Contents [hide]
1 Technological development
2 Procedure
2.1 Preoperative
2.2 Operation
2.2.1 Flap creation
2.2.2 Laser remodeling
2.2.3 Reposition of flap
2.3 Postoperative
3 Higher-order aberrations
3.1 Wavefront-guided LASIK
4 Complications
4.1 Intraoperative complications
4.2 Early postoperative complications
4.3 Late postoperative complications
4.4 Other
4.5 Factors affecting surgery
5 Patient satisfaction
6 Safety and efficacy
7 References
8 See also
9 External links

[edit] Technological development
The LASIK technique was made possible by the Colombian-based Spanish ophthalmologist Jose Barraquer, who, around 1950 in his clinic in Bogotá, Colombia, developed the first microkeratome, used to cut thin flaps in the cornea and alter its shape, in a procedure called keratomileusis. He also provided the knowledge about how much of the cornea had to be left unaltered to provide a stable long-term result.

Later technical and procedural developments included the RK (radial keratotomy) started in the 70’s in Russia by Svyatoslav Fyodorov and the development of PRK (photorefractive keratectomy) in the 80’s in Germany by Theo Seiler.

In 1968, at the Northrup Corporation Research and Technology Center of the University of California, Mani Lal Bhaumik and a group of other scientists, while working on the development of a carbon-dioxide laser, would develop the Excimer laser, where molecules that do not normally exist come into being when xenon, argon or krypton gases are excited. This would form the cornerstone for LASIK eye surgery. Dr. Bhaumik announced his discovery in May of 1973 at a meeting of the Denver Optical Society of America in Denver, Colorado. He would later patent it. [1]

The introduction of Laser in this refractive procedure started with the developments in Laser technology by Rangaswamy Srinivasan. In 1980, Srinivasan, working at IBM Research Lab, discovered that an ultraviolet excimer laser could etch living tissue in a precise manner with no thermal damage to the surrounding area. He named the phenomenon Ablative Photodecomposition (APD).[2]. Dr. Stephen Trokel published a paper in the American Journal of Ophthalmology in 1983, outlining the potential of using the excimer laser in refractive surgeries.

Using these advances in laser technology and the technical and theoretical developments in refractive surgery made since the 50's, LASIK surgery was developed in 1990 by Lucio Buratto (Italy) and Ioannis Pallikaris (Greece) as a melding of two prior techniques, keratomileusis and photorefractive keratectomy. It quickly became popular because of its greater precision and lower frequency of complications in comparison with these former two techniques. Today, faster lasers, larger spot areas, bladeless flap incision, and wavefront-optimized and -guided techniques have significantly improved the reliability of the procedure as compared to that of 1991. Nonetheless, the fundamental limitations of excimer lasers and undesirable destruction of the eye's nerves have spawned research into many alternatives to "plain" LASIK, including all-femtosecond correction (Femtosecond Lenticule EXtraction, FLIVC), LASEK, Epi-LASIK, sub-Bowman’s Keratomileusis aka thin-flap LASIK, wavefront-guided PRK, and modern intraocular lenses.

[edit] Procedure
There are several necessary preparations in the preoperative period. The operation itself is made by creating a thin flap on the eye, folding it to enable remodeling of the tissue underneath with laser. The flap is repositioned and the eye is left to heal in the postoperative period.

[edit] Preoperative
Patients wearing soft contact lenses typically are instructed to stop wearing them approximately 5 to 7 days before surgery. One industry body recommends that patients wearing hard contact lenses should stop wearing them for a minimum of six weeks plus another six weeks for every three years the hard contacts had been worn. [3] Before the surgery, the patient's corneas are examined with a pachymeter to determine their thickness, and with a topographer to measure their surface contour. Using low-power lasers, a topographer creates a topographic map of the cornea. This process also detects astigmatism and other irregularities in the shape of the cornea. Using this information, the surgeon calculates the amount and locations of corneal tissue to be removed during the operation. The patient typically is prescribed an antibiotic to start taking beforehand, to minimize the risk of infection after the procedure.

[edit] Operation
The operation is performed with the patient awake and mobile; however, the patient typically is given a mild sedative (such as Valium) and anesthetic eye drops.

LASIK is performed in two steps. The first step is to create a flap of corneal tissue. The second step is remodeling of the cornea underneath the flap with laser. Finally, the flap is repositioned.

[edit] Flap creation
A corneal suction ring is applied to the eye, holding the eye in place. This step in the procedure can sometimes cause small blood vessels to burst, resulting in bleeding or subconjunctival hemorrhage into the white (sclera) of the eye, a harmless side effect that resolves within several weeks. Increased suction typically causes a transient dimming of vision in the treated eye. Once the eye is immobilized, the flap is created. This process is achieved with a mechanical microkeratome using a metal blade, or a femtosecond laser microkeratome (procedure known as IntraLASIK) that creates a series of tiny closely arranged bubbles within the cornea.[4] A hinge is left at one end of this flap. The flap is folded back, revealing the stroma, the middle section of the cornea. The process of lifting and folding back the flap can be uncomfortable.

