The LASIK technique was made possible by the Colombia-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. Stephan Schaller assisted. Barraquer also provided the knowledge about how much of the cornea had to be left unaltered to provide stable long-term results.
Later technical and procedural developments included the RK (radial keratotomy), started in the '70s in Russia by Svyatoslav Fyodorov , and the development of PRK (photorefractive keratectomy) in the '80s in Germany by Theo Seiler. RK is a procedure where radial corneal cuts are made typically using a micrometer diamond knife, and has nothing to do with LASIK
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, developed the Excimer laser. This formed 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.
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). 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.
The first patent for LASIK was granted by the US Patent Office to Gholam A. Peyman, MD on June 20, 1989, US Patent #4,840,175, "METHOD FOR MODIFYING CORNEAL CURVATURE", describing the surgical procedure in which a flap is cut in the cornea and pulled back to expose the corneal bed. This exposed surface is then ablated to the desired shape with an excimer laser, following which the flap is replaced.
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, intraoperative pachymetry, and wavefront-optimized and -guided techniques have significantly improved the reliability of the procedure 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.
LASIK is performed in three steps. The first step is to create a flap of corneal tissue. The second step is remodeling of the cornea underneath the flap with the laser. Finally, the flap is repositioned.
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. Typical pulses are around 1 mJ of pulse energy in 10 to 20 nanoseconds.
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: 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.
The most common complication from refractive surgery is the incidence "dry eyes". According to an American Journal of Opthamology study of March 2006, the incidence rate of dry eyes from LASIK after the six month post operative healing period was 36.36%.. The FDA (Food and Drugs Administration) website states that "dry eyes" may be permanent
The risk for a patient of suffering from disturbing visual side effects such as 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. 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. The following are some of the more frequently reported complications of LASIK :
Complications due to LASIK have been classified as those that occur due to preoperative, intraoperative, early postoperative, or late postoperative sources:
Lasik and other forms of laser refractive surgery (i.e. PRK, LASEK and Epi-LASEK) change the dynamics of the cornea. These changes make it difficult for your optometrist and ophthalmologist to accurately measure your intraocular pressure, essential in glaucoma screening and treatment. The changes also affect the calculations used to select the correct intraocular lens implant when you have cataract surgery. This is known to ophthalmologists as "refractive surprise." The correct intraocular pressure and intraocular lens power can be calculated if you can provide your eye care professional with your preoperative, operative and postoperative eye measurements.
Although there have been improvements in LASIK technology, a large body of conclusive evidence on the chances of long-term complications is not yet established. Also, there is a small chance of complications, such as haziness, halo, or glare, some of which may be irreversible because the LASIK eye surgery procedure is irreversible.
The incidence of macular hole has been estimated at 0.2 percent to 0.3 percent. The incidence of retinal detachment has been estimated at 0.36 percent. The incidence of choroidal neovascularization has been estimated at 0.33 percent. The incidence of uveitis has been estimated at 0.18 percent
Although the cornea usually is thinner after LASIK, because of the removal of part of the stroma, refractive surgeons strive to maintain a minimum thickness to avoid structurally weakening the cornea. Decreased atmospheric pressure at higher altitudes has not been demonstrated as extremely dangerous to the eyes of LASIK patients. However, some mountain climbers have experienced a myopic shift at extreme altitudes. There are no published reports documenting scuba diving-related complications after LASIK.
In situ keratomileusis effected at a later age increases the incidence of corneal higher-order wavefront aberrations. Conventional eyeglasses do not correct higher order aberrations.
Microfolding has been reported as "an almost unavoidable complication of LASIK" whose "clinical significance appears negligible."
Blepharitis, or inflammation of the eyelids with crusting of the eyelashes, may increase the risk of infection or inflammation of the cornea after LASIK.
Myopic (nearsighted) people who are close to the age (mid- to late-forties) when they will require either reading glasses or bifocal eyeglasses may find that they still require reading glasses despite having undergone refractive LASIK surgery. Myopic people generally require reading glasses or bifocal eyeglasses at a later age than people who are emmetropic (those who see without eyeglasses), but this benefit is lost if they undergo LASIK. This is not a complication but an expected result of the physical laws of optics. Although there is currently no method to completely eradicate the need for reading glasses in this group, it may be minimized by performing a variation of the LASIK procedure called "slight monovision." In this procedure, which is performed exactly like distance-vision-correction LASIK, the dominant eye is set for distance vision, while the non-dominant eye is set to the prescription of the patient's reading glasses. This allows the patient to achieve a similar effect as wearing bifocals. The majority of patients tolerate this procedure very well and do not notice any shift between near and distance viewing, although a small portion of the population has trouble adjusting to the monovision effect. This can be tested for several days prior to surgery by wearing contact lenses that mimic the monovision effect.
