Download the full version of the textbook now at textbookfull.

com

Refractive Surgery 3rd Edition Azar

https://textbookfull.com/product/refractive-
surgery-3rd-edition-azar/

Explore and download more textbook at https://textbookfull.com

 Recommended digital products (PDF, EPUB, MOBI) that
you can download immediately if you are interested.

Refractive cataract surgery best practices and advanced

technology Second Edition John A. Hovanesian (Editor)

https://textbookfull.com/product/refractive-cataract-surgery-best-
practices-and-advanced-technology-second-edition-john-a-hovanesian-
editor/
textbookfull.com

Textbook of Endocrine Surgery 3rd Edition Orlo Clark

https://textbookfull.com/product/textbook-of-endocrine-surgery-3rd-
edition-orlo-clark/

textbookfull.com

Bovine Surgery and Lameness, 3rd Edition A. David Weaver

https://textbookfull.com/product/bovine-surgery-and-lameness-3rd-
edition-a-david-weaver/

textbookfull.com

Nanosized Tubular Clay Minerals Halloysite and Imogolite

1st Edition Peng Yuan

https://textbookfull.com/product/nanosized-tubular-clay-minerals-
halloysite-and-imogolite-1st-edition-peng-yuan/

textbookfull.com
Foucault s Critical Ethics 1st Edition Richard A. Lynch

https://textbookfull.com/product/foucault-s-critical-ethics-1st-
edition-richard-a-lynch/

textbookfull.com

Project Management Case Studies Harold Kerzner

https://textbookfull.com/product/project-management-case-studies-
harold-kerzner/

textbookfull.com

Qualitative Research in European Migration Studies Ricard

Zapata-Barrero

https://textbookfull.com/product/qualitative-research-in-european-
migration-studies-ricard-zapata-barrero/

textbookfull.com

Analysis of Pseudo Differential Operators Shahla

Molahajloo

https://textbookfull.com/product/analysis-of-pseudo-differential-
operators-shahla-molahajloo/

textbookfull.com

Brainwashing : the science of thought control Second

Edition Kathleen Eleanor Taylor

https://textbookfull.com/product/brainwashing-the-science-of-thought-
control-second-edition-kathleen-eleanor-taylor/

textbookfull.com
Logic Pro For Dummies 3rd Edition English

https://textbookfull.com/product/logic-pro-for-dummies-3rd-edition-
english/

textbookfull.com
Refractive Surgery
Third Edition

Dimitri T. Azar, MD, MBA

Distinguished University Professor and B.A. Field Chair of Ophthalmic Research, University of Illinois at Chicago,
Chicago, IL, USA;
Senior Director and Ophthalmology Lead
Verily Life Sciences (formerly Google)
San Fransisco, CA, USA

Associate Editors

Damien Gatinel, MD, PHD

Head
Department of Anterior Segment and Refractive Surgery, Rothschild Foundation
Paris, France

Ramon C. Ghanem, MD, PHD

Director of Cornea and Refractive Surgery Department
Sadalla Amin Ghanem Eye Hospital
Joinville, Brazil

Suphi Taneri, MD
Director, Center for Refractive Surgery
Department of Ophthalmology at St. Franziskus Hospital
Münster, NRW, Germany;
Associate Professor of Ophthalmology
Eye Clinic, Ruhr University
Bochum, NRW, Germany

For additional online content, visit expertconsult.inkling.com

First edition 1997 © Appleton & Lange
Second edition 2007 © Elsevier Inc.

Copyright © 2020, Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each product
to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products, instructions,
or ideas contained in the material herein.

ISBN: 978-0-323-54769-7

E-ISBN: 978-0-323-55116-8

Content Strategists: Russell Gabbedy, Kayla Wolfe

Content Development Specialists: Trinity Hutton, Joanne Scott
Publishing Services Manager: Deepthi Unni
Project Manager: Nayagi Athmanathan
Design: Amy Buxton
Illustration Manager: Teresa McBryan
Illustrators: David Gardner, Danny Pyne, Paul Kim, MS, CMI, Matrix Art Services
Marketing Manager: Claire McKenzie

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Video Table of Contents

8.1 IntraLase Femtosecond Laser LASIK 15.12 Removal of Epithelial Ingrowth Island After
Ramon C. Ghanem Femtosecond Laser LASIK
8.2 LDV Femtosecond Laser-Assisted LASIK Ramon C. Ghanem
Ramon C. Ghanem 15.13 Treatment of Flap Folds After LASIK
8.3 Microkeratome-Assisted LASIK (Moria SBK) Dimitri T. Azar and Ramon C. Ghanem
Ramon C. Ghanem 16.1 Standard SMILE Technique Using Double-Ended
13.1 Excimer Laser Ablation Patterns Dissector With Taneri Spoon Tip
Ramon C. Ghanem Suphi Taneri
14.1 Topography-Guided PRK for Hyperopia After 17.1 Preparation of Lenticule With SMILE
Radial Keratotomy Double-Ended Dissector With Taneri
Ramon C. Ghanem Spoon Tip
14.2 Topography-Guided Transepithelial PRK for Suphi Taneri
Keratoconus Regularization 17.2 Epithelial Abrasion on Cap Surface at the
Ramon C. Ghanem Sidecut
14.3 Topography-Guided Transepithelial PRK for Suphi Taneri
Central Scar After Foreign Body 17.3 Suction Loss Before Preparation of
Ramon C. Ghanem Sidecut. Manually Performed Incision With
15.1 Free Cap in Microkeratome-Assisted-LASIK, Diamond Knife
Ablation, and Flap Repositioning Suphi Taneri
Ramon C. Ghanem 17.4 Incomplete Lenticule Preparation by the Laser
15.2 Reposition in Slit Lamp of Early Flap Dislocation Due to Conjunctiva Sucked Into the Interface
After LASIK Between Cornea and Action Cone
Ramon C. Ghanem Suphi Taneri
15.3 Anterior Chamber Gas Bubbles After Corneal 17.5 Suction Loss Before Preparation of Sidecut
Flap Creation With a Femtosecond Laser Suphi Taneri
Dimitri T. Azar, José de la Cruz, Ramon C. Ghanem 17.6 Epithelial Abrasion on Cap Surface
15.4 Suction Loss During Flap Creation With a Suphi Taneri
Femtosecond Laser 17.7 Epithelial Cells Within SMILE Interface
Dimitri T. Azar and Ramon C. Ghanem Suphi Taneri
15.5 Incomplete LASIK Flap Due to Suction Loss 18.1 PRK for Hyperopia With Mechanical Epithelial
Ramon C. Ghanem Removal and MMC
15.6 Flap Tear After Suction Loss Due to Mechanical Ramon C. Ghanem
Block in Microkeratome LASIK 18.2 Alcohol-Assisted PRK Retreatment After LASIK
Ramon C. Ghanem Ramon C. Ghanem
15.7 Flap Adhesions in Femtosecond Laser LASIK + 18.3 Topography-Guided Transepithelial PRK for
Alcohol-Assisted-PRK After 3 Months Irregular Astigmatism and Central Corneal
Ramon C. Ghanem Scarring After Foreign Body Accident
15.8 Buttonhole Flap Ramon C. Ghanem
Dimitri T. Azar and Ramon C. Ghanem 19.1 LASEK Technique
15.9 Transepithelial PTK With Prophylactic MMC After Suphi Taneri
Buttonhole LASIK Flap 19.2 Epi-LASIK
Dimitri T. Azar and Ramon C. Ghanem Suphi Taneri
15.10 Treatment of Epithelial Ingrowth With Fibrin 20.1 OCT-Guided Trans PTK + PRK for Granular
Glue Adhesive Dystrophy
Vinícius Coral Ghanem Ramon C. Ghanem
15.11 Treatment of Epithelial Ingrowth 20.2 PTK in Recurrent Epithelial Erosion Syndrome
Dimitri T. Azar and Ramon C. Ghanem Ramon C. Ghanem

v
vi Video Table of Contents 

20.3 PTK for Epithelial Erosion Syndrome Due to 30.2 Artiflex Implantation With Enclavation Needle in
EBMD in a Patient With Previous LASIK a Patient With Keratoconus
Ramon C. Ghanem Ramon C. Ghanem
20.4 Focal PTK for Apical Leucoma Syndrome 30.3 ARTISAN for Hyperopia After Radial Keratotomy
Vinícius C. Ghanem Ramon C. Ghanem
20.5 Manual Keratectomy and PTK for Corneal Scars 31.1 Posterior Chamber Phakic IOL Implantation in
After Pterygium Surgery High Myopia
Ramon C. Ghanem Jean L. Arne
20.6 Transepithelial PTK in Avellino Dystrophy 32.1 Traumatic Dislocation and Successful
Dimitri T. Azar and Ramon C. Ghanem Re-enclavation of an ARTISAN Phakic IOL
22.1 Epi-off Cross-linking Ramon C. Ghanem
Ramon C. Ghanem 33.1 ARTISAN Bilensectomy
24.1 Radial Keratotomy Veronica Vargas Fragoso and Jorge L. Alió
Emir A. Ghanem 33.2 Phakic IOL Exchange
25.1 Conductive Keratoplasty “Light Touch Veronica Vargas Fragoso and Jorge L. Alió
Technique” 33.3 Bilensectomy
Dimitri T. Azar and Ramon C. Ghanem Veronica Vargas Fragoso and Jorge L. Alió
26.1 Keraring Implantation for Keratoconus 38.1 KAMRA Corneal Inlay
Regularization—Manual Technique Damien Gatinel
Ramon C. Ghanem 39.1 Diffractive Trifocal Intraocular Lens Implantation
26.2 LDV Z8 Femtosecond Laser-Assisted 300 Ramon C. Ghanem
Degrees Cornealring Implantation for 39.2 Toric Extended Depth of Focus Intraocular Lens
Advanced Keratoconus Implantation
Ramon C. Ghanem Ramon C. Ghanem
26.3 Intralase Femtosecond Laser-Assisted INTACS 42.1 Femtosecond Laser Arcuate Keratotomy for High
Implantation Astigmatism After DALK
Dimitri T. Azar and Ramon C. Ghanem Ramon C. Ghanem
26.4 Ferrara Ring ICRS for High Astigmatism 42.2 Manual Arcuate Keratotomy for High
After Keratoplasty Astigmatism After DALK
Ramon C. Ghanem Ramon C. Ghanem
26.5 ICRS Explantation 42.3 Femtosecond Laser-Assisted Wedge Resection
Ramon C. Ghanem After Penetrating Keratoplasty
30.1 Artisan for Myopia With VacuFix Enclavation Ramon C. Ghanem and Dimitri T. Azar
Ramon C. Ghanem
Foreword

Richard Wagner worked for nearly 30 years to complete the 95% confidence interval of spherical refraction. This
the tetralogy of The Ring—from 1848 to 1876 until the means that we can’t make the success rate any better; it is
premiere in Bayreuth, starting in Dresden and continuing as good as the refraction that needs to be corrected. Regard-
in Switzerland and Bayreuth, the hometown of my grand- ing complications, the paper of Masters et al. showed clearly
father. You may ask what The Ring has in common with that, at the latest, after 3 years the risk of microbial keratitis
Dimitri Azar’s book on refractive surgery. First, Dimitri is higher with contact lenses compared to LASIK. But it
and I share the passion for Wagner’s music. Second, it took refractive surgery 30 years to appear at the bright side
also took nearly 30 years to make refractive surgery, espe- of ophthalmology!
cially laser vision correction, an accepted subdiscipline in This book arrives, therefore, at the right time. The list of
ophthalmology—30 years seems to be an acceptable time the authors reads like a “who’s who” of refractive surgery,
to create a masterpiece. Third, many of the primers in and each of the chapters is worth reading. In addition, it
modern refractive surgery happened also in Germany and covers the whole spectrum and includes new techniques
Switzerland (e.g., phototherapeutic keratectomy [PTK], (SMILE, customized cross-linking) as well as traditional
wavefront-optimized treatments, wavefront-guided treat- procedures, such as PRK and keratotomies.
ments, topography-guided ablation, small-incision lenticule Thank you, Dimitri, for writing and collecting so many
extraction [SMILE], corneal cross-linking, and customized original articles, and thus creating a standard book on
cross-linking). modern refractive surgery!
When laser refractive surgery commenced by the end of
the 1980s, it was considered “the dark side of ophthalmol- Theo Seiler, MD, PhD
ogy”—by the way, for good reasons. Meanwhile, refractive Institut für Refraktive und
success rate and complication rate has outperformed soft Ophthalmo-Chirurgie (IROC)
contact lenses. Typical refractive success rates (± 0.5D) of Stockerstrasse, Zürich
myopic LASIK are around 94%, comparable or better with 2018

vii
Foreword to the First Edition

Evolution of medical information progresses inexorably, surgery needs to undergo some periodic respites that allow
though sometimes unpredictably. The lifetime of a major both the evaluation and teaching of new ideas and data that
new clinical concept often lasts no longer than one to three have become available to date. Herein lies the value of
decades and then, new or revitalized ideas emerge, and Dimitri Azar and his welcome book. During his several
like juggernauts, vigorously plow ahead, casting aside pre- years at the Wilmer Eye Institute, Dr. Azar displayed the set
existing beliefs that stand in their way. Their rate of growth, of attributes required of an editor and author of a compen-
interestingly, is akin to that of a new colony of microorgan- dium whose goals include promulgating new surgical ideas
isms (i.e., an S-shaped curve with an initial slow phase, for the therapists of both today—tomorrow; namely, highly
followed by exponential and sometimes explosive growth, developed ethics, communicative skills, intellectual prowess,
finally terminating in a plateau, or, in some case, a final and technical virtuosity. He is also well endowed with the
steep descent and even extermination). For example, the last combination of exuberance and perseverance that are neces-
quarter of the 20th century may reasonably be considered sary both for proselytizing favorable principles and practices
the golden age of vitreous surgery, at least as we now know and simultaneously promoting the caution that is essential
it. This is not to say that we have seen the final innovative whenever patients are subjected to revolutionary interven-
ideas in this arena; indeed, we are about to enter the impor- tions that have not been wholly vindicated. Indeed, as
tant derivative activities utilizing vitreoretinal surgical tech- pointed out by the author:
nique, such as submacular surgery, retinal cell transplants, We must continue to validate refractive surgical procedures
drug delivery, and hopefully, gene transfer. The age of initial by ensuring their predictability and reproducibility through
revolutionary ideas, however, occurred in the early 1970s, controlled and well-designed scientific investigations.
and many of the later concepts and techniques should be Dr. Azar’s imprimatur is evident throughout this book—
considered important refinements instead of epiphanies. his ideas, his original writings and illustrations, and, of
Now, with the passage of time, the field of refractive course, his selection of outstanding American and inter-
surgery rises and glows, piquing our interests and chal- national authors. Importantly, the authors represent both
lenging our priorities. These refractive ideas promise to younger and older refractive surgeons—gay blades and
rejuvenate both therapeutic and cosmetic approaches to experienced savants, so to speak. Both groups have much to
ocular problems that, according to conventional wisdom, offer, and, as they themselves would be quick to admit, their
have previously been considered technically, economically, valuable offerings represent information which is state-of-
or ethically insurmountable. As in the case of most such the-art, but which, of necessity, is in dramatic flux. Future
innovations involving human health and its associated com- editions (and one hopes there will be several) will reflect the
mercial enterprises, there is a spectrum of opinion, with result of careful clinical scrutiny; some current ideas that are
enthusiastic advocates and their understandable hyperbole fervently propounded will die, and better ones will evolve.
recognizable at one end and died-in-the-wool naysayers at Perhaps the very vigilant among us would wish to be
the other extreme. Of course, the “truth” lies somewhere clairvoyant before embarking on this journey, utilizing a
in the middle. With history in mind, one can predict that crystal ball to predict what the future of this field foretells;
ingenious ideas, instruments, and surgical procedures will on the other hand, the excitement and much of the value
rather quickly and dramatically proliferate in this emerg- of unpredictable and presently unfathomable new ideas
ing field. Darwinian natural selection influenced, some- would be lost. We should look to the future, therefore, with
times regrettably but unavoidably, by the marketplace will pleasure and bated breath, but also with judicious circum-
have its say and, within a decade or so, refractive surgery spection. There will be many opportunities for appropriate
will evolve more completely. Eventually, the public will mid-course corrections. For the moment, however, this
become well served by a combination of properly evalu- book is an outstanding contemporary summary of refractive
ated surgical procedures and superbly trained eye surgeons. surgery for both the neophyte and the sophisticate. It is the
This process requires a continual sifting of new concepts forerunner of an epoch of eye surgery that will occupy our
and techniques. Through repeated trial and error that are minds and our operating rooms for years to come.
enhanced by ethical, objective, and wise evaluation of sci-
entifically obtained clinical data, a mature discipline will Morton F. Goldberg, MD
emerge that benefits patients who are carefully selected, Director and Chairman
informed, treated, and followed up. The Wilmer Ophthalmological Institute
In the early stages of its evolution, now about to enter Baltimore, Maryland
the exponential phase of growth, the field of refractive September 1996

