It is a wretched taste to be gratified with mediocrity
when the excellent lies before us.
The boundaries for licensed practice of medicine and surgery are based on political, protective, and geographic demands. Communication and mobility in this 21st century increasingly shrink the globe, aiding a universal dissemination of knowledge while maintaining strict boundaries on practice privileges. Although cultural variations and language issues limit the mobility of medical men and women, some barriers that formerly prevented movement of the work force are being lowered, such as the current expansion of the European Union to incorporate 10 former Soviet satellite countries. Thus, doctors may now have the opportunity to practice in areas formerly forbidden to them.
In this respect, it is interesting to look back to the evolution of licensed medical practice. Two hundred years ago in Great Britain, medical men practiced with university degrees, various forms of licenses, sometimes a combination of degrees and licenses, and sometimes none at all. Medical training varied from classical—university education and the study of Greek and Latin medical texts, on the one hand, to broom-and-apron apprenticeship in an apothecary's shop, on the other—and sometimes involved no recognizable education at all. Quacks, “empirics”, and drug peddlers practiced freely with no legal sanctions against them, while a physician in London could be disciplined by his college for preparing and selling a prescription to his patient.1
If a refractive surgeon were to follow the advice of William Osler, 1849–1919 (“One finger in the throat and one in the rectum makes a good diagnostician”—[aphorism from his bedside teachings]), he or she would have to be preternaturally sharp to solve a complex corneal surgery problem. Despite being deluged as we are with an unquenchable flow of clinical evidence of a manner that could not have been conceived in days of yore, refractive surgical problems may arise because of an irresistible impetuosity to make clinical decisions, a possible consequence of high-volume practice.
One current predicament is the absence of an internationally recognized accreditation for the practice of refractive surgery at a time when the world is shrinking in terms of the ability of medical practitioners to perform outside their training country. Not quite a parallel with the free for all in 1804, but it is worth the pursuit of international training and accreditation.
A select committee of the houses of parliament of the United Kingdom met in February 2004 in response to a motion presented and discussed some days earlier in a full parliamentary session. The motion expressed concerns by the United Kingdom government on behalf of the public regarding the safety and practice of corneal refractive surgery in the United Kingdom. Presentations were made by refractive surgeons representing the different types of clinics, expressing the successes of the process as well as the inherent dangers. These crystallized as poor training and use of itinerant surgeons in some clinics. A point was made that it is not important where corneal laser surgery is practiced—hospital-based practice, private clinic, or a private clinic chain—but how it is practiced. As refractive surgery in general and LASIK in particular are relatively recent events and practiced almost exclusively in the private sector, it was obvious that ophthalmologists in training in the United Kingdom are not exposed to that aspect of ophthalmic surgery and have no chance for hands-on experience. Refractive surgical training is accessible through fellowship attachments to established refractive surgery clinics and through the many opportunities for self-training in courses at meetings of the European Society of Cataract & Refractive Surgeons, the American Society of Cataract and Refractive Surgery, the American Academy of Ophthalmology, and local meetings in many countries. Accreditation for theoretical as well as practical skills has not yet achieved anything like universal recognition. Not surprisingly, it was apparent from the United Kingdom parliamentary committee that the process of corneal refractive surgery succeeds or fails according to the skills and clinical judgment of the individual surgeon. There was a consensus that the guidelines for corneal refractive surgery recently published by the Royal College of Ophthalmologists were entirely appropriate (Royal College of Ophthalmologists Guidelines for the Practice of Corneal Laser Surgery 2003).
Current guidelines pave the way for safe practice and represent a consensus on contemporary clinical care standards. Refractive surgery, as all branches of medicine and surgery, is a dynamic process with advancement of knowledge leading to constant improvements in standards of care. Six articles in this issue contribute to our continuing professional development through their attention to different aspects of corneal refractive surgery, LASIK in particular. They verify the journal's contribution to our continuing medical education and thereby enhance the didactic events mentioned above. It exemplifies the vibrant nature of the subject, where every morsel of shared knowledge contributes to patient welfare everywhere, for we live in a global community in which an increase in scientific and clinical knowledge is freely shared, as befits medical practice. However, the capacity for instantaneous sharing of information can be used to undermine public confidence in refractive surgery as well as for the betterment of medical practice. One complication may create a disgruntled patient who, more often than not aided, abetted, and encouraged by a partner and or by friends, seeks media exposure to denigrate an overwhelmingly successful process. This may deter potential patients from seeking proper counseling and the prospect of the benefit of treatment. Two hundred years on, there are still elements in our surgical society that run parallel to the diverse backgrounds and skills of our surgeon precursors, acknowledged but not necessarily approved by the supervising authorities of that time.
Three aspects of LASIK flaps are investigated by Mahler et al. (page 1320–1325), Javaloy et al. (page 1300–1309), and Ito et al. (page 1240–1247). Ito et al. report an incomplete flap rate of 0.67% compared to a reported rate in the literature of 0.68% to 1.60%. Of these complications, 83% occurred through use of a manual keratome and, perhaps not unsurprisingly, more frequently in the hands of less experienced surgeons (fewer than 100 cases). Thin flap complications were logically attributed to inadequate suction. Reassuringly, there were no serious issues concerned with flap recut after an interval and only 1 eye lost 2 lines of best corrected visual acuity.
Flap quality was assessed by Javaloy's group using confocal microscopy to search for differences between 3 microkeratomes, 1 of which has been largely superseded by the same companies; Hansatome® (Bausch & Lomb) and the Moria M2 are the other keratomes. The confocal microscope allows in vivo flap comparisons previously a facet of in vitro studies by electron microscopy. The authors used confocal microscopy through focusing (CMFT) analysis, which allowed observation of the different reflective intensities generated by successive layers within the cornea. They were able to correlate every point on a CMTF curve with the image to accurately calculate the distance between different corneal sub-layers with good predictability. Microkeratome cut evaluation and particle analysis within the interface were possible. Among the authors' conclusions was that the depth quality and predictability of cut, but not the density of particles at the interface, seemed to influence corneal transparency after LASIK surgery.
Flap diameter variations with 3 different Hansatome microkeratomes utilized by 4 different surgeons was studied by Mahler et al., who concluded that the actual flap size was larger in all eyes than the ring size, irrespective of which of 3 Hansatome variants were used in the hands of 4 surgeons.
Hyeropic LASIK raises many issues, one of which is the mode of centration of the laser ablation. Hyperopic patients often exhibit a significant angle kappa, raising uncertainties as to where the ablation should be centered. Should it be pupil centered or on the first Purkinje image, which according to the angle kappa may be quite eccentric from the pupil center? Nepomuceno et al. report their experience using the LADARVision 4000 platform for treatment of hyperopic eyes and concluded that the ablation zone centered on the coaxially sighted corneal reflex did not adversely affect best spectacle-corrected visual acuity or contrast sensitivity. This will be a reassuring message to those surgeons who do likewise.
What is clear is that the semi-mechanical aspects of the LASIK process comparing like with like is virtually impossible. Surgical skills, experience, clinical judgment allied to different microkeratomes and different laser platforms, even different laser locations for the same type of laser, may influence outcomes if only to a small degree. This makes the apparent uniformity of excellence of outcome generally accepted as a great achievement given the multiple variables referred to. As quality of vision rather than quantity becomes the new goal, the subtle differences may make a greater impact.
1. Peterson JM. The Medical Profession in Mid-Victorian England. Berkeley, CA, University of California Press, 1978