Although some contact lenses (notably modern RGP and soft silicone hydrogel lenses) are made of materials with greater oxygen permeability that help reduce the risk of corneal neovascularization, patients considering LASIK are warned to avoid over-wearing their contact lenses. Usually, it is recommended that they discontinue wearing contact lenses days or weeks before the LASIK eye surgery.
The FDA has approved LASIK for age 18 and over. More importantly the person's eye needs to be stable for two years prior to surgery.
Some patients with poor outcomes from LASIK surgical procedures report a significantly reduced quality of life because of vision problems. Patients who have suffered LASIK complications have created websites and discussion forums to educate the public about the risks, where prospective and past patients can discuss the surgery. In 1999, Surgical Eyes was founded in New York Cityby RK patient Ron Link as a resource for patients with complications of LASIK and other refractive surgeries. Other patient-founded websites to assist those with complications are LaserMyEye founded in 2004 and Vision Surgery Rehab in 2005.Most experienced and reputable clinics will do a full-dilated medical eye exam prior to surgery and give adequate post-operative patient education care to minimize the risk of a negative outcome.
For best results, Dr. Steven Schallhorn, an ophthalmologist who oversaw the US Navy's refractive surgery program and whose research partly influenced the Navy's decision to allow its aviators to get Lasik, recommends patients seek out what's called "all-laser Lasik" combined with "wavefront-guided" software.
The FDA website on LASIK clearly states: "Before undergoing a refractive procedure, you should carefully weigh the risks and benefits based on your own personal value system, and try to avoid being influenced by friends that have had the procedure or doctors encouraging you to do so. As such, prospective patients still need to fully understand all the potential issues and complications, as satisfaction is directly related to expectation.
The FDA received 140 "negative reports relating to LASIK" for the time period 1998–2006.
The reported figures for safety and efficacy are open to interpretation. In 2003, the Medical Defence Union (MDU), the largest insurer for doctors in the United Kingdom, reported a 166 percent increase in claims involving laser eye surgery; however, the MDU averred that these claims resulted primarily from patients' unrealistic expectations of LASIK rather than faulty surgery. A 2003 study, reported in the medical journal Ophthalmology, found that nearly 18 percent of treated patients and 12 percent of treated eyes needed retreatment. The authors concluded that higher initial corrections, astigmatism, and older age are risk factors for LASIK retreatment.
In 2004, the British National Health Service's National Institute for Health and Clinical Excellence (NICE) considered a systematic review of four randomized controlled trials before issuing guidance for the use of LASIK within the NHS. Regarding the procedure's efficacy, NICE reported, "Current evidence on LASIK for the treatment of refractive errors suggests that it is effective in selected patients with mild or moderate short-sightedness," but that "evidence is weaker for its effectiveness in severe short-sightedness and long-sightedness." Regarding the procedure's safety, NICE reported that "there are concerns about the procedure's safety in the long term and current evidence does not appear adequate to support its use within the NHS without special arrangements for consent and for audit or research."
Leading refractive surgeons in the United Kingdom and United States, including at least one author of a study cited in the report, believe NICE relied on information that is severely dated and weakly researched.
On October 10, 2006, WebMD reported that statistical analysis revealed that contact lens wear infection risk is greater than the infection risk from LASIK. Daily contact lens wearers have a 1-in-100 chance of developing a serious, contact lens-related eye infection in 30 years of use, and a 1-in-2,000 chance of suffering significant vision loss as a result of infection. The researchers calculated the risk of significant vision loss consequence of LASIK surgery to be closer to 1-in-10,000 cases.
On February 21, 2007, the Food and Drug Administration (FDA) issued a Class I recall of the LADAR-6000 surgical laser, manufactured by Alcon. The recall was because the algorithm used to calculate the laser treatment left some patients with inaccurate surgical outcomes that could not be re-treated with additional surgery.