LASIK

Fundamentals, Surgical Techniques,

and Complications

edited by

Dimitri T. Azar
Massachusetts Eye and Ear Infirmary
Schepens Eye Research Institute
and Harvard Medical School
Boston, Massachusetts, U.S.A.

Douglas D. Koch
Cullen Eye Institute
Baylor College of Medicine
Houston, Texas, U.S.A.

Marcel Dekker, Inc. New York Basel

Copyright 2002 by Marcel Dekker, Inc. All Rights Reserved.

Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress.

ISBN: 0-8247-0797-4

This book is printed on acid-free paper.

Headquarters
Marcel Dekker, Inc.
270 Madison Avenue, New York, NY 10016
tel: 212-696-9000; fax: 212-685-4540

Eastern Hemisphere Distribution

Marcel Dekker AG
Hutgasse 4, Postfach 812, CH-4001 Basel, Switzerland
tel: 41-61-260-6300; fax: 41-61-260-6333

World Wide Web

[Link]

The publisher offers discounts on this book when ordered in bulk quantities. For more information,
write to Special Sales/Professional Marketing at the headquarters address above.

Copyright 2003 by Marcel Dekker, Inc. All Rights Reserved.

Neither this book nor any part may be reproduced or transmitted in any form or by any means, elec-
tronic or mechanical, including photocopying, microfilming, and recording, or by any information
storage and retrieval system, without permission in writing from the publisher.

Current printing (last digit):

10 9 8 7 6 5 4 3 2 1

PRINTED IN THE UNITED STATES OF AMERICA

To Nathalie, Alexander, Nicholas, and Larafor all the joyful moments that we share.

DTA

To my wife, Marcia, who makes it all so much more meaningfuland fun.

DDK
 Preface

Dov mio figlio? . . . pi non lo vedo:

In te pi Alfredotrovar non so

For decades, the majority of ophthalmologists have been embarrassed by and highly
suspicious of refractive surgery, at times with good justification. They have been repelled
by its tactics in patient recruitment, uneasy about its seemingly cavalier use without long-
term data, eager to defend its unsuspecting victims, and deeply concerned that its short-
term benefits are outweighed by its burdensome long-term consequences. And so the words
of Germont, uttered pursuant to the most dramatic moment in Verdis La Traviata, echo the
extreme and oftentimes passionate contempt expressed by so many colleagues and close
friends towards academically oriented ophthalmologists who marched among the van-
guards of laser refractive surgeons. Their repudiation was not unlike Germonts scorn of
his son Alfredo for offending Violetta and for making himself worthy of disdain:

Where is my son? . . . no more do I see him.

I am unable to see Alfredo in you.

The ophthalmological peer-reviewed publications and textbooks prior to the late

1980s reflected this disinterest in or hostility toward refractive surgery. Unfortunately, in
the pre-LASIK era, there were relatively few high-quality peer-reviewed reports on refrac-
tive surgery. Criticisms of the scientific rigor with which clinical studies were conducted
were often justified, which, in turn, discouraged academically bound graduates of ophthal-
mology training programs from dedicating their careers to this subspecialty. Comprehen-
sive textbooks of ophthalmology in the pre-LASIK era also kept refractive surgery at arms
length, relegating it to a minor chapter on the topic. Refractive surgery was viewed as an
outlier of great potential but little practical merit in mainstream ophthalmology. But this
has all changed with the advent of LASIK!

v
vi Preface

This book is the first in a series dedicated to Refractive Surgery by Marcel Dekker,
Inc. It will most certainly be judged by many as just another LASIK book. While there is
abundant coverage of the topic in other books, this volume has several unique features. Its
coverage of LASIK is relatively comprehensive, in that it is not limited to LASIK history,
surgical techniques, complications, and their management. New aspects of lasers, optics,
refraction, diagnostics, and instrumentation are combined with the science and general
principles of LASIK, and indications for its use. Although not meant to be encyclopedic,
key references abound. They are intended to serve as a guide to the literature on the topic.
Thus, this book is not so much a chronicle of LASIK, as an attempt to serve as a source of
information relevant to clinical practice.
We are indebted to the students, residents, and colleagues who have made valuable
contributions to this book. Several have included original work and analysis in their chap-
ters. It is evident that the authors have attended diligently to their assignments. We are
grateful for their effort in integrating the sometimes limited information in peer-reviewed
literature with the knowledge derived from their clinical experiences and interactions with
colleagues. We hope that this has resulted in a text that is both clinically relevant and as ev-
idence-based as possible.
We thank Dr. Geoffrey Greenwood and Elizabeth Curione of Marcel Dekker, Inc.,
for their commitment to this project and Drs. Tsubota, Boxer Wachler, Hoang-Xuan, Ang,
and Gatinel for their assistance in future books in this series. Special thanks go to Leona
Greenhill, for her editorial assistance, and to Rhonda Harris, who managed this project with
care and precision. Her attention to detail and her dedication have enabled us to work co-
herently in the face of adversity.
We take the opportunity to acknowledge the pioneering surgeons and researchers in
the field of refractive surgery. Their work and vision have provided the basis not only for
current refractive developments that we can offer to our patients, but also for future ad-
vances to be made by the next generation of thoughtful contributors to this important field.

