5 Questions With Robert K. Maloney, MD

As one of the first surgeons to perform LASIK in the US, what are your thoughts on the direction it has taken? When I participated in the first FDA trial for LASIK in 1991, I never imagined it would be a treatment for any condition other than the most extreme levels of myopia. It seemed to be an incredibly invasive, aggressive, and dangerous alternative to RK and PRK. Similarly, phacoemulsification was originally applied only to soft crystalline lenses, and now nearly every cataract undergoes the procedure.

What has been your most important achievement in ophthalmology? Antonio Capone, MD, and I traveled to the Marshall Islands, a nation of 1 million inhabititants in the South Pacific where thousands of people are blind from cataracts. Diagnosis did not even require a slit lamp. After removing cataracts for 3 days, we had not even made a dent. So, during the next 2 weeks, we trained a local ENT surgeon, Philip Pastoral, to do cataract surgery. Two years later, we sent one of our graduating residents, Colin McCannell, MD, to resume where we had left off. We instructed him on how to be efficient by addressing only the visibly white cataracts. Upon his return, I asked, “Weren't those cataracts incredible?” He looked puzzled and said, “I didn't see any cataracts.” Dr. Pastoral had removed all of them. Curing blindness in an entire nation by training a capable doctor has been the most meaningful achievement of my career.

Please comment on your experience practicing at a private clinic versus a hospital or university. I practiced with a group of very bright colleagues and physicians for 7 years at the Jules Stein Eye Institute. However, the bureaucracy made it difficult to conduct clinical research, which was hampered by the recalcitrant IRB and the university's control of intellectual property. I've been a more effective clinical researcher since I left the university. On a personal level, I enjoy the more attentive care I can provide in a private practice. My intention is to continue practicing solo and maximize my enjoyment of caring for people by continuing with moderate volumes of surgery.

With the recent innovations in lens technology, do you anticipate that IOL implantation will replace LASIK as the dominant refractive procedure? Phakic IOLs seem aggressive, but it's entirely conceivable that, in 10 years, LASIK will be considered primitive. I'm very excited about the Light Adjustable Lens. Potentially, every patient could be em-metropic with this technology. Delivering 20/15 to 20/12 vision to patients even after cataract surgery would become routine. The lens also corrects astigmatism, so limbal incisions would no longer be necessary. The Light Adjustable Lens will eventually be adapted to a phakic IOL, but, for now, I see it replacing the IOLs in standard cataract surgery. As far as other developments, we're far from having a successful IOL that delivers 2.00 D of accommodation, because we must deal with the fibrosis of the capsular bag and the disruption of the normal mechanical relationships of the zonule and ciliary muscle in relation to the capsular bag. Scleral approaches to accommodation (eg, scleral expansion bands or ciliary sclerotomy) have been an abject failure.

How have your recent prime-time TV appearances impacted your practice? Surprisingly only 6% of my patient visits in the second quarter were due to viewing Extreme Makeover, confirming the fact that LASIK is a referral business and is not driven by the media. Fewer doctors are advertising today compared with a few years ago. It's a reflection on how we've found advertising to be relatively ineffective and expensive. It would be nice if people came because of the show, but it's reassuring to know that we're still a medical profession and not a commercial business.