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Apply lessons of the LASIK experience to refractive lens exchange
Surgeons should take it slow when it comes to this new lens-based refractive technique.
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This month we are going to take a short detour from our discussion of specific techniques used in refractive lens exchange. I would like to bring out an issue that needs to be addressed as this procedure takes center stage. Let us call it the bandwagon effect or “the next new thing” problem. After rereading each of my past columns on refractive lens exchange, I noted a clear sense of concern in comments such as these:
“I am one who feels strongly that the transition from cataract surgery to refractive lens exchange ought not be taken for granted.”
“The techniques are proven and ready. As surgeons are we ready?”
“Performing cataract surgery without the cataract suddenly shifts the outcome equation to results that consistently must be very near perfect. In order to cross the 20/20 threshold responsibly, each surgeon must ask, ‘Have I prepared enough to be sure that I can deliver results at this level on a consistent basis?’”
What concern lies beneath statements like these? Why am I suddenly the sober cautionary voice of restraint? After all, my revolutionary credentials are intact. I was on the barricades teaching phaco and IOL-related innovations throughout the ’80s and ’90s. I have long been on record saying that refractive lens exchange is a procedure whose time has come, predicting that it will play a central role in the future of refractive surgery. Now that the tipping point has arrived and more and more surgeons are reaching the same realization, why am I suddenly feeling uneasy?
I think the answer is that I am concerned for what might happen to refractive lens exchange if it becomes the next new thing. I see increasing signs of hyperbole in such projections as the entire baby boom generation lining up to have their presbyopia corrected at $3,000 per eye just as soon as one of the accommodating IOLs becomes available. If experience with LASIK has taught us anything, it should be that hype is not in the long-term interest of our profession.
Jumping on the bandwagon
Refractive lens exchange, increasingly seen as the fastest growing refractive surgery technique, is currently a white-hot topic. After steadily working with this approach in my cataract patients since 1986, the suddenness with which this procedure has become a front-page feature has begun to make me uneasy.
It reminds me of the first years of PRK and then LASIK, which was almost immediately proclaimed the treatment of choice for all refractive error from +8 D to –20 D. It never happened, of course. As the limitations of LASIK have become increasingly difficult to ignore, the recommended treatment range shrunk steadily to what is now a range somewhere around plano to –8 D. This is close to LASIK’s starting point when it was introduced on the heels of radial keratotomy.
No one would argue that LASIK is not a major advance over RK. Significant progress was made, but in getting there, we got it backward. Instead of a measured, step-wise advance from —7 D (where RK had brought us), we joined in a collective leap of faith to –20 D and have spent a good part of the past decade backpedaling. How did we manage to get this one so wrong? I think it happened in part because LASIK was arguably our first bandwagon phenomenon — jump on now or risk being left behind. The seeds of the LASIK letdown were sewn from the start when LASIK was snagged by the next new thing phenomenon. The rest is history — a history that we must not repeat and with lessons that we must be sure to learn.
Too far, too fast
This bandwagon effect was enhanced by several factors. At least part of its origin can be found in the phaco and IOL revolution. We are all aware that this first technology-driven revolution led to a golden age of unprecedented progress in cataract and refractive surgery. Ophthalmology can be justifiably proud of the truly remarkable accomplishment that is cataract surgery today.
Revolution, however, is almost always a two-edged sword, and history repeatedly tells us that revolutions can end up devouring themselves if they are unchecked and allowed to carry too far. This phenomenon — call it overshoot — typically occurs because of the inevitable transfer of power at the center of every successful revolution. The principal players in the old power structure either capitulate and join the revolt, or they are marginalized. Either way, the old guard’s conservative, usually self-interested voice of restraint and moderation is silenced. Like a coiled spring suddenly released, the momentum of unchecked forces for change can easily carry too far, jeopardizing the original gains of the revolution.
