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Refractive surgery: Not just for myopia anymore
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Almost 8 years ago we had the distinct privilege of being among the first eye care providers in the United States to offer photorefractive keratectomy (PRK). I recall being in utter awe of the excimer laser — its ability to sculpt the human cornea to a micron level of accuracy without collateral tissue damage and a resultant optically smooth surface.
I also recall being dumbfounded by the technology’s limitations: the finicky nature of the laser, extreme patient discomfort postoperatively, prolonged healing period and the limited range of correction. Then, we were only able to correct simple myopia up to 6 D. No high myopia. No astigmatism. No hyperopia. At times, we wondered whether the procedure was worth it.
Improved healing, equipment
Indeed, much has changed since the early days. We’ve found that therapeutic agents and bandage contact lenses are invaluable adjuncts in manipulating wound healing, thus affording patients less pain and inflammation. We’ve also learned the importance of surgical technique, as evidenced by the rapid visual recovery afforded by transepithelial PRK and laser in situ keratomileusis (LASIK).
And last, but not least, we’ve learned the value of engineering a better laser. Undoubtedly, today’s impressive outcomes are influenced by purer lasers, better delivery systems (multi-beams, flying spots, scanning slits) and increasingly refined ablation algorithms.
Improved results
The results of these efforts are equally impressive. Postoperative uncorrected visual acuity of 20/25 to 20/20 is more the norm than the exception. The number of satisfied PRK and LASIK patients in the United States is rapidly approaching 1 million. And the Food and Drug Administration, cautiously optimistic over the excimer’s safety record, has seen fit to expand the allowable prescription range. In fact, as we enter 1999, laser refractive surgery can be prescribed for myopia up to 12 D, for astigmatism up to 4 D and for hyperopia up to 6 D.
As if this is not enough, the imminent arrival of Intrastromal Corneal Ring Segments (Keravision, Fremont, Calif.) and holmium laser thermokeratoplasty, as well as the prospect of phakic intraocular lenses, provides refractive surgeons with even greater choice.
Offer guidance
Interestingly enough, all these choices can place the primary care optometrist in either a favorable or precarious situation. Favorable in that we can finally consider refractive surgery a viable "full spectrum" option, assuming a rightful place among spectacles and contact lenses. Good news for our patients who are contact lens intolerant and for whom eyeglasses are functionally unacceptable.
On the other hand, these developments can be equally precarious. Precarious in that we must now — more than ever before — seriously entertain patient inquiries regarding refractive surgery. With so many prescription options, one can no longer dismiss refractive surgery as a specialty to be enjoyed by a select few. Indeed, we must be competent in every facet of refractive surgery.
So, what do you tell the 8-D myope or the 2-D astigmat or the 3-D hyperope this time around? My guess is that these folks have been loyal to your practice, value your opinion and are patiently awaiting your approval. At the very least, we should provide an honest and accurate assessment of their candidacy. More appropriately, they deserve your knowledge, compassion and guidance.
Best wishes for a happy, healthy and prosperous new year.