The Eyes Have It The two ways of looking at radial keratotomy

August 24, 1993|By Stephanie Shapiro | Stephanie Shapiro,Staff Writer

Proponents of radial keratotomy call the brief surgical procedure a "5-minute miracle" that corrects myopia and sometimes even eliminates the need for glasses or contact lenses.

Skeptics say the irreversible procedure is unperfected and not worth the risk it poses to the vision of those with healthy, albeit nearsighted, eyes.

The operation, which is designed to reduce mild to moderate myopia, involves making four to 16 "pie-cut" incisions in the cornea, flattening it out and changing the way light rays focus on the retina. Ever since physicians in the United States began performing RK in 1978, it has been the subject of quiet but raging controversy over its long-term safety and effectiveness, as well as the ethical implications of performing what amounts to cosmetic surgery on the eye.

More recently, the controversy has widened in scope. Manufacturers of surgical equipment and ophthalmologists are tapping into the lucrative potential of RK, an elective procedure not covered by insurance, by appealing to the millions of prospective candidates in the United States who are nearsighted.

Aggressive mass-marketing campaigns have spread across the country. RK has been touted in People magazine, in direct mailings to homes and in radio and newspaper ads that range from tasteful to outright tacky. A recent issue of Optometric Management calls attention to RK advertising that "seems to be reaching a new level of cheesiness," including an offer for a "two-for-one" surgery package and a television commercial that shows a nearsighted man mistakenly entering a women's restroom.

Others who take a more restrained approach to promoting RK are careful to disassociate themselves from their less subtle counterparts, but nevertheless share the same profit motive.

Thanks in part to the advertising blitz, the number of RK surgeries performed annually in the United States has surged from 30,000 in 1988 to 250,000 last year, according to the American Association of Cataract and Refractive Surgery.

Though slow to mount the RK bandwagon, Maryland is catching up as the procedure, and a similar operation to correct astigmatism, becomes available at centers affiliated with hospitals and in private practices throughout the state.

But RK's growing popularity has not immunized the procedure from debate, and ophthalmologists remain divided on its merits.

RK is "probably one of most exciting and rewarding things I've ever done. It's like a miracle," says Dr. Geri L. Goodman, a Baltimore ophthalmologist and member of the Greater Baltimore Refractive Surgery Center. (Dr. Goodman had her left eye

corrected recently, opting for excimer laser surgery, an alternative to RK that uses a beam from a computerized laser machine to flatten the cornea. She chose laser surgery because the procedure also removed troubling scar tissue from her cornea, something RK cannot accomplish, she says. Dr. Goodman is undecided on which procedure to choose to correct her right eye.)

In contrast to Dr. Goodman's rave reviews, Dr. Walter J. Stark, a corneal surgeon at Johns Hopkins Hospital's Wilmer Eye Institute, says that any risk associated with RK, however minimal, is not worth taking.

"I'm a very conservative doctor. If you have normal eyes, then you probably shouldn't take the risk with any type of surgery, unless you are totally disabled with glasses and can't wear contact lenses," he says.

A major 1983 study of hundreds of patients found that RK reduced myopia but that its efficacy varied.

The study, the Prospective Evaluation of Radial Keratotomy, (PERK), funded by the National Eye Institute, (NEI), part of the National Institutes for Health, is the most comprehensive look at the long-term merits and safety of RK.

A five-year PERK follow-up of 757 cases shows that 19 percent of the eyes were undercorrected by RK. Another 17 percent were overcorrected, virtually guaranteeing a future need for glasses for farsightedness. As a result, most RK practitioners avoid overcorrection by deliberately undercorrecting a patient's vision. If necessary, they will also perform touch-up procedures to reach a patient's visual objectives.

In 22 percent of the eyes, the surgery had a progressive effect, shifting patients toward nearsightedness.

Serious complications, including infection and loss of visual acuity, were rare.

In all cases, experts say, RK weakens the cornea, leaving it vulnerable to corneal rupture should an RK patient be struck in the eye. Other complications that can ensue include problems with glare, fluctuating vision and light sensitivity. Doctors have reported cases of blindness and retinal detachment in RK cases.

A 10-year PERK update has been funded by NEI. In 1993, participating patients will undergo a follow-up examination, and findings will be published the following year.

Statistics, ophthalmologists say, do not tell the whole story. Patient satisfaction is also a critical measure of success.

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