New York Laser Eye Surgery

History of Laser Eye Surgery
by Allan Robbins, MD

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The first laser operation developed for nearsightedness is called PRK or Photorefractive Keratectomy. With this technique, the outer skin of the eye (epithelium) is removed with a blunt instrument and the underlying tissue ablated with the laser. The amount of tissue removed is measured in microns (1/1000 of a millimeter) and many patients only require the removal of 30 or 40 microns of corneal stroma. For reference, the average human hair is 125 microns in diameter, so very little tissue is actually removed and the structural integrity of the eye is not diminished. The outer skin grows back over a period of days and the healing process begins. Following some initial discomfort while the skin reforms, there is a gradual improvement in uncorrected vision over a period of weeks to months. Depending on the capabilities of the laser, we now can correct most types of refractive errors via PRK. The major drawbacks to this operation are the amount of discomfort experienced, the relatively slow visual recovery and the appearance of vision-limiting corneal haze in a small percentage of patients. Studies indicate that the incidence of haze increases as more tissue is removed, so it is more difficult to treat people with strong prescriptions with this technique.

The next step forward is known as Laser In Situ Keratomileusis (a.k.a. LASIK or "Flap and Zap"). This technique combines the minimal wound healing effects of corneal cuts along with the accuracy of the excimer laser. An instrument called the microkeratome is used to plane a thin flap off the outer surface of the cornea, and tissue is removed by the laser deeper than with PRK. The outer skin is then gently repositioned and the healing process proceeds more rapidly. Patients experience less discomfort compared to their PRK counterparts and haze is rarely encountered. The patient also does not need to be on medications for a lengthy period of time, and bilateral laser eye surgery can be performed if the indications exist and both parties are comfortable with this decision. LASIK is becoming the procedure of choice for people with higher degrees of myopia or the desire for bilateral laser eye surgery.

Some individuals have anatomical contraindications to LASIK such as a thinner than average cornea or narrow lid fissures. The latest wrinkle in laser eye surgery is LASEK. The "E" stands for epithelial and the outer flap is peeled by treating the outer skin with a dilute alcohol solution. LASEK is a synthesis of LASIK and PRK and shares features of both. Preliminary results with LASEK appear to be superior to PRK with healing times somewhere between LASIK and PRK. In excahnge for a somewhat slower visual recovery than LASIK, LASEK provides and even greater margin of safety. LASEK is considered an "off-label" application for any laser since the procedure is so new it has not yet received FDA approval.

During the past few years, the lasers themselves have improved in leaps and bounds. The large, bulky dinosaurs of old have been replaced with sleek, flying spot devices that look like they belong on the bridge of the Starship Enterprise. The most advanced LADARVision system not only identifies the patients and speaks, but also tracks every eye movement with a laser radar system developed by NASA!

The decision to undergo laser vision correction is a highly individual one. The person must realize that the goal of laser eye surgery is not to totally eliminate the need for glassed or contact lenses. In fact, the FDA and Federal Trade Commission (FTC) have some very specific guidelines about what can and cannot be claimed in advertisement. Some of the latest developments in laser vision correction have moved the goalposts beyond the 20/20 line. Yet we cannot guarantee any patient that he or she will never need any optical aids following laser eye surgery.

Most insurances do not cover refractive surgery and consider the operation to be cosmetic. Therefore, there is a significant out of pocket expense and patients sometimes inquire "Should I wait until the technology improves or prices drop?" These are the same people who still do not own a computer because "Prices are dropping" or "Processors keep getting faster". There is no doubt that despite what appears to be a significant expense, in the long run laser vision correction will save you money. I can't tell you how many patients tell us that undergoing laser vision correction was "the best decision of my life". Just waking up in the morning and being able to see the clock or being able to follow the kids around a water park becomes a reason to celebrate.

Laser vision correction has arrived and is here to stay, so you might as well get used to all the advertising or move into a cave!

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