The number of Japanese that choose to undergo refractive procedures has steadily increased in recent years and is getting closer to a "core figure" needed for a society-wide burst such as American photorefractive surgery underwent almost a decade ago, according to Japanese observers.

	Steve Schallhorn, M.D., and Hiroya Goto, M.D., stand in front of a Navy poster that promotes refractive surgery.
			A Navy poster that touts "better vision, better war fighters." Source: Steve Schallhorn, M.D.

The numbers are based on information collected by Nidek's sales representatives and sales analysis of microkeratomes. Nidek is the parent company of Nidek Inc., based in Fremont, Calif.

"Those patients with previous surgical experiences are the key," said Hiroya Goto, M.D., an ophthalmologist and captain in the Japanese Army, who is studying refractive surgery with the U.S. Navy and with David Schanzlin, M.D., University of California, San Diego.

"When PRK started, the number of surgeries in the U.S. was about 50,000 to 200,000 and once the number of experienced patients reached 500,000 to 1 million, then there was a big increase," he said.

Compared to refractive surgery's consumer popularity in the United States, Japanese refractive surgery advocates appear to have a considerable marketing job ahead.

By comparison to the estimated 48,000 annual photorefractive procedures among Japan's 130 million people, about 1.4 million refractive procedures were estimated to have occurred in 2003 among the U.S. population of about 280 million.

Reasons cited for the Japanese reluctance to embrace refractive surgery - unusual in most technologically advanced nations - appear to stem, at least in part, from the work of a pioneering surgeon Tsutomu Sato, M.D.

In the mid-1930s, he performed some of the earliest work in radial keratotomy by making deep incisions in posterior side of the cornea. Striking visual improvements in hundreds in the short term were replaced by swollen and cloudy corneas years later.

Widely publicized RK and PRK complications among patients operated on by non-ophthalmologists, including cosmetic surgeons, added to refractive surgery's public relations, Dr. Goto said.

Others blame the Japanese reticence on its conservative culture and media reports that "clouded the market with negativism for LASIK and refractive surgery," said Kuntal Joshi, director of global marketing, Nidek.

Japan is also newer to the refractive field, with LASIK not yet approved, phototherapeutic keratectomy (PTK) only approved in April 1998, and PRK approved in January 2000.

Advocates of refractive surgery are turning the situation around by successfully loosening "severe" government regulations on medical advertisement and increasing the acceptance of refractive among Japanese ophthalmologists.

Although estimates place the number of refractive surgeons at less than 300, Dr. Goto said its popularity is increasing enough that some surgeons have left the military to seek out work in private laser centers in Japan.

Another factor that may encourage growth is the ever-increasing numbers of myopic Japanese, which is growing, at least in part, because of increasing use of computers and videogames by the nation's youth, according to a recent study by researchers at the Australian National University, Canberra.

Already one-third of the overall Japanese population is myopic and a much higher percentage of the highly educated are myopic.

Although the Japanese military does not formally track myopia, Dr. Goto said about half of new recruits are myopic enough to require spectacle correction. That compares to a 1996 National Eye Institute study that found that 60% of Americans between 23 and 34 years old are myopic.