The Conservative Approach.

I had refractive surgery (RK) on April 7, 1995 because it had been represented to me as a substitute for contacts and/or glasses. Four weeks prior, I had been for a check up with my family optometrist. I was concerned about wearing contact lenses as a fire fighter and performer, although they never impeded my ability to function.

I used to sleep with my contacts in at the firehouse as did a few other of my fire comrades and it was never a problem. Wearing them for a few days in a row, as I was sometimes prone to do, would result in a feeling of dryness that was to be expected. I had had an audition for a sizeable role in a film (after one of these multiple-day wearing stints). Just prior, I had doused my eyes with drops since I my eyes were dry. I had a chance to view the audition tape and realize that my blinking and "droopey eyed" look had sunk the audition.

So, when I visited my optometrist I asked about the state of refractive surgery. We had talked about it a few times in the past, as I was never totally comfortable with the concept of sleeping in contacts although it never interfered with my ability to function. Every time we touched on the subject, the counsel was the same…"things aren't where they should be". His apparent conservatism gave me confidence that my eye health was his primary concern. I had read things now and again about coming laser treatments and the great promise that they held. So when I asked about where laser stood at this point in time, his enthusiasm for the talents of a specific surgeon and the recent advanced state of development for RK was nothing like his previous reluctance to recommend any surgical procedure. I asked "isn't laser supposed to be better?" and the answer was that RK had a long track record and there were now "advances in technology" that made it an excellent alternative to contacts or glasses. Laser was too new and not enough was known.

I thought, well, this does seem to be in keeping with his conservative philosophy (the reason I had continued to go to him for over 20 years in the first place) and if the alternative now existed, it would make sense to explore it. I was clear about my expectations of not having to wear contacts or glasses including at night. My concerns were offset every time by the statement that this surgeon was "the best". For every question that I had, "the best" was pitched back to me with the warm smile and look of confidence that I had come to TRUST after 20 years of care under this optometrist. Questions like "does the surgery cause a need for reading glasses"? "No, everyone will eventually need reading glasses" was the answer. Right there, had I known the TRUTH of the benefits of my myopia in offsetting having to use reading glasses until much later in life, I would now be doing something other than birthing and nurturing the growth of Surgical Eyes.

Every step of the way towards the moment of surgery was like a beautifully orchestrated seduction. Just like the manual used to teach RK, "…we close…the patients…" as if it were akin to selling someone a piece of real estate.

I have been over every factor that led to my decision to have RK and came to realize that the seeming intransigence of my current perspective is based on what I and every other person who has had "vision correction" surgery had a right to know, before the surgery. A consent form simply lists some of the possible complications. I, as a patient, expected my optometrist and the surgeon to fully inform me of how these risks applied to me.

Following is a quote from a highly regarded member of the ophthalmological community "What is disturbing to me and what I think is a hidden growing problem for patients as consumers of medicine,are the latent relationships that exist between optometrists and certain ophthalmolgists which are undisclosed to the patient. This is also a problem happening in LASIK and I've heard in southern California and elsewhere about patients being coerced into having LASIK surgery only with a particular surgeon and not being given the opportunity to explore other surgeons (or even refractive options) in part due to a pre-existing business relationship that is not disclosed... Radial Keratotomy is an operation which has steadily fallen increasingly out of favor in the field due to problems with predictability, accuracy, stability as well as qualitative aspects of vision which you so correctly identified as being essential measures of "success" on the radio program. With the excimer laser being approved in November 1995, I think that your surgeon did a disservice if there was not careful discussion in the informed consent process about alternatives to surgery including glasses, contact lenses and excimer laser surgery, an emerging technology for which data was already known at the time."

Additionally, the scientific journal literature existed long before my surgery and continued to be produced which clearly contradindicated performing RK without advising the prospective patient with my degree of myopia and 7 mm pupils of the degree of probablity of the symptoms which are listed on a surgical consent form.

1987 EIGHT YEARS PRIOR TO MY SURGERY
"Authors Applegate RA. Trick LR. Meade DL. Hartstein J. Institution School of Optometry, University of Missouri, St. Louis 63121. Title Radial keratotomy (RK) increases the effects of disability glare: initial RESULTS. Source Annals of Ophthalmology. 19(8):293-7, 1987 Aug. Abstract Attempts to correct myopia by surgical intervention (radial keratotomy (RK)) are increasing, and disability glare is emerging as a common subjective postsurgical complaint. To date, efforts to quantify this complaint have failed. By measuring increment thresholds in the presence of a point-glare Source, we have been able to measure large glare effects (up to six times normal) at low BACKGROUND luminance levels."