Dimitri T. Azar
Douglas D. Koch
 Contents

Preface v
Contributors xi

1. Refractive Errors and Their Treatment 1

Liane Clamen Glazer and Dimitri T. Azar

2. History of LASIK 21
Ioannis Pallikaris and Thekla Papadaki

3. Lasers in LASIK: Basic Aspects 39

Rodrigo Torres, Robert T. Ang, and Dimitri T. Azar

4. Microkeratomes 57
Sandeep Kakaria, Thanh Hoang-Xuan, and Dimitri T. Azar

5. Adjunctive Instrumentation in LASIK 71

Robert T. Ang and Dimitri T. Azar

6. LASIK Indications, Contraindications, and Preoperative Evaluation 91

Richard E. Braunstein, Marc Winnick, and Kenneth A. Greenberg

7. Preoperative Optical Considerations in LASIK: Refractive Errors,

Monovision, and Contrast Sensitivity 101
Balamurali K. Ambati, Leon Strauss, and Dimitri T. Azar

8. Corneal Topography and LASIK Applications 111

Li Wang, Douglas D. Koch, Dimitri T. Azar, Robert T. Ang,
and Rengin Yildirim
vii
viii Contents

9. Wavefront Technology and LASIK Applications 139

Naoyuki Maeda

10. Preoperative Considerations: Diagnosis, Classification,

and Avoidance of Keratoconus Complications 153
Paul Chung-Shien Lu and Dimitri T. Azar

11. Corneal Stability and Biomechanics After LASIK 163

Esen Karamursel Akpek, Rana Altan-Yaycioglu, and Walter J. Stark

12. LASIK Techniques 175

Dimitri T. Azar, Kathryn Colby, and Douglas D. Koch

13. Microkeratomes and Laser Settings 189

William J. Lahners and David R. Hardten

14. Centration of LASIK Procedures 199

Marsha C. Cheung, Chun Chen Chen, and Dimitri T. Azar

15. Surgical Caveats for Managing Difficult Intraoperative

Situations 229
Samir G. Farah and Dimitri T. Azar

16. Bilateral Simultaneous LASIK: Advantages, Disadvantages,

and Surgical Caveats 243
David R. Hardten, Elizabeth A. Davis, Richard L. Lindstrom,
and William J. Lahners

17. Postoperative Management Protocols for Uncomplicated

LASIK Procedures 255
Melanie A. R. Graham and Dimitri T. Azar

18. Visual Outcomes After Primary LASIK 265

Samir G. Farah and Dimitri T. Azar

19. Quality of Vision After LASIK 277

Patrick C. Yeh and Dimitri T. Azar

20. LASIK for Hyperopia, Hyperopic Astigmatism, and Presbyopia 285

Neal A. Sher

21. LASIK Retreatments 297

Ayman F. El-Shiaty and Brian S. Boxer Wachler

22. LASIK Following Radial Keratotomy and Photorefractive

Keratectomy 313
Natalie A. Afshari and Dimitri T. Azar
Contents ix

23. LASIK After Penetrating Keratoplasty 319

Glenn C. Cockerham and Natalie A. Afshari

24. Bioptics: Combined LASIK and Phakic Intraocular Lens Surgery 329
Jos L. Gell, Mercedes Vzquez, Fortino Velasco, and Felicidad Manero

