Eye believe

(The Observer, 26 September 1993)

Surgeons all over Britain claim to be able to cure myopia with scalpel and laser beam. Over a year ago, Richard Askwith took his sight in his hands and underwent photo-refractive keratectomy. Only now can he answer the pressing question: does it work?

AS THE scalpel blade, improbably large, descended into my right eye, scenes from my past life – and more specifically from the past hour – began to replay themselves in my mind, vividly. Not dramatic scenes, just ordinary moments transformed by the joy of sight: a walk through empty West End streets on a golden winter morning; a flying bird reflected in a windscreen; a reassuring smile on the face of my wife.

So much life experienced through the eyes; so much taken for granted. And now I was risking it all – for what? To see what happened, I suppose. To remove a minor inconvenience from my life. Also, to be honest, to take advantage of a freebie.

Like many people, I had noticed the increasing prevalence of advertisements in newspapers for ‘laser treatment to correct short sight’. Sometimes you can see three or four, scattered among the plastic surgeons and the hair loss clinics, in a single issue of the London Evening Standard, all advertising different clinics. Could it really be as kosher, as risk-free, as their proliferation suggested? I doubted it. On the other hand, surely they couldn’t all be cowboys?

Ivor Levy and Douglas Muir-Taylor of Harley Street Eye Laser Associates would be horrified to be described as cowboys. They are, among other things, highly respected ophthalmologists at the Royal London Hospital. They are also so confident that their private activities can stand up to public scrutiny that slightly more than a year ago they approached the Observer, offering to treat a short-sighted journalist for free. It seemed a good idea. I was selected as guinea pig.

Surgical correction of short sight comes in two main forms. Radial keratotomy – pioneered in Japan in the 1930s, perfected and popularised in the Soviet Union in the 1970s and 1980s, and now performed some 200,000 times a year in the USA alone – involves making micro-incisions with a scalpel around the edge of the cornea. These flatten the cornea as they heal. Photo-refractive keratectomy (PRK), first performed on non-blind patients in 1989, achieves the same end – flattening the cornea – by the more direct means of shaving away from the front of the cornea, with a laser beam, a layer of molecules half a cell thick known as Bowman’s membrane. In each case, the improved shape makes light focus exactly on the retina, as in a non-myopic eye, and not slightly in front of it.

Although several million people around the world have undergone radial keratotomy, in Britain it has recently been overtaken in popularity by PRK. There are three main reasons for this. First, keratotomy is more invasive, causing more damage to the eye and thus making it fundamentally weaker, as well as creating a risk of serious infection; PRK, doing less, should be safer. Second, the word ‘laser’ inspires an

irrational confidence in many people. Third, growing numbers of ophthalmologists have invested heavily in expensive laser technology (Mr Levy and Dr Muir-Taylor spent around £250,000 on theirs) and have therefore been trying to whip up public enthusiasm for the operation.

Had I paid for it, my operation would have cost me about £2,500. This is relatively expensive: some clinics charge as little as £400 per eye for the same operation, although their upmarket rivals claim that they can do so only because they offer an unacceptably low level of after-care. The average seems to be around £1,500. Whichever clinic you choose, though, it is clearly a lot to spend on an operation that is little more than cosmetic. Or is it?

I am 33 years old and have been short-sighted for about eight years. I tried and failed to get on with glasses, then switched to soft contact lenses about six years ago. What with cleaning equipment (about £175 a year), insurance (£35 a year) and replacement lenses every three years or so (about £150 a pair), I estimate that my lenses cost me more than £250 a year, or £1,500 over six years. And that’s not taking into account the time they took up; or the inconvenience (always remembering to buy the right bits and pieces, and to pack them when travelling); or the fairly regular discomfort; or the slight but constant possibility of being half-blinded by the loss of a lens.

Looked at like that, a one-off payment of £2,500 can seem a modest price for permanently solving the problem of sight – especially if someone else is paying the £2,500. And so it was that I found myself, earlier this year, leaning back in a chair rather like a dentist’s chair while Ivor Levy scraped at my eye with a scalpel and Douglas Muir-Taylor, a few feet away, pored over the controls of a machine that looked like a giant photocopier.

As usually happens with this procedure, I was having my weaker eye operated on first. If all went well, 24 hours later my vision through that eye would be blurred and substantially long-sighted. The blurring would clear in a week or so; the long sight would correct itself over the next three to six months. Only then would they move on to my other eye.