1990 FIVE YEARS PRIOR TO MY SURGERY
"Authors Applegate RA. Gansel KA. Institution Department of Ophthalmology, University of Texas Health Science Center, San Antonio 78284-7779. Title The importance of pupil size in optical quality measurements following radial keratotomy (RK). [Review] [33 refs] Source Refractive & Corneal Surgery. 6(1):47-54, 1990 Jan-Feb. Abstract This review considers the importance of pupil size when specifying the optical quality or visual performance of eyes following radical keratotomy. The experimental evidence presented includes measurements both before and after radial keratotomy (RK) of the eye's: 1) corneal curvature; 2) optical aberrations; 3) modulation transfer function; 4) visual acuity as a function of test beam entry; and 5) disability glare. Together these five lines of evidence demonstrate that pupil size is a key factor influencing both the optical quality of the eye and visual performance."

1991 FOUR YEARS PRIOR TO MY SURGERY
"Authors Applegate RA. Institution Department of Ophthalmology, University of Texas Health Science Center, San Antonio. Title Acuities through annular and central pupils after radial keratotomy (RK). Source Optometry & Vision Science. 68(8):584-90, 1991 Aug. Abstract The corneal radius of curvature after radial keratotomy (RK) (RK) increases centrally in the surgery-free area while remaining relatively unchanged paracentrally and peripherally in the surgical areas. These corneal topography changes suggest that the imaging properties of the cornea should vary with the area of the cornea allowed to participate in image formation. To test this hypothesis visual acuities were measured both through a central and an annular pupil for normals and RK patients as a function of time after surgery. Annular acuities were decreased significantly after RK and remained decreased over time. Best corrected central acuity increased as a function of time after surgery, becoming significantly better than presurgery acuities but not as good as normals with similar low refractive corrections. Clinical implications include: (1) variations in visual performance (e.g., acuity, contrast sensitivity, glare) and optical quality measures (e.g., refraction, higher-order aberrations) as a function of pupil size; (2) use of a large a surgery-free area as possible; (3) careful centering of the surgery-free area on the natural pupil; (4) new contact lens designs for correcting RK patients' residual refractive error; and (5) counseling patients in general, and patients with naturally large pupils in particular, concerning possible variation in visual function with pupil size. In summary, this study indicates that postsurgery RK paracentral/peripheral corneal optics experience a loss in optical quality as compared to either normal eyes with a low refractive correction or the same eye before surgery."

1996 ONE YEAR AFTER MY SURGERY
"Authors Applegate RA. Hilmantel G. Howland HC. Institution Department of Ophthalmology, University of Texas Health Science Center, San Antonio, USA. Title Corneal aberrations increase with the magnitude of radial keratotomy (RK) refractive correction. Source Optometry & Vision Science. 73(9):585-9, 1996 Sep. Abstract BACKGROUND: Refractive surgery induces optically abrupt changes in shape in the midperiphery of the cornea. The abruptness of this change is in part dependent on the magnitude of the surgically induced refractive change. Therefore, the optical aberrations of the cornea, as quantified by wavefront variance (WFV), may be expected to increase as the surgically induced change in the refraction increases. PURPOSE: It is the PURPOSE of this study to test the hypothesis that as the surgery-induced change in refraction increases, so does the WFV of the cornea. METHODS: Fourteen radial keratotomy (RK) (RK) patients and seven normal patients served as subjects. Measurements were made before and 2 years after RK surgery. To quantify the WFV of the cornea, we used corneal topography measurements to calculate the surgically induced change in corneal WFV with respect to two different reference surfaces, a sphere and the presurgical cornea. To quantify the surgically induced change in the equivalent spherical correction (ESC), cycloplegic refractions were performed. The measurements were summarized by regressing the surgically induced change in the WFV against the surgically induced change in the ESC. RESULTS: For large pupils (7 mm diameter), the correlation between the change in the WFV referenced to a sphere and the change in the ESC was significant (p 0.0001, r2 = 0.745) and dominated by fourth order aberrations. Similar RESULTS were found for the surgical lens. For small pupils (3 mm diameter), the effects were markedly reduced. CONCLUSIONS: (1) As the magnitude of the surgically induced refractive change increases so does the WFV of the cornea, particularly for large pupils. (2) The increase in corneal WFV for large pupils is dominated by fourth order aberrations. (3) The increase in corneal WFV is consistent with reported decreases in visual function (contrast sensitivity and low contrast visual acuity), particularly for large pupil diameters in combination with large surgically induced changes in refractive error."

