Origins and Development of LASIK Surgery
By Arthur Benjamin, M.D.
is a safe and comfortable All-Laser procedure that is quick to perform (minutes), has a short recovery period (hours), and is followed by many years of excellent vision. But it wasn't always like this. Here is a historical perspective on the evolution of refractive surgery.
Like that of spectacles and contact lenses before it, the origins of LASIK
are crude. Ever since glasses where invented by a monk in the 13th Century, humans have dreamt of freeing themselves of the need for such devices to achieve good vision.
The idea of performing surgery to improve vision without glasses is not new. As far back as 1896, Lendeer Jans Lans of Holland proposed and idea of creating penetrating corneal cuts to correct astigmatism. It was not until 1930, that a Japanese ophthalmologist Tsutomu Sato made the first practical attempt to perform such surgery. Volunteer military pilots, many of whom were destined for suicide missions during World War II, were the first to experience this procedure. Since most perished in the war, long term follow up was not possible. Dr. Sato's technique involved making the incisions on the inner surface of the cornea. Since this was associated with a high rate of complications it was eventually abandoned.
The idea of incisional surgery was reborn in the 1960's when a Russian ophthalmologist Svyatoslav Fyodorov serendipitously discovered Radial Keratotomy (RK). This happened when one of his patients fell off a bicycle and had particles of glass from his spectacles lodge in his eyes. Dr. Fyodorov removed the glass shards and sutured the resulting radial cuts that extended from the periphery of the cornea to the pupil like spokes of a wheel. The day after the procedure, Dr. Fyodorov found that the eye that sustained the traumatic radial incisions had almost a zero prescription while the eye that was not affected remained nearsighted with a prescription of -6.00. While others would have ignored this finding, Dr. Fyodorov realized that if incisions in the cornea could be made in a controlled and deliberate fashion, one could predictably reduce or eliminate nearsightedness. Dr. Fyodorov popularized the techniques and instruments used in the development of Radial Keratotomy (RK). In 1978 after much study, the RK was granted FDA approval in the United States. This procedure, while generally helpful to patients with myopia, came with a number of unpleasant side effects: variations in vision, pain, glare, starburst or halo effects and in the long term has produced a shift in correction towards hyperopia.
In 1963, Jose Ignacio Barraquer, considered by most to be the father of modern refractive surgery, developed the first proficient refractive surgery technique called keratomileusis, which means "corneal reshaping." Dr. Barraquer used devices of his own invention: an Automated Lamellar Keratome and a cryolathe to perform his ALK procedure. In this precursor to LASIK a corneal cap was harvested from the patient's cornea using the Automated Lamellar Keratome. The cap was then frozen solid and placed on a cryolathe. The cryolathe was used to reshape the corneal cap to compensate for nearsightedness. The reshaped cap was then replaced on the patient's cornea. The procedure worked fairly well, but was extremely difficult to perform. It was also not very precise. Though in retrospect this procedure is rudimentary, it was a revolutionary idea that laid the groundwork for what is now Laser Vision Correction.
In 1981, an inventor at IBM laboratories, Rangaswamy Srinivasan, discovered that an Ultraviolet Excitable Dimer (EXCIMER) Laser that was designed to manufacture silicone chips, could be used to etch living tissue without causing any burn damage to the surrounding cells. He called this process: Ablative Photodecomposition (APD). In 1983 in collaboration with an ophthalmic surgeon at Columbia University Dr. Stephen Trokel, the first Laser Vision Correction
procedure termed Photo Refractive Keratectomy was performed. During the procedure the corneal surface was reshaped with a computer controlled EXCIMER laser beam, effectively etching a permanent contact lens on its surface. The procedure produced a never before seen improvement in vision with excellent stability.
The microkeratomes used to create corneal flaps as well as the lasers used to reshape the cornea have improved drastically over the following 20 years.
Now we use a femtosecond laser to fashion a precise corneal flap. We use a wavefront optimized flying spot laser to reshape the cornea in such a way that we can now potentially give patients better vision than is possible with glasses or contacts.