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RK Factory - Photo and Text Excerpt, National Geographic, Nov. 92

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Vision Factory

The Henry Ford of Ophthalmology, Moscow's Svyatoslav Fyodorov (center) pioneered surgical correction of nearsightedness - and created an assembly-line procedure that dismays many U.S. physicians.

Eight patients at a time lie on tables in Fyodorov's clinic (below). When the five attending surgeons each finish their specialized portion of the surgery, the tables rotate for the next step. Each doctor's activity is monitored on TV screens over the surgical arena (above).

Fyodorov was inspired to invent the turntable approach in 1986, when the Soviet government agreed to pay him on a per-surgery basis. "This way I became immediately rich, " decleares Fyodorov, who is searching for even more ways to automate. "Our main task now is to exclude the doctor from surgery because he is the main cause of mistakes."

Many U.S. doctors now perform a similar procedure, charging patients roughly $3,000 for the chance to throw away their glasses. According to an ongoing study, they can do so in only 67 percent of cases, far below the 99 percent success rate Fyodorov claims.

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Excerpted from the National Geographic magazine,"The Sense of Sight", November 1992.

Fyodorov's RK Factory & Monitor Station

Note: The lower photo is intentionally blurred since it was taken with a low shutter speed setting while the gurneys were rotating.
This article is highly recommended and should be available at your public library.

Sight for Four Eyes - by Mary Roach, Health, Nov./Dec. 1992 PP. 70+

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Sight for Four Eyes

Dusk hits surburban Moscow like glaucoma. Day fades and a thousand concrete high rises blur into a featureless murk. With no sidewalk cafes open late, no neon signs or blinking marquees, one light breaks the tarry monotony of the Beskudnikovo District night. High on the roof of the Hotel Spectr, lit from within and visible for miles, is a giant rotating eye.

Like the glowing red stars on the Kremlin spires, the eye stays on all night. For guests of hotel Spectr, this is fortunate. Without it, many might never find their destination. They can't read the letters on the building or the numbers above the door. They're not illiterate, just nearsighted.

Hotel Spectr is the in-house hotel of the Moscow Eye Microsurgery Research Institute, where each day upward of 300 myopes take their turn on the Automated Recovery of Sight Line - the world's first conveyor-belt operating room. The operation being done is radial keratotomy (RK), a painless ten-minute procedure to correct nearsightedness, invented in 1971 by the institute's director, Svyatoslav Fyodorov.

In Russia, RK is as common and inexpensive as contact lenses are here. With branches in 12 Russian cities, the institute is making its way, eyeball by eyeball, toward Fyodorov's goal and the institute's motto: Beautiful Eyes for Everybody.

Not as many beautiful eyes here yet, but more than 700,000 Americans have had RK since U.S. surgeons first learned the technique from Fyodorov over a decade ago. Of course that still leaves an estimated 40 million nearsighted American adults uncut and apparently wary. RK is a simple procedure, but so is putting on glasses or a pair of contacts, and only one of them involves a knife. Does convenience justify surgery - on healthy eyes? Is vanity reason enough to scrimshaw your corneas?

As a lifelong myope, I want to say yes. My glasses are thick and geeky. They bow the walls and distort my face. Contacts dry my eyes and fray my patience. How lovely it would be to drop them down the drain one last time.

I want very much to believe that RK is safe and reliable. Fyodorov and his staff, whom I'm meeting tomorrow, have done more myopia surgery -- RK and also its new no-knives cousin, excimer laser surgery -- than just about everyone else combined. If anyone can convince me, it's them.

For now, it's TV and room service at Hotel Spectr. I'm watching the Moscow educational channel, a daffy hash of makeup instruction and language course in broken English ("Right, I'll take the longer short one and the shorter long one!"). Outside in the corridor, it's Night of the Living Myopes -- mute, shuffling Russians with bandages and bloodshot eyes. A tray arrives. Tonight's special: headcheese in aspic. It's going to be a longer short week.