1998 THREE YEARS AFTER MY SURGERY
"Authors Applegate RA. Howland HC. Sharp RP. Cottingham AJ. Yee RW. Institution Department of Ophthalmology, University of Texas Health Science Center at San Antonio 78284-6230, USA. applegate@uthscsa.edu Title Corneal aberrations and visual performance after radial keratotomy (RK). Source Journal of Refractive Surgery. 14(4):397-407, 1998 Jul-Aug. Abstract BACKGROUND: Refractive surgery and videokeratography have allowed us to study the effects on visual performance of relatively large changes in corneal aberration structure induced by surgical changes in corneal shape. METHODS: We quantified in one eye of nine normal and 23 radial keratotomy (RK) patients, the area under the log contrast sensitivity function (AULCSF) and corneal first surface wavefront variance for two artificial pupil sizes (3 and 7 mm). Contrast sensitivity was measured with sine-wave gratings at six spacial frequencies. Wavefront variance was derived from videokeratographs using Zernike polynomials. RESULTS: For normals eyes there were no significant changes over time. For eyes that had radial keratotomy, there were significant pupil size-dependent changes. For the 3 mm pupil, there were significant surgery-induced changes in the corneal wavefront variance which became large (approximately 30 times preoperative values) at 7 mm. Significant correlated changes in AULCSF for the 7 mm pupil but not for the 3 mm pupil occurred immediately following surgery and remained. CONCLUSIONS: Radial keratotomy (RK), like photorefractive keratectomy (PRK), shifts the distribution of aberrations from third order dominance (coma-like aberrations) to fourth order dominance (spherical-like aberrations). Radial keratotomy (RK)-induced aberrations and loss in contrast sensitivity are reduced with increasing clear zone diameter. Radial keratotomy (RK) induces an increase in the optical aberrations of the eye and the increase for large pupils (7 mm) but not small (3 mm) is correlated to a decrease in contrast sensitivity."

When I went to my optometrist who had been my optometric caregiver for over 20 years, how was I to know that he had lead me to certain visual ruin? The appearance of conservative professionalism belied the larger truth of complex forces at work. It seems absurdly simple to state that it came down to compromise. Yet, it is the larger truth. Individuals who chose to ignore scientific evidence in pursuit of personal gain.

In my professional calling as a fire fighter, I had a keen interest in issues involving optimal health. Optimal anything was a prime motivating factor in all areas of my life. I pushed myself hard: graduated top of my fire class; competed and placed in national team athletic competitions; scored highest on a combined written/interview fire promotion exam; instructed fire fighters in hazardous materials response and auto extrication; supervised two open-water beaches as guard captain for over ten years; and garnered awards by working hard on local stages as an actor and/or musician. I squirm every time I read the preceding sentence because I'm concerned about coming off as a blowhard. I take the sentence out and always end up putting it back because I expected "the best" in my surgeon to embody the same principles and ethics that had been my guide.

When I reflect back, it's as if a part of me died in back on that fateful day in 1995. From the point that my surgeon and I met for the very first time seconds before the knife did its work, from that point forward, all the things that I used to be able to do with bodily ease and attendant psychosynergistic confidence were to be no more.

The Downward Spiral.
The day after my surgery, I went to watch a performance at the Cleveland Performance Art Festival in early evening hours. As I sat in my seat below a stained glass skylight waiting for the program to begin, daylight was beginning to fade and everything began to become quite fuzzy and indistinct. I became concerned that perhaps I shouldn't be out so I left before the performance to give my eyes a rest. The following day I went to a rehearsal for a theatre/dance piece. I got there early and the first thing I noticed was that I could not see across dimly lit room well enough to get to the light switch was on the opposite end of the hall. I had always arrived early at the same time and as such was often the first to turn on the lights. I had to wait for someone else to get there. The rehearsal was a disaster, as I could not see my feet well enough to even walk down a wide bench that I had practiced on many times prior. I ran into the other performers, as I could not easily judge distances. My part was rewritten to accommodate my liability which I had faith was only temporary as I needed to give my eyes a chance to heal.

The very next day at work, I was slated to drive the engine as I had many times in the past ten years. In the middle of the night I awoke to the sound of an alarm and proceeded to the apparatus floor. The minute we got out on to the street, I knew that I was in trouble. My eyesight was horrible. What I now know as ghosting was in full effect, starbursts and haloes were everywhere and things just appeared to melt into each other. Luckily, it was a false alarm. When we got back to quarters I had a conversation with my officer who agreed to allow me to remove myself from driving duties, as I was going on a leave of absence in 6 more weeks, to study overseas at the Royal Academy of Dramatic Art in London.

