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Public support of excimer surgery depends on us

Issue: January 1997

ByMichael D. DePaolis, OD, FAAO

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--- Michael D. DePaolis, OD

Where, oh where, have all the myopes gone?

This is one of the most commonly asked questions in refractive surgery circles today. And for good reason. After years of exhaustive clinical testing and intense regulatory scrutiny, excimer laser photorefractive keratectomy (PRK) arrived 15 months ago with much fanfare and lofty industry projections. Interestingly enough, the public's reception has been less than stellar. The question, of course, is why haven't more myopes undergone PRK in the past year? Personally, I think the excimer's modest first-year reception is attributable to five factors. Factors, I might add, that were not well anticipated.

1. Alternative surgical techniques. Like any technology, excimer PRK had its share of early enthusiastic candidates. Unfortunately, while this procedure experienced a lengthy regulatory gestational period, many of these potential patients grew impatient. A fortunate few enrolled in the Food and Drug Administration study, some went outside the United States for PRK and many opted for radial keratotomy (RK).
2. Prescription limitations. Although excimer PRK has been deemed safe and effective, its correction limitations are well recognized. Indeed, some of the most enthusiastic patients manifest refractive errors outside the FDA-approved range.
3. Patient apprehension. The FDA and the eye care community say excimer PRK is safe, but are patients convinced? Clearly, this isn't an easy decision for most patients. Despite excimer PRK's impressive track record, certain patients simply want the assurance of more long-term data before undergoing the procedure themselves.
4. Cost. While many patients are quite enthused by excimer PRK, they are often taken back by its cost. This is particularly true when they realize this procedure is not covered by their health care insurance.
5. Practitioner confusion. It is our responsibility to educate and inform, and a competent clinician should discuss every option with each patient. But with all of the options — astigmatic keratotomy, automated lamellar keratoplasty, laser in situ keratomileusis, photorefractive astigmatic keratectomy, PRK and RK — it is easy to see why certain patients leave their consultation more confused than they were before.

Of these factors, perhaps none is more detrimental than that of practitioner confusion. Indeed, the refractive surgery community itself may be a major impediment to excimer PRK's growth. We desperately need to arrive at some consensus regarding different refractive surgery procedure indications. Until we do, our patients — equally confused — will opt to "wait until it's perfected." And although it is prudent to defer surgery if in doubt, be careful not to mislead your patients with a false delusion of some future refractive surgery panacea.