A brief history of Refractive Surgery :The Road to Mini A.R.K. (by Hari Navarro)

Many are under the misconception that Mini A.R.K. (Asymmetric Radial Keratotomy) is a totally new and radical form of ocular treatment.
Although it is true that this asymmetric, shortened incision form of R.K. (Radial Keratotomy) is an inspired departure from previous forms of the technique, refractive surgery in fact has its roots many years ago.

As far back as 1869, Dutch ophthalmologist Herman Snellen (born 1834, Zeist [Utrecht]; died 1908) contemplated the use of corneal incisions across a steepened meridian to flatten and, thus, correct astigmatism.
[His name synonymous with the famous eye chart].

But it was Xavier Galezowski (Polish-French ophthalmologist, born 1832, Lipowice [Poland]; died 1907), some 20 years later, that would actually attempt to surgically flatten the corneal contour, although he was to meet with little success. These were times of innovation and disappointment but historical, ground-breaking discoveries in ophthalmology were about to be realized.

Trainee Dutch physician Leendert Jan Lans was, in about the same period, meticulously studying the base principles that would go on to define what we now consider keratotomy. His work is still regarded by many as a standard by which modern refractive surgery is assessed. He was a forerunning practitioner of surgical corneal flattening, this he achieved by incisions made on the anterior surface of the cornea. In varying the number, direction and shape of the incisions, he could manipulate the refractive error and customize the correction.

The modern age of refractive surgery is generally acclaimed to the late professor Tsutomu Sato of the Juntendo University, Tokyo. In 1936, he observed that spontaneous breaks in the Descement membrane in keratoconus patients produced a flattening of the cornea when these wounds healed. This led him to the idea of posterior corneal incisions. He also observed that injury to the Descemet membrane was greater than that induced by injury on the Bowman layer, suggesting that surgery on the posterior cornea would be more effective than surgery on the anterior cornea. In the late 1940s, anterior incisions were added to enhance the effect of the posterior incisions after experimental studies on radial and tangential incisions in rabbits to correct astigmatism. His work built upon the principles outlined by Lans nearly half a century earlier and thus he applied his variant R.K. incisions to his corneal surgeries.

After a period of dormancy, refractive surgery and radial keratotomy were to have their next burst of creativity halfway around the world, in the former U.S.S.R.

Svyatoslav Nikolatevich Fyodorov (August 8, 1927- June 2, 2000) was one of those men whose intense intellect was only to be surpassed by his all encompassing lust for life.
He was a giant in the field of ophthalmology, with his true achievements only now being fully appreciated. Born in Pruskurov (now Khmelnytskyy, Ukraine), he graduated from Rostov Medical Institute, then worked as a practicing ophthalmologist in a small town in Rostov Oblast.

In 1960 he performed the first intraocular lens replacement operation in the Soviet Union.
During the 1970s and 80s, Fyodorov developed a system of anterior radial keratotomy that, by varying the number of incisions and the amount of uncut, clear central zones between them, permitted him to carefully control the degree of visual correction.

He opened his work and clinic to the world and began teaching foreign specialists his methods.
Many took their new-found knowledge that radial keratotomy (R.K.) could indeed reduce or eliminate myopia, back to their respectively sceptical countries. Fyodorov had started performing surgery in humans in 1974 using a freehand razor blade fragment in a blade holder, checking the depth of the incision with a depth gauge and deepening the incisions as required.

In 1980 he became a head of the Moscow Research Institute of Eye Microsurgery.
Fyodorov also had political aspirations and was a member of Congress of People\’s Deputies in 1989-1991. He was elected to the lower house of the Russian parliament Duma in 1993. He ran for Russian president in 1996.
Tragically the world was to abruptly lose the mind and influence of this man far ahead of his time, when in June 2000 he died in a helicopter crash outside of Moscow.

Prof. Massimo Lombardi a frequent pupil of Fyodorov had, even by 1984, imported (RK) radial keratotomy from Moscow into his native Italy.
The ophthalmologic establishment were far from welcoming, making no secret of their distain for what they regarded a radical procedure. The fact that it originated within the former Soviet Union provided prejudices of its own.

Remember that at this time even intraocular lens implants were not being performed or even considered in Italy, Fyodorov had been doing so since the 60s.

Prof. Lombardi’s diamond blade surgery for myopia, it would seem, stood little chance of acceptance. The academic fighting, rejection and recriminations were to continue for many years. That is until the excimer laser, a godsend for those not capable or willing to devote the many years required to perfect surgical skills, descended and created master surgeons at the push of a button.

It was in this early part of the 80’s that Prof. Lombardi pondered that “If strategically located incisions on a cornea flatten the points of application correcting myopia diopters, maybe the same could occur in those affected by keratoconus”.
Putting his contention into practice R.K for keratoconus met with early success, he began operating systematically with increasing results.

Patients were happy but not fully because they still experienced some visual distortion. It soon became apparent that by applying the symmetric R.K. as taught by Fyodorov, he was repeating the same irregularities below the previous Keratometric level.

Improved sight and myopia correction was still achieved, but there was the feeling that some sort of adaptation was required.

At the time there was no way to perceive the corneal surface, there wasn’t a method to see what effect asymmetrically placed incisions would make.
This problem was solved when the first corneal map was presented at congress. Immediately the answer became evident, and A.R.K. (Asymmetric radial keratotomy) was born.

Many years of technical refinement and improvement followed. Then one day, whilst in surgery, Prof. Lombardi\’s then assistant, Dr. Marco Abbondanza, commented that recently an American ophthalmologist had published a paper on mini-R.K suggesting very good results using shorter incisions.
Prof. Lombardi then decided that same day to try this reduced version of R.K in his A.R.K., considering that he could always prolong the incisions should the experiment fail.

This turning point was witnessed by Prof. Lombardi’s nurse and ophthalmologic assistant Silvia Micarelli, the anaesthesiologist, Dr. Franco Bianco and colleague Dr. Massimo Fratalocchi. Also the secretaries at
the Lombardi clinic, Giovanna and Angela, whom are still there to this day, knew of the new modification
the same day.
[I only mention this as there is some contention as to Mini Arks beginnings].

And so Mini A.R.K. came into existence, but still the road its life and evolution seem to take is a rocky one.
The paternity of its creation is contested; it is classified as an outdated technique by those who know nothing of its function; it is beaten and bruised from all quarters… all quarters, that is, except for those patients, such as myself, that can see again and will be forever indebted to the road it took to get here.

At the end of the day the politics mean nothing, they pale in the face of the result… And its true the results do vary, each case is unique, each patient has a diffrent expectation of what they consider \’Success\’.
All I can personally hope is that, at the very least, Mini A.R.K can be held up as a viable option… to be seen as an addition to an arsenal in which we KCer\’s have far too few weapons.

Please understand that this is only my take on the sequence of events, I invite discussion on any inaccuracies I may have unintentionally made.
Hari Navarro [Nov. 2005]