viii
Preface

The original idea of publishing a comprehensive multi- tive applications. Nor would it have been possible without
author “Refractive Surgery” textbook materialized in 1996, the continued energy and commitment of Joanne Scott,
while I was on the faculty of the Wilmer Institute, witness- Nayagi Athmanathan, Trinity Hutton, Russell Gabbedy,
ing and documenting, the renaissance of the field. More and the publishing team at Elsevier, who approached the
than two decades later, refractive surgery is still advancing, third edition with unfailing enthusiasm, keeping up with
with the development of more precise and sophisticated our constant revisions to incorporate and update new topics
applications. and techniques, as rapid developments in the field of refrac-
As in previous editions, the third edition of this book tive surgery showed few signs of abating.
maintains the essential backbone of the refractive surgery As we dedicate this textbook to our families and teachers,
story. Advancements in technology have expanded the we express our gratitude to the contributors who gave their
options for refractive surgical vision correction and improved valuable time, writing and revising manuscripts with dedi-
clinical outcomes. Correspondingly, the number of proce- cation. The breadth and the depth of this edition are attrib-
dures performed has continued to increase. This third utable to the collective expertise of more than 75 refractive
edition describes the principles and practice of refractive surgeons and researchers who contributed chapters, gener-
surgery. We describe advances in various surgical tech- ously sharing their knowledge and expertise, and made
niques, their indications, patient selection, limitations, and helpful suggestions throughout the process of producing
complications. We have abridged the introductory and this volume.
corneal healing, corneal inclusions and orthokeratology sec- I would also like to acknowledge the valuable assistance
tions, and we have updated the Optics chapters and included of Pushpanjali Giri. Her relentless communication with the
an overview of anterior segment optical coherence tomog- publisher and with contributors was paramount in keeping
raphy (OCT) in refractive surgery. The lamellar surgery the project on schedule.
section now encompasses laser in situ keratomileusis When I wrote the closing coda to the second edition, I
(LASIK), Q-based and wavefront-guided custom LASIK, was transitioning from the Massachusetts Eye and Ear Infir-
TopoLink and small-incision lenticle extraction (SMILE). mary and the Schepens Eye Research Institute at Harvard
We added a collagen cross-linking section and expanded the Medical School to the Department of Ophthalmology and
sections of refractive intraocular lenses (IOLs), phakic IOLs, Visual Sciences, and the Lions of Illinois Eye Research
and presbyopia surgery. Many chapters continue to benefit Institute, at the University of Illinois at Chicago (UIC). I
from illustrative surgical and educational videos as well as write this preface, more than a decade later, as I start a new
high-resolution representative photographs and illustra- chapter in my career assuming new responsibilities in San
tions. Emphasizing the visual nature of refractive surgery, Francisco as Senior Director of Ophthalmic Innovations
several figures representing comprehensive themes are com- and Ophthalmology Lead at Alphabet Verily Life Sciences.
posites, often presented in single illustrations. I am indebted to my many colleagues, fellows, residents,
This textbook would not have been possible without and students at UIC for their friendship and unwavering
the contributions of the associate editors, Drs. Damien support while I was engaged in the production of this book.
Gatinel, Ramon Ghanem, and Suphi Taneri. Their contri-
butions have broadened the scope of this book and have Dimitri T. Azar, MD, MBA
provided an international, world-wide perspective of refrac- San Francisco, CA, 2019

ix
List of Contributors

The editor(s) would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without
whom this new edition would not have been possible.

Elena Albé, MD Dimitri T. Azar, MD, MBA

Consultant Distinguished University Professor and B.A. Field Chair
Eye Clinic, ISTITUTO CLINICO HUMANITAS, of Ophthalmic Research
Rozzano, MI, Italy University of Illinois at Chicago, Chicago, IL, USA;
Senior Director and Ophthalmology Lead
Jorge L Alió, MD, PhD Verily Life Sciences (formerly Google), San Fransisco, CA,
Professor and Chairman of Ophthalmology USA
Vissum Alicante, Spain
Miguel Hernández University of Alicante, Spain Richard E. Braunstein, MD
Miranda Wong Tanga Associate Professor of Clinical
Norma Allemann, MD Ophthalmology
Adjunct Professor, Head of Discipline Harkness Eye Institute, New York, NY, USA
Department of Ophthalmology, Federal University of São
Paulo—UNIFESP Salim I. Butrus, MD
Clinical Volunteer Faculty in Ophthalmology— Clinical Professor
Department of Ophthalmology & Visual Sciences— Department of Ophthalmology, Georgetown University
University of Illinois at Chicago—UIC and George Washington University, Washington, DC,
USA
Mazen Amro, MD
Ophthalmologist Florence Cabot, MD
Université Libre de Bruxelles, Brussels, Belgium International Clinical Cornea Fellow
Erasmus Hospital, Brussels, Belgium Anne Bates Leach Eye Hospital and Ophthalmic
Biophysics Center, Bascom Palmer Eye Institute,
Jean-Louis Arné, MD University of Miami, Miller School of Medicine, Miami,
Professor Emeritus FL, USA
Head of Ophthalmology Department, Paul Sabatier
University, Toulouse, France Jonathan Carr, MD, MA(Cantab), FRCOphth
Medical Director
M. Farooq Ashraf, MD, FACS Lasik Plus—Paramus, Paramus, NJ, USA
Medical Director
The Atlanta Vision Institute, Atlanta, GA, USA Fábio H. Casanova, MD, PhD
Director, Memorial Oftalmo Recife Eye Center, Brazil
Janine Austen Clayton, MD
NIH Associate Director for Research on Women’s Health Wallace Chamon, MD
Director Professor
NIH Office of Research on Women’s Health, Bethesda, Department of Ophthalmology and Visual Sciences,
MD, USA Escola Paulista de Medicina, Universidade Federal de São
Paulo (UNIFESP), São Paulo, SP, Brazil;
Nathalie F. Azar, MD Clinical Volunteer Faculty
Clinical Professor and Director of Pediatric Department of Ophthalmology and Visual Sciences,
Ophthalmology University of Illinois at Chicago, Chicago, IL, USA
University of Illinois at Chicago, Department of
Ophthalmology, Chicago, IL, USA

x
 List of Contributors xi

Philippe Chastang, MD Pushpanjali Giri, BA

Corneal and Refractive Surgical Specialist Research Specialist
Chirurgie Oculaire Et Réfractive Department of Ophthalmology, University of Illinois at
Consultation Cabinet; Chicago, Illinois Eye and Ear Infirmary, Chicago, Illinois,
Formerly, Fondation Ophthalmologique A. de Rothschild, USA
Paris, France
Andrzej Grzybowski, MD, PhD, MBA
Pauline Cho, PhD, FAAO, FBCLA Professor of Ophthalmology
Professor Department of Ophthalmology, University of Warmia
School of Optometry, The Hong Kong Polytechnic and Mazury, Olsztyn, Poland
University, Hong Kong, SAR, China Foundation Ophthalmology, Poznan, Poland

José de la Cruz, MD Shilpa Gulati, MD

Cornea Fellow Department of Ophthalmology and Visual Sciences,
UIC Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at
The University of Illinois Eye Center, Chicago, IL, USA Chicago, Chicago, IL, USA

Roberto Fernández-Buenaga, MD, PhD Rosario Gulias-Cañizo, MD, MSc

Consultant Ophthalmologist Research Coordinator
Vissum Madrid, Spain Research Department, Universidad Nacional Autónoma
de México, Asociación Para Evitar la Ceguera en México
Jorge Alió-del Barrio, MD, PhD “Hospital Dr. Luis Sánchez Bulnes”, Mexico City,
Consultant Ophthalmologsit CDMX, Mexico
Vissum Alicante, Spain
Joelle Hallak, PhD
Ana Mercedes García-Albisua, MD Assistant Professor
Second-Year Cornea Fellow, Chief Resident Executive Director
Cornea and Refractive Surgery, Asociación Para Evitar la Ophthalmic Clinical Trials and Translational Center,
Ceguera en México “Hospital Dr. Luis Sánchez Bulnes”, Department of Ophthalmology and Visual Sciences,
Mexico City, México University of Illinois at Chicago, Morgan, Chicago, IL

Damien Gatinel, MD, PHD Rola N. Hamam, MD

Head Assistant Professor of Ophthalmology
Department of Anterior Segment and Refractive Surgery, Department of Ophthalmology, University of Beirut,
Rothschild Foundation, Paris, France Beirut, Lebanon

Emir Amin Ghanem, MD David R. Hardten, MD

Ophthalmologist Director of Refractive Surgery
Sadalla Amin Ghanem Eye Hospital, Joinville, SC, Brazil Minnesota Eye Consultants
Adjunct Associate Professor of Ophthalmology
Marcielle A. Ghanem, MD University of Minnesota, Minneapolis, MN, USA
Refractive Surgery Department, Sadalla Amin Ghanem
Eye Hospital, Joinville, SC, Brazil Everardo Hernández-Quintela, MD, MSc, FACS
Chief of Service
Ramon C. Ghanem, MD, PhD Department of Cornea and Refractive Surgery Services,
Director of Cornea and Refractive Surgery Department Universidad Nacional Autónoma de México Asociación
Sadalla Amin Ghanem Eye Hospital, Joinville, Brazil Para Evitar la Ceguera en México, Hospital Dr. Luis
Sánchez Bulnes, Mexico City, CDMX, Mexico
Vinícius Coral Ghanem, MD, PhD
Ophthalmologist and Medical Director, Department of Peter S. Hersh, MD, FACS
Ophthalmology Sadalla Amin Ghanem Eye Hospital, Cornea and Laser Eye Institute—Hersh Vision Group
Joinville, SC, Brazil Professor of Clinical Ophthalmology, Director of Cornea
and Refractive Surgery
Rutgers Medical School Visiting Research Collaborator
Princeton University, Princeton, NJ, USA
Visit https://textbookfull.com
now to explore a rich
collection of eBooks, textbook
and enjoy exciting offers!
xii List of Contributors 

Arthur Ho, MOptom, PhD, FAAO Michael C. Knorz, MD

Chief Scientist and Innovation Officer Professor of Ophthalmology
Brien Holden Vision Institute, Sydney, NSW, Australia; FreeVis LASIK Center, Klinikum Mannheim, Mannheim,
Visiting Professorial Fellow Germany
School of Optometry and Vision Science, University of
New South Wales; Jeffrey C. Lamkin, MD
Voluntary Professor of Ophthalmology Private Practice
University of Miami, Miller School of Medicine, Miami, Akron, OH, USA
FL, USA
François Malecaze, MD, PhD
Thanh Hoang-Xuan, MD Professor of Ophthalmology
Professor of Ophthalmology Hospital Purpan, Toulouse, France
University of Paris, American Hospital;
Formerly, Fondation Ophthalmologique A. de Rothschild, Fabrice Manns, PhD
Paris, France Professor of Biomedical Engineering and Ophthalmology
Ophthalmic Biophysics Center, Bascom Palmer Eye
Brien A. Holden, PhD, DSc, OAM Institute, University of Miami
Formerly Deputy CEO Miller School of Medicine, Miami, FL;
Vision Cooperative Research Centre, The University of Chairman of the Department of Biomedical Engineering,
New South Wales, Sydney, NSW, Australia University of Miami College of Engineering, Coral
Gables, FL
Sandeep Jain, MD
Professor of Ophthalmology Marguerite B. McDonald, MD, FACS
Cornea Service Clinical Professor of Opthalmology
Director, Cornea Translational Biology Laboratory NYU School of Medicine;
Director, Dry Eye Service and oGVHD Service Tulane University School of Medicine, New Orleans, LA,
University of Illinois at Chicago, Department of USA
Ophthalmology, Chicago, IL, USA
Françoise C. Abi Nader, MD
Elias F. Jarade, MD Optometrist
Ophthalmologist, Cornea and Refractive Surgeon Laser Eye Medical Center, Dubai, United Arab Emirates
Beirut Eye & ENT Specialty Hospital, Beirut, Lebanon
Ioannis G. Palliakaris, MD, PhD
Joel Adrien D. Javier, MD Dean and Professor of Ophthalmology
Clinical Consultant Vardinoyannion Eye Institute of Crete/Institute of Vision
Bausch & Lomb, Singapore and Optics, University of Crete Medical School, Voutes,
Crete, Greece
James V. Jester, PhD
Professor of Ophthalmology and Biomedical Engineering Jean-Marie Parel, IngETS-G, PhD, FAIMBE,
University of California, Irvine, Irvine, CA, USA FARVO
Henri and Flore Lesieur Chair in Ophthalmology
Piotr Kanclerz, MD, PhD Ophthalmic Biophysics Center, Bascom Palmer Eye
Medical Doctor Institute, University of Miami
Department of Ophthalmology, Medical University of Miller School of Medicine, Miami, FL;
Gdańsk, Gdańsk, Pomorskie, Poland Vision Cooperative Research Center, University of New
South Wales, Sydney, Australia
Vikentia J. Katsanevaki, MD, PhD
Head of Refractive Department Kévin Pierné, MD
Vardinoyannion Eye Institute, University of Crete Medical Practitioner in Ophtalmology
School, Crete, Greece Hospital Purpan, Toulouse, France

