Thursday, February 10, 1994

THERE IS NO ERASER AT THE END OF A SCALPEL. Radial keratotomy, the unkindest cut


A few years ago I started collecting anecdotes about radial keratotomy, an eye surgery that promises nearsighted people a life without glasses. Then I realized that radial keratotomy is no joke.

Something is wrong!

Radial keratotomy, in my opinion, is an unnecessary procedure that is being driven by newspaper, magazine and television advertising, and that too often leads to sad complications.

I am an optometrist, not an eye surgeon. That means I often see patients in my practice after they have had this surgery. Several have had less-than-desirable outcomes; a few have been virtual disasters.

And I am not alone. A California jury recently awarded a $5,414,075 verdict in a malpractice case against an opthalmologist after a failed radial keratotomy. The high numbers of such poor outcomes and mixed results led Consumers Union, publishers of Consumer Reports, to write in August, "Our medical consultants believe that the benefits of the operation are not worth the risks. Evidence suggests that very few eye doctors have undergone the operation themselves. The main force driving the boom seems to be money."

Radial keratotomy uses tiny incisions to flatten the cornea and change the way it focuses light. There is a tremendous push to have this surgery accepted as a "cure" for nearsightedness. The truth is that low to moderate nearsightedness is not a disease and certainly doesn't require surgical interference. Being nearsighted is common in a significant portion of the world population, and affords many advantages compared to being farsighted.

The surgery was first attempted in Norway in 1885. Disasters there were followed by more recent problems in Japan and Russia. The original surgery, consisting of 32 corneal cuts, has periodically been reduced to 16, eight and now four. Some advocate a further reduction to three.

Even the surgeons themselves express their doubts -- in private. I edited the following from the American Academy of Ophthalmology publication, "Ophthalmology July 1993":

"Undercorrection is the initial goal. The outcome cannot be precisely predicted for any individual eye. Repeat operations called `enhancement' procedures, are less standardized than the initial surgery, and are even less predictable. Radial keratotomy is neither reversible nor easily modified. It is neither predictable nor free of complications. Statistics, facts and documentation about procedures to alleviate astigmatism are inadequate, at best."

Private insurance plans rarely cover radial keratotomy. Medicare and other government plans do not cover it, either.

Radial keratotomy is a permanent disqualifier for enlistment in all branches of the armed forces.

The truth is that all surgery presents risk, and radial keratotomy is no exception.

Potential complications are many. Radial keratotomy patients usually require bifocals or reading glasses at an earlier age than other people. This applies to everyone no matter how old they were at the time of surgery. Thirty-six percent of the patients need corrective lenses five years after surgery.

Once cut, the cornea is permanently weakened, which places the eye at increased risk from future trauma. A few patients have had subsequent corneal ruptures (but this can also occur in unoperated patients.)

Later in life, many people require eye surgery for conditions such as cataracts. The weakened cornea may make such surgery more difficult and recuperation more complex. There is also a permanent loss of corneal sensitivity.

Many patients remain somewhat nearsighted after the procedure; the amount of correction cannot he predicted accurately for any individual in advance. There is no unanimity among surgeons regarding the most effective technique.

In short, the potential to render good vision must be weighed against known risks.

Prospective patients should be alert to these facts:

Patients are not always properly informed about risks.

There is no eraser at the end of a scalpel.

There is a difference between signing a consent form, and giving proper informed consent.

Some hospitals discourage radial keratotomy on the premises to avoid possible malpractice claims.

Here's another Catch 22 regarding this procedure. Radial keratotomy can cause irregular astigmatism; contact lenses are the best way to correct irregular astigmatism; but radial keratotomy makes contact lens fitting more difficult and complex.

Successful contact lens fitting is now so simple there is no reason to subject anyone to surgery. Most optometrists and ophthalmologists can guarantee contact lens success. Unfortunately, the same is not true for radial keratotomy.

The public is entitled to true information and the chance to evaluate facts.

[Dr. Joseph H. Smith (deceased) was an optometrist in private practice in Forty Fort.]

Original article posted at LINK

Disclaimer: The information contained on this web site is presented for the purpose of warning people about refractive surgery complications prior to surgery. Patients experiencing problems should seek the advice of a physician.