25. LASIK and Intrastromal Corneal Ring Segments (ICRS) 335

Jonathan D. Primack, Samir G. Farah, and Dimitri T. Azar

26. Intraoperative Complications 351

Li Wang, Manjula Misra, and Douglas D. Koch

27. Postoperative Complications of LASIK 365

Samir G. Farah, Jae Bum Lee, and Dimitri T. Azar

28. Optical Aberrations After LASIK 387

Samir A. Melki, Cinthia E. Proano, and Dimitri T. Azar

29. Posterior Segment Complications of LASIK 397

Ron Afshari Adelman and Natalie A. Afshari

30. Management of Topographical Irregularities Following LASIK 403

Jeffrey Johnson, Roselyn Jeun, and Dimitri T. Azar

31. LASIK and TopoLink for Irregular Astigmatism 421

Michael C. Knorz

32. Management of Flap Complications in LASIK 431

Manolette R. Roque, Samir A. Melki, Dimitri T. Azar, and Emily Yeung

33. Management of Interlamellar Epithelium 463

Nan Wang and Douglas D. Koch

34. Management of Infections, Inflammation, and Lamellar

Keratitis After LASIK 477
Bilal F. Khan, Margaret Chang, Sandeep Jain, Kathryn Colby,
and Dimitri T. Azar

35. The Future of LASIK 491

Nan Wang and Douglas D. Koch

Index 495
 Contributors

Ron Afshari Adelman, M.D. Massachusetts Eye and Ear Infirmary, Boston, Mas-
sachusetts, and Yale University Eye Center, New Haven, Connecticut, U.S.A.

Natalie A. Afshari Cornea Service, Duke University Eye Center, Durham, North Car-
olina, U.S.A.

Esen Karamursel Akpek, M.D. Cornea and External Disease Service, The Wilmer Eye
Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.

Rana Altan-Yaycioglu, M.D. Cornea and External Disease Service, The Wilmer Eye In-
stitute, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.

Balamurali K. Ambati, M.D. Massachusetts Eye and Ear Infirmary and Department of
Opthalmology, Harvard Medical School, Boston, Massachusetts, U.S.A.

Robert T. Ang, M.D. Cornea and Refractive Surgery Service, Massachusetts Eye and
Ear Infirmary and Harvard Medical School, Boston, Massachusetts, U.S.A., and Asian Eye
Institute, Makati, The Philippines

Dimitri T. Azar, M.D. Cornea and Refractive Surgery Service, Massachusetts Eye and
Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

Brian S. Boxer Wachler, M.D. Refractive Surgery Service, Jules Stein Eye Institute at
UCLA, Los Angeles, California, U.S.A.

Richard E. Braunstein, M.D. Department of Ophthalmology, Columbia University

College of Physicians and Surgeons, and Harkness Eye Institute, New York, New York,
U.S.A.
xi
xii Contributors

Margaret Chang Columbia University College of Physicians and Surgeons, New York,
New York, U.S.A.

Chun Chen Chen, M.D. Cornea and Refractive Surgery Service, Massachusetts Eye and
Ear Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston,
Massachusetts, U.S.A.

Marsha C. Cheung Massachusetts Eye and Ear Infirmary and Harvard Medical School,
Boston, Massachusetts, U.S.A.

Glenn C. Cockerham, M.D. Department of Surgery, Allegheny Ophthalmology and Or-

bital Associates, Pittsburgh, Pennsylvania, U.S.A.

Kathryn Colby, M.D., Ph.D. Cornea and Refractive Surgery Service, Department of
Opthalmology, Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute,
and Harvard Medical School, Boston, Massachusetts, U.S.A.

Elizabeth A. Davis, M.D., Ph.D. Department of Ophthalmology, University of Min-

nesota, and Minnesota Eye Consultants, Minneapolis, Minnesota, U.S.A.

Ayman F. El-Shiaty, M.D. Department of Ophthalmology, Faculty of Medicine, Cairo

University, Cairo, Egypt, and Jules Stein Eye Institute at UCLA, Los Angeles, California,
U.S.A.

Samir G. Farah, M.D. Massachusetts Eye and Ear Infirmary, Boston, Massachusetts,
U.S.A.

Liane Clamen Glazer, M.D. Massachusetts Eye and Ear Infirmary and Department of
Ophthalmology, Harvard Medical School, Boston, Massachusetts, U.S.A.

Melanie A. R. Graham, M.D. Greater Baltimore Medical Center, Baltimore, Maryland,

U.S.A.

Kenneth A. Greenberg, M.D. Department of Ophthalmology, Columbia University

College of Physicians and Surgeons, New York, New York, U.S.A.