Johnny M. Khoury, MD Antony M. Poothullil, MD

Assistant Professor of Ophthalmology Kaiser Permanente, Ophthalmology, Portland, OR, USA
Director, Refractive Surgery Division
American University of Beirut Medical Centre, Beirut,
Lebanon
 List of Contributors xiii

Ana Belén Plaza-Puche Walter Stark, MD

Optometry Office of the Research Development & Boone Pickens Professor of Ophthalmology
Innovation Department, Vissum Alicante, Spain The Director of the Stark-Mosher Center for Cataract and
Corneal Services
Cynthia J. Roberts, PhD The Wilmer Eye Institute, The Johns Hopkins Hospital,
Professor of Ophthalmology & Visual Science and Baltimore, MD, USA
Biomedical Engineering
Martha G. and Milton Staub Chair for Research in Mario Antonio Stefani, PhD
Ophthalmology R&D Board Chairman
The Ohio State University, Columbus, OH, USA R&D Medical Division, Opto Eletrônica S/A, São Carlos,
SP, Brazil
Renan Rodrigues, MD
Ophthalmologist, Post-doctoral Student Leon Strauss, MD, PhD
Department of Ophthalmology/Cataract and Refractive Instructor
Surgery Division, Federal University of São Paulo The Wilmer Eye Institute, The Johns Hopkins University,
(UNIFESP)/ São Paulo Hospital/ UNIFESP, São Paulo, School of Medicine, Baltimore, MD, USA
SP, Brazil;
Co-founder of CONUS—Keratoconus Center Suphi Taneri, MD
Director, Center for Refractive Surgery
Mark Rosenblatt, MD, PhD Department of Ophthalmology at St. Franziskus Hospital,
Professor and Head of Ophthalmology and Visual Münster, NRW, Germany;
Sciences in the UIC College of Medicine Associate Professor of Ophthalmology
Chicago, IL, USA Eye Clinic, Ruhr University, Bochum, NRW, Germany

Mirwat Sami, MD, FACS Vance Thompson, MD

Houston Eye Associates, Houston, TX, USA Director of Refractive Surgery
Vance Thompson Vision
Valeria Sánchez-Huerta, MD, FACS Professor of Ophthalmology
Head of Academics University of South Dakota Sanford School of Medicine,
Department of Cornea and Refractive Surgery Services, Sioux Falls, SD, USA
Universidad Nacional Autónoma de México
Asociación Para Evitar la Ceguera en México “Hospital Josep Torras, MD
Dr. Luis Sánchez Bulnes”, Mexico City, CDMX, Mexico Department of Ophthalmology, Mutua Terrassa Hospita,
Barcelona, Spain
David J. Schanzlin, MD
Partner, Gordon Schanzlin New Vision Institute Kazuo Tsubota, MD
Professor of Clinical Ophthalmology (Emeritus) Professor and Chairman
University of California, San Diego, San Diego, CA, USA Department of Ophthalmology, Keio University School of
Medicine, Tokyo, Japan
Theo G. Seiler, MD
Department of Ophthalmology, University of Bern, Bern, Veronica Vargas
Switerland Refractive Surgery Fellow
Department of Investigation, Development and
Theo Seiler, MD, PhD Innovation at Vissum Alicante, Alicante, Spain
Professor and Chairman
Institut für Refraktive und Ophthalmo-Chirurgie Frédéric Vayr, MD
(IROC), University of Zurich, Zurich, Switerland Corneal and Refractive Surgical Specialist
Institut Laser Vision, Noémie de Rothschild;
Ashish G. Sharma, MD, FACS Formerly, Fondation Ophthalmologique A. de Rothschild,
Retina Consultants of Southwest Florida Paris, France
Fort Myers, Florida, USA
Steven M. Verity, MD
Professor
Department of Ophthalmology, Cornea/External Disease
and Keratorefractive Surgery, University of Texas
Southwestern Medical Center at Dallas, Dallas, TX, USA
xiv List of Contributors 

Jayne S. Weiss, MD Sonia H. Yoo, MD

Associate Dean of Clinical Affairs Professor of Ophthalmology
Chair, Department of Ophthalmology Anne Bates Leach Eye Hospital and Ophthalmic,
Herbert E Kaufman MD Endowed Chair Biophysics Center, Bascom Palmer Eye Institute,
Professor of Ophthalmology, Pathology and Pharmacology University of Miami, Miller School of Medicine, Miami,
Louisiana State University School of Medicine, LSUHSC, FL, USA
New Orleans, LA, USA
Bavand Youssefzadeh, DO
Albert Chak-Ming Wong, MBChB (CUHK), Ophthalmology Associate Physician
MRCSEd, MMedSc (HK), MMed (Ophth), Cornea/Refractive Department, Gordon Schanzlin New
FCOphthHK, FHKAM (Ophth), FRCSEd (Ophth) Vision Institute, San Diego, CA, USA
Clinical Assistant Professor (Honorary)
The Jockey Club School of Public Health and Primary
Care, Faculty of Medicine, The Chinese University of
Hong Kong;
Director
Department of Ophthalmology, Albert Eye Centre, Tsim
Sha Tsui, Kowloon, Hong Kong
 Dedication

To Lara, Nicholas, and Alexander;

To Nathalie,
for sharing my profession with dedication and excellence,
my long days with patience and assistance,
my leisure with cheerfulness and laughter,
and my happy moments with affection and optimism;
and for providing Alexander, Nicholas, and Lara with wonderful roots
and magnificent wings;
To all my fellows and residents for being the source of my learning and inspiration;
To Ilene, Fred, Mort, Claes, Bob, Michael, and Andy for their friendship
and mentorship;
And in memory of my loving parents; I can no longer see them with my eyes, but I see
the light they have brought to the world still shining, long after they have gone.
Dimitri T. Azar, MD, MBA

To my teachers, students, family, and friends.

To the curious minds.
Damien Gatinel, MD, PHD

I dedicate this work to my dear family for their constant inspiration and support.
With reverence to my grandfather, Sadalla Amin Ghanen, in memoriam;
to my beloved parents, Emir Amin Ghanem and Cleusa Coral-Ghanem, models of
wisdom, courage, dedication, and professional ethics;
to my brother Vinícius, a friend at all times, a professional colleague, and an example
to be followed.
to Marcielle, my great love and mother of our sons, Nicolas, Henrique, and Gabriel;
and, finally, to two great mentors, Professors Newton Kara-José and Dimitri T. Azar.
Ramon C. Ghanem, MD

To my father and mother for their unconditional love,

to Anneanne, Remziye Teyze, Ertug Amca in memoriam, and Ufuk Hala for their
loving support,
to Nicola for passionately sharing her life with me,
to Mavi-Nur and Sinan for adding fun and excitement,
and to Heinrich Gerding, Kunibert Krause in memoriam, H. Burkhard Dick, and
Dimitri T. Azar
Suphi Taneri, MD
1
Terminology, Classification, and
History of Refractive Surgery
SHILPA GULATI, ANTONY M. POOTHULLIL, AND DIMITRI T. AZAR

Introduction: Why Do Patients Choose Emmetropia, Ametropias, and Presbyopia

Refractive Surgery?
The successful performance of refractive surgery demands a
Patients desire refractive surgery for a variety of reasons. thorough understanding of the optics of the human eye.
For patients seeking laser in situ keratomileusis (LASIK) The refractive power of the eye is predominantly deter-
or surface ablation, the most common motivation is a mined by 3 variables: the power of the cornea, the power
desire to decrease contact lens or spectacle use.1–3 Some of the lens, and the length of the eye. In emmetropia, these
individuals require improvement in their uncorrected visual 3 components combine in such a way as to produce no
acuity (UCVA) because of their careers. Others have ocular refractive error. When an eye is emmetropic, a pencil of
or medical conditions that make contact lens wear dif- light parallel to the optical axis and limited by the pupil
ficult or dangerous. Some prefer to be free of glasses or focuses at a point on the retina (i.e., the secondary focal
contacts when engaging in sports and recreation. Presby- point of an emmetropic eye is on the retina; Fig. 1.1). The
opic patients may want to be able to read clearly without “far point” in emmetropia (defined as the point conjugate
glasses. Still others have anisometropia or spectacle-related to the retina in the nonaccommodating state) is optical
anisophoria such that corrective spectacle lenses result in infinity.
prominent eyestrain and an unacceptable degree of dis- Eyes with refractive errors can have abnormalities in one
comfort. Cosmetic appearance may also be a reason for or more of the above variables, or all variables can be in the
surgery. normal range but incorrectly correlated, resulting in a
The number of refractive surgical procedures available to refractive error. For example, an eye with an axial length in
patients has increased dramatically since the early days of the upper range of normal may be myopic if the corneal
radial keratectomy (RK) and keratomileusis. Recent devel- variable is also in the steeper range of normal. In a myopic
opments are discussed in this textbook, including custom- eye, a pencil of parallel rays is brought to focus at a point
ized LASIK, small-incision lenticule extraction (SMILE), anterior to the retina. This point, the secondary focal point
presbyopic implants, and multifocal IOLs. Patients who of the eye, is in the vitreous. Rays diverging from the far
have had LASIK for the correction of myopia are generally point of a myopic eye will be brought to focus on the retina
very happy. In a survey by Miller et al., approximately 85% without the aid of accommodation.
were at least “very pleased” with their refractive outcome The hyperopic eye, on the other hand, brings a pencil of
and 97% said they would decide to have the procedure parallel rays of light to focus at a point behind the retina.
performed again.4 Factors that correlated well with patient Accommodation of the eye may produce enough additional
satisfaction were postoperative improvements in UCVA, plus power to allow the light rays to focus on the retina.
decreased cylindrical correction, and absence of side effects, Rays converging toward the far point farther behind the
such as dry eye. While this may be comforting, it is impor- eye will be focused on the retina while accommodation is
tant to remember that the vast majority of refractive surgery relaxed.
is performed on patients with excellent corrected visual For full correction of myopia and hyperopia, a distance
acuity and a decrease in quality of vision is ultimately unde- corrective lens placed in front of the eye must have its sec-
sirable. With continued advancements of refractive proce- ondary focal point coinciding with the far point of the eye
dures, we can minimize complications, improve outcomes, so that the newly created optical system focuses parallel rays
and educate our patients and ourselves. onto the retina.

2
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery 3

TABLE Classification of Lenticular and Scleral

1.1 Refractive Procedures
F2 M MyA H HA MxA A P
CLE + +
Far point = x
PIOL + +

(A) Emmetropia Bioptics + + + + + +

Multifocal + + +
Accommodative IOL + + +
Phaco-Ersatz +
Far point
Scleral relaxation, ±
expansion

A, Aphakia; CLE, clear lens extraction; H, hyperopia; HA, hyperopic

(B) Myopia astigmatism; IOL, intraocular lens; M, myopia; MxA, mixed astigmatism;
MyA, myopic astigmatism; P, presbyopia; PIOL, phakic intraocular
lenses.

F2 with spectacles can simply remove their glasses for improved

reading vision. Latent hyperopes, on the other hand, use
their accommodative reserve for clear distance vision; as the
amplitude of accommodation wanes with age, reading dif-
(C) Myopia ficulties emerge.

Classification of Refractive Procedures

F2
Refractive surgery procedures are undergoing constant
development and modification. In the late 1990s, LASIK
has essentially replaced RK as the preferred treatment for
patients with myopia. More recently, SMILE and multifocal
(D) Hyperopia IOLs have gained increasing popularity and phakic intra-
ocular lenses (PIOLs) have undergone numerous modifica-
• Fig. 1.1 Schematic diagrams of emmetropia, myopia, and hyperopia. tions for the treatment of higher degrees of myopia or
(A) In emmetropia, the far point is at infinity, and the secondary focal
point (F2) is at the retina. (B and C) In myopia, the far point is in front hyperopia. With an expanding repertoire of options, it is
of the eye and the secondary focal point, F2, is in the vitreous. (D) In important to have an organized understanding of the surgi-
hyperopia (bottom), the secondary focal point, F2, is located behind cal techniques that are available to the refractive surgeon.
the eye. (Modified with permission from Azar DT, Strauss L. Principles Refractive surgery procedures for the correction of
of applied clinical optics. In: Albert D, Jakobiec F, eds. Principles and
Practice of Ophthalmology. Philadelphia: WB Saunders; 1994.)
myopia, hyperopia, presbyopia, and astigmatism achieve
emmetropia by modifying the optical system of the eye. In
this chapter, we have divided surgical techniques into 2
Astigmatism may be caused by a toric cornea or, less broad categories: keratorefractive (corneal-based) and len-
frequently, by astigmatic effects of the native lens of the eye. ticular or scleral surgical procedures. Keratorefractive tech-
Astigmatism is regular when it is correctable with cylindrical niques surgically alter the cornea without entering the
or spherocylindrical lenses so that pencils of light from anterior chamber and are the main type of refractive surgery
distant objects can be focused on the retina. Otherwise, the performed today. The lenticular or scleral refractive proce-
astigmatism is irregular. Visual acuity is expected to decline dures include intraocular techniques, such as the insertion
for the different degrees of astigmatism. Astigmatism of of multifocal, accommodating, and adjustable lenses, and
0.50 to 1.00 diopters (D) usually requires some form of extraocular methods, such as scleral relaxation or expansion
optical correction. An astigmatic refractive error of 1.00 to procedures for presbyopia (Table 1.1).
2.00 D decreases uncorrected vision to the 20/30 to 20/50
level, whereas 2.00 to 3.00 D may decrease UCVA to the Keratorefractive Surgery
20/70 to 20/100 range.5
Presbyopia is the age-related loss of accommodation. Keratorefractive surgeries rely on at least five major methods
Onset of presbyopia will vary with the refractive error and to reshape the corneal surface: lasers, incisions, corneal
its method of correction. For example, myopes corrected implants, thermal procedures, and nonlaser lamellar surgery.
4 se c t i o n I Introduction

All procedures induce corneal changes by affecting the More commonly, the laser is used to perform corneal
corneal stroma. Excimer lasers are used to subtract tissue stromal ablation under a lamellar flap, termed laser in situ
from the stroma and modify corneal shape. With incisional keratomileusis (LASIK).
surgery, a blade is used to make precise cuts into the stroma.
These incisions result in wound gape, altering the corneal Laser Procedures for Myopia
surface contour, resulting in changes in the refractive power In PRK, the excimer laser is applied to the anterior surface
of the cornea. Corneal implants can be placed into the of the cornea for reshaping (Fig. 1.2). The laser may be used
corneal stroma to change corneal shape. Thermal techniques
cause focal changes in stromal collagen architecture in order
to change corneal contour. At present, thermal methods are
limited to the correction of hyperopia or presbyopia. Non-
laser lamellar surgeries add or subtract tissue from the
cornea in order to reshape it. With lamellar addition pro-
cedures, donor corneal tissue is transplanted to the host
cornea. Lamellar subtraction procedures involve two stages:
(1) lamellar stromal dissection and (2) removal of stromal
tissue. Many of these procedures have the unintended side
effect of reducing corneal tensile strength. Our understand-
ing of corneal biomechanics has increased and has allowed
us to develop safer keratorefractive procedures for our indi-
vidual patients.6–9

