Journal of Refractive Surgery

The articles prior to January 2013 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here

Patient Preference-Contact Lens or Radial Keratotomy?

Luc Haverbeke, MD

Abstract

ABSTRACT

BACKGROUND: Past clinical experience has suggested that patients are more satisfied after radial keratotomy than when wearing contact lenses.

METHODS: One- hundred patients who had worn contact lenses prior to receiving radial keratotomy compared subjectively these two methods for correcting myopia. The postoperative follow up ranged from 3 months to 13 years.

RESULTS: The vast majority (93%) preferred radial keratotomy to the handling of contact lenses.

CONCLUSIONS: The desire to be independent of optical correction is a sufficient indication for refractive surgery. [Refract Corneal Surg 1992;8:315-318.)

Abstract

ABSTRACT

BACKGROUND: Past clinical experience has suggested that patients are more satisfied after radial keratotomy than when wearing contact lenses.

METHODS: One- hundred patients who had worn contact lenses prior to receiving radial keratotomy compared subjectively these two methods for correcting myopia. The postoperative follow up ranged from 3 months to 13 years.

RESULTS: The vast majority (93%) preferred radial keratotomy to the handling of contact lenses.

CONCLUSIONS: The desire to be independent of optical correction is a sufficient indication for refractive surgery. [Refract Corneal Surg 1992;8:315-318.)

While spectacles and contact lenses, with their impressive track records, are universally accepted as optimal means for the correction of myopia, refractive surgery is considered by many ophthalmologists as imprecise and risky.

Contact lenses generally provide good visual acuity. Rigid lenses have been used for over 40 years, evolving from PMMA to gas permeable materials with excellent oxygen transmissibility and fewer complications than soft lenses. While easier to fit and more comfortable, soft lenses, which have been in use for almost 20 years, cause a wide array of complications. These include microbial, Acanthamoeba, and mycotic keratitis; giant papillary conjunctivitis; tight lens syndrome; and deep stromal neovascularization. Chronic corneal hypoxia has been associated with endothelial polymegethism and pleomorphism. Aside from lens loss and warpage, hypersensitivity reactions to lens solutions have also complicated contact lens wear.1-4

Good visual results can also be obtained with radial keratotomy. This procedure always reduces myopia and enables approximately 90% of the patients with myopia between 1.50 and 5.Û0 D to function normally and drive a car without additional correction.5 Although radial keratotomy is considered safe,6 numerous complications have been reported.7-8 The most serious complications (bacterial keratitis, cataract, endophthalmitis, traumatic rupture of the globe) are very rare, occurring in less than 1% of published series. The most important problems in the immediate postoperative period include pain, discomfort, photophobia, glare, and significant fluctuations in refraction. The most common longterm complications include overcorrection and undercorrection. Irregular astigmatism around the incision sites is often seen, but rarely impairs visual acuity. Mild glare and diurnal fluctuations are frequently observed, although patients are generally not disturbed by these phenomena. About 25% of radial keratotomy patients display corneal instability, which may lead to a continuous shift in the hyperopic direction.5"8

Contact lens fitting has been performed by the author since 1972, and radial keratotomy since 1978. There has been a general impression in the office that the "satisfaction rate" of the radial keratotomy patients is much higher than that of the contact lens wearers.9 Since satisfaction is difficult to quantify, a study covering both subjective and objective criteria was designed.

PATIENTS AND METHODS

One-hundred radial keratotomy patients (194 eyes), representing consecutive office appointments between September 3 and October 19, 1990, were included in the study. All patients had worn contact lenses preoperatively (Table 1). Follow up ranged from 3 months to 13 years. At the time of the study, the author's radial keratotomy data base contained some 7800 patients.

Table

Table 1Types of Lenses Worn Before Radial KeratotomyTable 2Reasons for Discontinuing Contact Lens Wear and Undergoing Radial Keratotomy*Table 3Symptoms and Complaints After Radial KeratotomyFIGURE 1: Satisfaction score for 100 patients, after comparing their evaluation of contact lens wear with radial keratotomy. The grading scale was as follows: 0 to 2 = very dissatisfied, 3 to 4 = not satisfied, 5 to 6 = rather satisfied, 7 to ? = satisfied, and 9 to 10 = very satisfied.

