Journal of Refractive Surgery

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Letter to the Editor 

AVOID BOTH RADIAL KERATOTOMY WITH SMALL OPTICAL ZONES AND HEXAGONAL KERATOTOMY

Lee T Nordan, MD; W Andrew Maxwell, MD, PhD

Abstract

As reasonably experienced corneal/refractive surgeons, we have watched with interest the renewed popularity of radial keratotomy, hexagonal keratotomy, and associated instructional refractive surgery courses. Radial keratotomy, when used appropriately, is an excellent procedure for correcting myopia.

In our opinion, however, it is of the utmost importance to alert the public and our colleagues to the dangers and complications associated with hexagonal (box, circular) keratotomy. This procedure is capable of improving uncorrected visual acuity but almost always, in our experience, results in irregular corneal astigmatism and a significant decrease in the quality of best corrected vision.

Hexagonal keratotomy seems to have a risk/ benefit ratio that does not justify its use.

For at least 10 years, American refractive surgeons have known and reported that radial keratotomy with optical zones of 2.50 mm or less also carry an enormous risk of causing intractable glare, irregular astigmatism, and the significant, permanent loss of quality of vision. We believe that surgeons who attempt to justify such small optical zones on the basis of uncorrected visual acuity without appreciating the factors that affect the quality of vision are making a grave mistake. There is no improved surgical technique or diamond blade currently being used that in anyway changes these issues.

A general issue, however, of even greater significance than those specific issues mentioned above, has surfaced. The issue is this:

Should a surgeon perform surgery on a routine basis that he or she knows (or should know) has a large chance of permanently reducing a patient's best corrected visual acuity by 1 to 2 lines of vision and reduce the quality of vision, even if an informed consent for such a procedure is obtained?

We believe that the answer to the issue stated above is an emphatic "no." A surgeon does not have the right to allow patients to elect to hurt themselves. No truly informed "informed consent" can be obtained about a defective surgical procedure that does significant, permanent damage.

It would be unthinkable that intraocular lens companies be allowed to produce IOLs that allowed only 20/40 visual acuity; surgeons have the responsibility to refrain from performing a surgery that produces a poor result a majority of the time, whether the consumer desires such surgery or not.

Many cataract/IOL surgeons may not realize that responsible refractive surgeons have struggled for years to honestly inform patients of the potential risks involved with their surgery. Now that many cataract/IOL surgeons feel financial pressure to start radial keratotomy, it is shocking that some are willing to consider lowering the standards for refractive surgery, rather than performing surgery that meets the higher standard. Ophthalmology simply does not have an adequate surgical solution for every refractive error, yet.

We understand, and have been involved with, the often difficult and unpredictable path that a new product or procedure must endure before it is accepted or rejected by each surgeon and patient. For us, hexagonal keratotomy has been given a fair chance and has proven itself to be a failure. Patients who have experienced overcorrection with radial keratotomy and are then treated with hexagonal keratotomy are especially prone to severe corneal complications. Similar problems accompany radial keratotomy with small optical zones.

We urge those ophthalmic surgeons performing, advocating, and teaching hexagonal keratotomy and radial keratotomy with optical zones of 2.50 mm and less to critically reevaluate their results and the responsibilities incumbent upon them.…

As reasonably experienced corneal/refractive surgeons, we have watched with interest the renewed popularity of radial keratotomy, hexagonal keratotomy, and associated instructional refractive surgery courses. Radial keratotomy, when used appropriately, is an excellent procedure for correcting myopia.

In our opinion, however, it is of the utmost importance to alert the public and our colleagues to the dangers and complications associated with hexagonal (box, circular) keratotomy. This procedure is capable of improving uncorrected visual acuity but almost always, in our experience, results in irregular corneal astigmatism and a significant decrease in the quality of best corrected vision.

Hexagonal keratotomy seems to have a risk/ benefit ratio that does not justify its use.

For at least 10 years, American refractive surgeons have known and reported that radial keratotomy with optical zones of 2.50 mm or less also carry an enormous risk of causing intractable glare, irregular astigmatism, and the significant, permanent loss of quality of vision. We believe that surgeons who attempt to justify such small optical zones on the basis of uncorrected visual acuity without appreciating the factors that affect the quality of vision are making a grave mistake. There is no improved surgical technique or diamond blade currently being used that in anyway changes these issues.

A general issue, however, of even greater significance than those specific issues mentioned above, has surfaced. The issue is this:

Should a surgeon perform surgery on a routine basis that he or she knows (or should know) has a large chance of permanently reducing a patient's best corrected visual acuity by 1 to 2 lines of vision and reduce the quality of vision, even if an informed consent for such a procedure is obtained?

We believe that the answer to the issue stated above is an emphatic "no." A surgeon does not have the right to allow patients to elect to hurt themselves. No truly informed "informed consent" can be obtained about a defective surgical procedure that does significant, permanent damage.

It would be unthinkable that intraocular lens companies be allowed to produce IOLs that allowed only 20/40 visual acuity; surgeons have the responsibility to refrain from performing a surgery that produces a poor result a majority of the time, whether the consumer desires such surgery or not.

Many cataract/IOL surgeons may not realize that responsible refractive surgeons have struggled for years to honestly inform patients of the potential risks involved with their surgery. Now that many cataract/IOL surgeons feel financial pressure to start radial keratotomy, it is shocking that some are willing to consider lowering the standards for refractive surgery, rather than performing surgery that meets the higher standard. Ophthalmology simply does not have an adequate surgical solution for every refractive error, yet.

We understand, and have been involved with, the often difficult and unpredictable path that a new product or procedure must endure before it is accepted or rejected by each surgeon and patient. For us, hexagonal keratotomy has been given a fair chance and has proven itself to be a failure. Patients who have experienced overcorrection with radial keratotomy and are then treated with hexagonal keratotomy are especially prone to severe corneal complications. Similar problems accompany radial keratotomy with small optical zones.

We urge those ophthalmic surgeons performing, advocating, and teaching hexagonal keratotomy and radial keratotomy with optical zones of 2.50 mm and less to critically reevaluate their results and the responsibilities incumbent upon them.

10.3928/1081-597X-19920701-17

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