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    My refractive surgery journey as surgeon and patient

    Spanning 40 years from early research to my own procedures, including cataract surgery

    My interest in refractive surgery started in 1976 when my good friend and fellow University of Southern California (USC) ophthalmology resident Rick Villaseñor returned from his course in keratomileusis surgery with Jose Barraquer in Bogota, Columbia.

    Rick was very excited about this surgery, and after he explained what he learned my interest was also stimulated. Fortunately, we were both on the voluntary attending staff at USC under the direction of Drs. Steve Ryan and Ron Smith. We discussed the very complicated keratomileusis surgery with them and asked for their assistance in studying the procedure as a research project at the Doheny Eye Foundation.

    Early days of refractive surgery

    With the support of Drs. Ryan and Smith, we obtained access to the Doheny research lab where we met every Friday for over a year. Somehow we were able to obtain funding to purchase a cryolathe and a Barraquer microkeratome. The Doheny lab had a Terry keratometer, and we had access to cadaver eyes from the Doheny Eye Bank. Dr. Villaseñor also eventually purchased a cryolathe for his own practice.

    Keratomileusis was an incredibly complex procedure which involved obtaining a free cap of cornea with the manual microkeratome, placing it on the cryolathe, then reshaping the cornea to correct myopia by shaving off the proper number of microns of corneal tissue and suturing this lenticule back on the cornea.

    It involved calculations with a Texas Instruments calculator (this was before the invention of computers). We had to follow a detailed manual and audio tape outlining about 60 steps to accomplish the surgery. We practiced on cadaver eyes for over a year before actually operating on patients, but we eventually performed a few cases of myopic keratomiluesis and keratophakia.

    In the late 1970s, radial keratotomy (RK) was introduced in the United States by Dr. Leo Bores. This was a much simpler procedure to reduce myopia, so we began to study it in the laboratory in cadaver eyes by monitoring the changes in the cornea following RK incisions with the Terry keratometer. Dr. Smith also allowed us to performs the RK procedure on monkeys he was using to study histoplasmosis in their retinas.

    This led to a series of publications and presentations about RK in peer-reviewed journals and major eye meetings.1-8 USC was selected as one of the Prospective Evaluation of Radial Keratotomy (PERK) centers, and Rick and I were PERK surgeons. After the PERK patient enrollment was completed, we began performing RK and astigmatic corneal incisions on private patients.

    James J. Salz, MD
    Clinical professor of ophthalmology, University of Southern California, Los Angeles

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