Table 1

Types of Lenses Worn Before Radial Keratotomy

Table 2

Reasons for Discontinuing Contact Lens Wear and Undergoing Radial Keratotomy*

Table 3

Symptoms and Complaints After Radial Keratotomy

FIGURE 1: Satisfaction score for 100 patients, after comparing their evaluation of contact lens wear with radial keratotomy. The grading scale was as follows: 0 to 2 = very dissatisfied, 3 to 4 = not satisfied, 5 to 6 = rather satisfied, 7 to ? = satisfied, and 9 to 10 = very satisfied.

Each patient included in the study completed a questionnaire under the guidance of a certified ophthalmic nurse, and then underwent a complete ophthalmic examination including keratometry, refraction, visual acuity, and slit-lamp microscopy. The examinations were performed between 4:00 and 6:30 PM to minimi y.e the influence of diurnal fluctuations.

Questionnaire

The questionnaire, comprising six questions, graded on a scale of 0 to 10, covered the type of contact lens worn (Table 1), the amount of satisfaction (visual acuity and comfort) during lens wear, the reason for discontinuing lens wear (Table 2), the amount of satisfaction following radial keratotomy (Fig 1), current problems (Table 3), and whether the patient would make the same decision to undergo radial keratotomy again.

In conjunction with the comprehensive ophthalmie examination, the change in the uncorrected and best spectacle corrected visual acuity was noted. At the same time, it was determined what percentage of time the patient was dependent on glasses or contact lenses, and whether the patient had chosen to have the radial keratotomy procedure on only one eye.

Surgical Technique

Between 1978 and 1983, a steel blade was used, and the radial incisions (usually eight) were made from the center to the limbus.10"12 During that period, an optical pachometer was used. Prom 1983 to 1986, and based on the assessment of past cases,10·13 the limbus to optical zone incision replaced the earlier technique. Three to 16 incisions of varying depths were used.5 The procedure was usually performed under topical anesthesia, using the one-handed technique described by Trau.11 No patch was used, and the postoperative treatment consisted of chloramphenicol and indomethacin drops for 5 days.

Patients who were overcorrected at 2 weeks postoperatively were sometimes treated with topical beta blockers until they were emmetropic. Undercorrected eyes were treated with topical corticosteroids for 2 months. Those who were emmetropic at 2 weeks postoperatively received no further treatment.6 A slight undercorrection (-1.00 D) was aimed at when operating the first (nondominant) eye. The dominant eye was operated 1 to 2 weeks later, and emmetropia was the goal.

Table

Table 4Need for Additional Correction After Radial KeratotomyFIGURE 2: Spherical equivalent refraction before and after radial keratotomy. <A) Spherical equivalent manifest refraction before radial keratotomy. (B) Spherical equivalent manifest refraction after radial keratotomy.

Table 4

Need for Additional Correction After Radial Keratotomy

FIGURE 2: Spherical equivalent refraction before and after radial keratotomy. <A) Spherical equivalent manifest refraction before radial keratotomy. (B) Spherical equivalent manifest refraction after radial keratotomy.

FIGURE 3: Change In uncorrected visual acuity in number of Snellen lines from before to after radial keratotomy.FIGURE 4: Change in best spectacle corrected visual acuity from before to after radial keratotomy indicates that onty two eyes lost two or more Snellen lines.

FIGURE 3: Change In uncorrected visual acuity in number of Snellen lines from before to after radial keratotomy.

FIGURE 4: Change in best spectacle corrected visual acuity from before to after radial keratotomy indicates that onty two eyes lost two or more Snellen lines.

RESULTS

The results of the questionnaire and refractive results are summarized in Tables 1 to 3 and Figures 1-5. Most patients had worn their contact lenses for years without major complications. After an average of 10 years, problems arose. The majority of patients had been satisfied with their contact lenses (Fig 1). Complaints after radial keratotomy (Table 3) generally had to be elicited and were rarely mentioned spontaneously. Ninety-three percent of the radial keratotomy patients stated that they would undergo the operation again. Six percent answered "perhaps" to this question, and only 1% would refrain from radial keratotomy if they had to make up their minds again.

As shown in Table 4, most radial keratotomy patients managed well without additional correction. However, one of three patients needed spectacles or contact lenses for specific tasks.

Only 6 of 100 patients refrained from having the second eye operated. In four of these cases, the second eye had myopia of less than 1.50 D. One patient had experienced contact lens intolerance in only one eye, and one patient was disappointed with the refractive result of the first eye.

