Radial keratotomy

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Radial keratotomy (RK) is a refractive surgical procedure to correct myopia.

Contents

[edit] Discovery

The procedure was discovered by accident by Svyatoslav Fyodorov who removed glass from the eye of one of his patients who had been in an accident. A boy, who wore eyeglasses, fell off his bicycle and his glasses shattered on impact, with glass particles lodging in his eyes. A procedure was performed consisting of making numerous radial incisions which extended from the pupil to the periphery of the cornea in a pattern like the spokes of a wheel. After the glass was removed (by this method) and the cornea healed, he found that the patient's eyesight was significantly improved.[1]

[edit] Procedure detail

Schematic diagram of RK, with incisions drawn in orange.
Schematic diagram of RK, with incisions drawn in orange.

In radial keratotomy (RK), incisions are made with a precision calibrated diamond knife. It has been found that incisions that penetrate only the superficial corneal stroma are less effective than those reaching deep into the cornea,[2] and consequently incisions are made quite deep. One study cites incisions made to a depth equivalent to the thinnest of four corneal-thickness measurements made near the centre of the cornea.[3] Other sources cite surgeries leaving 20 to 50 micrometres of corneal tissue unincised (roughly equivalent to 90% of corneal depth based on thickness norms).[2]

Arcuate keratotomy is still popular to correct astigmatism. It is also done with a diamond knife but in these cases, cuts are made circumferentially, parallel to the edge of the cornea.

[edit] Postsurgical healing

Cross-section schematic of postsurgical epithelial plugs. Example of a desirable outcome left, and an undesirable outcome right.
Cross-section schematic of postsurgical epithelial plugs. Example of a desirable outcome left, and an undesirable outcome right.

The healing corneal wounds are comprised of newly abutting corneal stroma as well as fibroblastic cells and irregular fibrous tissue. Closer to the wound surface lies the epithelial plug, a bed of the cells that form the normal corneal epithelium, which have fallen into the wound. Often this plug is three to four times as deep as the normal corneal epithelium layer. As the cells migrate from the depth of the plug up to the surface, some die before reaching the surface, forming breaches in the otherwise healthy epithelial layer. This consequently leaves the cornea more susceptible to infection.[4][5][6] This risk is estimated to be between 0.25%[7] and 0.7%[8] Healing of the RK incisions is very slow and unpredictable, often incomplete even years after surgery.[9] Similarly, infection of these chronic wounds can also occur years after surgery,[10][11][12] with 53% of ocular infections being 'late' in onset.[13] The pathogen most commonly involved in such infections is the highly virulent bacterium Pseudomonas aeruginosa.[14]

[edit] Side effects

Large epithelial plugs may cause more scattering of light, leading to symptoms of flare and 'starbursts'. This can happen especially in situations like night driving, where the stark glare of car headlights abounds. These dark conditions cause the pupil to dilate, maximizing the amount of scattered light that enters the eye. In cases where large epithelial plugs lead to such aggravating symptoms, patients may seek further surgical treatment to alleviate the symptoms.[4]

Increasing altitude can cause partial blindness in radial keratotomy patients, as discovered by mountaineer Beck Weathers (who had had the surgery) during the 1996 Mount Everest disaster.


The incisions of RK are used to relax the steep central cornea in patients with myopia. Popularized by Dr. Svyatoslav Fyodorov of Russia, the original technique of incisions from periphery to center was called the Russian technique (Gulani AC, Fyodorov S: Future Directions in Vision course, June 1997) while the later advances of performing controlled incision from center to periphery was called the American Technique (Gulani AC, Neumann AC: Refractive Surgery Course, Feb 1996). Radial keratotomy enjoyed popularity during the 1980s and was one of the most studied refractive surgical procedures. It’s 10 year data was published as the PERK (Prospective Evaluation of Radial Keratotomy) study, which proved the onset of progressive hyperopia often found a decade after the original surgery due to continued flattening of the central cornea. A conceptually opposite technique of using hexagonal incisions in the periphery of the cornea is known has Hexagonal Keratotomy or HK Described by Dr. Antonio Mendez of Mexicali, Mexico), which was used to correct low degrees of Hyperopia. The idea of HK was to make six peripheral incisions to form a hexagon around the central cornea to steepen the hyperopic flat cornea and therewith focus the rays of light onto the retina. These incisions could further be of two types; connecting and Non-connecting (Gulani AC: 10 Refractive Procedures for Hyperopia. ISOPT 2001).