Fyodorov's office is vast, an Olympic swimming pool drained and paneled in cherry. The decor says three things: I am rich, I like horses, I am an eyeball wizard-techno hotshot. Fyodorov sits at the far end of the room, behind a desktop clutter of horse statues and telephones, three or four of each. Covering the wall to his left is a bank of video monitors, five across and six high. Each screen shows a magnified close-up of an operation underway somewhere in the institute: 30 full-screen human eyeballs under the knife.

Fyodorov hangs up and extends a hand. At 66, his is the stout, gruff mien of an aging general. The rib cage is heroic; the head, massive and jowled. The face and silver brush cut are instantly familiar, perhaps because I've see them so many times. Fyodorov's picture is everywhere, on walls, brochures, his business cards, my lapel. (The souvenir shop sells "Eye Microsurgery by Fyodorov" buttons.)

Fyodorov hits a lever and eye number 12 flickers into view on a larger screen behind him. It's a radial keratomy. The surgeon has come from Spain to learn the technique. In the late seventies, Fyodorov taught RK to a group of American surgeons, who went on to teach it to others. Now most of them feel they've one-upped Fyodorov, improving the RK technique.

Fyodrov disagrees, mightily. Epically, like a gladiator. "We have now quality ten times better than U.S. We have five hundred and sixty doctors, three hundred engineers, and plant with twelve hundred people. It's impossible to have such quality, such technology, in one local doctor, like in United States. It's the same as if I make television myself. How to compete with Samsung, Sony?" From his desk he takes a lacquer box. "Look. Sharpest-in-the-world knife to sell to U.S. doctors."

On the lid is a painting of the Kremlin. "This," says Fyodorov, "we will take away and put instead our institute." With that, the conversation broad-jumps from eyes to politics. Disgusted with the pace of economic reforms, Fyodrov and a handful of Russia's other capitalist elite are forming their own political party.

"Our government today monopolizes everything, land, buildings, raw materials!"

The interview is out of control, galloping breakneck like so many verdigris horses on an eye surgeon's desk. I interrupt to ask Fyodorov about his vision.

"My vision for this country! Yes! We have now to make capitalistic period of economy..."

"Actually, I..."

"Our people are slaves! We must...""

"Sir, I meant your eyesight."

"Oh. My eyes. Is okay. Not myopic. Just little bit reading problem." There is a lull in the conversation, which Fyodorov seizes by the neck. He wants to show me plans for his latest project, a hot air zeppelin with an on-board operating room. He's already built a surgical yacht -- the swimming clinic, my interpereter later called it.

"Could we talk about RK? Please."

"Okay, very simple," We start with the basics. The eye works like a camera. The pupil is the aperture, the hole through which the light rays enter. Under this is the lens, which helps bend the rays so they focus on the back of the eye. Where a camera has film, the eye has a retina, whose nerves relay the image to a 24-hour fotomat known as the brain.

If you are nearsighted, your lens and retina are fine but the whole camera is misshapen. Nearsighted eyeballs are too long; they're more like eggs than balls. Instead of focusing on the retina, light rays fall short, focusing just in front of it. To adjust the focus, you can either add a second lens (get glasses or contacts) or fiddle with the shape of the eyeball (have RK).

Sepecifically, RK flattens the front of the eyeball, Fyodorov points to the colored front of the eye. "This is cornea, yes?" Actually, you can't see it, but the cornea covers the iris like a a clear contact lens. "Behind is pressure, always pushing out against cornea. Now, I will put here some incisions." As though cutting a pie, he traces eight lines in from the edge of the cornea. On each, he stops three-fourths of the way in, leaving the center uncut.

"Where cut, cornea becomes more weak, eye bulges outs. More bulge in peripheral part of cornea makes flatter in center part. Because the eyeball has changed shape slightly, the light rays now focus on target."

Fyodorov has an analogy. "Our cornea like woman's breast. If women want to have big breast, they pushing on side with bra and breast becomes more steep." That's a nearsighted breast. Radial keratotomy is like taking off the bra or slitting the underwire. The results is a less pointy silhouette.