The scalpel did not hurt, thanks to anaesthetising eye drops administered during the previous half hour. Nor was it more than a routine preliminary to the operation proper: Mr Levy was removing the epithelium, or outer skin of the eye, to expose the cornea to the laser. Nonetheless, there is something upsetting about an eye being interfered with in this way. A few weeks earlier, watching the same process being performed on another patient, I had fainted.

Now, lying beneath the Excimer Laser machine while its computer calculated the precise amount of ‘shaving’ required to correct my degree of short-sight, I felt not so much queasy as curious. For a few minutes I stared into soft green and red haloes of light, my left eye patched, my right eye held open with a metal clip, while everything was lined up. Then, for about 10 seconds, there was a clicking sound like an electric typewriter, small silver stars exploded delightfully in front of my eye, and there was a disconcerting smell of burning cornea.

Ten minutes later, patched up and liberally supplied with painkillers and sleeping pills, I was back out on the street. It had all seemed alarmingly casual: an eye test a week or so earlier; a blood test to ensure that I was suffering from no systemic disorders liable to delay healing; some questions about my medical history; a last minute consent form (‘I understand fully the implications of all the potential complications’); and, clickety-click, someone I hardly knew had vapourised my Bowman’s membrane, irrevocably.

Nevertheless, it seemed to work. I groped my way home and slept for 24 hours, then went back to be checked. The patch was removed; the eye saw daylight, blurred but full of recognisable objects; and a wave of relief swept over me. Never mind the details: at least I wasn’t blind.

I had been worrying about the possibility of serious complications for most of the previous 48 hours: not because I doubted the ophthalmologists’ competence but because PRK is still so new as to be verging on the experimental. The night before the operation, a doctor friend told me that I ‘must be mad’ to try such a ‘young’ operation. On the morning itself, I felt sad and afraid. Why on earth had I committed myself to jeopardising my only set of eyes, just for the sake of a good story?

In fact, the figures are, on the whole, reassuring. There are now anything up to 100,000 people around the world who have had PRK, including about 10,000 in Britain. Yet so far only two cases of major complications have come to public notice; both of which, according to Mr Levy, involved patients suffering from systemic healing disorders who should have been screened out beforehand. One recent study found that 78 per cent of patients receiving the treatment regained normal vision, with a further 19 per cent near enough normal to pass a driving test and the remainder merely remaining short-sighted.

‘They wouldn’t allow it if it wasn’t safe’ was another comforting thought; but of course they probably would. In the UK, new surgical procedures are not subject to anything like the same safety regulations as new drugs. Then again, surely Mr Levy and Dr Muir-Taylor wouldn’t risk exposure in the press – and thus professional ruin – unless they were absolutely confident?

What really coaxed me into the ophthalmologists’ chair, though, was the realisation that my fears were irrational. What was I putting at risk? Perfect sight? I lost that years ago. The certainty that my eyes would never deteriorate further? A delusion. Even if I chickened out, I might still end up blind; especially if I was going to spend the next 50 years putting contact lenses in my eyes. (Disorders already associated with long-term contact lens use include corneal vascularisation, allergic conjunctivitis and corneal ulcers.) On balance, therefore, and money being no object, was it not better to choose the course that seemed likely to improve my quality of life in the short and medium term? So I did; and it has.

True, there are more important things in life than being able to read the numbers on the radio alarm when you wake up, or to swim, run, travel and generally live without half a thought always on your lenses or glasses. Nevertheless, it makes you feel free.

In the months following my first operation, I returned for numerous checks, first weekly, then monthly. The ophthalmologists professed themselves delighted with my progress. All traces of discomfort and most traces of distorted vision disappeared after a couple of weeks. It was hard to read at first, and I tended to fumble when performing ‘close’ tasks such as inserting keys in locks. But this was no great hardship, and it was comforting to be told that, the longer it took for the treated eye’s long-sightedness to correct itself, the better were my chances of perfect, stable sight in the end.

After seven months, I had my left eye treated. Two months later, my vision is more or less normal, although it will probably be Christmas before the long-sightedness in the second eye has totally disappeared and I acquire, perhaps for the first time in my adult life, 20/20 vision.

I still worry, every now and then, that in later life I will regret having jumped so blithely on to a novel medical bandwagon – like people who have had silicon breast implants. Yet the premise behind this worry – that it is reckless to take advantage of any medical procedure that is less than 50 years old – is self-evidently absurd.

PRK works best on people like me: relatively young (say 25-40) with relatively mild myopia. What puts such people off the procedure is the thought: ‘If it ain’t broke, don’t fix it.’ But of course it is broke; and I for one am glad to have fixed it.

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