Patients with Radial Keratotomy (RK) may present with a variety of incisions. They can have 4,8,16 or 32 incision surgeries and also all kinds of patterns and linearity based on their refractive errors, surgeon's style or training when it was initially done. Many of these patients have had additional incisional surgeries like Astigmatic Keratotomy or AK where incisions are placed at the steepest points of the cornea in patients with astigmatism to relax and transform the cornea to a more spherical shape. Some patients have had a combination of intraocular surgeries such as Pseudophakia or Phakic implants along with their keratotomies and many of them also underwent purse-string suture to control the over-correction (Dr. Green’s Lasso suture). RK patients could very well be an epidemic of the modern era in refractive surgery presenting a new challenge not only to understand the visual deficits but also to individualize the plans. Technological challenges of how to calculate the IOL power post RK surgery for an associated cataract as well as the aberrations induced along with stability questions of a changing refraction in a patient population that has not changed their expectations is the question of the hour as we progress into the future. The presenting visual complaints are outlined in a new classification system below wherein the patient could be presenting with hyperopia as stated by the PERK study and that too at an age of Presbyopia (both require Plus lenses to correct them and therefore are a compounded problem) or with associated age relate deterioration from cataracts. Due to the instability of the cornea along with age-related pathologies many physicians find it difficult to address these patient’s visual acuity satisfactorily. In order to simplify the complete visual impact of the surgery/surgeries and also the associated pathologies to best understand and therewith customize a plan for visual freedom, we have suggested the following system. Primary Visual factors: Quantitative: Decreased visual acuity (Myopia, Hyperopia, Astigmatism) Qualitative: Irregular astigmatism Small Optic Zone Incisions Secondary (Associated) Visual Factors: Presbyopia Cataracts Corneal Scars Corneal Instability (thin / ectasia / trampoline effect) A promising contemporary surgical technique and ophthalmic super-specialty known as Corneoplastique™ provides the opportunity for RK patient to see once again. Arun C. Gulani, founder of the Gulani Vision Institute and former professor of ophthalmology, established Corneoplastique™ and continues to teach his concept worldwide. We can therewith use modern technologies like the Excimer laser in a Laser Vision mode as well as combine lens based surgery as cataract surgery with Mono or Multifocal or even Toric lens implants to address these patients and their unique presentations.

[edit] References

  1. ^ San Francisco LASIK Eye Surgery & Vision Correction - San Francisco LASIK Surgeon
  2. ^ a b Bashour M, Benchimol M. (2005) Myopia, Radial Keratotomy. Emedicine. Viewed 12 October 2006. <http://www.emedicine.com/oph/topic669.htm>
  3. ^ Waring G, Moffitt S, Gelender H, Laibson P, Lindstrom R, Myers W, Obstbaum S, Rowsey J, Safir A, Schanzlin D, Bourque L. (1983) ‘Rationale for and design of the National Eye Institute Prospective Evaluation of Radial Keratotomy (PERK) Study’. Ophthalmology 90(1):40-58
  4. ^ a b Bergmanson J, Farmer E. (1999) ‘A Return to Primitive Practice? Radial Keratotomy Revisited’. Contact Lens and Anterior Eye 22(1):2-10
  5. ^ Bergmanson J, Farmer E, Goosey J. (2001) ‘Epithelial plugs in radial keratotomy: the origin of incisional keratitis?’ Cornea 20(8):866-72
  6. ^ Deg J, Zavala E, Binder P. (1985) ‘Delayed corneal wound healing following radial keratotomy’. Ophthalmology 92(6):734-40,
  7. ^ Waring G, Lynn M, McDonnell P. (1994) ‘Results of the prospective evaluation of radial keratotomy (PERK) study 10 years after surgery’. Arch Ophthalmol 112:1298-1308
  8. ^ Holler K, Darin J, Pettit T, Hofbaner J, Elander R, Levenson J. (1983) ‘Three years experience with radial keratotomy: the UCIA study’. Ophthalmology 90:627-636
  9. ^ Binder P, Nayak S, Deg J, Zavala E, Sugar J. (1987) ‘An ultrastructural and histochemical study of long-term wound healing after radial keratotomy’. Am J Ophthalmol 15;103(3 Pt 2):432-40.
  10. ^ McClellan K, Bernard P, Gregory-Roberts J, Billson F. (1988) ‘Suppurative Keratitis: a late complication of radial keratotomy’. J Cataract Refract Surg 14:317-320
  11. ^ Mandelbaum S, Waring G, Forster R, Culbertson W, Rowsey J and Espinal M. (1986) ‘Late development of ulcerative keratitis in radial keratotomy scars’. Arch Ophthalmology 104:1156-1160
  12. ^ Wilhelmus K, Hanburg S. (1983) ‘Bacterial Keratitis following Radial Keratotomy’. Cornea 2:143-6
  13. ^ Jain S, Azar D. (1996) ‘Eye infections after refractive keratotomy’. J Refract Surg 12:148-155
  14. ^ Heidemann D, Dunn S, Chow C. (1999) ‘Early- versus late-onset infectious keratitis after radial and astigmatic keratotomy: clinical spectrum in a referral practice’. J Cataract Refract Surg 25(12):1615-9.


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