The first successful RK was an accident. In 1971, Fyodorov treated a patient whose eye had been scored in a fight by shards from his glasses. "Someone punch this man" he says, "and make beautiful surgery." Treating him, Fyodorov noticed the man's vision had improved.

The first intentional RKs were only slightly less primitive. Instead of slivers of glass, surgeons used tiny bits of razor. Given the crudeness of these early RKs, the results were impressive; four fifths of patients were seeing well enough not to need glasses after one year. Today, with the help of computer calculations and diamond blades, the success rate is much higher.

I ask Fyodorov for his most recent figures.

"Yes of course, statistics. Radial keratotomy, in 99 percent of good candidates, it will be okay. That's why we say, "Beautiful Eyes for Everybody."

To find out whethere I 'm a candidate for RK, Fyodorov has sent me down to the Diagnostic Conveyor Belt, a Tilt-A-Whirl of vision tests complete with sonographic eyeball measurements. The computer's conclusions are being explained by ophthalmologist Leonid Lyogkikh. Lyogkikh works in the training department, teaching RK to foreign and Russian doctors. An accomplished surgeon with some 5,000 eyes under his belt, he is as humble as Fyodorov isn't. Where Fyodorov hangs portraits of Fyodorov, Lyogkikh has a small bust of Hipporcrates.

Since Lyogkikh speaks little or no English, and I no Russian, I 've been provided with a staff interpreter, Natasha, a comely Ukrainian with perfectly applied eye shadow and somewhat less expertly applied English language skills. (Doubtless a victim of educational TV.)

Lyogkikh says good candidates are people who can at least read the big E on the eye chart (20/400, meaning that what they can read at 20 feet, someone with perfect vision can read at 400). People who squint at the big E but are over 45 may also be good candidates. RK works better on older, slower-healing corneas.

Beautiful Eyes for Many People. But not yet for me. "The doctor says your cornea, she is too steep." I am 20/1200, with a prescription of -7.00 diopters for glasses and contacts. My eyes are Anita Ekber's bosom in "La Dolce Vita," Madonna's in a Gaultier halter. Five hundred sixty doctors and the sharpest-in-the-world knives can't make me see 20/40 or better. About the best I could hope for is 20/100.

Compared to the way I see now, this would be a gift.

However, as Lyogkikh talks, I'm hearing two reasons why I should still think twice before having it done. First, I'd have to wear glasses (rather than my preferred contacts) to correct the nearsightedness that remained. Standard contacts don't fit the abnormal contour of an eye that had RK. Second, I'd need 12 incisions. And the more cuts (they range from three to 16), the more likely you'll be bothered by RK's main longer-term side effects, starbursts and fluctuating vision.

Starbursts are glary rays seen around lights when it's dark. At best, it's hard to notice. At worst, it's hard to drive. Headlights are exploding supernovas; streetlamps are the star of Bethlehem on a dimestore Chrismas card. Whenever it's dark, the pupil dilates to a size larger than the uncut center area of the eye; you're looking out through the scars of the RK incisions -- like looking at a light through scratched glass.

Fluctuations in vision happen because RK weakens the cornea, which then might change shape in response to changes in intraocular pressure that normally take place over the course of the day. Someone with RK who sees 20/20 in the morning may see 20/50 by evening.

A less common but more unsettling side effect is called progressive hyperopia. In about 5 percent of todays's RK patients, the cornea continues to flatten; as when you focus a projector, vision goes from sharp to sharper. If RK has left you undercorrected and this happens, it's fine -- your sight just gets better. But if you are now 20/20, you may gradually overfocus and go farsighted. This time, you'll need glasses for reading -- or, worse, all the time.

