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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 refractive surgery procedure

    One day, one of my prospective RK patients said, “If this surgery is so great, why are you wearing glasses?” Excellent question, I responded, and I will consider it.

    At the time, I had minimal astigmatism in my right eye, but my left eye had uncorrected visual acuity of 20/200 and my refraction was: +1.50 -4.00 D x 180. Because arcuate incisions flatten the steep meridian and steepen the flat meridian, I was a perfect candidate for arcuate incisions. Theoretically, paired arcuate incisions should result in a near emmetropic result without RK incisions.

    Rick Villaseñor also had mixed astigmatism, so one day after perhaps too many margaritas, we decided we would operate on each other to eliminate our glasses—we would be able to tell patients we had the procedure ourselves. So we scheduled our surgery at Rick’s surgery center a few days apart.

    Because I did not want to flip my astigmatism, I had Rick first make one pair of arcuate incisions and analyze the effect. He added another pair four weeks later when the refraction was stable. My topography showed symmetrical with-the-rule mixed astigmatism in my left eye, and I was an excellent candidate for arcuate keratectomy.

    My uncorrected vision improved to 20/30, and for over 10 years I was in refractive heaven with excellent uncorrected visual acuity in both eyes.

    Changes over time

    Just as RK incisions can have a progressive effect over time, resulting in continued corneal flattening and hyperopia, arcuate incisions can also have a progressive effect. So 30 years after my AK surgery, my UCVA was back to 20/200, and my astigmatism was now 2.00 D against the rule with a refraction of +1.25 – 2.25 x 90. My map showed asymmetric astigmatism, steeper below, so it resembled a pellucid marginal degeneration (Figure 1).

    I would eventually require cataract surgery, and I knew I would not be a candidate for a toric lens implant with my warped corneal shape. So I emailed my map to Dr. David Lin in Vancouver.

    David is one of the leading experts in topography-guided photorefractive keratectomy (PRK). I also happened to be his proctor when he first started his career in laser vision correction with the VisX laser after a fellowship with Dr. Marguerite McDonald at Louisiana State in New Orleans.

    After reviewing my topography and refractions, David said I was a good candidate for topography-guided PRK with the Schwinn laser system. I spent two days in Vancouver, and David performed the surgery. I told him I wanted to have mild monovision because he was operating on my non-dominant eye. After reviewing my records, he told me we could try to set my postop K readings at about 49.00 D, which should leave me between -1.00 D and -1.50 D.

    The topography-guided PRK was performed with the transepiithelial approach, which took approximately 40 seconds, while the stromal portion took about 12 seconds (Figure 2). There was no discomfort, and believe me, I did not move my eye even 1.0 mm while looking at the fixation light. The video looks like a PRK on a dead person!

    We tell patients they will experience a faint smell like a burning hair. That’s because the surgeon is a couple of feet away from the cornea. When you experience it as a patient with the plume next to your nose, you think your eye is cooking.

    David also applied mitomycin C. My partner Dr. Barry Seibel removed my bandage contact lens five days postop, and my postop course was uneventful with no corneal haze.

    Initially, my refraction was about -4.00 D, but in a few weeks it was down to -2.00 D. At one year, my refraction was -1.25 D. My final K readings were near 49.00 D just as Dr. Lin had predicted (Figure 3).

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


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