I was quite concerned and called the office of the surgeon when I finally got through to his chief optometrist. When I described my night vision issues he recommended glasses for the time being and I told him that I was having problems up close as well and he said that I would be "able to tell the difference between an alligator and a log" so I should not worry. Still having faith that it was just a healing issue, I proceeded overseas albeit with glasses. I later was told that with my degree of myopia, there was " 30% chance" that I would need an enhancement, information that was not shared as part of my so-called work-up. I had also had surgically induced irregular astigmatism in my left eye which frankly, at the time, I assumed would just heal.

I got overseas and had a difficult time trying to function naturally on stage, although I pushed myself very hard, and wrote insistent letters to the surgeon and my family optometrist. Finally, I was sent me a batch of different sizes and strengths of contact lenses which got me through, but not with the vision that I once had. I was to have proceeded on to New York to begin an internship with the world-class theatre ensemble, the Wooster Group, but because of my need for "an enhancement", had to call them and sadly report that I would not be arriving in New York as I had hoped.

At that point, I decided to relieve some of the stress and took a solo train trip to a small town in the South of Wales to visit a castle that a friend at the Royal Academy had told me about. What happened next was the straw that broke the camel's back. I suffered a criminal attack by a group of drunken thugs who decided to have at it with me because, as the police put it, I was "alone and an American". I tried to shield my eyes from their blows from every direction so my head absorbed many of their kicks. I was diagnosed with traumatic brain injury here in the US and entered on a path of ongoing cognitive rehab therapy. The effects of the traumatic brain injury unfortunately plague me to this day. I realized later how lucky I had been that my corneas did not give out from the attack. I had eye muscle damage but the RK cuts did not split open. I returned to the States after plastic surgery, and after a three-week delay, had the so-called enhancement on my right eye that improved my ability to see an eye chart. The ghosting, starbursting, and haloes persisted as did my fluctuating vision, which I later learned was not uncommon with post-RKs.

I was not a happy camper. And now, the exactitudes of someone who has undergone multiple traumas took their due. Denial was in full bloom. This was just temporary, I needed to heal, I still believed in the goodness of my doctors. I had to believe. Faith is bedrock, right? My family optometrist (the same one who recommended the surgery) posited that maybe my eyeballs were torqued in my head from the assault and the cuts had widened to explain my degree of complaint. At the time, a plausible explanation that later proved groundless Subsequent exams by other ophthalmologists targeted the issue as one of pupil size being too large for the optic zone that I was left with. Combined with a technique, that even by RK standards was considered very aggressive for the number of cuts and optic zone deemed as appropriate. But I went right on believing that healing would take its course, not realizing that emotional healing would eventually take place, but at a tremendous price.

I tried to put it all behind me. I arrived in New York in January of 96 having given my face a chance to heal from the plastic surgeries from the criminal assault and at the same time devoted to finding a prosthetic solution (contact lens) for my diminished visual capacity. I had money set aside for living expenses as I was not foolish enough to believe that I was going to be "discovered" and lifted into the stellar regions. I was ready to pound the pavement and give my best. What happened next reads like a Sunday night movie script.

I began a quest to find the best pair of contact lenses to bring me back to square one. I spent thousands on contact lenses, eyeglasses, holistic and faith healers, blue light machines, etc. I never ventured out at night and went to TWO auditions in a span of 9 MONTHS. I walked right over a chair in the first audition because of my compromised depth and peripheral vision. The second audition was horrible as it took place in your typical dimly lit theatre environment. I had lost my sense of place in space, which for an actor and even worse for a fire fighter, can mean the difference between life and death, in the one case figuratively and in the other, quite literally.

As compromised as I was, the whole time I maintained a faith that my eyes would heal. That my family optometrist and the surgeon had acted in my best interest. I had not yet begun my descent and reemergence on the other side of hell. My personality began to change as well. In ten years of professional fire fighting coupled with another ten of open water life guarding, I had lived through more of a particular kind of stress than most people. When things got to their most chaotic, I would enter "the zone" that is often described by those in emergency response. A sense of heightened reality where you rise to the occasion through a combination of experience, training, intuition, desire, or even luck. Car versus car, truck versus train, basement fires, attic fires, cliff rescues, missing persons, heart attack victims, running down the beach and swimming out and grabbing a kid before they went under, nothing, nothing prepared me for the perpetual stress of simple daily living after refractive surgery.