As with RK's other side effects, creeping farsightedness is thought to be less common in patients with fewer incisions. During RK's early years, surgeons routinely made more than 16 incisions. These days, the average is more like four or eight, so the farsightedness rarely advances more than one line on the eye chart. To be on the safe side, many surgeons aim for slight undercorrection. Says Lyogkikh, "Better to think of future and leave small myopia."

I ask Lyogkikh how common it is for a doctor to miscalculate and overcorrect an eye. He says it happens only when a doctor lacks training and experence. His students practice on 100 pig eyes before moving on to humans. RK isn't a very difficult procedure, except for someone who's never done it before. A journalist, for example.

"Oh my God, look what you do to this pig!" cries Natasha.

Lyogkikh has set me up with a trainer eye, a glistening blue-grey blob cupped atop a small stand, like something served for breakfast on a UFO. The RK blade is so tiny you can't feel it cut. It doesn't help that you're being watched. It helps even less that one of the eyes watching you is the one you're cutting.

"Now your angle is all wrong," says Natasha. "The doctor say you will poke into the lens, and this very pig now will have cataracts."

Even when the doctor doesn't slice through to the lens, bad things can happen after RK -- and not only to pigs. Cataracts are listed as a possible complication on some RK informed-consent forms. So are glaucoma, coneal ulcer, drooping eyelid, and a dozen other ocular ghastlies. But all are extremely rare. So is the most commonly heard horror story about RK, which involes a phenomenon called globe rupture. Here is Natasha's version: " I have seen one woman. Her child by accident hit her after the surgery, and her eye broken into slices, like an orange!"

With the cornea weakened by RK, scientists had thought it would take slightly less force to rupture the eye. John S. Kung and John Lucca, opthalmologists at Columbia University's Harkness Eye institute, spent months in the lab, dropping weights onto eyeballs in plastic tubes. But, as the two found out, eyes don't exist in plastic tubes; they exist in faces, with sockets and brows and protective cushioning. According to Kung and Lucca, the incidence of rupture among RK patients (16 eyes out of more than a million) is actually no higher than among the general population.

The patient looks peaceful. His hands rest at his sides. On his head is a tall white cap with a floppy peak, like a nightcap's. He could almost be sleeping.

But wait, one eye is open.

"And now," announces Natasha, " the surgeon will activate the laser,"

If he was asleep, he isn't now.....

The Institute has performed 9,000 such operations in the last four years. In Germany, a patient survey found that 96% would recommend excimer surery to friends. In the current FDA trial, about 1,400 eyes have been treated at ten U.S. academic research centers. So far the statistics look equally good.

The man walks out of the excimer chamber. He pulls off the surgical cap, smooths his hair, and adjusts the lapel of his blue serge suit. Aside from a gauze eye patch, he appears, unchanged. He might as well have walked away from an automatic teller machine.

I ask if the operation was painful, Natasha shakes her head. "Because of Anastasia, there can be no pain."

"Who is Anasthasia?"

Natashaa squints at me. "What who? Is drugs. For numbing."

"Oh. Anesthesia."

"Yes of course, Anasthasia." With the eye anesthetized, the most noticeable sensations are visual - flashing lights and colors. " Like special effects in a low-budget science fiction movie," is how one patient described it.

"And afterward?" This is the man's second laser treatment. His right eye was operated on six months ago. "No problems?"

Natasha shakes her head. "He has nothing bad feeling about this operation." The same cannot be said for Donna Jones, an office manager in Los Angeles. Jones suffers from "excessive haze." A worrisone complication that has dampened the initial optimism of U.S. researchers. "Like looking through an unwashed glass that had milk in it" is how she describes it.

Ironically, Jones works in the office of ophthalmologist and excimer investigator James J. Salz, now completing his chunk of the FDA study at Cedars-Sinai Medical Center. Even while her eye filmed over, Jones contineud to make appointments for new subjects. "Look at the statistics, " she explains. "Doctors have done about seven hundred patients in the U.S., and this has happened twice. One German doctor has done fifteen hundred excimers, he's retreated thirty or forty for haze, and only one was extreme like me."

