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   Table of Contents      
EDITORIAL
Year : 2002  |  Volume : 50  |  Issue : 4  |  Page : 259-260

LASIK - The Indian eye controversy


Correspondence Address:
S Shah


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Source of Support: None, Conflict of Interest: None


PMID: 12532489

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How to cite this article:
Shah S. LASIK - The Indian eye controversy. Indian J Ophthalmol 2002;50:259-60

How to cite this URL:
Shah S. LASIK - The Indian eye controversy. Indian J Ophthalmol [serial online] 2002 [cited 2020 Jun 2];50:259-60. Available from: http://www.ijo.in/text.asp?2002/50/4/259/14768

LASIK is an elective surgery generally performed on young healthy people who perceive refractive correction by external eyewear, such as spectacles or contact-lenses to be a limitation in their active lifestyle. They desire superior aid-free natural vision to expand their personal, professional or avocational lifestyle choices. The goal of LASIK is to improve natural vision and thereby improve quality of life through minimised dependence on external eyewear. In this sense, LASIK is a lifestyle surgery. With excellent visual results, a relatively painless course and rapid return of unaided natural vision, it is not surprising that LASIK has captured the hearts of doctors and patients alike as the most prominent choice for the surgical correction of refractive errors, worldwide. Despite an established track record of safety, LASIK was recently put on trial by a controversy in the national media that suggested Indian eyes were unsuitable for LASIK due to thin corneas and concerns of progressive ectasia. Let us play the devil's advocate and address the fundamental question, "Is LASIK safe for Indian eyes?" from a scientific perspective.

During LASIK, a hinged lamellar corneal flap is raised followed by precise application of excimer laser pulses to reshape the exposed stromal bed, and later the flap is replaced. The amount of stromal tissue removed by the excimer laser depends on the optical zone of treatment and the magnitude of the refractive error.

Ablation depth = [Diopters of correction x (Optical zone)2]/3

It is believed that the flap after treatment does not contribute to the biomechanical stability of the eye. A residual stromal bed of at least 250 microns is recommended to avoid the risk of progressive thinning or keratectasia. Considering these variables, too low a pachymetry, too large an optical zone or too high an attempted correction could raise a genuine concern for keratectasia. To support the claim that Indian corneas are thin and therefore unsuitable for LASIK, we need data from a study conducted on a representative indigenous population, supported by peer review and compared with Caucasian eyes. In absence of such evidence, it becomes extremely difficult to accept the findings of the quoted study, with any more than equivocal enthusiasm. In fact, the alleged disadvantage of a racial variation in corneal pachymetry is offset by the fact that Indian eyes have darker irides and therefore, a smaller scotopic pupil than Caucasian eyes. This allows the use of smaller optical zones of treatment and increases the safety limit of LASIK in Indian eyes as far as iatrogenic keratectasia is concerned. Therefore, in absence of concrete evidence to the contrary, LASIK is indeed safe in Indian eyes. But, there is a specific caveat to this. Adequate preoperative assessment is required to screen for suitability. Preoperative pachymetry can exclude those at high risk for postoperative keratectasia. In addition, corneal topography should also be performed to exclude subclinical forms of keratoconus, to ensure that there is no pre-existing ectasia. Intuitively, one would presume that all standard tests are performed prior to patient selection for elective vision correction surgery on young and healthy eyes. Though dramatised to the point of being unappealing to our professional sentiments, the efforts of the media are laudable for having increased the public awareness of thorough preoperative assessment.

What then, could be the seminal factors that snowballed into a national controversy? Let us look at the background of LASIK in India. The growth of LASIK in India has been impressive, from a handful of centres in 1995 to approximately 100 or more in 2002! Philosophically, LASIK practices are a continuum from strictly professional at one extreme to commercial centers at the other extreme. The vast majority of these centers are suboptimally utilised. As the technology involved in LASIK is capital intensive, medicine and business are invariably intertwined. This leads to a variety of marketing strategies, to increase volumes and support debt. Further, cost of surgery varies significantly between different centers even in the same city. It would be nave to assume sheer altruism as the motivating force driving these practices. Therefore, if costs vary across centers, the quality of treatment is likely to be different. It becomes a challenge to balance economic pressures against professional priorities and as a natural consequence, it is possible that screening criteria may be variable or relaxed in some cases.