[edit] Laser remodeling
The second step of the procedure is to use an excimer laser (193 nm) to remodel the corneal stroma. The laser vaporizes tissue in a finely controlled manner without damaging adjacent stroma. No burning with heat or actual cutting is required to ablate the tissue. The layers of tissue removed are tens of micrometers thick. Performing the laser ablation in the deeper corneal stroma typically provides for more rapid visual recovery and less pain, than the earlier technique photorefractive keratectomy (PRK).

During the second step, the patient's vision will become very blurry once the flap is lifted. He/she will be able to see only white light surrounding the orange light of the laser. This can be disorienting.

Currently manufactured excimer lasers use an eye tracking system that follows the patient's eye position up to 4,000 times per second, redirecting laser pulses for precise placement within the treatment zone. The average power for each pulse is usually in the milliwatt range [5] Typically, each pulse is on the order of 10–20 nanoseconds.

[edit] Reposition of flap
After the laser has reshaped the stromal layer, the LASIK flap is carefully repositioned over the treatment area by the surgeon, and checked for the presence of air bubbles, debris, and proper fit on the eye. The flap remains in position by natural adhesion until healing is completed.

[edit] Postoperative
Patients are usually given a course of antibiotic and anti-inflammatory eye drops. These are discontinued in the weeks following surgery. Patients are also given a darkened pair of goggles to protect their eyes from bright lights and protective shields to prevent rubbing of the eyes when asleep. Patients should be adequately informed by their surgeons of the importance of proper post-operative care to minimize the risk of post-surgical complications.

[edit] Higher-order aberrations
Higher-order aberrations are visual problems not captured in a traditional eye exam which tests only for acuteness of vision. Severe aberrations can effectively cause significant vision impairment. These aberrations include starbursts, ghosting, halos, double vision, and a number of other post-operative complications listed below.

Concern has long plagued the tendency of refractive surgeries to induce higher-order aberration not correctable by traditional contacts or glasses. The advancement of LASIK technique and technologies has helped reduce the risk of clinically significant visual impairment after the surgery. One of the major discoveries was the correlation between pupil size and aberrations:[2] Effectively, the larger the pupil size, the greater the risk of aberrations. This correlation is the result of the irregularity between the untouched part of the cornea and the reshaped part. Daytime post-lasik vision is optimal, since the pupil is smaller than the LASIK flap. But at night, the pupil may expand such that light passes through the edge of the LASIK flap into the pupil which gives rise to many aberrations. There are other currently unknown factors in addition to pupil size that also affect higher order aberrations.

In extreme cases, where ideal technique was not followed and before key advances, some people could suffer rather debilitating symptoms including serious loss of contrast sensitivity in poor lighting situations.

Over time, most of the attention has been focused on spherical aberration. LASIK and PRK tend to induce spherical aberration, because of the tendency of the laser to undercorrect as it moves outward from the center of the treatment zone. This is really a significant issue for only large corrections. There is some thought if the lasers were simply programmed to adjust for this tendency, no significant spherical aberration would be induced. Hence, in eyes with little existing higher order aberrations, "wavefront optimized" LASIK rather than wavefront guided LASIK may well be the future.

In any case, higher order aberrations are measured in µm (micrometers) on the wavescan taken during the pre-op examination, while the smallest beam size of FDA approved lasers is about 1000 times larger, at 0.65 mm. Thus imperfections are inherent in the procedure and a reason why patients experience halo, glare, and starburst even with small naturally dilated pupils in dim lighting.

[edit] Wavefront-guided LASIK
Wavefront-guided LASIK[3] is a variation of LASIK surgery where, rather than apply a simple correction of focusing power to the cornea (as in traditional LASIK), an ophthalmologist applies a spatially varying correction, guiding the computer-controlled excimer laser with measurements from a wavefront sensor. The goal is to achieve a more optically perfect eye, though the final result still depends on the physician's success at predicting changes which occur during healing. In older patients though, scattering from microscopic particles plays a major role and may exceed any benefit from wavefront correction. Hence, patients expecting so-called "super vision" from such procedures may be disappointed. However, while unproven, surgeons claim patients are generally more satisfied with this technique than with previous methods, particularly regarding lowered incidence of "halos", the visual artifact caused by spherical aberration induced in the eye by earlier methods.

[edit] Complications

A subconjunctival hemorrhage is a common and minor post-LASIK complication.The incidence of refractive surgery patients having unresolved complications six months after surgery has been estimated from 3%[4] to 6%.[5] The risk for a patient of suffering from disturbing visual side effects like halos, double vision (ghosting), loss of contrast sensitivity (foggy vision) and glare after LASIK depends on the degree of ametropia before the laser eye surgery and other risk factors.[6] For this reason, it is important to take into account the individual risk potential of a patient and not just the average probability for all patients.[7] The following are some of the more frequently reported complications of LASIK[8][6]:

SOURCE: WIKIPEDIA.COM