Keratorefractive Procedures: Myopia and

Myopic Astigmatism
Myopia is the most common visually significant refractive
error, with a rising prevalence of 25% to 40% in Western
countries.10,11 In the United States, the prevalence of myopia
has doubled in the last 30 years and pathologic myopia
(over 8.00 D) has risen eightfold.12 Numerous procedures
have been developed to treat myopia by altering the corneal
curvature. The cornea is responsible for 60% of the eye’s
refractive power; small changes in curvature can produce
significant refractive changes. Corneal procedures correct
myopia by flattening the anterior curvature or changing the
index of refraction of the cornea. All keratorefractive pro-
cedures for the treatment of myopia modify the corneal
thickness to produce anterior curvature alterations except
for RK, in which the corneal curvature is flattened by tec-
tonic weakening without changing the central thickness.13

Laser Procedures
The excimer laser, a 193-nm argon fluoride (ArF) beam,
has become the technology of choice for keratorefractive
surgeons worldwide. A major advantage of the laser is its
ability to precisely ablate tissue with submicron pulses. The
excimer laser-ablated surface has the potential of being
smoother than that obtainable by other surgical techniques.
Since its introduction in 1983 by Trokel and Srinivasan for
linear keratectomy, the excimer laser procedure has under-
gone a rapid evolution.14 Myopic excimer laser treatments
achieve their effect by flattening the central cornea. The
• Fig. 1.2 Schematic illustration of myopic photorefractive keratec-
laser can reshape the cornea by ablating the anterior corneal tomy. The shaded area refers to the location of tissue subtraction.
surface, as in photorefractive keratectomy (PRK) or laser- More stromal tissue is removed in the central as compared to the
assisted subepithelial keratectomy (LASEK or epi-LASEK). paracentral region.
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery 5

to remove the corneal epithelium. Alternatively, the epithe- Myopic LASIK

lium may be removed by scraping with a surgical blade or
by using dilute ethanol and a cellulose sponge. For myopia
of 1 D to 7 D, PRK has been shown to result in a high
rate of preservation of best corrected visual acuity (BCVA)
and minimal complications. In most series, 90% of patients
achieve 20/40 or better uncorrected acuity and are within
1 D of emmetropia. In this moderate myopia group, the
initial overcorrections generally regress toward emmetropia
over several months, with stabilization after 6 to 12 months.
Highly myopic patients often regress 6 to 12 months after
surface PRK, presumably because of stromal regeneration
and/or epithelial hyperplasia, which cause resteepening of
the ablated zone.15 Dense subepithelial haze occurs rarely
but is greater in PRK treatments exceeding 6 D and may
reduce the BCVA. Mitomycin C has been applied during
PRK treatments in order to decrease the incidence of haze
formation.16 Artola et al. found that induced corneal aber-
rations after PRK for myopia created a multifocality that
enhanced near acuity, which may delay the onset of pres-
byopic symptoms. However, this multifocality also reduced
the quality of the retinal image for distance at low contrast.17
LASEK and epi-LASIK are modifications of the PRK
procedure in which the corneal epithelium is preserved,
displaced prior to surface ablation, then replaced after laser
application. Advantages over PRK include decreased post-
operative discomfort, reduced postoperative scarring, and
faster visual recovery. Prior to laser application, the epithe-
lium is treated with 15% to 20% ethanol. This treatment
weakens hemidesmosomal attachments between the corneal
epithelium and the underlying Bowman membrane. The
epithelial sheet can then be easily displaced and protected
by moving it outside of the ablation zone. Following stromal
ablation, the epithelial sheet is returned to its original loca-
tion, covering the ablated area.18 Pallikaris et al. have • Fig. 1.3 Schematic illustration of myopic and hyperopic laser in situ
keratomileusis. A superficial corneal flap is raised. The shaded area
described epi-LASIK, using an automated blade to remove refers to the location of tissue subtraction under the flap. After treat-
the corneal epithelium mechanically, without the applica- ment, the flap is repositioned.
tion of alcohol. They suggest that this technique should
provide improved comfort and decreased haze formation
compared to PRK, and histologic studies show better pres- used to photodisrupt the corneal stroma with a preset depth
ervation of the corneal epithelial sheet when compared to and pattern. When used for LASIK, the laser creates the
LASEK.19,20 corneal flap prior to excimer laser application.21
LASIK is a two-stage procedure that combines lamellar Customized corneal ablations use Q-based or “wave-
surgery with laser application. It has become the most front” aberrometers to detect and treat both spherocylindri-
widely performed refractive procedure in the United States. cal error and higher-order aberrations (HOAs) that can
Its main advantages over surface ablation procedures include affect visual acuity. At the time of publication, these devices
faster visual recovery, less postoperative discomfort, and are approved in the United States for the treatment of
decreased incidence of postoperative corneal scarring or myopic and astigmatic refractive errors. These custom lasers
haze in patients with higher refractive errors. During LASIK, offer the possibility of improved vision compared to tradi-
an anterior corneal flap is created and then is lifted, the tional excimer lasers because they address additional factors
excimer laser is applied to the stromal bed, and the flap is that may be contributing to blur in an individual’s optical
returned to its original position (Fig. 1.3). The corneal flap system.22 A study of 132 eyes undergoing LASIK using the
can be created with either a microkeratome or an intrastro- NIDEK Advanced Vision Excimer Laser (NIDEK) showed
mal laser. Microkeratomes are affixed to the globe via a that fewer HOAs were induced when compared to non-
suction device and the blade is passed via a manual or custom LASIK, and 93% achieved uncorrected vision of at
automated mechanism. The femtosecond (FS) laser is a least 20/20. Preoperative sphere and cylinder ranged to
solid-state laser with a 1053-nm wavelength that can be −8.25 D and −3 D, respectively.22
6 se c t i o n I Introduction

corneal biomechanics. Long-term follow-up has demon-

strated a reduction in HOAs and minimal refractive regres-
sion, though some potential advantages, such as improved
biomechanical stability and postoperative inflammation,
have yet to be established.
Laser Procedures for Myopic Astigmatism
Compound myopic astigmatism can be treated with nega-
tive or positive cylinder ablation. Negative cylinder ablation
flattens the central cornea in both the flat and the steep
meridians. Positive cylinder ablation may allow a larger
optical zone with no change in the central depth of abla-
tion.24 One study examined 74 eyes with compound myopic
astigmatism treated with the Meditec MEL 10 G-Scan
(Zeiss) excimer laser. Patients were followed for 1 year and
had myopia from −4.50 D to −9.88 D and astigmatism up
to 4.00 D. At 1 year, mean postoperative spherical equiva-
lent was −0.49 and mean cylinder refraction was 0.59.25

Incisional Procedures: A Historical Perspective

In the early 1970s, RK was performed by ophthalmologists
in the Soviet Union, including Beliaev,26 Yenaliev,27 and
Fyodorov and Durnev.28–31 RK was performed for the first
time in the United States in 1978.32,33 The RK procedure for
myopia places deep, radial, corneal stromal incisions, which
weaken the paracentral and peripheral cornea and flatten
the central cornea. Refractive power of the central cornea
is reduced and myopia is decreased (Fig. 1.6). The surgeon
can control the refractive effect by adjusting three variables:
central optical zone, incision number, and incision depth.
Incisional Procedures for Myopia
RK achieves the best results in patients with low and moder-
ate degrees of myopia (up to 5 D). In patients with higher
amounts of myopia (6–10 D), the response to surgery is
much more variable34–43 and undercorrection is more
common. The age of the patient partially determines the
upper limit of attainable correction. Older patients achieve
a greater correction by approximately 0.75 D to 1.00 D per
10 years of age exceeding 35 years.44 Other patient variables
• Fig. 1.4 Small-incision lenticule extraction (SMILE). may affect outcomes but are difficult to quantitate. For
example, reports show that a premenopausal female with a
flat cornea, low intraocular pressure, and a small corneal
diameter may achieve less correction than would be gener-
SMILE is a refractive procedure in which an FS laser is ally predicted for a particular RK technique.45–47
used to create a corneal stromal lenticule, which is extracted RK has been studied thoroughly, most notably by the
whole through a 2- to 3-mm incision (Fig. 1.4). Outcomes National Eye Institute (NEI)–funded, multicenter Prospec-
have been noted to be similar to those of LASIK: in a meta- tive Evaluation of Radial Keratotomy (PERK) study, a col-
analysis by Zhang et al.23 comparing SMILE and FS-assisted laborative effort of 9 clinical centers. Predictability of results
LASIK (FS-LASIK) in 1101 eyes, no significant difference remains problematic.35–45 Early studies of predictability
was found in refractive outcomes. SMILE was found to showed that about 70% of eyes have a residual refractive
result in higher postoperative corneal sensitivity but fewer error within ±1 D of the predicted result and 90% within
dry-eye symptoms than FS-LASIK. The biomechanical sta- ±2 D.45–49 Later studies, with a staged approach, report
bility after SMILE surgery is expected to be greater than 80% to 90% of eyes within 1 D of emmetropia.49–51 Stabil-
that after LASIK and may be comparable to PRK and ity of refraction after radial keratotomy is also inade-
LASEK. Fig. 1.5 compares RK, PRK, LASIK, and SMILE quate.52–54 The 10-year PERK results revealed long-term
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery 7

A B

C D
• Fig. 1.5 Simulated displacements in corneal shape on the surface resulting from the four refractive surgi-
cal procedures at a normal intraocular pressure of 15 mm Hg. The dark-red areas involve maximum
displacements (>0.5 mm) outwards (body expansion), and the dark-blue areas involve zero displacement
near the constrained boundary of the models. The “preoperative surface” is displacement of the normal
cornea. (A) Radial keratectomy: maximum displacements located at middle incisions; (B) photorefractive
keratectomy: maximum displacement at central cornea; and (C) LASIK and (D) SMILE: maximum displace-
ments located around the central cornea (unit: mm). (From Shih P-J, Wang I-J, Cai W-F, Yen J-Y. Bio-
mechanical simulation of stress concentration and intraocular pressure in corneas subjected to myopic
refractive surgical procedures. Sci Rep. 2017;7(1):13906. doi:10.1038/s41598-017-14293-0.)

instability of refractive errors; 43% of eyes changed refrac- straight fashion perpendicular to the steep meridian of astig-
tive power in the hyperopic direction by 1 D or more matism (Fig. 1.7A). AK offers the patient a very good
(hyperopic shift) between 6 months and 10 years.52 chance of significant improvement by correcting astigmatic
RK has essentially been replaced by newer excimer laser errors.61–63 In general, patients with greater than 1.5 D of
keratorefractive procedures. In 2003, one survey showed astigmatism may be candidates for AK. Deeper and longer
that 4% of cataract and refractive surgeons performed RK, incisions closer to the center of the cornea produce greater
down from 46% in 1996.53 effect, but cuts beyond 75 degrees are not recommended.
Effects of cuts increase dramatically with age. This proce-
Incisional Procedures for Myopic Astigmatism dure is now performed with the femtosecond laser and,
Naturally occurring astigmatism is very common and up rarely, with a diamond blade.
to 95% of eyes may have some clinically detectable astig- Relaxing incisions in the steep meridian were developed
matism in their refractive error.55 Between 3% and 15% of by Troutman (Fig. 1.7B). These decrease astigmatism in the
the general population has astigmatism greater than 2 D.56 steep meridian, but the results can be unpredictable.64,65
Although there is some variability, approximately 10% of This procedure may be combined with wedge resection or
the population can be expected to have naturally occur- suturing in the flat meridian. These techniques have been
ring astigmatism greater than 1 D, where the quality of used to correct postkeratoplasty astigmatism and surgically
UCVA might be considered unsatisfactory.9,57 Surgically induced astigmatism at the time of cataract surgery.65–67
induced astigmatism can occur following cataract surgery. A study of 52 eyes showed a mean astigmatic change of
The incidence of astigmatism following extracapsular cata- −0.8 D in patients who had clear cornea cataract surgery
ract extraction greater than 2 D is approximately 25% to with placement of limbal relaxing incisions (LRIs). The
30%.58,59 With clear corneal incision phacoemulsification control group of 47 eyes had a mean astigmatic change of
procedures, the incidence of astigmatism is much less. Bel- +0.50 D.68
trame et al. showed 0.66 D to 0.68 D of surgically induced The Ruiz procedure, now rarely used, employs trapezoi-
astigmatism 3 months after phacoemulsification through a dal cuts, four transverse cuts inside two radial incisions
3.5-mm clear cornea incision.60 (Fig. 1.7C). Although important in its time, stacking mul-
Astigmatic keratotomy (AK) involves performing trans- tiple rows of astigmatic incisions is no longer felt to be
verse (also called tangential, or T) cuts in an arcuate or prudent because of poor predictability. A pair of tangential
Visit https://textbookfull.com
now to explore a rich
collection of eBooks, textbook
and enjoy exciting offers!
8 se c t i o n I Introduction

5mm 7mm

C
• Fig. 1.7 Correction of myopic astigmatism. (A) Astigmatic keratot-
omy. (B) Limbal relaxing incision. (C) Ruiz procedure.

Keratomileusis refers to carving or chiseling the cornea.