Jos L. Gell, M.D., Ph.D. Instituto de Microciruga Ocular, Barcelona, Spain

David R. Hardten, M.D. Department of Ophthalmology, University of Minnesota, and

Department of Medicine, Minnesota Eye Consultants, Minneapolis, Minnesota, U.S.A.

Thanh Hoang-Xuan, M.D. Fondation Ophtalmologique Adolphe de Rothschild, and

Paris University, Paris, France

Sandeep Jain, M.D. Cornea and Refractive Surgery Service, Massachusetts Eye and Ear
Infirmary, Schepens Eye Research Institute, and Harvard Medical School, Boston, Mas-
sachusetts, U.S.A.

Roselyn Jeun, O.D. Massachusetts Eye and Ear Infirmary, Boston, Massachusetts,
U.S.A.
Contributors xiii

Jeffrey Johnson, O.D. Massachusetts Eye and Ear Infirmary, and Department of Oph-
thalmology, Harvard Medical School, Boston, Massachusetts, U.S.A.

Sandeep Kakaria, M.D. Department of Ophthalmology, Cornell University Medical

Center, New York, New York, U.S.A.

Bilal F. Khan, M.D. Massachusetts Eye and Ear Infirmary and Department of Ophthal-
mology, Harvard Medical School, Boston, Massachusetts, U.S.A.

Michael C. Knorz, M.D. University of Heidelberg, Heidelberg, Germany, and Baylor

College of Medicine, Houston, Texas, U.S.A.

Douglas D. Koch, M.D. Department of Ophthalmology, Cullen Eye Institute, Baylor

College of Medicine, Houston, Texas, U.S.A.

William J. Lahners, M.D. University of South Florida, Tampa, and Center for Sight,
Sarasota, Florida, U.S.A.

Jae Bum Lee Cornea and Refractive Surgery Service, Massachusetts Eye and Ear Infir-
mary, Schepens Eye Research Institute, and Harvard Medical School, Boston, Mas-
sachusetts, U.S.A.

Richard L. Lindstrom, M.D. Department of Ophthalmology, University of Minnesota,

and Department of Medicine, Minnesota Eye Consultants, Minneapolis, Minnesota, U.S.A.

Paul Chung-Shien Lu, M.D. Department of Ophthalmology, Chang Gung Memorial

Hospital, Taipei, Taiwan, and Harvard Medical School, Boston, Massachusetts, U.S.A.

Naoyuki Maeda, M.D. Departments of Ophthalmology and Medical Robotics and Im-
age Sciences, Osaka University Medical School, Osaka, Japan

Felicidad Manero Instituto de Microciruga Ocular, Barcelona, Spain

Samir A. Melki, M.D., Ph.D. Cornea and Refractive Surgery Service, Massachusetts
Eye and Ear Infirmary, and Boston Cornea Center, Harvard Medical School, Boston, Mas-
sachusetts, U.S.A.

Manjula Misra, M.D. Cullen Eye Institute, Baylor College of Medicine, Houston,
Texas, U.S.A.

Ioannis Pallikaris, M.D. Department of Ophthalmology, University of Crete Medical

School, and Ophthalmology Clinic, University Hospital of Heraklion, Heraklion, Crete,
Greece

Thekla Papadaki, M.D. Refractive Surgery Service, Vardinoyannion Eye Institute of

Crete, University of Crete Medical School, Heraklion, Crete, Greece

Jonathan D. Primack, M.D. Massachusetts Eye and Ear Infirmary, Boston, Mas-
sachusetts, U.S.A.
xiv Contributors

Cinthia E. Proano, M.D. Cornea and Refractive Surgery Service, Massachusetts Eye
and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, U.S.A.

Manolette R. Roque, M.D. Massachusetts Eye and Ear Infirmary and Department of
Ophthalmology, Harvard Medical School, Boston, Massachusetts, U.S.A.

Neal A. Sher, M.D., F.A.C.S. Department of Ophthalmology, University of Minnesota

Medical School, and Department of Surgery, Phillips Eye Institute, Minneapolis, Min-
nesota, U.S.A.

Walter J. Stark, M.D. Cornea, Cataract and Refractive Services, The Wilmer Eye Insti-
tute, Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.

Leon Strauss, M.D., Ph.D. The Wilmer Eye Institute, Johns Hopkins University School
of Medicine, Baltimore, Maryland, U.S.A.