This historical template aligns perfectly with the phaco revolution. After a struggle (Ridley, Kelman and many early pioneers have all described this), the old guard of traditional ophthalmology finally capitulated and joined the ranks of phaco and IOL surgeons. They had seen their influence eclipsed. They had lost the spotlight to a ragtag army of private practitioners who took control of the podium, describing small-incision cataract surgery performed in unprecedented volumes with remarkable efficiency and vastly superior results.
The old guard learned all too well the futility of resisting the power of an idea whose time had come. It is hardly surprising that they were determined not to be on the wrong side of the next revolutionary concept when it first came into view. The stage was set with the bandwagon at the ready. Ophthalmology (surgeons and industry) scanned the technology-laden horizon for the next new thing. It was PRK and then LASIK, and the scramble to get on board erupted with a vengeance.
Progress with precautions
At the core of the next new thing problem is that it does not encourage the slow, steady and thoroughly verified progress that patients assume has already occurred by the time they encounter a new technique. The threshold for accepting and utilizing new technology tends to fall beneath the level required by the more sober long-term demands of our profession. In this overheated environment with a sense of urgency not to miss the boat, our collective point of persuasion can get reset too low, blurring the vital distinction between science and salesmanship.
We practitioners can too easily forget the one thing we must never forget: The industry representatives are the salesmen, and we are the scientists. Hype is often a completely appropriate tool for the sales force with specific short-term financial goals or a strategy for gaining market share. For us physicians, it can only be counterproductive. There is a line at which the interests of the industry and those of our profession, which are usually well aligned, can act at cross-purposes. One of our primary responsibilities as medical professionals is to carefully monitor that line.
Lessons from haiku
The oath we took separates us and defines us as the most esteemed of professions. We have much to lose when we fail to fully honor that oath.
This is a wonderful ideal that unfortunately may be at risk of becoming a cliché. Let me conclude with an appeal to resharpen our focus on that sentiment, for in my opinion it lies at the heart of this issue.
There are two Japanese art forms that I have particularly enjoyed since first visiting Japan to teach phaco with Dick Kratz and Dave Dillman in 1988. The first is a form of calligraphy that allows the artist only a single brush stroke. The other is a form of three-line poetry known as haiku in which the poet must follow this highly restrictive format: The first line has five syllables, the second line has seven syllables, and the third and final line has five syllables.
Artists who work in these media are set apart and defined by the restrictions to which they adhere. Their task is more difficult and the product of their efforts is therefore more highly esteemed. Should they fail to adhere to the restrictions then, de facto, they are no longer a member of that artistic group.
In like manner, we physicians have agreed to be restricted by the dictum of the Hippocratic oath, “First, Do No Harm.” Just as with this group of artists, we physicians have accepted the challenge of greater restrictions on our efforts to advance progress with new technology and clinical innovation. By agreeing to do no harm, we accept that we must find ways to accomplish progress without a significant overshoot, without harm. Ophthalmology is not permitted the cyclical approach to progress: three steps forward followed by two steps back. Note that this core principle does not preclude progress. It does, however, require that our progress unfold in smaller, more measured and well-verified steps.
When we succeed, we fulfill our contract to the patient and continue to earn the trust and higher esteem in which physicians have long been held. However, if we sidestep the more measured approach to progress, if we overreach and create a significant innovation overshoot, then we too are de facto, no longer members of our more select professional group. We risk losing that trust and esteem and will eventually be seen as little different from a sales force, which as we know has a different dictum: caveat emptor.
I am not at all anti-industry. I just want to shine a bright light on this crucial fact: Physicians and sales people are defined by different roles and different rules. Only we have the responsibility that accompanies patients’ trust because only we have taken the oath to protect them from harm, even as we advance progress.
So as we move now in earnest toward refractive lens exchange, I would like to appeal for a collective downshift to a lower gear. We may move slower, but as we have seen here, for us physicians that is exactly as it should be and as it must be if we are to continue to earn the trust and esteem that sets us apart.