The first reported clinical results were published in 1964 by
• Fig. 1.6 In radial keratotomy, radial incisions are placed in the cornea Jose Barraquer, and keratomileusis was first performed in
(top), resulting in forward bowing of the midperipheral cornea and
compensatory flattening of the central cornea (middle). Postoperative
the United States in 1980 by Swinger.69–71 For myopia,
appearance of radially symmetric spokes can be appreciated (bottom). keratomileusis involves excision of a lamellar button (lenti-
cule) of the patient’s cornea with a microkeratome, reshap-
ing the lamellar button such that the central corneal
or arcuate incisions achieves significant correction. Addi- curvature is flattened, and replacing it in position with or
tional incisions have minimal added benefit. without sutures. Automated lamellar keratoplasty (ALK),
also called keratomileusis in situ, was initially developed for
Nonlaser Lamellar Procedures for Myopia: higher myopia (Fig. 1.8). ALK uses a mechanized micro-
A Historical Perspective keratome to remove a plano lenticule (corneal cap) or to
create a hinged corneal flap. A second pass of the micro-
Lamellar procedures for myopia involve corneal lamellar keratome in the stromal bed resects a disc of central corneal
dissection combined with the addition or subtraction of stroma, and the corneal cap or flap generally is replaced on
corneal stromal tissue to result in overall flattening of corneal the stromal bed without sutures. The lenticule, at the time
curvature. Nonlaser lamellar techniques include keratomi- of the first pass, can be secured by a small residual hinge of
leusis, automated lamellar keratoplasty, and epikeratophakia. tissue (flap) to minimize the possibility of losing the cap.
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery 9

The procedure enables correction of large degrees of myopia

(5 D to 18 D), but major problems include irregular astig-
matism, unpredictability, and long visual recovery time
(freezing damages tissue).72–75 Corrections beyond 18 D
require greater tissue resections, resulting in instability and
unpredictability.71,72 Clinically significant irregular astigma-
tism can occur in 10% to 15% after ALK, but this may
decrease with time.73,76,77
Epikeratoplasty (also known as epikeratophakia and onlay
lamellar keratoplasty) was introduced by Kaufman, Werblin,
and Klyce at the LSU Eye Center in the late 1970s and
early 1980s.78,79 It involves removal of the epithelium from
the patient’s central cornea and preparation of a peripheral
annular keratotomy. No microkeratome is used. A lyophi-
lized donor lenticule (consisting of the Bowman layer and
anterior stroma) is reconstituted and sewn into the annular
keratotomy site (Fig. 1.9).80 Theoretical advantages of epik-
eratophakia are its simplicity and reversibility.81 This proce-
dure is capable of correcting greater degrees of myopia than
keratomileusis, but irregular astigmatism, delayed visual
recovery, and prolonged epithelial defects are common.77,82
Corneal Implants for Myopia
Synthetic materials can be embedded between corneal
stromal lamellae to correct myopia. Intracorneal rings can
be threaded into a peripheral midstromal tunnel or placed
in a peripheral lamellar microkeratome bed to effect flatten-
ing of the central cornea.83,84 Their advantage lies in the
avoidance of manipulation of the central cornea and visual
axis (Fig. 1.10). Studies have also examined synthetic intra-
corneal lens implants that are placed in a centrally dissected
corneal stromal pocket for the correction of aphakia and
myopia (Fig. 1.11).85 These lenses have high indices of
refraction and are made of materials such as polysulfone.86–88

Hyperopia and Hyperopic and

Mixed Astigmatism
Although hyperopia affects approximately 40% of the adult
population,89,90 it is much less visually significant than
myopia. The great majority of young hyperopes regard their
eyes to be optically normal. They may experience early pres-
byopia and manifest hyperopia in their mid- to late thirties.
Hyperopia may also be the result of overcorrection following
radial keratotomy for myopia. This may require surgical
intervention, but a waiting period of approximately 1 year
may be necessary.91 Many of the keratorefractive procedures
used for hyperopia are similar in design to those used to
treat myopia but act to increase the cornea’s refractive power.
Laser Procedures
Excimer laser techniques—such as PRK, LASEK (or epi-
LASEK), and LASIK—can be used to treat hyperopia. An
• Fig. 1.8 Automated lamellar keratoplasty. Schematic illustration of in
situ automatic corneal reshaping of the keratomileusis bed. The shaded ablation pattern allows for maximum ablation in the mid-
area refers to the location of tissue subtraction. A corneal button is periphery for an overall steepening of the optical zone. At
raised using a microkeratome (top). A second pass modifies the stromal present, custom corneal ablations are not approved for
bed to allow corneal flattening after replacing the cap (middle). hyperopic corrections in the United States.
10 se c t i o n I Introduction

• Fig. 1.9 Schematic illustration of epikeratoplasty. A preshaped donor lenticule (bottom) is sutured to the
recipient stromal bed to correct myopia (left) and hyperopia (right). The shaded areas refer to the locations
of tissue subtraction.

Laser Procedures for Hyperopia behind the retina. Treatments that combine hyperopic
Patients with low degrees of hyperopia treated with LASIK sphere with myopic cylinder treatments or hyperopic cylin-
achieve more predictable results and achieve refractive sta- der with myopic cylinder treatments spare the most tissue.95
bility more quickly than those with higher amounts of In a study by Salz and Stevens,96 65 patients with mixed
hyperopia (> 5 D).92,93 Stability with hyperopic LASIK is astigmatism were treated with the Alcon LADARVision
usually reached by 3 months.14 One study has compared excimer laser. Uncorrected visual acuity was 20/20 in 52%
LASEK and PRK for the treatment of hyperopia of up to at 12 months.
5.0 D. LASEK patients experienced less postoperative pain,
decreased haze, faster visual recovery, and greater refractive Incisional Procedures for Hyperopia
stability compared to patients with hyperopic PRK.94 Hexagonal keratotomy, devised by Mendez in 1985, is an
incisional treatment for hyperopia consisting of circumfer-
Laser Procedures for Hyperopic and ential connecting hexagonal peripheral cuts around a clear
Mixed Astigmatism 4.5-mm to 6.0-mm optical zone. This procedure allows the
Hyperopic astigmatism occurs when both meridians are central cornea to steepen, thereby decreasing hyperopia
focused behind the retina. Patients with this profile can be (Fig. 1.12).97 A second procedure using nonintersecting
treated in minus-cylinder or plus-cylinder format. When hexagonal incisions was described by Casebeer and Phillips
treating in minus-cylinder format, both meridians are flat- in 1992.98 A study in 1994 of 15 eyes reported complica-
tened centrally, with the steeper meridian being flattened tions that included glare, photophobia, polyopia, fluctua-
more. In plus-cylinder format, both meridians undergo tion in vision, overcorrection, irregular astigmatism, corneal
peripheral steepening, with the flatter meridian being steep- edema, corneal perforation, bacterial keratitis, and end-
ened more. Azar and Primack showed that plus-cylinder ophthalmitis.99 These authors concluded that hexagonal
ablations spare more tissue when treating hyperopic astig- keratotomy was unpredictable, unsafe, and had high rates
matism.95 A study of 124 eyes with hyperopic astigmatism of complications.99
treated with the Alcon LADARVision excimer laser showed
results similar to those with hyperopic spherical treatment, Nonlaser Lamellar Procedures for Hyperopia
with 53.1% achieving 20/20 uncorrected visual acuity at 12 ALK, keratophakia, and epikeratophakia have been used
months with a small overcorrection of the cylinder.96 to treat hyperopia. In hyperopic ALK (also known as ker-
In patients with mixed astigmatism, one meridian must atomileusis), a deep lamellar keratectomy is performed
be flattened and the other must be steepened because one with a microkeratome, elevating a corneal flap. The stromal
meridian is in focus in front of the retina and the other bed subsequently develops ectasia under the flap, which
 CHAPTER 1 Terminology, Classification, and History of Refractive Surgery 11

• Fig. 1.11 Schematic illustration of an intracorneal lens inlay. The

synthetic lens is placed in the corneal stroma after creation of a lamellar
flap (illustrated here) or within a lamellar pocket (not shown).

• Fig. 1.12 Conductive keratoplasty (CK). Spot algorithm used to

predict the effect of CK. A greater effect is obtained with neutral-
pressure CK.

is replaced without additional surgery. Alternatively, the

stromal side of the resected disc is remodeled into a convex
hyperopic lenticule that, when placed in the original
stromal bed, results in steepening of the central cornea.
Hyperopic ALK has poor predictability and the risk of
progressive ectasia limits its usefulness. Homoplastic ALK
B has been performed to hyperopia from 4 D to 10 D. In
this procedure, the microkeratome removes a small disc
• Fig. 1.10 Corneal intrastromal ring segments. (A) The ring is placed (80–100 mm in thickness, 5–7 mm in diameter) that is
in the stroma (top) resulting in central flattening (middle); the central discarded and replaced by a 350- to 400-µm thick donor
cornea is not manipulated (bottom). (B) Photograph of intrastromal
segments (arrows).
lenticule (generated using the microkeratome). The safety
12 se c t i o n I Introduction

and efficacy of hyperopic and homoplastic ALK have not causing focal shrinkage of collagen fibers, steepening the
been fully established.100 central cornea and flattening the periphery (see Fig. 1.12).
Keratophakia is a technique developed by Barraquer for Applications are made in concentric 6-, 7-, or 8-mm circles;
treating high hyperopia or aphakia. A lamellar keratectomy the amount of effect depends on the number of spots placed.
is first performed on the patient’s cornea using a microkera- At the present time, CK has been approved for the treatment
tome. Donor corneal tissue is then shaped into a lens after of hyperopia (0.75–3.25 D, with no more than 0.75 D of
removal of the epithelium, Bowman layer, and anterior astigmatism) and presbyopia in emmetropes and hyperopes
stroma. This donor lens is placed intrastromally within the (by induction of myopia, −1.00 D to −2.00 D).107,108
recipient and the anterior lamellar cap is sutured in place.
This process creates a steeper anterior cornea and increases Aphakia
refractive power. Synthetic intracorneal lenses have also
been developed for implantation in the lamellar bed but are Most aphakic patients who are intolerant of contact lenses
investigational. Hyperopic epikeratophakia uses a prepared or simply desire refractive correction undergo secondary
donor lenticule without microkeratome removal of tissue. intraocular lens placement. Aphakic patients who are at
Although theoretically safer than keratomileusis, it lacks high risk for intraocular procedures may benefit from kera-
predictability and may induce irregular astigmatism.101 torefractive surgery. These procedures for the treatment of
aphakia are similar to nonlaser lamellar techniques, such as
Thermal Procedures for Hyperopia keratophakia and epikeratoplasty or corneal implants for
Thermal energy can be used to shrink collagen of the corneal high hyperopia. As described before, keratophakia involves
stroma and increase central corneal power. When applied the intrastromal placement of donor stromal tissue that has
to the paracentral or peripheral cornea, these techniques been shaped into a lens. The donor tissue lens is thicker in
result in increased central corneal curvature and peripheral the center than in the periphery. Epikeratophakia has been
corneal flattening. Three methods are described: radial described previously for myopia and hyperopia and involves
intrastromal thermokeratoplasty, laser thermokeratoplasty, sewing a donor lenticule to the anterior surface of the pre-
and conductive keratoplasty. pared cornea. Widespread use of epikeratophakia is limited
Radial intrastromal thermokeratoplasty shrinks the because of problems with epithelial healing and graft clarity.
peripheral and paracentral stromal collagen, producing a Its main use is in the correction of aphakic children aged 1
peripheral flattening and a central steepening of the cornea to 8 years who are spectacle and contact-lens intolerant, in
to treat hyperopia. Radial thermokeratoplasty (hyperopic order to avoid amblyopia. The highest success rates in epi-
thermokeratoplasty [HTK]) for the correction of hypero- keratophakia have been reported in the treatment of 8- to
pia was developed in the then Soviet Union in 1981 by 18-year-old patients with aphakia.109
Fyodorov. A retractable cautery probe tip produces a series Intracorneal lens implants are under investigation.
of preset-depth (≈ 95%) stromal burns in a radial pattern Advantages include improved refractive quality and predict-
similar to that used in RK.41,102–105 Although an initial ability and faster visual recovery when compared to nonlaser
reduction in hyperopia was observed, lack of predictability lamellar techniques for aphakia. In addition, corneal
and significant regression are problems.41,102–105 However, implants eliminate the risks associated with the use of
there may be less induced astigmatism with radial ther- human donor tissue. Materials such as hydrogel85 or fenes-
mokeratoplasty than with hyperopic ALK or hexagonal trated polysulfone,110 with a high index of refraction, have
keratotomy.106 been studied. Steinert et al. reviewed the use of a hydrogel
Solid-state infrared lasers, like the holmium:yttrium alu- implant (lidofilcon A) in patients with aphakia, followed
minum garnet (Ho:YAG) laser, have been used in a periph- over 2 years. A total of 88% of these patients had a refrac-
eral intrastromal radial pattern (laser thermokeratoplasty tion within 3 D of plano. Complications included loss of
[LTK]) to treat hyperopia of 4 D and less.107 LTK works BCVA, irregular astigmatism, and irregular microkeratome
by causing thermal shrinkage of stromal collagen in the resections in some patients.111
paracentral cornea, with a resultant steepening of the central
corneal curvature, thereby reducing hyperopia. Recent work Presbyopia
on human eyes has demonstrated appropriate topographic
changes with at least short-term stability.108 This laser energy Near vision correction is an especially important consider-
can be delivered by a handheld probe or slit beam system and ation when planning refractive surgery in the presbyopic age
appears most useful for limited amounts of hyperopia group. Myopic patients may experience difficulty with near
and hyperopic astigmatism. However, the long-term effects vision if their refractive error is fully corrected. Undercor-
and refractive stability of Ho:YAG LTK are unknown. rected myopes may experience less-than-optimal distance
Conductive keratoplasty (CK) is a technique that has vision but may retain some of their ability to see clearly at
been recently approved by the US Food and Drug Admin- near distances. Keratorefractive procedures for presbyopia
istration (FDA) for the treatment of hyperopia and presby- include monovision, a procedure that leaves a residual
opia. CK uses a special probe to deliver radiofrequency wave myopic correction in one eye, and multifocal corneal abla-
energy to the deep stroma of the midperipheral cornea, tion, a procedure that is still in development.
Random documents with unrelated
content Scribd suggests to you:
to her husband, Frank. He was really one of the most circumspect of
men, but if he stopped for a moment to talk with Miss Kempton, the
sixty-year-old dressmaker, poor Helen was quick to imagine him
taking advantage of her affliction to exchange nonsense with the
other ladies. And right here let me say to the deaf and the near-
deaf: force yourselves to believe that your friends, and particularly
the members of your family, are absolutely true; do not ever permit
your mind to suggest that those upon whom you must rely for help
or interpretation are unfaithful. Never admit this until you cannot
escape the conviction. Remember that most persons we meet are
kindly and well disposed, if selfish and thoughtless. They are not
plotting our destruction or even our unhappiness. It is too easy for
the deaf to turn life into a veritable hell by permitting the hideous
devils of depression to master the brain.
Now, Helen Brewster was jealous without reason, and perhaps the
unreasonable phase of that disease runs its most violent course. The
Brewsters lived on the ground floor of an old-fashioned town house.
In the family living on the upper floor was a daughter, Mary
Crimmins, who caused Helen’s worst paroxysms. In Winter, after an
unusually hard storm, the old roof was endangered by its load of
snow. Mary Crimmins called from her window to Frank as the only
man then in the house to mount the roof and shovel away the snow.
And Helen, washing dinner dishes at the sink, saw the two talking,
Frank looking up and smiling, and immediately concluded that the
topic was much warmer than snow. Frank got a ladder and a shovel,
and mounted to the roof, while poor Helen sat in the sitting-room
bathing her soul in misery, for while men do not usually present a
ladder when planning an elopement in broad daylight, all things
were possible to her distorted mind. Soon there came a small
avalanche of snow from the roof, but the distracted deaf woman did
not hear it. Then her son came rushing into the room, screaming
with such breath as was left in him:
“Oh, ma! It’s terrible!”
“What’s the matter?”
“The snow all slipped and knocked the ladder down, and pa—”
“What about pa?”
“He’s up there hugging—”
Johnnie really finished his sentence, but the words “pa” and
“hugging” were enough for Helen.
“He is, is he? I’ll attend to him!” And she rushed upstairs and
knocked loudly at the door; then, without waiting for any invitation,
she strode in. Old Mrs. Crimmins sat knitting by the window, while in
a corner behind her sat Mary with a stranger, a fine-looking young
man. Before the irate deaf woman could properly unload her mind,
Mary blushing red, came and screamed in her neighbor’s ear:
“This is my fiance, Henry Jordon. We meant to keep it secret, and
you are the first one I’ve told. I know you won’t repeat it.”
“But where’s Frank?” the astonished Helen at last managed to say.
Johnnie had followed her upstairs, and he was well drilled in
handling the deaf. So he caught hold of his mother’s dress and
pulled her to the door.
“Come and see, ma,” he cried.
He led her downstairs, out into the snow and pointed. And there was
pa. The snow had slipped beneath his feet, and carried him to the
very edge of the roof. He had saved himself only by catching at the
chimney. There he stood, with both hands clasped about it,
“hugging” literally for dear life.
It was a very silent and thoughtful deaf woman who raised the
ladder and gave her husband a chance to discontinue his attention
to the chimney. And that is about the way nine-tenths of our
imaginary troubles terminate. It never did pay to hug a rumor or a
delusion too strenuously. Better conserve your strength for
something more substantial.
 CHAPTER XIV
Cases of Mistaken Identity

Traveling for the Deaf—When the

Deaf Man Saved a Leg for
Someone Else—The Cornetist Who
Couldn’t Play a Note—When the
Deaf Meet the Drunk.