Rodrigo Torres Massachusetts Eye and Ear Infirmary and Harvard Medical School,
Boston, Massachusetts, U.S.A.

Mercedes Vzquez, M.D Instituto de Microciruga Ocular, Barcelona, Spain

Fortino Velasco Instituto de Microciruga Ocular, Barcelona, Spain

Li Wang, M.D. Cullen Eye Institute, Baylor College of Medicine, Houston, Texas,
U.S.A.

Nan Wang Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, U.S.A.

Marc Winnick, M.D. Department of Ophthalmology, Columbia University College of

Physicians and Surgeons, and Harkness Eye Institute, New York, New York, U.S.A.

Patrick C. Yeh Cornea and Refractive Surgery Service, Massachusetts Eye and Ear In-
firmary, Schepens Eye Research Institute, and Harvard Medical School, Boston, Mas-
sachusetts, U.S.A.

Emily Yeung, M.D. Massachusetts Eye and Ear Infirmary, Schepens Eye Research In-
stitute, and Harvard Medical School, Boston, Massachusetts, U.S.A.

Rengin Yildirim, M.D. Refractive Surgery Department, Cerrahpasa Medical School,

University of Istanbul, Istanbul, Turkey
 1
Refractive Errors and Their Treatment

LIANE CLAMEN GLAZER

Massachusetts Eye and Ear Infirmary and Harvard Medical School,
Boston, Massachusetts, U.S.A.
DIMITRI T. AZAR
Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute,
and Harvard Medical School, Boston, Massachusetts, U.S.A.

A. LASIK: DEFINITION AND OVERVIEW

Laser in-situ keratomileusis (LASIK) involves creating a corneal flap so that midstromal
tissue can be ablated directly and reshaped with an excimer laser beam (1,2). The proce-
dure allows the ophthalmologist to surgically reshape the cornea in an attempt to obviate
the need for corrective lenses (Fig. 1.1). LASIK is a modification of Colombian Jos Bar-
raquers ingenious innovations. In 1949, Barraquer first described his technique, and in
1964 he published clinical results of his attempts to achieve emmetropia by shaving and re-
shaping the cornea (35). With Barraquers technique of keratomileusis (i.e., carving the
cornea), a lamellar button (lenticule) of the patients cornea was excised with a manual mi-
crokeratome. Barraquer then reshaped the lenticule so that the central corneal curvature
was flattened and the refractive power of the cornea decreased. He then replaced the lentic-
ule in position, either with or without sutures. Barraquers specific attempts to correct my-
opia were called cryolathe keratomileusis, because they involved freezing and reshaping
the removed lenticule with a cryolathe.
Troutman and Swinger introduced cryolathe keratomileusis to the United States in
1977 (6). While keratomileusis produced good results when performed by experienced sur-
geons, the procedure was technically very difficult and the results were therefore variable
(711). Innovations to this procedure, however, eventually led to the creation of the more
highly refined procedure of LASIK.
The introduction of the excited dimer (excimer) 193 nm UV laser allowed for the
1
2 Glazer and Azar

Figure 1.1 Schematic diagram of emmetropia. In emmetropia, the far point is optical infinity, and
the secondary focal point (F2) is at the retina. Parallel rays of light focus on the retina. (From
Ref. 115.)

development of LASIK. The argonfluoride excimer laser is capable of precise ablation of

corneal tissue with minimal disruption of adjacent tissue. The excimer lasers effect on the
cornea was first studied in animal models in 1983 (12). In 1989, Peyman first used a laser
to remove corneal stroma from a lamellar bed in animals (13). Shortly thereafter, similar
attempts were made in human eyes (14,15). This early work supported the theory that in
situ keratomileusis was better than surface ablation because it induced less activation and
proliferation of stromal keratocytes, thereby avoiding both haze and regression. In addition,
the excimer laser allowed for more accurate tissue removal, thereby eliminating one of the
main deterrents to lamellar surgery (see Chap. 2).
The LASIK procedure, in its current refined state, involves increasing the eyes in-
traocular pressure to at least 65 mmHg with a suction device, and then using a microker-
atome to create a corneal flap that is at least 6 mm in diameter and 150 microns thick. This
flap, which allows the Bowmans-layer epithelial complex to remain intact, is then care-
fully lifted to expose the layers of the cornea that will be reshaped by the excimer laser. The
size of the optical zone and the depth and profile of the laser ablation will determine the
correction achieved (Fig. 1.1).

