DOCTORS' EYES ON THE PRIZE; WHILE LASER CAN IMPROVE SIGHT, ALL AREN'T SOLD ON PROCEDURE.

Byline: Stephen Smith Knight-Ridder Tribune News Wire

The eye, an orb of tranquil blue, flickers onto the television screen, larger than life.

Soon, a symphony of medical machinery begins clattering. First, the gentle ``hummm, hummm, hummm'' of a physician's tiny plane, whirring back and forth, back and forth, 15,000 times a minute. Then, the muffled jackhammer staccato of the laser, pumping out six bursts of cold ultraviolet rays every second.

Kellie Henley's left eye will never be the same.

Which is exactly the point.

``I couldn't wear contacts anymore because my eyes were just too dry and painful,'' says Henley, age 37 and vision 20/400. ``And glasses weren't much of an option, because I love to Rollerblade and ski.''

So, like the 94,500 Americans who got laser refractive eye surgeries in 1996, according to the American Academy of Ophthalmology, here she is, flat on her back as a doctor slices a layer of eye thick as a split hair so that a laser can chip directly at the heart of the cornea, vaporizing a small chunk.

Henley has opted for the latest incarnation of refractive eye surgery, a technique that goes by the acronym LASIK. It is a direct descendant of an operation called PRK and a distant cousin of the progenitor of all vision-correcting procedures, radial keratotomy.

In an era when human fixer-up projects are all the rage - machines that suck away fat, pills that take off pounds, injections that nurture plumper lips - the purveyors of corrective eye surgery have found the most lucrative market of all.

And they have given us a 20/20 view into the realities of health care, circa 1997, when medicine and economics unite in a shotgun marriage.

Want your eyes fixed? Be prepared to pay - out of your own pocket, because insurance almost never covers these techniques. Say you can't afford it all at once? No problem. Installment plans are available, just like for your car. Which is a good thing, because the cost of fixing your eyes can be as high as the price of a used car.

Consider the potential market: The procedures now are used to mend the myopic, an army of Americans numbering 60 million, nearly one of every four people. And soon the same techniques are expected to be adapted to the farsighted, a market of 30 million Americans expected to grow larger as baby boomers grow older.

``It is going to be absolutely mind-boggling the amount of surgery it will create,'' says Dr. J.S. Pannu, a Lauderdale Lakes, Fla., specialist who has performed 6,000 corrective eye surgeries. ``There's not one person in this world who likes to wear glasses, so if they can be rid of glasses, why would they have them?''

That is why ophthalmologists like Pannu - and major universities - have spent upward of $600,000 buying excimer lasers to perform LASIK and PRK.

But some specialists insist that consumers are being lured into operations costing as much as $6,000 for both eyes when radial keratotomy, typically done for $2,000, works just as well.

``A lot of people are making money off of this - that's allowed, this is America. And I'm a capitalist, too. I want to make a lot of money, too,'' Kendall, Fla., ophthalmologist Stanley Rosenberg says. ``But how can I in good conscience tell somebody that a procedure costing $4,800, or more, is better than a $2,000 procedure when I really don't believe that?''

The disagreements ring with fierce intensity, with specialists at places like Emory University arguing that LASIK - laser in-situ keratomileusis - is by far the preferred method. Emory, in fact, is the epicenter of research into the efficacy of LASIK, research critical to gaining federal regulators' approval.

LASIK in focus

The U.S. Food and Drug Administration has already given its blessing to the use of two lasers for eye surgery. And in July, an FDA panel gave a conditional embrace to LASIK.

Full approval would let doctors market the technique. But they can use the lasers for LASIK even without that formal OK: Federal law lets doctors use an approved device for a purpose not originally intended if they think scientific evidence justifies it.

``The panel said this procedure looks very promising, but before we can recommend an approval, we need to see some more data, we need to see some more patients followed up, we need to see more on glare,'' FDA spokeswoman Sharon Snider says.

Emory researchers are gathering the requested data, the latest scientific work in a field born half a century ago in Japan. That's where a doctor invented radial keratotomy - commonly known as RK - three decades before it would reach America's operating rooms.

In that procedure, a doctor makes deep cuts in the cornea, cuts resembling spokes. That's done to flatten the cornea, bowed outward in people who are nearsighted.

RK got a black eye in its early days in America, with patients developing complications and frequently needing repeat surgeries to adjust their vision. But advocates of RK, like Rosenberg, maintain that better cutting tools and broader experience have diminished the complications.

``It's not to make you perfect,'' he says. ``It's to make you functional and make you live most of your life without glasses.''

Even as thousands of Americans were undergoing RK procedures, scientists were perfecting the use of lasers in eye-repair work - technology designed to be less invasive than RK, leaving the eye more stable. By the mid-1990s, PRK - photorefractive keratectomy - had become an accepted method for fixing myopic eyes.

In that technique, a laser is trained directly on the surface of the cornea, etching away the bulge to make the eye flatter. That can cause scarring and require use of eye drops for three months or longer.

So doctors began perfecting a related procedure - a procedure that requires more surgical skill but leads to a faster recovery.

``LASIK is the most advanced thing we have,'' says Dr. Keith Thompson, medical director of the Emory Vision Correction Center in Atlanta, ``and with it we get the best results.''

It works like this:

Anesthetic drops are dribbled into the eyes, the only pain-deadener the patient gets. Then, a suction ring is inserted to stabilize the eye, allowing the cornea to protrude.

Using a microkeratome, an automated device resembling a carpenter's plane, the surgeon makes a hinged flap on the surface of the cornea, like peeling back the protective foil on a bottle of aspirin. That way, the laser can sculpt directly on the bed of the cornea instead of the top of the eye. And that's beneficial because lower layers differ from the top in this vital way: They aren't as prone to scarring because they don't recognize that much of anything has happened.

``If you remove the outside curvature of the eye, your body will try to restore it like a fingerprint,'' Coral Gables ophthalmologist Roberto Beraja says. ``It will say, `Hey

That's not how the cornea is supposed to look.' ''

Armed and ready

When the laser begins thumping, reducing a swatch of eye to dust, the bed of the cornea sits passively, with no impulse to heal. By the time the laser has finished - it emits rays, typically, for a minute or less - 5 to 10 percent of the cornea has been excised.

``We're removing only a quarter to a third of the thickness of a human hair,'' says Dr. Terrence P. O'Brien, director of refractive eye surgery at Wilmer Eye Institute at Johns Hopkins Hospital in Baltimore. ``I'm still amazed that it can make such a big difference in someone who comes in with thick glasses and is exiting without the need to wear them.''

CAPTION(S):

2 Photos, Box

Photo: (1--Cover--Color) VISION QUEST

Laser eye surgery promises life without glasses but is it worth the risks?

Photo illustration by David R. Crane

(2) Before laser surgery was developed, surgeons used conventional instruments to make incisions in the cornea.

Myung J. Chun/Daily News

Box: The eyes have it

A guide to choosing the elective surgery that's right for you

Sources: Emory University, Johns Hopkins University, University of Miami, Drs. Roberto Beraja, J.S. Pannu and Stanley Rosenberg