Some deaf persons make the mistake of concluding that the

affliction chains them at home and that they should not attempt to
travel. This is wrong, for they thus lose many extraordinary
adventures. It is better for us to get about if possible, and to take
our chances with the world. I travel about as freely as any man with
perfect ears might do, and thus see much of human nature which
would otherwise be lost to me. No adventures are more amusing or
exciting than those which start with mistaken identity. I have come
to think that in the molding or shaping of humanity comparatively
few patterns are really used, judging from the number of times that
I and other deaf men have been mistaken for strange persons in the
mental shuffle of ordinary minds. The man with good ears can
usually explain at once, but we do not always understand, and we
are led into embarrassing situations.
Once years ago I went to the country to spend the night with an old
friend. It was dark when we reached the little town where I was to
meet “an elderly man with a gray beard,” who would drive me to the
farm. We deaf are careful to have all such arrangements understood
beforehand. It was a black, gloomy night, and there were no lights
at the little station except the lanterns carried by the agent and a
few farmers. The deaf man is at his worst in darkness. It holds
unimaginable terrors for him. Perhaps I should say perplexities, for
the deaf are rarely afraid.
Most of us do more or less lip-reading, whether we make a study of
the science or not, and through long habit we come to make use of
the eyes without realizing how largely our lives must depend upon
light. Thus, when suddenly plunged into darkness, we are lost. I
carried in my hand a small black case containing the electric
instrument which I used as an aid to hearing, and this proved my
undoing. Such a case may be accepted as professional evidence; it
may contain only a lunch or your laundry, but lawyers and physicians
also carry similar ones. As I stood looking about in the dim light an
elderly man with a short beard stepped up and held his lantern so as
to view my face. I saw his lips frame the words:

“Come on; hurry! We are all waiting.”

I supposed he referred to supper, for I knew my friend had a very
orderly and precise wife, who is a little deaf. One must be promptly
on time in keeping appointments with such a character. The old man
caught me by the arm, hurried me to a carriage, and fairly bundled
me into it. He paid no attention to my questions, but jumped into
the front seat and urged on the horse to full speed. The lantern
swinging from the front axle went out as we bumped off into the
darkness over mud holes and ruts without number. I tried to get my
electric device into operation, but the plug had dropped out of place
and I could not make connections. So on we plunged. Soon I found
that the old man in front was nearly as deaf as I. The combination of
two deaf men in the darkness rushing through what was to one of
them an absolutely unknown country should have been thrilling, but
the deaf man rarely experiences a thrill; he must wait for some one
to tell him what it is all about. As usual, my mind worked back for
some comparative incident.
I remembered two. The year before I had gone to Canada during
the Winter. A farmer met me at the station after dark. It was very
cold, and the body of a closed carriage which had been put on
runners was filled with straw. This made a warm, comfortable nest,
and the farmer got in with me, while his son sat up in front to drive.
The same plug to my hearing device had dropped out, and in order
to give me a light for finding it, my host struck a match. He held it
too long and it burned his fingers. Then it fell into the straw and
started a great blaze. No two men ever showed greater activity than
we did as we plunged out of that carriage and threw in snow until
the fire was extinguished. That scene came to my mind, and then
followed the story by Ian Maclaren of the great surgeon who came
up from London to perform an operation, and was carried off into
the wilderness against his will by the local doctor.
We drove several miles, it seemed to me, and then suddenly turned
into the yard of a farmhouse. I felt the carriage shudder as the
wheel grazed the stone gatepost. The door opened and a long
splinter of light darted out upon us. Two women hurried down the
walk and helped me out of the carriage. They were strangers to me,
and now I was sure that I was in the midst of an exciting adventure,
not at the home of my friend. The women escorted me to the house,
where I found two solemn-faced gentlemen evidently waiting for
me. One of them held up a finger and beckoned me into an
adjoining room, where upon a bed lay a man who glared at me with
no agreeable face. By this time I had my “acousticon” in working
order, and as this man evidently had something to say, I held the
mouthpiece down to him and heard him shout:
“I tell you I won’t have it cut off!”
The two men who had brought me in were very much startled when
the exact contents of my black case was revealed. They glanced at
each other and then promptly escorted me out of the room. We
went into the kitchen, and there, beside the stove, the mystery was
explained. One of the men looked curiously at me and then asked:
“Are you not Dr. Newton of New York?”
I hastened to explain that I had never before heard of Dr. Newton.
Then it was revealed to me that these men were country doctors,
waiting to hold a consultation with the great surgeon, who had been
expected to arrive on my train. The man on the bed had had serious
trouble with his knee. These physicians had agreed that the limb
must be removed, yet both hesitated to perform a complicated
operation. Hence, the surgeon was coming to do it. The sick man’s
father-in-law had gone to the station; he had been instructed to
bring back a man of medium size, who said little and carried a black
case of surgical instruments. I was to look for an elderly man with a
gray beard. Father-in-law and I had mixed our signals.
It took me but a short time to convince these physicians that I could
not fill the bill or saw off the leg. At last it developed that the actual
surgeon was detained and could not come until the following day.
The man on the bed forgot his terror and laughed when I told him
my story, and it gave him the fighting courage to compel his wife to
telegraph the surgeon not to come at all. But those doctors acted as
though I had deprived them of their prey. In my capacity as
substitute surgeon I gave the patient the best advice I knew of:
“As one afflicted man to another, I advise you to hang right on to
your leg. Try the faith cure and make yourself believe it can be
saved.”
“You bet I will. They’ll have to cut my throat before they cut this leg
off!”
I saw him some years later. He carried a cane and limped, but he
still had two legs.
“They never cut it off,” he reported. “They put a silver cord in the
joint, and it has held ever since. It’s a little stiff—but it’s a leg. I
guess if Pa Morton and you hadn’t been deaf that night they would
have finished the job.”
I have heard of a deaf man who had an experience somewhat
similar to this. He also left the train one dark, stormy night in a
good-sized city. He was a stranger, so he was quite unfamiliar with
the place. He carried a small black case containing his hearing
device and a few toilet articles. As he stood in the dim light looking
about for his friends, two men rushed up to him, talking quite
excitedly; they grasped him by the arms and hurried him outside the
station. Unable to understand the performance, the deaf man
followed, trying to explain that he was waiting for his friends. Almost
before he knew it he found himself inside a car with these excitable
gentlemen, driving rapidly through the streets. Of course, you
wonder why deaf men under such conditions do not explain and
break away.
“You wouldn’t catch me in any such situation,” says my friend Jones.
“I’d soon make ’em understand.”
There is only one thing the matter with Jones’ point of view—he has
never lived in the silence. Let him try that and he will understand
that philosophy assumes a form of patience in such situations. We
are usually quite helpless in the darkness, and when we go among
strangers we must either suspect everyone who approaches us or
consider him a friend. Most of us conclude from experience that it is
wiser to drop suspicion and assume that the majority of human
beings are honest. And as the great emotion of fear apparently
enters the brain through the ear, we are apt to be calm under most
extraordinary conditions.
We left our puzzled deaf man rushing in a car through the streets of
an unknown city. The auto finally entered a narrow, dark alley and
stopped before what appeared to be the back door of a large
building. The deaf man was urged out of the car by his nervous
companions and was hurried up a steep stairway. They blundered
through several dark passages and finally came out on the stage of
a theater, where they stood in the wings and watched a long-haired
pianist in the center of the stage laboring to unlock the keys of a
piano in a way calculated to let loose a horde of imprisoned
melodies. A vast audience filled the house.
A man who appeared to be master of ceremonies rushed up to the
deaf man and wrote on his notebook:
“Delighted to see you! We feared you were not coming. Your first
number is next on the program. We will give the professor an encore
while you are preparing.”
The poor deaf man could only stare and protest in wonder, but soon
a ponderous German puffed up the stairs in great excitement. He
pulled the unfortunate victim back among the heaps of properties
and roared, shaking his fist:
“I am the cornetist what plays here! What do you mean, you
impostor, who try to take my place?”
After they had succeeded in pacifying the German they explained to
the deaf man. They had engaged a celebrated cornet soloist for the
benefit concert, and had sent a reception committee to the station
to meet him. It was late, and these nervous men had never seen the
great musician. They did see a dignified man carrying what looked
like a case for musical instruments. When they asked him if he was
Professor Hoffman, the deaf man merely nodded his head as the
quickest way to get rid of them, and they naturally rushed him to
the theater without further ado, leaving the musician to find his way
alone.
This deaf man had a keen sense of humor, and greatly relished the
situation, but the German had never recognized a joke in his life, so
he continued to glare at the “impostor.” After a most humble apology
about all the committee could offer as recompense was an invitation
to the deaf man to remain and hear the music. He remained and
was interested in seeing his musical rival blow himself up to nearly
twice his natural size in order properly to express his feelings
through his cornet.
Many of his most amusing and at the same time tragic experiences
come to the deaf man through his association with drunken people.
We meet them in all our travels, and I must confess that I have
never found a more interesting study than that which deals with the
effect of alcohol upon the human character. A drunken deaf man is a
most pitiable object, but to the observant deaf man his drunken
neighbor presents a case of infinite wonder and variety. We see men
naturally grim and silent singing ridiculous songs, or attempting to
dance. Men usually profane, making no pretense at religion,
suddenly quote from the Scriptures devoutly. Quarrelsome men of
rough, ugly temper overwhelm us with attentions, while men of
kindly nature challenge us to fight. We see it all, and must judge
such people mainly by their actions.
Usually drunken men begin to talk to me. When they find that I do
not reply they generally foam over with sorrow or anger, and it is
hard to decide which is the more embarrassing. Once in a strange
town when I was looking about for my friends the town drunkard
accosted me. I have never known just what he did want, but when I
explained that I was a stranger looking for a certain street he
volunteered to show me the way. So he caught my arm and led me
up the street, staggering against me at every other step, and talking
loudly. And on our way we met my friend and his wife, sober and
dignified persons who were horrified at my appearance under the
escort of the town drunkard. In his sober moments my guide would
never have thought of associating with these aristocratic
representatives of Main Street, but now he greeted them jovially, as
old friends. It was a most embarrassing situation, and my friends,
being absolutely devoid of humor, have never felt quite sure of me
since the incident.
A drunken man once approached a friend of mine with a remark
which he did not understand, as he was deaf, so he merely shook his
head and turned away. The intoxicated man, full of fight, followed,
shouting challenges and pulling off his coat. A crowd gathered about
them, and two rough-looking fellows got behind the deaf man and
offered to act as his seconds. One of them advised:
“Give him an upper cut on the chin whisker and follow it up with one
on his basket!”
What the deaf man did was to pull out his notebook and pencil and
give them to the drunken man, who now was quite ready for the
fray.
“I cannot hear a word you say. Write it out for me!”
This is offered as a suggestion to the peace-makers, that they may
be more blessed than ever before. Whenever a man curses you, and
you want to gain time—ask him to write it out! Here the drunken
man looked curiously at the deaf man and then at the notebook. He
pondered deeply for a moment and then slowly began to put on his
coat. He walked unsteadily to a little box nearby, mounted it
carefully and delivered a short speech something like this:
“Ladies and gentlemen, I am wrong. This man is not my enemy, but
my friend, made so through affliction. He is in need. I suggest that
we all chip in and help him on his way. I’ll start with the price of
three drinks! Come now, loosen up! He who giveth let him give
quickly!”
Once I lived in the house with a kindly man who had a fierce craving
for drink. He really fought against it, but it mastered him again and
again. One year at Christmas he had gone for several months
without drinking. He was like a consumptive who imagines that he
has overcome his disease while it still lurks within only waiting for
favorable conditions to blaze up. A few days before Christmas
several old friends stepped out of his wild past and broke down the
man’s self-control. When I came home he was “roaring drunk”—I
had never seen him in worse condition. As I came up the stairs he
rushed suddenly out of his room and caught me unexpectedly by the
collar. As I was taken off my guard he was able to pull me inside the
room, shut the door and throw himself against it. At that time I
could hear much of what he said. He glared at me like a maniac. His
fists were clenched, his eyes were bloodshot and he was altogether
a terrifying and a pitiful spectacle.
I expected him to throw himself upon me, and I was ready. I had no
idea wherein I had offended, and I did not want to hurt him. I
derided that when he sprang at me I would sidestep and give him
the “French trip” which I had learned in the lumber camps. That will
floor anyone who is not prepared for it, and I knew that I could tie
him if necessary. But there was no fight in him except the frightful
battle he was waging against himself. His fists opened and he held
out his hands appealingly.
“I’ve brought you here to pray for me! Get right down on your knees
and pray that I may be a man and not a skunk!”
Well—take it as you like, the deaf man has his share of excitement
with all sorts of men. There seems to be no good reason that we
should lead uneventful lives! I have often wondered what various
pompous friends of mine would have done with the above situation.
Or I should like to see them master another incident which involved
the same man. Once he approached me as I stood talking with
visitors.
“I want you to do me a favor!” he said in the thick, eager voice of
the intoxicated. “I want you to kick me, and kick me hard!” As I did
not reply he thought I had not heard, so taking off his coat he
backed up to me in a way any deaf person could understand!
 CHAPTER XV
All in a Lifetime

The Training School for Robbers—

Eavesdroppers Who Heard Not a
Word—The Fox and the Wolf—The
Murderer—The Plans for Eloping—
Regarding the Deaf as Uncanny—
The Narrowness and Prejudice of
the Deaf Themselves—Dancing
and Singing Eliminated—The Blind
and the Deaf, and the Man with
Both Afflictions.