Nonetheless, the FDA wants to know what is happening to those milky eyes. At its behest, ophthalmologists at the Harkness Eye Institute [are completing additional research.]

The haze problem also explains why the Moscow Institute still favors RK. "Excimer laser today is the bigger risk," Fyodorov told me. "Sometimes it's nice, sometimes it's opacification. You cannot predict." He uses the laser only on people who are poor RK candidates or whose RK has left them still myopic. Lucca and Kung, who call themselves "generally pro-laser people," right now also prefer RK. Says Lucca: "We're seeing such great results with it." Until he recently found out he's not a good candidate, Kung had planned to have his partner perform RK on him.

At the end of the RK conveyor belt is a sitting room with a large brass samovar. The price for surgery includes postoperative tea and cookies. Natasha has offered to help me interview patients as they walk out of the operating room. As I sit down with my cup, she is chatting with a middle-aged woman. I ask her to translate. "... I am inside a room with marble walls. Slowly I move toward the center. I look there, in the center, and I can see a body laid flat, with spotlight on its face. Soon I am there in the center of the room. I am feeling something strange, and my eye fill with tears. Then the line moves on and soon I am at the other end and it's over."...

There ensues a lengthy discussion fractured by head shakes and loud snapping nyets. As it turns out, the woman has been talking not about the experience on the conveyor belt, but her experience at Lenin's tomb. Like many patients, she has combined her trip to the institute with a sight-seeing tour of Moscow.

I ask the woman why she decided to have RK. She shrugs. I might as well have asked her why she had her teeth capped in gold. The practice is so common place that no one really questions it.

In the United States the decision is not so simple. "If your're a contact lens wearer and you have no problems," says James J. Salz, "then you've got to think twice about either of these procedures."

Still and all, I may yet enter this brave new surgical world. Rather than have RK now, I could wait for the excimer laser people to refine their technique and solve the haze problem. Then again, if I wait ten years or so, my corneas might by slow-healing enough for RK to leave me with nearly perfect sight.

Perry S. Binder, a clinical professor of ophthalmolgoy and an excimer investigator at Miricos Eye Institure of Scripps Memorial Hospital in La Jolla, California, suggests a fourth alternative. "We could get you down to around 20/100 with radial keratomy now, then you could have excimer laser later on to finish off the residual myopia." And the residual life savings, RK and excimer each costs $1,200 to $2,000 per eye.

Of course, you may have either done in Moscow for about half that. Fyodorv has worked a special deal for foreigners: the price covers surgery, hotel, food, plus complimentary one-eyed sight-seeing tour replete with "excursion... to the theatre, wearing dark glasses."

Natasha has gone to smoke a cigrette. A young man enters from the operating room and sits in her seat. He speaks little English but seems to understand "journalist." He motions me close and lifts a corner of the gauze eye patch. His eye is a wet, cringing red thing. I'm not sure what to say. I've learned threee Russian phrases this week: spaseebba nyet (no thanks), pakhmyel'y (hangover), and ohchen karashoh (wonderful). Though all three seem equally apt, I go with the last one.

He nods and says something in Russian. Then he stands. He pretends to put on glasses, then lifts them from his face. He draws one leg back behind him, and grinning, drop-kicks the imaginary glasses. "Ohchen kharashoh."


End Text
Excerpted from Health magazine,"Sight for Four Eyes", Nov./Dec. 1992, pp. 70+, by Mary Roach. For the full text, please contact your central library. Some of Ms. Roach's facts and statistics are not accurate. For example, excessive cornea curvature is rarely the cause of myopia (although many refractive surgeons tell patients that it is); rather, it is an elongation of the eyeball structure, which is impossible to surgically alter. In addition, this article is somewhat dated, and you should review the most current studies of RK, PRK and LASIK for statistical improvments and details regarding complications and side-effects. Please see the EyeKnowWhy homepage and the Modern RK/PERK section.

Mail GIF If you have any questions or comments, please contact eyeknowwhy@aol.com.

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