I developed a very short fuse. Whereas before I used to maintain a sense of calm even in the most trying of circumstances, I was now perpetually irritable and began to withdraw from ordinary social contact. I developed a rigid routine of avoiding darkness and started to watch television more in one year than I probably have my entire life. I went through endless cycles of hope and despair, waiting for the postal delivery person for that set of contacts that was going to set me free. Trying them on and then beginning to cry when I realized that they were like all the rest.

Then a friend gave me an article that they had sent away for which was a reprint of an article in a mid-early nineties edition of Consumer Reports that talked about RK. I had trusted my family optometrist with the eyes of the child that I had met him with instead of the eyes of a wary adult. I had no reason not to trust him. I asked to speak to someone who had RK (knowing now that everyone's eyes are unique not just in terms of refractive or astigmatic error). I asked what I thought were all the right questions.My spirit fell to a new low.

My internship with the Wooster Group had fizzled out as my personality took on odd dimensions. I behaved like a loon. I was not fun to be around. I attempted to write and perform a theatre piece with a Wooster Group associate that dissolved in a puddle of overwrought emotion. I was so distracted by my vision that I eventually mounted the production in an abandoned theatre in Cleveland. It was a nightmarish rendering of what my world had become after refractive surgery. My eyes red and shot full of pilocarpine (sent by the surgeon's managing optometrist who had advised me "move to where the sunshine is" to keep my pupils small), two other actors and I performed the piece that I had written. Replete with images of Frankenstein flickering on the screen behind the performance, a repetitive loop of surgical instruments laid out next to the hapless creature as Dr. Frankenstein prepared to operate. Fire, smoke, extremes of noise and darkness, howling screams that erupted into atonal musical throttles which were my attempt to express what my world had become. The audience of over a hundred people was spellbound, and it won a grant award from the Ohio Arts Council. Unfortunately, shortly thereafter I entered a long period of clinical depression. And then I crashed. I bottomed out.

In the spring of '97, I attempted to find a job. I took some computer classes and ended up teaching at the school. From there, I entered the world of the temporary worker. I can function in front of a computer. I lost one chance at a permanent job because I bolted from a training session that was conducted in a dimly lit training center with a low contrast overhead projector. I had tried moving to other parts of the room but I could not see the screen. I was too embarrassed to explain and started to feel panic so I left. I used to forge into burning buildings for a living and here I was breaking into a sweat that soaked my shirt as I strained to see an image projected on a wall. This is what surgically induced low contrast sensitivity will do for you. I remember driving out to the office of my family optometrist in the winter of 95, to discuss with him my confounding vision. He agreed to see me late at night that was my time of highest complaint. I looked at the chart and sure enough I made out that 20/20 line. He could not understand what I was telling him. Hell, I didn't even know what I was telling him. Since then, I have become educated in what brought me to this point and have developed the skill to express the various visual manifestations.

I now work at a bank fulltime making charts and graphs for analysts. It's a predictable life at a good firm. As long as the lights are really bright and the detail work isn't overly fine, I manage. I can't see my face very well in a mirror and shaving is an exercise in faith. Since, I can't fire fight any longer, it's the most dangerous thing that I do. I can't tell the difference between a soft and hard leather sandal much to the amusement of those that I visit wearing two different shoes. Other people notice right away. That's what compromised contrast sensitivity will do for you.

I don't drive at night unless I absolutely have to because my vision is akin to a grade B movie rendering of what the unfortunate protagonist sees whose been "slipped a mickie" just before they lose consciousness. Multiple ghosts, glare, starbursts, indistinguishable shapes and shadows. I rarely go out at night and now when I stand at the subway platform, I don't imagine anymore how I might be able to help someone who would happen to fall. I don't look for electrical dangers, safe voids, points of leverage or anchors. Firefighters think like that. I have to be careful not to stand too close to the edge because everything looks fuzzy down there. This is what refractive surgery did for me.

Seeing is Believing
The Surgical Eyes Foundation was created to help others out of the darkness that I have passed through. I have spent thousands of dollars and hundreds of hours of research in my quest to regain my vision and to learn what happened. What I learned is more than I ever wanted to know. But had to know, to continue on with my life. The failure of the ophthalmologic community at large, to reign in the zealots within their ranks who have put personal gain ahead of principled health care, has to be addressed. If it weren't for the good doctors that I have met on my current path and those that I continue to meet, I would be less hopeful of the odds of achieving lasting change and finding a way to better vision for myself and thousands of others whose lives have been compromised by a complex beast of a problem.

Make yourself a cup of coffee and visit the rest of our site. Having said that, know that neither a large coffee maker, nor any other industry representative floats this organization. We have gotten numerous emails from those that question our "hidden agenda". There is nothing mysterious about who we are. Our doors are wide open. You are welcome to take a look around.