LASIK Eye Surgery
LASIK is the acronym for Laser-Assisted in Situ Keratomileusis, a type of refractive laser eye surgery performed by ophthalmologists for correcting myopia, hyperopia, and astigmatism. The procedure is preferred to photorefractive keratectomy, PRK, because it requires less time for the patient's full recovery, and the patient feels less pain, overall. Many patients choose LASIK eye surgery as an alternative to wearing corrective eyeglasses or contact lenses.
What You'll Find Here:
Early postoperative complications
Late postoperative complications
Factors affecting surgery
Safety and efficacy
LASIK Eye Surgery Technological development
The LASIK technique was made possible by Spanish ophthalmologist Jose Barraquer, who, around 1960, developed the first microkeratome, used to cut thin flaps in the cornea and alter its shape, in a procedure called keratomileusis.
In 1980, Rangaswamy 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). Srinivasan and his co-inventors ran tests using the excimer laser and a conventional, green laser to etch organic matter. They discovered that while the green laser produced rough incisions, damaged by charring from the heat, the excimer laser produced clean, neat incisions. In 1983, Srinivasan collaborated with an ophthalmic surgeon to develop APD to etch the cornea.
LASIK eye 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.
LASIK Eye Surgery - Procedure
Patients wearing soft contact lenses typically are instructed to stop wearing them approximately 10 to 15 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. 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.
LASIK Eye Surgery - 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. 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. 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.
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 by releasing the molecular bonds that hold the cells together. 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 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 energy of each pulse is usually in the milliwatt range. Typically, each pulse is on the order of 10–20 nanoseconds. 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.
LASIK Eye Surgery - 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.
LASIK Eye Surgery - 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: 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.
However, higher order aberrations are measured in µm (micrometers) as indicated on the wavescan taken during the pre-op examination, but the smallest beam size of all FDA approved lasers is 0.65 mm(millimeters). The lasers are supposed to remove imperfections that are measured 1000 times smaller than its smallest beam. This is one of the reasons patients experience halo, glare, and starburst even with a small naturally dilated pupils in dim lighting.
Wavefront-guided LASIK 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.
LASIK Eye Surgery - Factors affecting surgery
Typically, the cornea is avascular, because it must be transparent to function normally, its cells absorbing oxygen from the tear film. Thus, low oxygen-permeable contact lenses reduce the cornea's oxygen absorption, sometimes resulting in corneal neovascularization—the growth of blood vessels into the cornea. This causes a slight lengthening of inflammation duration and healing time and some pain during surgery, because of greater bleeding.
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.
A 2004 Wake Forest University study established that heat and humidity affect LASIK surgery results, both during the procedure and in the two weeks before the surgery.
Patient satisfaction with LASIK Eye Surgery
The surveys determining patient satisfaction with LASIK, have found most patients satisfied, with satisfaction range being 92–98 per cent.]
Some patients with poor outcomes from LASIK surgical procedures report a significantly reduced quality of life because of vision problems, and are concerned about how LASIK eye surgery is marketed to patients. Patients who have suffered LASIK complications have published websites to educate the public about the risks, and as discussion forums where prospective and past patients can discuss the surgery.
LASIK Eye Surgery - Cost
Cost varies with the country it is performed in -- the United States, England, Australia, New Zealand, and all other countries have different costs, some may be low cost. Some people travel to Mexico or Europe or other countries to get the procedure performed for a discount or a low cost LASIK eye surgery. In the United States it can run anywhere from $1500 to $2000 per eye. The LASIK eye surgery procedure may be covered by vision insurance or under standard health insurance policies. Check your insurance plans first to see if LASIK is covered.
LASIK Eye Surgery Complcations see on this site: LASIK Eye Surgery Complications
LASIK Eye Surgery - Safety and efficacy
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 per cent 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 per cent of treated patients and 12 per cent 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, it was 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
We continue to add information about LASIK eye surgery each week as news and information becomes available.
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