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Innovations | Sep 2007

Europe Led the Way

Many great refractive technologies and innovators were born

As has been customary with many innovative concepts, refractive surgery experienced a period of rejection before it was accepted as a standard ophthalmic practice. The first idea of refractive surgery occurred in 1936, when Tsutomu Sato, MD, PhD, of Japan, discovered corneal flattening after traumatic eye injuries.1 Even though the idea occurred in Japan, the formal birth of refractive surgery happened in Europe.

Surfacing in the late 1940s, the practice of refractive surgery began when José Ignacio Barraquer, MD, of Spain, created a surgical technique to reshape the cornea. He removed, froze, reshaped, and reapplied a portion of the human cornea to create a refractive correction. This process, keratomileusis, was not well received by Professor Barraquer's colleagues. Like all skeptics, surgeons needed to be convinced that refractive surgery deserved a place in the ophthalmic market. This convincing slowly occurred over the next 50 years. By the 1990s, more ophthalmologists were practicing refractive surgery than were cynical about it.

QUICKLY CONVINCED
I was one of these ophthalmologists, as I quickly became convinced of the benefits that practicing refractive surgery offered. As the Chairman of Ophthalmology at the University of Alicante, Spain, I had access to so many patients who had already undergone refractive surgery—at that time, mostly radial keratotomy. I started to realize that the benefits of refractive surgery were real, and I began to practice it between the late 1980s and early 1990s. During this time, I studied books on refractive surgery, attended meetings, and observed other surgeons in the hopes of introducing myself to refractive surgery.
My experience is similar to that of so many European ophthalmologists. In its early stages, no formalized education existed to teach refractive surgery. One common denominator worldwide is that refractive surgery was a specialty that was not included in residency or professional training programs. Instead, surgeons were self taught, and they often learned by trial and error. Simply put, it was too easy to have access to a calibrated diamond knife or to an excimer laser and press the foot pedal to start a refractive procedure. Many ran into complications, and this added to the connotation that refractive surgery was dangerous.

Therefore, a large part of Europe was still adamant that the concept of refractive surgery should not be included in ophthalmology. Generally speaking, southern Europe was more accepting of the new modality compared with northern and central Europe. I have found that southern Europe is less conservative, quicker to implement innovations, and more creative. Early results in refractive surgery were promising, and that stimulated southern Europe to proceed with its practices. But, some ophthalmologists argued that not enough scientific evidence was available to conclude that refractive surgery was safe and effective.

So, two schools of thought existed: those who believed that refractive surgery was the way of the future and those who believed that refractive surgery was a violation of practice. The second group argued that operating on an apparently healthy eye to correct a refractive error was unnecessary, because spectacles were available to correct the patient's vision.

As controversy grew, patients also started to hear about refractive surgery, and the demand for its use grew. A tremendous volume of patients waited for a myopic solution, and they believed that refractive surgery was the answer. Unfortunately, many were operated on during a time where these ideas were new, and the lack of education was apparent. Increasing education and the access to technology eliminated the origin of poor refractive outcomes, and patient satisfaction grew.

EUROPEAN CONRIBUTIONS
All of these early discoveries (and failures) led to the refinement of refractive surgery techniques. It is quite evident that Europe is responsible for the development of refractive surgery through the contribution of many innovators and technologies. The main contributions of Europe to refractive surgery include phakic IOLs, radial keratotomy, incisional surgery, and LASIK.

In terms of innovators, Europe's contributions are plentiful. In 1885, Hjalmar Schiotz, MD, of Norway, described a procedure in which 19.50 D of astigmatism was reduced—by 12.00 D—with a limbal relaxing incision.2 Now, we refer to this procedure as keratotomy. Several years later in 1898, Leendert Jan Lans, of Holland, investigated the effects of corneal incisions to correct refractive errors.3 Svyatoslav N. Fyodorov, MD, of Moscow, picked up where Dr. Sato's failed work left off, and he refined the technique to create radial keratotomy. This was achieved by changing the amount of myopic correction. Dr. Fyodorov varied the size of the optical zone as well as changed the number of radial incisions.4

Phakic IOLs were also born in Europe.5 Benedetto Strampelli, MD, of Italy, implanted the first phakic IOL in the 1950s. D. Peter Choyce, MD, FRCS, of the United Kingdom, was also one of the first to implant a phakic IOL. In 1963, he developed the first anterior chamber IOL.

The second wave of phakic IOLs surfaced in the 1980s. This time, Dr. Fyodorov, Georges Baikoff, MD, of France, and Paul U. Fechner, MD, of Germany, developed new phakic implants including the phakic ICL.6 Dr. Fyodorov was a busy man in the 1980s, as he also popularized radial keratotomy, and thereafter, Jörg Krumeich, MD, of Germany, perfected astigmatic keratotomy.

As of other noteworthy refractive surgery milestones, Jan G.F. Worst, MD, of the Netherlands, invented the original Artisan lens.7 In 1988, Ioannis G. Pallikaris, MD, and colleagues at the University of Crete, Greece, developed LASIK by combining lamellar refractive corneal surgery with excimer laser photoablation of the residual cornea. It was performed under a hinged corneal flap.8 Lucio Buratto, of Italy, described LASIK applied at the flap level.9-12As one can see, Europe enjoys a broad perspective of its contribution to refractive surgery.

TECHNOLOGY ABUNDANT
Europe has also contributed to technology developments. The names of John Marshall, PhD, FRCPath, FCOptom(Hon), FRCOphth(Hon), of the United Kingdom, and Theo Seiler, MD, PhD, of Zurich, Switzerland, and others are linked to the early development of excimer laser photoablation as a refractive tool. Some of the larger companies in refractive surgery are located right here in Europe. For instance, Carl Zeiss Meditec AG (Jena, Germany) gave us the MEL excimer laser. Schwind-eye-tech-solutions (Kleinostheim, Germany) is a good excimer laser technology, as is the Allegretto (WaveLight AG, Erlangen, Germany). Along with the Allegretto came aspheric profiles as an ablation concept. Many of the modern microkeratomes were also invented, and manufactured in Europe.

Refractive surgery has not only changed the face of ophthalmology, but it has changed within itself. In the beginning, surgeons thought that operating on an apparently normal eye to correct refractive errors was barbaric. Now, we realize that it is a technique that allows our patients a better quality of life. As this process evolves, we are coming to better understand the optics of the eye, increase spectacle independence with multifocal and accommodating IOLs, combine refractive and corneal surgery, and make cataract surgery safer. After all, cataract surgery is now refractive surgery, as cataract surgeons also provide our patients with the best refractive outcome possible. The progress of cataract surgery has been made possible through refractive surgery concepts: to look for a better refractive outcome and better vision for all patients.

Today, refractive surgery is based on two innovations: IOLs and the laser. Phakic IOLs are a superb method of myopic correction, and they are ever-changing. The most popular models last year are already outdated and replaced by new models. And, LASIK appeared at the appropriate time, rivaling and superceding PRK in refractive correction. Both of these innovations were, I am proud to say, products of my European colleagues.

Jorge L. Alió, MD, PhD, is Professor and Chairman of Ophthalmology, Miguel Hernandez University, Alicante, Spain, and Medical Director of VISSUM Corp., in Spain. Professor Alió states that he is a consultant and receives grant support from Schwind-eye-tech-solutions. He may be reached at +34 96 515 00 25; jlalio@vissum.com.

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