FIGURE 5: Scattergram comparing the preoperative refraction on the x-axis to the change in refraction (obtained effect) on the y-axls shows the spread of refraction for 194 eyes, indicating that the majority of eyes were between ± 1 diopters, with an intentional trend toward undercorrection.

FIGURE 5: Scattergram comparing the preoperative refraction on the x-axis to the change in refraction (obtained effect) on the y-axls shows the spread of refraction for 194 eyes, indicating that the majority of eyes were between ± 1 diopters, with an intentional trend toward undercorrection.

DISCUSSION

The patients included in this study overwhelmingly preferred radial keratotomy to contact lens wear. Although the patients' preferences were expressed as subjective views in a questionnaire and were difficult to quantify objectively, this did not diminish the importance of these views. Rates of satisfaction elicited from patients are probably just as important as a quantifiable 20/20 visual acuity.

It may be argued that the sample presented in this study is not representative of the radial keratotomy population as a whole. However, the patients in this study were seen consecutively and were typical of unhappy contact lens wearers.

It is remarkable that contact lenses, which from a medical and optical viewpoint can reasonably be considered a better mode of correction than radial keratotomy, lose out to refractive surgery in this study. Lenses provide excellent vision and wear can always be discontinued if complications occur. Yet, the patients preferred radial keratotomy, which often does not provide 20/20 visual acuity, frequently requires additional correction, and is irreversible.

Contact lenses put the burden on the patient. It is the patient who has to handle lens care. It is also the patient who is chained by the lenses, always afraid of losing them. Radial keratotomy puts the burden on the surgeon, but provides freedom for the patient.

REFERENCES

1. Mandel E, Wagoner M. Atlas of Corneal Disease. Philadelphia, Pa: WB Saunders, 1989.

2. Ruben M. Color Atlas of Contact Lenses. London, Wolfe; 1982.

3. Girard L. Corneal Contact Lenses. St Louis, Mo: CV Mosby; 1970.

4. Gasset A, Kaufman H. Soft Contact Lens. St Louis, Mo: CV Moaby; 1972.

5. Haverbeke L, Levy J. La Keratotomie Radiaire. Paris: Masson; 1990.

6. Waring GO, Lynn MJ, Culbertson W, et al. Three year results of the prospective evaluation of radial keratotomy (PERK) study. Ophthalmology. 1987;94:1339-1354.

7. Rashid ER, Waring GO. Complications of radial and transverse keratotomy. Surv Ophthalmol. 1989;34:73-105.

8. Manner RH. Radial keratotomy complications. Ann Ophthalmol. 1987;19:409-411.

9. Haverbeke L. Why is it radial keratotomy patients are so satisfied? SOBEVECO Report. 1985:120-122.

10. Haverbeke L. La keratotomie doit-eUe se pratiquer en centripete ou en centrifuge? Bull Soc Belge Ophtalmol. 1989;234:1-8.

11. Trau R. Modification personnelle de la technique de K.R. selon Haverbeke. Bull Soc Belge Ophtalmol. 1989;234:35-38.

12. Haverbeke L, Radial keratotomy: comparing the results of 840 cases operated the American way vs 840 cases operated the Russian way. SOBEVECO meeting, Brussels, Belgium, 1988.

13. Haverbeke L. First considerations after six years (360 cases) of radial keratotomy. Bull Soc Beige Ophtalmol. 1984;213:153-156.

Table 1

Types of Lenses Worn Before Radial Keratotomy

Table 2

Reasons for Discontinuing Contact Lens Wear and Undergoing Radial Keratotomy*

Table 3

Symptoms and Complaints After Radial Keratotomy

FIGURE 1: Satisfaction score for 100 patients, after comparing their evaluation of contact lens wear with radial keratotomy. The grading scale was as follows: 0 to 2 = very dissatisfied, 3 to 4 = not satisfied, 5 to 6 = rather satisfied, 7 to ? = satisfied, and 9 to 10 = very satisfied.

Table 4

Need for Additional Correction After Radial Keratotomy

FIGURE 2: Spherical equivalent refraction before and after radial keratotomy. <A) Spherical equivalent manifest refraction before radial keratotomy. (B) Spherical equivalent manifest refraction after radial keratotomy.

10.3928/1081-597X-19920701-14

Sign up to receive

Journal E-contents