Eyeworld

EW NEWS & OPINION 28 November 2016 Insights by J.C. Noreika, MD, MBA ophthalmology, the acronym LASIK was coined as another acronym, the RBRVS (Resource-Based Relative Value Scale), would change cataract surgery's economic destiny. In 1989, Irving Arons of Arthur D. Little published a white paper, "The Evolution and Prospects for Laser Refractive Keratoplasty." It estimated 2 million procedures would be performed per year "after about five years following FDA marketing approval." Instead, an estimated 600,000 patients have undergone LASIK annually in recent years. Year-in-year growth has been modest. Arons further wrote that 52% of surveyed ophthalmologists would charge between $1,000 and $1,500 per eye; 29% would charge more than $1,500. According to lasikmd.com, a "realistic" average price in 2016 for basic unilateral LASIK is $1,700. The most expensive variation is wavefront IntraLASIK at an average of $2,400 per eye. Even a visionary like Arons could not have foreseen the field's extraordinary evolution and impact. In refractive surgery, radial keratotomy was the Betamax to LASIK's VHS, yet it laid the foun- dation for obsolescence of specta- cles and contact lenses for tens of millions worldwide. Initial forecasts in the U.S. were overly optimistic, but LASIK contributed nearly $2 billion to ophthalmology's income statement in 2015. The growth of discretionary income of millennials is expected to drive future market expansion, as approximately 85 mil- lion Americans are between 25 and 44 years of age. Radial keratotomy taught many lessons. The most important? Never bet against ophthalmology's ingenuity. EW References 1. Schanzlin D. "What Did We Learn From Radial Keratotomy And The PERK Study?" Refractive Eyecare, May 2011. 2. Trokel SL, et al. Excimer laser radial keratot- omy. Ophthalmology. 1985;92:206–208. Editors' note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years. Contact information Noreika: JCNMD@aol.com America in 1978. Dr. Fyodorov him- self visited that year and performed the procedure at Detroit's Kresge Eye Institute. Revolutionary and highly contentious, RK, as it became known, engendered the National Eye Institute's Prospective Evalua- tion of Radial Keratotomy (PERK) study to test its efficacy and safety. Participant David Schanzlin, MD, wrote that "PERK would become the first controlled, multicenter clinical trial of a new surgical procedure in ophthalmology." 1 RK did not withstand the test of time. Incisional imprecision, postop- erative halos and glare, fluctuating vision, irregular astigmatism, and, especially, hyperopic creep were ob- served. Sensational exposés ensued; the operation was coined "slash for cash" and "the only surgical proce- dure with a fool at both ends of the scalpel." Proponents sought and pa- tients demanded safer, more stable and predictable techniques. Laser energy was found to alter and ablate tissue. Bell Laboratories demonstrated the Nd:YAG in 1964. Nullifying the problem of posterior capsular opacification following cata- ract surgery, it came into widespread ophthalmic use. Beginning in 1983, Stephen Trokel, MD, collaborated with scientists at IBM and published "Excimer laser radial keratotomy" in Ophthalmology 2 years later. 2 Ger- many's Theo Seiler, MD, used an exci- mer ("excited dimer") laser on blind human eyes in 1985. The confluence of advances in laser technology and keratomileusis pioneered years before by Jose Barraquer, MD, led Ioannis Pallikaris, MD, to aim an excimer laser at exposed corneal stroma in 1989. Expanding the capability of 1885, Hjalmar Schiotz documented the placement of limbal relaxing incisions that reduced 7 of 19.5 D of astigmatic error in a postoperative cataract surgery patient's eye. Another 50 years passed before interest in refractive surgery re- emerged. Ironically, the resurgence nearly resulted in its stillbirth. In 1939, eminent Japanese ophthal- mology professor Tsutomu Sato deduced from his knowledge of keratoconus that alterations in Descemet's membrane could change the shape and thus the refractive power of the cornea. In the 1950s, Sato incised both anterior and posterior corneal surfaces to afford correction of myopia. The vital function of the corneal endothelium was then unknown. From 1951 to 1959, surgery was performed on 681 patients; severe bullous keratopathy eventually developed in many, the exact number unknown. This un- toward development severely slowed the advancement and adoption of refractive surgery in Japan. In 1960, Dr. Svyatoslav Fyodorov attended the Japanese Ophthalmological Society Confer- ence, hearing of Sato's work. He and F.S. Yenaleyev applied radial inci- sions to the anterior corneal surface and found that disturbing the cru- cial endothelium was unnecessary. Varying the number of cuts and size of the optical zone, they could alter the cornea's refractive power and mitigate myopia. In 1976, science trumped the Cold War's geopoli- tics. Under Dr. Fyodorov's tutelage, Arizonan Dr. Leo Bores successfully performed radial keratotomy in Rus- sia. He became a leading advocate of the procedure, introducing it to Radial keratotomy exploded on the eye surgery scene in the 1980s, fomenting enthusiasm, scorn, and innovation A merican physicians rate among the most highly compensated profes- sionals in the world. For years, ophthalmologists dominated the top precincts of Medical Economic's annual survey of income, often ranking second only to cardiothoracic surgery. As reimbursement for services paid by Medicare declined, the queen of subspecialties has fallen on comparatively hard times. Since the mid-1980s, inflation-adjusted reimbursement for cataract surgery has fallen as precipitously as the cost of computer memory, laptops, and rustbelt real estate. Yet ophthalmol- ogy continues to outperform if not prosper. Had not corneal refractive surgery emerged, permutated and matured, eye surgeons would be in a world of hurt. The concept of refractive sur- gery is old. Centuries ago, Chinese acupuncturists applied their art to eyes to improve vision. Later paraphrased famously by John F. Kennedy, Tacitus observed that success has many fathers. A cen- tury before radial keratotomy and the excimer laser, a group of Dutch ophthalmologists laid the scientific groundwork for corneal refractive surgery. Frans Cornelis Donders, author of the seminal The Anomalies of Refraction and Accommodation, founded an eye clinic and hired Herman Snellen of the eponymous vision chart to work with him. They advanced basic research on optics, refractive errors, and ac- commodation. At the close of the 19th century, another Dutchman, Leendert Jans Lans, comprehensive- ly studied corneal incisional tech- niques to modify refractive errors. In Ophthalmology's Betamax J.C. Noreika, MD, MBA

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