One of the top refractive surgeons in the world, Dr. J. Trevor Woodhams talks about his history of innovation in refractive surgery, where we are now, and the newest innovations such as the Presby-Fix procedure, which is a new procedure to treat Presbyopia using the KAMRA corneal inlay aperture from AcuFocus. Woodhams is the first clinic in Atlanta to perform the procedure. This interview was originally conducted for Points North Magazine June 2015 issue.
When did you begin doing refractive surgery in Atlanta and how did that come to be?
Oh, for over 30 years…since before it was recognized as a sub-specialty as refractive surgery. Refractive surgery is actually an outgrowth of cataract surgery, and the reason that's the case is because in cataract surgery you have to remove a cloudy lens. And the lens is of course a focusing device and in the old way of doing cataracts surgery there were no lenses you could use, lens implants, to replace that so people would have to wear these extremely thick glasses. So when lens implants were introduced and started to catch on was right about the time I was doing my training, and they were somewhat controversial in those days but they made a huge difference because by that time you could take out the cloudy lens and put in a clear artificial lens and people didn't have to wear glasses that were nearly as thick, although at that time they still had to typically wear glasses. As the technology developed people were developing better lens implants, better diagnostic instrumentation to measure the eye to predict what you needed, and so on.
Not long after that a Russian doctor invented a procedure for near-sightedness called radial keratotomy in the early 80's, maybe late 70's which involved a series of partial thickness radial incisions in the cornea which would flatten it and reduce the over-correction which was occurring causing the near sightedness. Being very nearsighted myself, I had gotten very interested in it, and in fact had RK done in one of my eyes. As I learned more and started to do it and started to get better results, word of mouth grew. By the late 80's there was a very long FDA trial on the use of a laser to reshape the cornea somewhat similar manner as radial keratotomy, but the trials were so long that by the time it was approved it was already outdated and another operation came to take its place and that came to be called LASIK.
What has been your experience with LASIK?
Many people still think that LASIK is just another term for "eye surgery" but it is not. LASIK is a combination, a marriage if you will, of two different operations. One is the surface treatment with the excimer laser called PRK but there was another operation called Keratomileusis. It was being done by a doctor down in Columbia, South America. I had gone down to Bogota, which was quite an experience in those days, but I saw it done and made a commitment to learn how to do it. Then just at that time, and non-freeze version of it was developed and I was, I believe the first person in the U.S. and the 9th person in the entire world to start doing this version of Keratomileusis, which developed into what we now know at LASIK, which is an acronym: Laser Assisted Intrastromal Keratomileusis.
So quite literally, Woodhams Eye Clinic was instrumental in ushering LASIK into what it is today…
Yes, in fact I was part of a study group comparing Keratomileusis, what came to be called LASIK, and another procedure too, to see which would be better. I wanted to get an excimer laser but at that time they had not been approved so I built my own and I was doing LASIK with this laser before anybody had ever heard of it, and it just began building by word of mouth. This was in the early 90's but everybody was afraid of it, it seemed weird and dangerous and all that but there was a Time Magazine cover, I remember seeing it, that said "should you have your eyes lasered" with a stylized picture of a laser and a silhouette of a patient, and it just exploded after that. It was like that was the official "mark of acceptance" I guess in the public and because I was the first person to do it, we began doing huge numbers of LASIK patients.
LASIK of course had this tremendous presence in the public and it did several things that had never really been done before. One was that it made it okay to have an operation that was not cosmetic but made you be able to function better, and that concept of "functional surgery" that has now been applied to a lot of different things, came out of that, and another thing it did was that patients came to accept the idea that some things were good enough to pay for out of pocket and not have to submit through an insurance carrier. And LASIK got better and better, and it developed to the point of being much better than contact lenses which of course was terrifying thing to optometrists and opticians that were selling contact lenses. Now millions of people have had LASIK and in fact got to be a little too blasé about it where you had discounters coming in, flying unlicensed doctors in, doing a bunch of lined up people and then flying out, so it kind of went through a reaction period where people began to realize it isn't risk-free.
In the meantime, as people continued to do cataracts surgery as I continued to do, lens implants were getting better and the technology of measuring the eye to determine what lens implant to put in was getting better. So we got the point with a, not perfect, but a high degree of accuracy we could take out a cloudy lens and put in another lens and they could get rid of their glasses at the same time by choosing the right prescription lens to put in, so if you had a cataract, it was a miraculous operation. It was an outpatient procedures, and for the most part people would experience a tremendous differences within 24 to 48 hours.
So where are we now?
Being 'gadgeteers', a lot of doctors and industry people are always trying to make it better and better, and have come up with ideas to make an artificial lens that could see both distance and near. It's very hard to make one that works exactly the way the human eye does, and we still don't really have that. There were two different technologies, one was a lens that could bend inside the eye, and I was part of the clinical trials with that, and the other version called a multi-focal lens. What we realized is that if you could get the results with the distance vision and you did a presbyopia correcting implant as part of a cataract operation you were basically taking a patient who wore very thick glasses, got rid of their cataracts number one, and got rid of their distance vision problem number two, and restored their near vision, problem number three all at the same time. We call that Pre-Lex, which stands for Presbyopic Lens Exchange which we define as the removal and replacement of the human lens with any degree of cataract where the primary goal is to restore uncorrected vision at all distances. So Pre-Lex was the evolutionary outcome of cataract surgery and lens implant surgery. But the primary market for Pre-Lex really became younger people who were too old for LASIK, because LASIK doesn't correct the near-vision problem, but are well this side of Medicare age, people in their 40's and 50's….and they do much better because of it.
Where is vision correction go from here?
Well there have been a whole host of new procedures like implantable lens that doesn't require the removal of the natural lens, called ICL, Implantable Contact Lens, which we use on people who are extremely near-sighted who are out of the range of LASIK, and we've been doing that for many years, too.
Presbyopia has always been kind of the holy grail of refractive surgery because it is so extraordinarily difficult to reproduce how the natural lens works to change focus, so the Acufocus company out of California, said "well, let's take a very simple approach" and that is to make a pinhole and somehow put this modified pinhole somewhere in the optical path, you could get the benefit of close vision without the need for any lens at all. That's what a new inlay device called a KAMRA corneal inlay does and it is actually put into the cornea itself (which alleviates the need for reading glasses).
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