LASIK History

A Brief History of Refractive Surgery

There were apparently no instruments to improve vision at the time of the ancient Egyptians, Greeks or Romans, supported by a letter written by a prominent Roman about 100 B.C. in which he complains that he can no longer read for himself, instead having to rely on his slaves. Lenses made of polished crystal did indeed exist, but were used as "burning glasses" to erase writing from wax tablets. According to Pliny, physicians even used burning glasses to cauterize wounds. Nero was known to hold a large emerald to his eye while watching gladiator matches, although he was probably using the green stone as a sunglass.

Around 1000 A.D. the reading stone, a segment of a glass sphere that could be laid against reading material to magnify the letters was first developed. The Venetians developed the first reading stones held in a frame in front of the eyes instead of directly on the reading material. However, it took over 350 years to develop a practical means to keep them on the face! Ribbons and strings were tied about the head for several hundred more years, until a London optician named Edward Scarlett perfected the use of rigid sidepieces that rested atop the ears in 1730. These spectacles cost as much as $200 in the early 1700's! Benjamin Franklin is credited with creation of the bifocal in the 1780's by cutting two lenses in half and placing one above the other. As glass-making improved, so did the lenses and improvements in frame-making and materials resulted in several styles to choose from. But even at the turn of the 20th Century, glasses fitting was largely trial and error with the patient responsible for determining the correct lens, often in a

rather casual manner. A short paragraph in the "Optical Journal" of 1901 warned that door-to-door peddlers were particularly dangerous: "If you value your eyesight, you will place no confidence in the statements of tramps who go from house to house selling spectacles. They will tell you your eyes are diseased and nothing but their electric or magnetised glasses will save you from blindness. Such talk is an insult to your intelligence." Indeed.

As early as 1845, Sir John Herschel suggested the idea for contact lenses, but he evidently did nothing about it. The term contact lens originated with Dr. A. Eugen Fick, a Swiss physician, who published the results of experiments with contact lenses in 1887. Early contacts were created by blowing glass in different-sized

bubbles and cutting them in half, polishing the edges and placing them in the eyes. Several doctors and optical firms in Europe cooperated in creating practical contact lenses over the decades around the turn of the 20th Century. By the early 1940's a variety of materials were available: blown glass, ground glass, molded glass, plastic and glass, and all plastic. All of these lenses were large and uncomfortable and couldn't be worn for long. By 1964 over 6 million people in the United States were wearing contact lenses, 65% of them women.

Dr. Stephen Trokel published the landmark paper in the American Journal of Ophthalmology in 1983, outlining the potential of using the excimer laser, which had been developed 10 years earlier for creation of computer chips, for reshaping the cornea and correcting vision. The first phototherapeutic keratectomy (a procedure for removing superficial scars from the cornea) in a sighted eye was performed in 1985 by Dr. Theo Seiler in Germany. Dr. Margeurite McDonald accidentally perfomed the first successful photorefractive keratectomy (PRK) in June of 1987. While performing one of the initial studies on patients with blind eyes, one of the subjects miraculously recovered her vision seven weeks after surgery. The patient apparently had a sudden reversal of hysterical blindness, a condition originally described by Freud. She was 20/20 upon the return of her vision and remained so in the years to follow. Dr. McDonald also performed the first PRK on a sighted eye (within an FDA trial) in 1988. Improvements in the excimer laser over the past 15 years have been made in the area treated, the homogeneity of the laser beam itself, and the addition of infrared tracking of the pupil to follow any eye movement during the procedure.

Any discussion of the beginnings of LASIK must begin with the "father of modern refractive surgery", Jose Ignacio Barraquer, M.D. of Bogota, Columbia. Dr. Barraquer's premise was to add or remove sufficient tissue from the cornea to change its shape and thus the refraction of the eye. He began work on the instrumentation needed for this shortly before 1949. His original surgeries involved removing a flap of tissue from the cornea freehand, then transporting it by car the half-mile to his laboratory, where he would

due to destruction of the important inner layer of the cornea, the endothelium (whose function was only later better under-stood). The greatest pioneer of radial keratotomy (RK) was Dr. Fyordorov in the former USSR. In the early 1960's he converted the incisions to the front of the cornea, and by making cuts 90% through the thickness of the cornea, was able to devise a system of correction for different degrees of near-sightedness by making the cuts longer or shorter. From 1978-80, Drs. Leo Bores, et al. imported RK to this country, improving upon it by devising ways to account for astigmatism. RK reached it's peak in the mid-1980's to early 1990's.

freeze the tissue and then carve it to shape using a modified contact lense lathe as seen to the left. He would then take the finished tissue back to the operating room and suture it back to the patient's eye! Over the next few years, he developed the motorized microkeratome to create better and more accurate corneal discs. He later developed the technique know as keratomileusis, by which the microkeratome was used to remove a layer of cornea, then replaced on the eye to remove a second thin layer of cornea which was discarded and the original layer then sewn back into place. Reasonably good results were achieved in the hands of a very skilled surgeon using these techniques.

By combining the reproducability of patient wound healing of lamellar surgery (surgery with a keratome) with the accuracy and extreme precision of the excimer laser, a new hybrid procedure was born. Ioannis Pallikaris, M.D. coined the term LASIK (laser-assisted in-situ keratomileusis), and was the first to create a "flap" of tissue with the microkeratome, rather than remove the entire top layer. He conducted the first animal trials of what is now modern LASIK in the late 1980's in his native Greece. Improvements in the creation of the corneal flap continue with improved keratome reliability and experimentation into alternative forms of flap creation, including using high-speed water jets or even a second laser.

One of the first references to surgical correction of vision came in the mid-1800's when a physician, J. Ball, advertised an eye cup that contained a spring-loaded mallet which supposedly flattened the cornea by striking it through the eyelid. "It restores your eyesight and renders spectacles useless," he claimed.

Dr. Tutomu Sato in Japan established the principles of transverse and radial keratotomy (RK) in rabbits and in people. They made deep incisions in the cornea, but approached it from the inside of the eye. This approach proved disasterous as the corneas that were operated on became swollen and cloudy