro Nishi, MD, of the Nishi Eye Hospital in Osaka.

According to data from the Japanese Ministry of Economy, Trade and Industry, the gross domestic product for this year reached 131 billion yen.

“Our debt is beyond this figure by 150%,” Dr. Nishi estimated.

Because of the heavy national debt, the government has cut down on spending, affecting pensions, production, imports, exports and employment.

“Luckily, the health care policy is substantial and has not been directly hit by the changes in government spending,” said Tomoaki Nakamura, MD, of the Refractive Eye Clinic in Nagoya.

But unfortunately, he said, in Japan as in most countries, refractive surgery such as LASIK is not covered by health care.

“LASIK is not insured and must be performed at the patient’s expense. With an uncertain economic outlook, Japanese people are more likely to spend less money, especially on new procedures they might be wary of,” he added.

Reluctant to risk money

Dr. Nishi agreed. “People are vaguely afraid of the future. They do not think the government will overcome the problem, so they are saving every penny.”

The typical charge for LASIK is 400,000 yen, or US$3,200, for both eyes.

“People feel that this price is too expensive — yet they will travel overseas and spend several hundred thousand yen to bring gifts back home, or even fix a tooth,” Dr. Bissen-Miyajima said.

According to Dr. Nakamura, this may be because the population as a whole has not been educated about LASIK.

“We have to teach people about the values of laser surgery, about the safety of the device and the technology, so that more patients will consider it as an option,” he said.

Unfortunately, this is a difficult task in a country where advertisements for surgical procedures are outlawed.

“People must learn about LASIK through word of mouth,” Dr. Bissen-Miyajima said. “But in our culture, people are not inclined to boast about their LASIK procedures or recommend others to do so, as in Western countries. This comes from the national character of the Japanese people.”

Cultural mindset

The Japanese reluctance to embrace LASIK shows that cultural beliefs are hard to overcome in a society in which caution and prudence are highly valued.

“In Japan, many people are opposed to tampering with the body that their parents bestowed on them,” Dr. Bissen-Miyajima said. The general population feels negatively toward the “so-called Hollywood smile of beautifully aligned white teeth and face-lifts,” she said.

Dr. Ohashi agreed: “The Japanese people, mostly the elderly population, are reluctant to change their way of life or become affected by something ‘unnatural’ or unfamiliar.”

Dr. Fukasaku agreed that medicine is conservative in Japan.

“People are prone to be too much concerned with the safety of the procedure rather than its effectiveness,” he said.

Doctors and patients are slow to adapt, especially to procedures introduced from abroad, he added.

“For example, phacoemulsification has become the standard for cataract surgery only in the last few years. Until recently, training programs taught mainly extracapsular cataract extraction,” he said.

Several surgeons noted that there has been a historical resistance to refractive surgery in Japan stemming from an unsuccessful early attempt at radial keratotomy in the 1950s. Some patients were left blind or with impaired vision in later years from these surgeries.

“These previous events made people conscious of the dangers of new procedures, and this has also made them reluctant to take chances again,” Dr. Fukasaku said.

“People have been careful, but maybe too careful,” Dr. Bissen-Miyajima added.

Procedures to increase

“On the surface, you may see the tendency for the Japanese to be hesitant about trying new things like plastic surgery, anti-aging drugs and hormone therapies,” Dr. Nishi said. “But in other ways the Japanese are bold to try new things like mobile phones, computers and e-mail.”

Among the younger generation there is a tendency to move away from conventions and to be more open to change, taking a more forward-looking, youthful view, Dr. Fukasaku said.

As a result, Dr. Bissen-Miyajima believes, the number of LASIK surgeries will increase steadily in the future.

“The number of LASIK cases will increase as the public becomes more educated. However, there will not be the LASIK boom that was seen in the United States and some European countries,” she said.

“We do not foresee the explosive growth in Japan as has been the seen in America, but many of us surgeons believe there will be a steady increase in the number of cases performed yearly by 10% to 20%,” Dr. Ohashi said.

This change will happen slowly, as the character of the Japanese culture turns from reluctance to understanding and acceptance, Dr. Fukasaku said.

“There is a lot of forethought that goes on in the minds of the Japanese people before making a major change, but when that change occurs, it becomes a lasting change,” he said.

Dr. Nakamura agreed.

“If you look at the history of Japan, there is not one thing that was good for Japanese culture that did not spread. I am confident that LASIK is necessary for the Japanese, and once recognized, it will persevere,” he said.

For Your Information

• Hiroko Bissen-Miyajima, MD, is director and associate professor in the department of ophthalmology, Tokyo Dental College, Suidobashi Hospital. She can be reached at 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061, Japan; +(81) 3-3262-3421; fax: +(81) 3-5275-1912; e-mail: hirokobm@aol.com.
• Yuichi Ohashi, MD, can be reached at the department of ophthalmology, Ehime University, 791-0295 Ehime Onsen-gun Shigenobu-cho Shizukawa, Japan; +(81) 89-960-5361; fax: +(81) 89-960-5364; e-mail: ohashi@m.ehime-u.ac.jp.
• Hideharu Fukasaku, MD, can be reached at the Yokohama S.T. Building 1-11-15 Kitasaiwai, Nishi-ku Yokohama 220-0004, Japan; +(81) 45-325-0055; fax: +(81) 45-325-0054; e-mail: h-f-eye@po.iijnet.or.jp.
• Okihiro Nishi, MD, can be reached at 4-14-26, Nakamichi, Hagashinari-ku, Osaka City, Osaka, 537-0025 Japan; +(81) 6-6981-1132; fax: +(81) 6-6981-5630; e-mail: okihiro@nishi-ganka.or.jp.
• Tomoaki Nakamura, MD, can be reached at the Refractive Eye Clinic, 3F 25-1 Namiyose-cho Atsuta-ku Nagoya 456-0002 Japan; +(81) 52-872-0490; fax: +(81) 52-872-0491; e-mail: rec@bc5.so-net.ne.jp.