B. THE EPIDEMIOLOGY OF LASIK

Refractive surgery is a young and rapidly growing field. In 1998, 400,000 Americans un-
derwent refractive surgical procedures. This represents an increase over 1997 of approxi-
mately 100% (16). Despite the many refractive surgeries that have been performed, the tar-
get population for laser vision correction at the turn of the century is still an estimated 44
million people. Currently, approximately 3,000 ophthalmologists have been trained to per-
form refractive surgery. This number is increasing at a rate of 500 to 1,000 surgeons per
year. Industry observers predict that the number of trained surgeons will approach 6,000 to
8,000, or approximately 50% of the U.S.-based ophthalmologists (16).
LASIK produces good refractive results for low, moderate, and high myopia (see
Chap. 18). Recent reports for low myopia show postoperative uncorrected visual acuities
of 20/40 or better in 100% of patients, and 20/20 or better in 81% of patients (17).
Potential complications of LASIK include halos, interface inflammation, haze, and
regression. However, significant complications causing a loss of two or more lines of best
Refractive Errors and Their Treatment 3

corrected visual acuity (BCVA) are rare (1,18,19). In addition, with improved instrumen-
tation and increasing surgeon experience, LASIK complication rates continue to fall.

C. REFRACTIVE ERRORS THAT ARE TREATABLE WITH LASIK

Three components of the eye work together to determine the refractive power of the eye:
the shape of the cornea, the power of the lens, and the length of the eye. The overall re-
fracting power of the eye is approximately 60 diopters: the cornea contributes about 45
diopters of power, while the lens provides approximately 15 diopters of refractive power to
the eye. When the cornea, lens, and length of the eye combine and produce no refractive er-
ror, emmetropia is achieved. In the instance of emmetropia, a ray of light parallel to the op-
tical axis and limited by the pupil focuses at a point on the retina. In other words, the sec-
ondary focal point is located on the retina. In addition, the far point (i.e., the furthest point
at which the eye can see clearly) is optical infinity (Fig. 1.2). Because the cornea accounts
for approximately two-thirds of the refractive power of the eye, it is logical that most re-
fractive surgeries attempt to change the shape of the cornea. Other methods of refractive
surgery include implanting intraocular lenses.
Traditionally, four major types of naturally occurring ametropias, or refractive errors,
have been described: myopia, hyperopia, astigmatism, and presbyopia. Wavefront analysis
of human eyes after correction of these optical abnormalities often show additional irregu-
larities that have been classified using Zernike polynomials into complex subgroups that
may be simplified into lower- and higher-order aberrations.
In myopia, the secondary focal point is anterior to the retina. In other words, the re-
fractive power of the eye is greater than that required for emmetropia; parallel rays of light
entering the eye are in focus at a location in the vitreous, rather than on the retina. Refrac-
tive myopia is due to steep corneal curvature or high lens power. Axial myopia is due to an
eye that is too long (i.e., longer than 22.6 mm). For every millimeter of axial elongation of
the globe, there are 3 diopters of myopia. When myopia is corrected with spectacles, con-
tact lenses, or refractive surgery, the parallel rays of light entering the eye come into focus
on the retina, which is consistent with a far point at infinity. The prevalence of physiologic
myopia in the general population is approximately 25% (20). LASIK corrects for myopia
by removing tissue in the center of the cornea, thereby flattening the cornea and decreasing
the refractive power of the eye.
A hyperopic eyes secondary focal point is posterior to the retina. In other words, par-
allel rays of light entering the eye come into focus at a location posterior to the retina. Re-
fractive hyperopia is due to a flat cornea (less corneal refracting power), or a lens with
lower power. Axial hyperopia is due to a short axial length. While hyperopia affects ap-
proximately 40% of the adult population, it is clearly less visually significant than myopia
(21). This is because accommodation may produce enough additional plus power to bring
the parallel rays of light to focus on the retina. Thus young hyperopes may compensate and
see well until their accommodative power weakens and they begin to experience manifest
hyperopia in their mid to late 30s. LASIK corrects for hyperopia by removing a ring of tis-
sue around the center of the cornea, thereby making the cornea steeper.
Astigmatism refers to a refractive error in which the curvature of the cornea, or less
commonly the curvature of the lens, varies in different meridians. In other words, patients
with astigmatism have two focal lines formed by the convergence of rays of light. The first
focal line, created by the more powerful corneal meridian, is closer to the cornea. The sec-
ond focal line, formed by the less powerful meridian, is further away. Dioptrically midway
4 Glazer and Azar