There is a tendency amongst our colleagues to trivialise LASIK as an "easy", "completely machine dependent", "anyone can do it" procedure. These ophthalmologists do a great disservice to our profession and belittle themselves and their colleagues. LASIK is a professional service and significant qualitative differences can and do exist among professionals. If the ophthalmologist perceives no difference in quality issues, this will reflect in the patient's decision-making process. The consequence is then obvious to anyone; if patients perceive no difference in quality, they want the lowest price possible. Patients only care about quality when they believe that it differs in important ways. This creates a situation wherein the patient goes "shopping for the best price" to different centres resulting in price slashing to an extent that it becomes impracticable to maintain the quality. Such a climate that discourages quality in refractive surgery offers an opportunity to remind ourselves that our first and foremost duty is to our patient. If we ignore such quality concerns as the sins of an open market, this will ultimately harm the profession.

The lead article in the current issue is an excellent review of complications in LASIK.[1] It underscores the importance of a balance of knowledge, skill and experience, otherwise serious sight-threatening complications can occur in a seemingly simple procedure. A good LASIK surgeon needs to have an understanding of the different ancillary technologies related to LASIK such as corneal topography, pachymetry, microkeratome, excimer laser and aberrometry. One must devote time to acquisition of skills and monitor our initial results until the learning curve is past and consistency is achieved. LASIK is a science and fine clinical judgment is required to avoid and manage complications. The stakes are high because the goal is not merely to reduce the refractive error, but to optimize the quality of vision in a normally sighted eye. Prospective patients need to understand that sight-threatening complications, though rare, can occur. Though established as extremely safe and effective in many studies, one must realise that such studies may have been conducted in academic centers and with standardised protocols, specific patient populations and mentoring of beginners by an experienced refractive surgeon. Unless, these conditions are emulated, the results cannot be generalised. A well-trained refractive surgeon with a scientific approach can manage complications such that they do not affect vision. This does not, however, limit LASIK to a few sub-specialists. LASIK is within the realm of the general ophthalmologist who is committed to acquiring the requisite skills. This will inspire confidence in both the patient and the surgeon and will reflect in happy surgeons, satisfied patients and practice growth.

Though early entrepreneurs have recognised the economic potential of the public vanity for perfect aid-free natural vision, LASIK is still in its infancy in India with single digit market penetration. Considering the suboptimal utilisation of existing laser centers, it appears that LASIK in India is industry driven and not patient or physician driven. This trend, however, appears to be changing. Increasingly, patients specifically request LASIK through this is not matched by the enthusiasm of the mainstream general ophthalmologist. Whether this lack of enthusiasm is related to economic concerns, limited access, lack of training centers or lack of confidence in the results of LASIK is unclear. We need to identify these issues and address them.

LASIK has the potential to help millions of Indians with vision disorders. We as physicians must put our patient's interests ahead of our own so that our patients can trust us to be their impartial advocates. It is this trust that allows us to flourish. If we are overtly optimistic or pessimistic about LASIK we need to ask ourselves, "Are we always acting in the interests of our natural allies, our patients?"

LASIK has arrived and is here to stay. It is an extremely safe, effective and versatile procedure when performed in a scientific way. Although the holy grail of perfect 6/6 vision for all patients still eludes us, we have come a long way. The recent controversy has presented a unique opportunity to all ophthalmologists to re-familiarize themselves with the principles, concepts, technology and results of this exciting new vision correction technique.

 
  References Top

1.
Sridhar M S, Rao S K, Vajpayee R B, Aasuri M K, Hannush S, Sinha R. Complications of Laser-in-situ-Keratomileusis. Indian J Ophthalmol 2002;50:265-82.  Back to cited text no. 1
    



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1 Neuro-ophthalmic disorders presenting as a diagnostic surprise during pre-LASIK evaluation
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[Pubmed]



 

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