On a lonely corner in New York City I once saw three boys practicing
the gentle art of highway robbery. One played the part of victim; he
walked along giving a good imitation of the ordinary citizen busy
with his own thoughts, giving little attention to his surroundings. The
other two boys approached him carelessly, apparently laughing at
some joke. As they passed, one of the “robbers” suddenly turned
and threw his left arm around the “citizen’s” head just below the
chin. Then he quickly slid his right arm down to pinion the arms of
the victim just above the elbow. He put his left knee at the middle of
the victim’s back and pulled with the left arm. It was a murderous
grip; the more the victim struggled the closer drew the “head lock”
under his chin, and the neck was forced back to the breaking point.
The other boys deftly emptied the unprotected pockets of watch and
money. Then they threw the victim to the ground and ran away.
They rehearsed this over and over—taking turns at the different
positions, perfecting themselves in this barbarous business.
I watched this fascinating play for some time, studying to think of
some way in which the victim might defend himself. He might
possibly use his feet, but taken unaware probably his breath would
be shut off before he could organize any defense. One can easily
realize how powerless an unsuspecting stranger would be at the
hands of three trained villains such as these boys seemed likely to
become.
Two years later I had occasion to pass through the street where this
rogue’s training had been carried on. It was after dark, and just as
my mind reverted to this grewsome drill two men appeared from
under the shadow of the elevated station. They stopped and spoke
to me, but I did not understand. One of them repeated his question,
pointing at my watch chain. Naturally I pulled back my arm to strike
him as I saw an opening, but the other man quickly caught my head
and arms in that murderous lock which I had seen those boys
practicing. He did not hurt me, but I found myself powerless to
move or speak. I cannot describe the feeling of utter helplessness
caused by that grip at my throat and arms. The first man took my
watch from my pocket and held it to the light, looked at it carefully—
and put it back again! He looked over my shoulder at his companion
who held me captive, and as his face was then in the light, I could
read the words on his lips:
“Only nine o’clock?”
Then I read once more:
“Thank you!”
My arms were set free, and, smiling, the two men hurried on. I
assume that they merely wanted to know the time. They saw that I
could not hear them and that I might call for help and put them in a
bad position, so they helped themselves to the time of day in true
hold-up style.
One man’s adventure illustrates how deafness may be converted into
an asset if the affliction can be kept concealed. He went to a city
park, and was sitting on a bench which was partly concealed by
trees and shrubs. He was undergoing one of those periods of
depression which often fall upon us in the silence, after some sharp
rebuff, or when the real trouble of our affliction is visited upon us by
some careless associate. Completely absorbed, this man did not
notice that a nearby seat was occupied by a young woman and a
man. Finally he did perceive that they were talking earnestly—the
man was evidently pleading and the woman was inclined to deny
him. But at last she evidently consented to his proposition, and he
looked cautiously around to make sure that they were alone before
sealing the agreement in the usual way. Then for the first time he
discovered my deaf friend within ten feet of their bench! Of course
these young people assumed that the deaf man had heard it all.
From the beginning conscience has made cowards of most of us.
The girl started to advertise her feelings with a scream, but her
companion checked her just in time by pointing to a park policeman
who was swinging his club at the corner of the path. Then he took
out his notebook, and without trying to talk he wrote this brief
explanation and handed it to the deaf man.
“Please don’t betray us. It is true that we have planned to elope. We
will be married this afternoon in New Jersey. I am sure her father
will forgive us when we return; it is our only way. You overheard by
accident—now be a good sport and let us alone!”
The deaf man put on his glasses to read the note. Through the film
which gathered on the lenses he saw only visions of youth and
romance. No woman would be likely to come into the land of silence
and elope with him! That would be but a clumsy and ridiculous
performance, and he knew it well. These young people were
probably all wrong. Yonder policeman would question them, find
where they lived and notify the father of the girl. As a sober-minded
citizen opposed to youthful folly and far removed from it, was it not
his duty to stop such nonsense? And yet—
He who hesitates is frequently spared the necessity for decision. He
looked up to find that the young people had disappeared, they had
slipped out of sight during his meditation. And in his lonely silence
the deaf man could smile, for he was glad that they got away.
Another deaf man was traveling through a Western State in a
Pullman. This man noticed two men who seemed to be engaged in a
most earnest discussion. They sat across the aisle from him and as
they talked they glanced furtively about. They were a forbidding pair,
one a great hulking brute with a broad red face—the other a little rat
of a man with a low, receding forehead and a bright, restless eye.
The wolf and the fox appeared to be hunting together. Frequently
the big man became emphatic and struck the back of the seat with
his great fist while the little man shook his head and bared his teeth
in a smile which seemed like a menace. The deaf man wished to
change his position so as to get a better view of the country, and he
happened to drop into the seat which backed up against the one in
which the wolf and the fox were laying their plans. At first they paid
no attention to him, but continued to argue and gesticulate. Finally
the fox realized that the head of the deaf man was within a foot of
their conversation. How was he to know that the “listener” might as
well have been a mile away in so far as successful eavesdropping
was concerned? He instantly signalled to the wolf and the discussion
stopped. They both soon moved to the smoking-room, where they
whispered for a little time; then the fox came to sit beside the deaf
man. He glanced about anxiously, but finally said:
“Did you happen to hear what we were saying?”
The “eavesdropper” read some of the words on the lips of the other,
and vaguely nodded his head. Then the fox took a piece of paper
and wrote:
“It is a good joke. I made a bet with my friend that we could make
you think we were in earnest in planning the job. Of course there is
nothing to it. It was a fake talk.”
Just then the wolf appeared with his hat and suitcase. The train was
approaching a small town. “Come,” he said, “we get out here.” His
friend jumped up to join him. They sprang off as the train stopped,
though the conductor said that their tickets would have carried them
fifty miles farther. The deaf man caught a look of fear and suspicion
from the fox as the two disappeared. Of course they were planning
mischief, but fear of this deaf man caused them to run from him as
they would have fled a plague.
Many years ago I passed a Winter in a lumber camp far up among
the snows of Northern Michigan. My bunk-mate was a gigantic, silent
man, a stranger and a mystery to all the rest of us. He said little and
made no friends. He had a curious habit of glancing hurriedly about
him; he started at light sounds and appeared to keep a watchful eye
always upon the door. Frequently at night I found him awake, gazing
at the lantern which always hung at the door, near the end of the
camp. One day the driver of the supply team smuggled a bottle of
whiskey into camp and my bunk-mate was able to get two good
drinks. We worked together that day in a lonely place, and he
became quite talkative. I could not hear him well, but he was
evidently trying to tell some incident of his own life. There in the
forest, knee deep in snow, he appeared to be acting out a tragedy.
At the last he did not seem to realize that I was there. He addressed
some imaginary person, holding out his hands as if in appeal.
Apparently this was rejected, and his face changed in anger. He
caught up his axe and rushed up to a fallen log; he struck it a blow
which sent a great chip flying a hundred feet away. Then he looked
at me in wonder, seeming to realize that I must have overheard him.
He sat on the log, took great handfuls of snow and held them
against his head. I found myself helping him with a great chunk of
ice which I had brought from the brook.
“It was the whiskey,” he suddenly shouted. “It’s poison. It makes me
talk and think. Say—did you hear what I said? What was it?”
He looked at me with hard, savage eyes. I had not heard his ravings
and did not recount his actions. He continued to stare at me silently,
axe in hand. Then he decided to believe my denial and he kept at
work as before, silent and grim. As we went back to camp that night
he asked me once more, with apparent irrelevance:
“Did you hear what I said?”
I again assured him that I had understood nothing, which was the
truth. He seemed satisfied, but during the evening he divided his
attention between me and the outside door; he was again puzzled
over the chance that I had heard. In the early morning I awoke to
find myself alone in the bunk. The man did not appear again.
Two nights later I sat on the bench by the camp stove drying my
clothes after another day in the wet snow. At the moment when I
was remembering that curious watch-dog habit of my bunk-mate’s
the door suddenly opened and two men entered. One was the
sheriff of a county in the lower tier, near the Ohio line; the other was
also armed. They were after my bunk-mate—too late.
“What’s it for?” asked the foreman.
“Murder, I reckon. He quarreled with his wife and hit her with an
axe.”
And to this day I wonder what would have happened to me in the
woods if I had heard what he said.
Deaf persons undoubtedly come to be really troublesome to many
kindly and essentially generous men and women. I have never been
able to understand the feeling; perhaps it resembles the creepy
terror which the touch or the sight of a cat arouses in some persons.
At any rate I have been introduced to people who are unmistakably
afraid of me. They cross the street to avoid a face-to-face encounter.
I think they would not dare to walk alone with me at night. I have
come to realize that a fair proportion of the human beings I meet
are actually afraid of me, or uncomfortable in my presence until I in
some way make them understand that I will not annoy them, or that
I have a message for them which can be delivered by no one else.
Some deaf people live tormented by the thought that society rejects
them, or at best merely tolerates them. They would be far happier to
admit frankly that they are not as other men, and realize that there
is no reason why the world should give them special
accommodation. They should rather seek to acquire original
personality or power which would make them so luminous that the
world would eagerly follow them. This is possible in some way for
every deaf person. It is our best hope.
One of the finest men I ever knew told me frankly that two classes
of people make him shudder; men belonging to the Salvation Army,
in uniform, and deaf persons, trying to hear. This friend is a
thoroughly sincere clergyman, with a leaning toward the full dignity
of the cloth. The Salvation Army came to his town, and being
charitably disposed toward the workers, he attended one of their
meetings. Greatly to his embarrassment the captain called in a loud
voice for Brother Johnson to pray. The clergyman started in the
formal manner but at the first period he was greeted with a loud
chorus—“Amen, brother!” While the drummer pounded on his drum
and clashed his brass. My friend still suffers from the shock. His
feeling for the deaf may be traced to Aunt Sallie. At the bedside of a
sick friend he was asked to pray. Before he could even start, Aunt
Sallie, very deaf but anxious to miss nothing, planted herself so
close as to place her ear about six inches from his mouth. I do not
wonder that this man will cross the street at the approach of
deafness or a uniformed Salvation Army officer.
And it must be admitted that it is quite easy for the deaf themselves
to become narrow and prejudiced. Frequently when exiled to the
silent world, with poetry and laughter shut out, we use a clipped
yard-stick to measure the good which is always to be found in
everyone. Sometimes prejudice is carried to a ridiculous extreme.
When I was a boy Deacon Drake of the Congregational Church went
to a funeral at which a Unitarian minister officiated. The Deacon had
not heard for years, but he sat stiff-necked and solemn until the
choir sang a hymn which visibly affected the people. He asked his
daughter for the name of the hymn and she wrote it out—“Nearer,
My God, to Thee.” The old man had heard not a note, but as he
disapproved of the sentiment expressed he rose and tramped firmly
out of the room.
Job asked “Where is wisdom to be found?” Surely the deaf may
eliminate singing and dancing as promising prospects for their
search! Once a deaf man went to a party and fell into the hands of a
feminine “joker.” This lady had wagered that she could dance a
Virginia reel with a man unable to hear a note of the music. She
contended that she would make him hear through vibration and thus
guide him properly. Of course the deaf man knew better, but what
was he to do? What could any man do in such a case? You yourself
would probably trample all over judgment and common sense and
stand out to make yourself ridiculous as man has done for centuries,
and will doubtless continue to do!
They started bravely, but half way down the line the music
quickened and the ill-starred deaf man landed heavily upon the foot
of his partner. It was a cruel smash. The vibration process was
reversed. She lost her wager and he was counted out, but he should
have known better.
Perhaps you have seen a deaf man trying to march in a parade; I
once saw one trying to keep step to his own wedding march! Well, I
may say that the wife of a deaf man has many trials, usually she
must do the marching for both.
I have often been asked whether total deafness is a greater affliction
than total blindness. It would be very difficult to decide. At times the
blind man would gladly exchange his hearing for sight; he so longs
to see the faces of old friends or of his children. Yet frequently he is
glad that the burden of deafness has not been laid upon him. In like
manner the deaf man would sometimes give all he has for the sound
of some familiar voice or the melody of some old song. Yet,
considering carefully and weighing all the evidence, total blindness
seems the greater affliction. But I have had blind men “feel sorry”
for me because I miss the sounds of the birds and cannot hear
whispered confidences.
However, I think the blind are happier than the deaf. There is less of
the torture of Tantalus about their affliction. If they are surrounded
by loving and considerate friends they have less to regret than the
deaf; their embarrassments are not brought home so cruelly, for
they do not see the consequences of their own blunders. I know a
woman who was suddenly blinded, twenty-five years ago. She has
lived usefully and happily with her family. Her children are now
middle-age men and women, showing the wrinkles and the wear of
life. Her husband and her brother have aged, but not for her. She
only sees the old vision of youth and power. An illuminated silence
would have given her all the signs of age creeping upon those
nearest her, and would have destroyed her intimate part in the
everyday family life. Her children never could have come to her,
weeping, seeking her sacred confidences, had she been unable to
hear them.
Society has a more kindly feeling for the blind man than for the deaf
—at least so it seems to us. You may find a good illustration of this
at some party or social gathering in the country. The neighbors
gather; very likely it is Winter and they come from lonely places,
eager for human companionship. It is a jolly gathering. Perhaps a
blind man and a deaf man of equal social importance, will enter the
room simultaneously. The blind man hears the laughter and the
happy chatter and at once enters into the spirit of the evening. The
deaf man catches no happy contagion, he feels a melancholy
irritation. He would have been far happier at home with his book,
but his wife and daughter urged upon him the duty of coming to
“enjoy himself” and—here he is.
Half a dozen people rush to the blind man. He must be guided to a
comfortable seat where a willing interpreter will quickly make him
feel at home. He is told about the new red dress which Mrs. Jones is
wearing, it is so becoming! Miss Foster is in blue, and her hair is
arranged in the latest New York style. Henry Benson has shaved off
his beard. John Mercer has a bandage on his hand where he cut it
with the saw. The Chase girls have new fur coats. The blind man
sees it through the eyes of his neighbor. It is a pleasure to sit
unobtrusively and talk to him—it gives one a thrill of satisfaction to
feel that the blind man is made happy.
But who rushes to the deaf man for the privilege of being his
interpreter? In all my experience I have known only one person to
do this. As he looks about him for a vacant seat the deaf man sees
few inviting hands or faces. If he is able to read facial expressions at
all he soon fancies that there are many versions of the thought:
“Oh, I hope that man will not sit near me!”
Who desires to attract attention by screaming at the deaf man or to
spend the evening writing out for him what others are saying?
A little handful of people once attended a prayer meeting at a little
country church back among the hills. It was during a severe, gloomy
Winter, a season of unusual trouble and unusual complaint. The little
stove could barely melt the thick frost on the windows. The feeble
lamps gave but a dim light. Yet as the meeting progressed through
prayer and song that melancholy group of farmers mellowed, and
undoubtedly something of holy joy came to them. I, of course, heard
not a word of the service, but apparently each person waited for the
spirit to move them, then rose and repeated some well-worn prayer
or a verse of Scripture. It was utterly crude and simple, but a certain
power fell upon that company and for the moment it was lifted out
of the dull commonplace of daily life. Little or nothing of the spiritual
uplift came to me. At the close of the service I saw people who had
come gloomy and depressed acting like happy children, shaking
hands, forgetting old troubles, buoyed and braced. And some of
them seemed to regard my calmness with wonder—I could not fully
join in their happiness.
It is evident that a sincere religious spirit can bring great comfort to
the deaf. Now and then I find a deaf man who practices what I call
professional religion with all the cant and the pious phrases
necessary. It never seems to ring true. The deaf are notorious
failures at deception. But a firm trust in God and a sincere belief in
His power and mercy should be “As the shadow of a mighty rock in a
weary land”—of silence. We must have the best possible moral
support.
I know of a man who is both blind and deaf. Once when I gave way
momentarily to depression his wife wrote me:
“I felt like writing an invitation to you to come and look at my
husband who is both blind and deaf. An accident twenty-one years
ago caused the loss of sight, which came on gradually but finally
became complete. When I told him you were to write “Adventures in
Silence,” he said, ‘Why not the wonders of silence and darkness?’
That has been his attitude all through these burdened years. These
are but a small portion of the misfortunes and trials which have
befallen us, but as he guides himself by lines hung from one point to
another just high enough to take the crook of his cane there comes
never a word of discouragement or despair. Here let me say that an
educated, trained mind is the finest gift you can give to your
children. It is the possession of a wonderful mind well trained by a
splendid education that has been next to God’s love that has kept
‘my man’ upright and strong through the darkened and silent valley.”
We may all of us readily understand that no human or material
power is strong enough to sustain a man through such a fate.
 CHAPTER XVI
“Such Tricks Hath Strong Imagination”

Imaginary Fears, Stuffed Lions

and Bogus “Wild Men”—Sound as
Stimulating Emotions, Even of
Animals—The Brazen Courage of
the Deaf—The Rum-crazed Men—
The Overflowing Brook—The
Drunken Prizefighter Challenged
by a Deaf Man—The Terrors
Lurking Within—Demons of
Depression—The Deaf Man and
the Only Girl.

