Greed

Only a minority of opthalomogists do LASIK. Behind the slick advertising and claims of risk-free, perfect vision there are a substantial number of doctors who do like what refractive surgery is doing to their profession. These doctors worry that with the rise of "consumer-oriented medicine," doctors will be transformed into businessmen, acting primarily in their own self interest, not in the interest of the patient. For these new MD businessmen, healing and the Hippocratic oath no longer represent their core values.

Letter from a Physician, Originally Posted at www.SurgicalEyes.org

"Unfortunately, some doctors allow greed to get in the way of a patient's best interest."

"I am saddened to read the tragic accounts of the many refractive surgical complications contained in your web pages. As a member of the American Academy of Ophthalmology, a board-certified, practicing ophthalmologist at the midpoint of my career I feel an obligation to set these issues in a meaningful context. While you already allude to many of these points, my perspective may be of some interest. For the present time I prefer anonymity to avoid involvement in the time-consuming litigation that will inevitably come from much of this.

I have a large, general practice which deals with the common problems associated with cataracts, glaucoma, strabismus and retinal diseases. I have chosen not to offer refractive surgery and find myself standing among a dwindling subset of practitioners. I took this position several years ago after I completed a course qualifying me to perform radial keratotomy. Then as now, I felt the risks of the procedure did not justify the benefits. Despite the relatively high success rate of RK, the fact that even a small number of patients would suffer serious, irreversible side effects was ample justification to regard the procedure as "experimental" and not suitable for widespread application.

The Hippocratic dictum, "Primum non nocere" (Do no harm), would seem to apply here. Of course RK had its day and is now a memory, so I recently took a qualifying course in LASIK and PRK, and came to the same conclusion. I am fascinated by the technology. I recognize the demand for a surgical solution to refractive errors and look forward to a time when I can offer a reliable and reversible procedure. I feel confident that this will come about soon. But the time is not now. So I have redirected my efforts to the more mundane aspects of general ophthalmology. I must confess my interest in these procedures goes beyond the fascination of science and high tech gadgetry.

There is a darker side to all of this in the realm of profit. To put it mildly, refractive surgery pays well. The more necessary cataract surgery, the traditional engine of profitability for most ophthalmology practices, has been seriously restrained by managed care regulatory practices and reimbursement shenanigans. In contrast, unregulated, refractive surgical procedures yield profits many times higher than cataract surgery with seemingly lower short- term risks. The severity of managed care's cuts into ophthalmology's profit line has been quick and painful. Many practices were caught off-guard having invested considerable sums into private free-standing operating facilities that run at very high overheads. In the new managed care environment, these facilities are hard-pressed to stay afloat. They need the swift cashflow of a new workhorse procedure. Even surgeons who have ambivalent feelings about the value of refractive surgery cannot afford to remain uninvolved.

A colleague of mine recently confessed that he had no choice but to go the refractive surgery route. Faced with mounting debt, the reality of losing his staff to the refractive surgeon across town, he decided to play Robin Hood by doing refractive surgery on the "well-endowed" to pay for the more necessary cataract surgery for the needy. He, as well as several members of his family, are myopic and continue to wear their corrective lenses. To ease his moral dilemma, he focuses on the many patients who are delighted in the near term with the results of their refractive surgery. I suspect he may well be among those doctors who cannot even begin to comprehend why it is that someone with a 20/20 result can be unhappy. Quite realistically he can no longer be objective. Having made the commitment to refractive surgery, he must plunge headlong to realize the promised profitability. To justify a mountain of start-up costs he must generate a large volume of cases.

