From Radial Keratotomy to PRK to LASIK: Refractive Surgery in Hungary
In Hungary, refractive surgery began with the use of (1) the scleral support method and (2) radial keratotomy. Both procedures were preferably used in anisometropia and just performed on one eye. In the 1980s, a number of Russian eye surgeons traveled to Hungary and performed radial keratotomies in private practice. In the 1990s, however, the number of such surgeries decreased, and by 2002, its use had ceased completely.1
Surgeons started performing the laser-based technique of refractive surgery in 1992, when the first argon fluoride (ArF) excimer laser instrument was introduced. The first ArF laser was university-owned—and therefore state property—which explains why phototherapeutic keratectomy (PTK) results2 were published earlier than PRK results. In 1995, Nagy et al3 were the first to publish results on PRK in the Hungarian journal Szemészet.
The monopoly of the state-owned laser lasted between 4 years and 5 years. Then, privately owned lasers came into use. Presently, 10 excimer lasers are used nationwide, servicing a population of approximately 10 million. The lasers are reasonably spread through Hungary: There are five in Budapest (for approximately 2 million people), and the remaining five are distributed over the rest of the country. The instruments are from various manufacturers, but among those with results attracting greater public attention are MEL 70 and MEL 80 G-scan lasers (previously Aesculap Meditec AG, Jena, Germany, now Carl Zeiss Meditec, Jena, Germany).
The introduction of flying-spot lasers revolutionized PRK and led to better results and patient satisfaction. In patients with a refractive error less severe than -6.00 D, normal UVCA is achieved in more than 98% of cases. With an improvement in results and an increase in instrument choices, treatment numbers have also increased. The peak years were 2000 and 2001, with the annual number of PRK treatments totaling 7,782 and 7,315, respectively. As new refractive surgery methods were introduced in the following years, treatment numbers diminished.
In the late 1990s, LASIK appeared in Hungary; the first results were published in 2002.4 In the same year, LASEK treatments also surfaced. These two methods have become widely used, and PRKs have decreased. Now, the average total number of refractive surgery treatments in this country is approximately 7,000 to 7,500 per year.
It quickly became clear that a standardized protocol for such interventions was needed, and a group of specialists coordinated by Dr. Nagy came to the rescue. Today, all surgeons are expected to treat their patients following the steps outlined below.
The surgeon is required to (1) determine the UCVA and BCVA for near and far distance, (2) perform corneal topography, (3) measure corneal thickness, (4) measure the automatic reflex of the undilated and dilated pupil, (5) perform applanation tonometry, and (6) perform a fundus examination with the pupil dilated.
After surgery, it is required to (1) perform follow-up examinations on the 1st, 5th, and 10th days, and at 1, 3, and 6 months and (2) apply antibiotic and corticosteroid drops.
The wavefront-guided technique (ie, wavefront aberration-supported corneal ablation [WASCA]) was the next step forward. By detecting and measuring higher-order aberrations, refractive errors (which were previously unmanageable with PRK) are now eliminated. The method itself was introduced in 2000, and the first Hungarian report was published in 2002.5 In Hungary, in addition to the Shack-Hartmann aberrometer, the Zywave aberrometer (Bausch & Lomb, Rochester, New York) is also used.
But, even with these highly developed techniques, unsolved problems — including the increase of intraocular pressure and the uncertain results of ophthalmic tonometry following refractive surgery—remain. Further studies seek to determine the role of tear film components or dry eye syndrome in refractive surgery.
Refractive surgery has brought along with it significant results regarding corneal wound healing. A group of Hungarian ophthalmologists, in cooperation with the Eye- and Skin-Clinic of the University of Erlangen, Germany, performed research that revealed the mechanism of post-PRK haze development due to ultraviolet-B exposure.6
Judging from its clinical results, the femtosecond laser seems to be a promising advance. In Hungary, we have one such instrument, mainly used for scientific studies. The country's first clinical results were published in 2003.7
Beside laser surgery, other refractive surgical methods have also been used. Before 2002, 10 to 15 intrastromal corneal ring implants were performed annually. There-after, though, they were given up entirely.8 Currently, approximately 300 thermokeratoplasties are performed each year, although the number is gradually decreasing. The number of phakic IOLs implants is eight to 10 per year, and the number of clear lens extractions is increasing.
One serious real-world difficulty is that health insurance does not usually cover refractive procedures. There were, at one time, private insurance companies that agreed to provide supplemental coverage. Since that time, they have withdrawn from the field because it is considered unprofitable. In certain cases of anisometropy, treatment (eg, PTK) on one eye was previously covered by the national health insurance. Recently, even this has been withdrawn.
As for the future, a decrease of refractive treatments is expected. On the institutional side, the financial state of the country will probably not allow for acquisitions of state-of-the-art instruments. Equally, on the consumer side, impoverishment of the individual inevitably points to a falling demand for refractive surgeries.
Ildikó Süveges, MD, PhD, DSc, is from the Department of Ophthalmology, Semmelweis University, in Budapest, Hungary. Dr. Süveges states that she has no financial interest in the products or companies mentioned. She may be reached at tel: +361 210 7334; fax: +361 210 7687; or si@szem1.sote.hu.
Zoltán Zsolt Nagy, MD, PhD, DSc, is from the Department of Ophthalmology, Semmelweis University, in Budapest, Hungary. Dr. Nagy states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +361 210 7334; fax: +361 210 7687.
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