Most of our fears are imaginary. I am convinced of this after a long

study of deaf people, and a careful analysis of my own experience in
the silence. I believe that physical fear is almost invariably induced
by sound. We all see lions in the way. The man with good ears hears
the roaring and hesitates, or turns aside. The horrible sound does
not reach the deaf man, and he feels more inclined to go ahead and
investigate. Most frequently the frightful object turns out to be a
stuffed lion, a creature without effective claws or teeth, with nothing
but wind in its roaring!
With a little thought every man can remember incidents which tend
to prove this statement, but in time of threatened danger he is likely
to forget them. Years ago in my boyhood days a couple of us
youngsters went to a circus in the country town. In one of the side-
shows was a fierce-looking creature labelled “The Wild Man of
Borneo.” It appeared to be a human being of medium size with long
claws, rolling eyes, and a dreadful, discolored, hairy countenance.
His most frightful characteristic was his voice, which was exhibited
by a horrible roar, a sound well calculated to chill the simple hearts
of the country people who listened to the “manager’s” tale of a
thrilling capture. There had been a bloody fight in which the wild
man had killed several dogs and wounded a number of hunters. He
would never have surrendered had they not first captured his mate;
he followed her into voluntary slavery—“Thus proving that love is the
primal and ruling force of the universe. The love-song of this
devoted couple, ringing over the hills and dales, would have daunted
the stoutest heart.” In proof of which the two caged creatures
started a chorus of roars which would have sent the country people
home to shudder in the darkness, had not a very practical deaf man
been moved to investigate. He heard nothing of the explanation, and
but little of the roaring; he only saw a couple of undersized
creatures, exceedingly dirty and not particularly interesting. The
“love song” gave them no glamour for him. So he idly lifted a curtain
which hung at one corner of the tent, and, lo, the fountain of sound
was revealed at its true source. A hot and perspiring fat man was
working industriously at the pedal of a “wind machine,” a device
resembling an old-fashioned parlor organ. Here was the real
explanation of those primitive cries proving the deep affection which
the “Wild Man of Borneo” felt for his mate. The deaf man pulled the
curtain completely down and exposed the humbug.
Well, it broke up the show! Next to the fury of a woman scorned is
the wrath of a crowd of country people who have paid their money
for a thrill only to find themselves served with a very thin trick. They
see no humor in the situation, and an exposure of this sort is a cruel
blow at their pride and judgment. People with humor and philosophy
would have laughed at the joke and polished it up for the benefit of
their friends, but this hard-headed, serious folk could only find relief
by pulling down the tent. In a far larger way this is what the solid,
unreasoning and unimaginative element of a population will do to a
state or a national government when some political trick has been
exposed.
It was the “wild man” himself who saved the situation in the circus
tent, and tamed the outraged audience. He pulled off his wig and
beard and shed the claws which were fitted to his fingers like gloves.
Then there stood revealed a small Irishman with a freckled, good-
natured face.
“Sure,” he said, “the game’s up and I’m glad, because it’s a tiresome
job. I’ve worked on a farm in my day, and I’d like to do it again. If
any of you farmers here will give me a job, I’ll take it.”
“And me, too!” said the “mate”; when “her” frowsy head dress came
off there was a red-haired young fellow of pleasant countenance.
They both got farm jobs and lived in that community for several
years. The “mate” finally married a farmer’s daughter!
It has been said that the primary effect of sound is the creating of
moods; psychologists have spent much time in analyzing the
connection between sound and fear and kindred emotions. It is easy
enough to realize that sight must inform or directly affect the
intellect. Theater managers prove the necessity of supplementing
sight with sound when they obtain a full play of emotion by giving
the audience appropriate music, which they stress during emotional
passages. Perhaps what we are is determined by what we see, while
what we feel is decided by what we hear. The deaf are frequently
termed hard-hearted and even cold-blooded. I have known deaf
persons actually to smile at cases of grief or injury which seemed
tragic to those who could hear what the unfortunate victims were
saying. They saw only the physical contortions. Suppose you with
good ears and I in my silence, walking together, meet a little crying
child. I can only observe the outward signs of distress; I see her
tears and watch the little chest rise and fall with her sobs. My
sympathy can be only vague and general—I may even smile to
myself over the shallow sorrows of childhood. It will pay you to
stoop over and hear the whole story, to catch every tone of the little,
grief-stricken voice. I have no means of offering intelligent
consolation, perhaps you can explain the trouble away or offer a
quick diversion.
There are hundreds of instances where the deaf have undergone
battles, shipwrecks or other frightful adventures with composure,
while their companions were stumbling or jabbering with fear. These
latter would tell you that the most horrible part of their experience
was the cries of the suffering who faced death in agony and fear.
The mere spectacle of the suffering did not upset the cool judgment
of the deaf.
It seems evident that sound also has a greater stimulating effect
upon the emotions of animals than do the other senses. A friend
who has studied this subject says:
“I have imitated different animals many thousand times, and can
easily deceive them at their own game, but cannot long deceive the
average person. A dog relying on sight, smell and hearing—and
maybe a little, a very little reasoning—although he may be very
brave—can easily be made to flee in terror by the right sort of
growling and noises connecting first wonder, then anger or terror. He
hears a very ferocious dog, but can neither see nor smell him; here
is something new, which he cannot reason out—he curls his tail,
gives a frightened yelp, registers fear in other ways and runs with all
his might.
“Recently I was out hunting wild turkeys, and had nearly induced
one to come near to me when a stick fell from a tree, and without
waiting to reason, away he went. My call would not deceive a
person, but any sort of an amateur squawk easily deceives a
gobbler. Not long ago, a friend of mine, while calling a gobbler,
called also a wildcat who was trying to get the gobbler for breakfast.
Animal sight may be ultra-human, but I am very sure that animal
hearing is not.”
Doubtless we all rely on hearing to keep us informed concerning the
fear instinct. Children hear a great deal subjectively, aided by their
fears plus imagination. I am almost prepared to state that deafness
is connected with fearlessness above the average, but I am not yet
sure of my ground. Any defect of the five senses strengthens in a
measure the remaining channels, and deafness cannot but assist
concentration in those persons of studious contemplative habit, since
it closes one avenue of interruption. I have noticed that with those
of a philosophical turn plus strong will—or won’t—deafness saves
nerve fatigue, from hearing many noises or remarks.
I have observed the habits of several deaf cats and dogs, and have
noted instances of exceptional bravery, and evidences of a new
sense, probably the substitute for the one they have lost. Some of
my own experiences also show how sound dominates physical fear.
During my Winter in a large lumber camp of Northern Michigan I
found how far life can swing from the ideal republic even in this
country. The snow had shut in our little community for the Winter.
The majority of our choppers were French Canadians and Swedes,
strains of humanity which are completely unlike until whiskey breeds
in both a desire to fight and kill. In some way the Canadians had
obtained a supply of “white whiskey” (a mixture of grain alcohol and
water) at Christmas, and the entire outfit prepared to celebrate
gloriously. The boss prepared to follow Grant’s famous plan of
campaign. He cut off the enemy’s base of supplies by locking the
door of the cook’s shanty and refusing to feed the rioters. This
brought the revolution to a head. A crowd of savage men gathered
in front of the buildings with their axes, and threatened to cut the
doors out and to kill the few of us who were left on guard. After it
was all over I was told that the cursing and the threatening of these
rum-crazed men was frightful, but as I could not hear a syllable of it
I walked up to them, entered the group and talked the situation over
with French Charlie, Joe the Devil and the Blue Swede. The rest of
my side expected to see me chopped into pieces, but most men who
threaten before they act will talk a full dictionary before they kill.
These drunken men were so astonished at a deaf man’s disregard of
their threats that they were diverted from their anger, and I was able
to make terms with them. I probably should not have dared to go
near them if I had received the curses and threats direct.
Years later a sudden cloudburst in the hills above our farm filled the
streams to overflowing. The little river near our home jumped out of
its bed and spread over the road—a rushing, roaring, shallow sheet
of water. I had to cross that part of the road in order to get my train,
and I took a steady horse, with one of the little boys in the buggy
with me. At the edge of this overflow we found a group of excited
men who were listening to the roaring, and were afraid to venture
over. I used my eyes calmly and observed that the bridge was quite
sound, and the water was too shallow to be really dangerous. So in I
drove with my boy—who was white with terror—while most of the
men tried to stop me. The old horse waded calmly and safely, and
we crossed without trouble. The water never reached the hub of the
wheel! Yet on the other side men stood half paralyzed because they
heard the roaring water and stopped to listen. On the other side my
boy said, “But you never would have done it if you could hear that
water!”
As I look from the silent land out into the busy world I see men
hesitate, falter and fall back at terrors which appear to me
imaginary. They stop to listen—and are lost. Like my boy on the
edge of the river, they hear the roaring water and become unfit for
calm judgment, or keen analysis of actual danger. Most people with
good hearing stop too frequently to listen. A scarecrow may have
been making a noise like a fighting man! If you listen long enough to
the tales of a liar you will come to regard him as a lion.
A friend of mine relates a strange adventure which befell him on a
New York subway train. He was a “strap-hanger” in a crowded
express car rushing up town. As is the habit of the deaf he forgot
the throng around him and let his mind become absorbed in the
business he was engaged in. This is the privilege of us deaf; we may
be near enough to a dozen men to touch them with our hands, yet
the mind can take us miles away from all distractions. This man was
rudely shaken from his oblivion by a great commotion in the car. The
passengers rushed forward past him, stumbling over each other in
their eagerness to get away to the front of the train. Two so-called
“guards” fled with the rest. The deaf man did not join the stampede
because he had no idea what it was all about, and long experience
of the vagaries of people who can hear had taught him the wisdom
of keeping out of the rush. He glanced over his shoulder and saw
that the back of the car was empty save for one man, who stood
quite near to him. This was a thick-set individual with a small, bullet-
shaped head, set firmly on a bull neck. He had a heavy red face, and
small, deep-set eyes, but his most singular feature was his right ear
—it did not look human at all, but resembled a small cauliflower. The
eyes of the deaf are quick to seize upon the most unusual or
conspicuous part of an object—my deaf friend noted first of all that
cauliflower ear.
Its owner advanced and shook his fist menacingly, shouting words
which only served to increase the confusion of the stampeders. The
deaf man merely hung to his strap and over his shoulder shouted
into the cauliflower ear:
“Oh, shut up! Give us a rest!”
The “guard” who was trying to jam through the door nearly fell with
astonishment. As the man continued to approach from behind, the
deaf man turned and pointed a finger at him.
“I can’t hear a word you say, and I don’t know who you are—but
shut up, and stop your noise!”
The antagonist glanced sharply at him—then the deaf man read on
his lips:
“Don’t you know who I am?”
“No, and I don’t care!”
“Can’t you hear what I say?”
“No, and I don’t want to! Mind your own business!”
The bullet-headed man uttered one short expressive word and sat
down. At Forty-second Street two good-sized policemen appeared,
but they waited for reinforcements before arresting the disturber.
However, he went willingly, casting back a look of mingled fear and
admiration at the deaf man. My friend did not know he was a hero
until he learned that the belligerent gentleman was a champion
middle-weight boxer, very drunk and very ugly. He had threatened to
clean out the crowd—hence the sudden stampede. This deaf man
tells me that if he had really known to whom the cauliflower ear
belonged he would have been the first man out of the car. As it
happened he gained a reputation for being the only man who ever
told a “champ” to shut up, and then cooled him off by shaking a
finger. I have known many deaf men who have escaped from such
situations most marvelously uninjured.
Yet while the deaf man is smiling at most of the terrors which
approach him from without, he falls an easy prey to those which
attack from within. Imagination will often lead a sensitive man into
untold misery. Our hardest struggles come when we must strangle
the imps of depression, our personal devils. They come with evil
suggestion, frequently with actual voices, eager to poison the will
and paralyze the courage. I have no doubt that Whittier’s great
poem beginning:
“Spare me, dread angel of reproach”
was written as the result of subjective audition. I suppose the
average person can never know how close the deaf are driven to
temporary insanity in their struggles to overcome doubts and
imaginary fears. Sometimes the fear concentrates upon the idea that
they will lose sight as well as hearing! Or perhaps doubt of wife,
children or friends will present itself forcibly. Little incidents, a feeling
that people are laughing at their expense, some unintentional slight,
a misunderstanding or a rude nervous shock, any of these may start
the hateful imps which live in one part of the brain at their fearful
work of poisoning the mind and the will. At times the deaf man finds
it almost impossible to wrench free from these accursed influences.
Some readers become so completely absorbed in books that they
cannot take the mind from a sad or an exciting story. I have known
deaf men to enter into such a story as George Eliot’s “Mill on the
Floss” so that they lived through the lives of the various characters
and found that they could not shake off the depression. Usually I
can tell when the author is deaf by the general character of the