Slick advertising campaigns, loss-leads, raffles, screenings, "public-service" stunts have become the tools of his new trade. Unfortunately the various professional organizations within ophthalmology offer little counterpoint. The pervasive financial interests of the laser manufacturers and all the associated industries have generated a tidal wave of momentum. It is unprecedented in ophthalmology that every time someone presses the button to activate the excimer laser, a predetermined portion of the patient's fee goes first to the partnership that owns the laser rights. Some goes to the surgeon and some goes to the referring doctor as a referral fee. (In programs such as Medicare, which does not reimburse for refractive surgery, referral fees or any manner of fee-splitting are strictly illegal and prohibited.) There have been ophthalmologists, although there are fewer today, who have spoken out against these practices and have raised serious questions about the advisability of refractive surgery receiving such premature and widespread application. But these brave individuals have to worry about being cast as Cassandras should all eventually pan out in the best case scenario. Dissenters also have to pay some attention to the possibility of restraint of trade allegations. The Academy of Ophthalmology already has been stung by such an allegation years ago when it attempted to restrain some of the RK enthusiasm. This cost the Academy considerable time and resources to defend. One is now wisely reluctant to confront the financial will of the refractive surgery interests. I notice that your web pages deal largely with the near-term complications of refractive surgery. Unfortunately this is too "myopic" a perspective.

There are long term issues that are generally overlooked: Refractive surgery is performed largely on myopic patients in the pre-presbyopic phase of their lives. In other words, most patients have refractive surgery before they recognize the need for reading glasses, which occurs most commonly in the mid-forties. Mild myopia in the presbyopic patient, who would otherwise have trouble seeing up close, is an asset. Before refractive surgery was available, many patients were pleased to remove their glasses to read The sad irony for many patients undergoing refractive surgery in their thirties is that they will soon need glasses anyway in their forties! I read a sad account recently of a patient who suffered all of the glare handicap of LASIK only to be told recently that he needed a pair of reading glasses. He was sharp enough to realize that these reading glasses effectively restored the nearsightedness he paid so dearly to correct. Unfortunately the glare remained. I and many prominent corneal specialists share a deep and perhaps too passive concern about the lack of knowledge regarding the long term response of the cornea to laser ablation. We simply do not have the experience to rest assured that the cornea will not respond to the loss of substantial amounts of its ablated stroma. Will these centrally thinned corneas eventually become distorted with ectasia ( a bowing forward of the cornea) and eventually require corneal transplantation? What is the long term effect on the other critical layers of the cornea? Will the cornea's natural barrier to infection be impaired? How will the cornea withstand injuries? We have already witnessed the unintended consequence of radial-keratotomized eyes rupturing upon airbag impact. Myopic eyes are more prone to retinal detachment, cataracts and glaucoma over the years. How will these eyes fare as they face these inevitabilities? While I hope current presumptions hold, I would feel better to see a greater degree of experience before the procedures are hawked on every street corner by every self-proclaimed laser specialist. It is particularly upsetting to see the level of interest in these procedures, fueled not by sober scientific inquiry, but by personal testimonials inspired by public relations experts and distributed to the targeted media of the "disposable-income classes". I suspect the recent, favorable run of articles in Barrons, the Wall Street Journal and similar publications are part of this process.

Despite the warnings of the FDA and the American Academy of Ophthalmology, unrealistic promises about a brilliant future of unaided sight is at least implied in every ad and testimonial. I applaud the efforts of your web site to bring all of these concerns to a wider audience. May I suggest that you appeal directly to the FDA office of ophthalmic devices. Were they to impose a very simple requirement that patients seek a second opinion and have the opportunity to question an unbiased professional prior to refractive surgery, it would at least give patients the opportunity to pause for a reality check. It is an outrage that the profit-motivated refractive surgeon is relegated the responsibility of providing "informed consent". This is a blatant conflict of interest. It is sad irony that insurance companies demand a second opinion prior to cataract surgery, often purely to discourage cost over-runs, while refractive surgery goes unchecked. Free-trade enthusiasts should be aware that this issue transcends that of a private commercial interaction between surgeon and patient. Should serious long term complications result, we will be faced with a public health crisis of serious proportions. Short of the protection of the federal government, the only redress patients seem to have is in the courts. While I am no fan of the malpractice profession, its sting should be felt by those who set aside their Hippocratic oath for short term profitability and volatile patient satisfaction.

I would like to extend my apologies and best wishes to all who continue to suffer the complications of refractive surgery. I feel somewhat guilty that those of us, who correctly anticipated your plight, have not found our voice soon enough to be heard. We can only hope that time and further advancements in more noble ophthalmic endeavors will reverse these damages."