Figure 1.2 Schematic diagrams of myopia and hyperopia. In myopia, the far point is in front of
the eye (top), and the secondary focal point (F2) is anterior to the retina, in the vitreous (middle). In
hyperopia (bottom), the rays of light are in focus at a point behind the retina. (From Ref. 115.)

between the two focal lines is the circle of least confusion. A proper refractive correction
will place the circle of least confusion on the retina.
While astigmatism is clinically detectable in up to 95% of eyes, astigmatism of less
than 0.50 diopters rarely requires optical correction (22). However, 10% of the general pop-
ulation has naturally occurring astigmatism greater than 1 D. Since an astigmatic refractive
error of 1.00 to 2.00 D can decrease uncorrected vision to the 20/30 to 20/50 level, this de-
gree of astigmatism causes an unacceptably poor quality of uncorrected visual acuity
(23,24).
Regular astigmatism refers to corneal curvatures that are different but symmetrical,
with principal meridians 90 degrees away from each other. For regular astigmatism, one
Refractive Errors and Their Treatment 5

can achieve a refractive correction with cylindrical or spherocylindrical lenses. LASIK can
correct regular astigmatism by removing more tissue from the steeper side of the cornea.
Irregular astigmatism refers to a condition in which the principal meridians change
from point to point across the pupil, or in which the amount of astigmatism changes from
one point to another. Examples of irregular astigmatism include keratoconus or traumatic
corneal scars. LASIK is contraindicated in eyes with irregular astigmatism. Often, rigid
contact lenses are the best way to improve the visual acuity for eyes with irregular astig-
matism. The use of Zernike polynomials to analyze the wavefront in patients with irregu-
lar astigmatism has allowed, at least in theory, the incorporation of this information into the
laser treatment algorithm in LASIK and paved the way for custom corneal treatments.
Presbyopia refers to the age-related loss of accommodative response. Presbyopia typ-
ically sets in at approximately 40 years of age. The condition results from either a loss of
lens elasticity or an anatomic change in the position of the lens equator to the ciliary body
position. Presbyopia is an important issue to discuss during the informed consent of pa-
tients seeking refractive surgery. Some physicians give their patient the option of monovi-
sion, in which one eye is corrected for near vision and the other for distance vision.

D. ETIOLOGY, EPIDEMIOLOGY, AND LASIK ALTERNATIVES

1. Corneal Subtractive Procedures
a. Lamellar Procedures
Lamellar refractive keratoplasty refers to the placement of a lenticule on or within the
cornea to change its refractive power, typically by altering its anterior curvature. As de-
scribed above and in Chap. 2, Jose Barraquers introduction of lamellar refractive surgery
and of cryolathe keratomileusis were followed by Ruiz introduction of the concept of in
situ keratomileusis (25). He introduced a microkeratome propelled by gears that could cre-
ate the corneal flap and allow one to perform intrastromal tissue subtraction. When ad-
vances in instrumentation allowed the lamellar keratoplasty to be performed more accu-
rately, the procedure became known as automated lamellar keratoplasty (ALK) (Figure
1.3). The initial results of ALK for myopia showed improvement over previous lamellar
techniques. Results described postoperative uncorrected visual acuities of 20/40 or better
in 86% of patients, with a 6% loss of two or more lines of best spectacle corrected visual
acuity (26,27). However, ALK outcomes were not significantly better than the results
achieved with contemporary radial keratotomy (RK) techniques (28,29). The accuracy of
ALK is limited by the imprecise nature of mechanical cutting.
Hyperopic ALK uses a very deep lamellar pass, cutting more than 70% of the stromal
depth (versus the 40% of stromal depth that is used for myopic ALK or for LASIK). The in-
traocular pressure causes the thinned cornea to bow forward, and thus the central cornea
steepens (Figure 1.4). As one may imagine, this procedure was often unpredictable and oc-
casionally led to progressive ectasia. Long-term results published in 1998 reported instabil-
ity of the postoperative refraction with a progressive myopic shift. Even worse, 26% of eyes
developed iatrogenic keratoconus, and 16.4% required penetrating keratoplasty (30,31).
Hyperopic ALK is now considered unsafe due to the risk of progressive corneal ectasia.
b. Surface Laser Ablation (PRK and LASEK)
Another form of refractive surgery that utilizes corneal subtractive procedures is photore-
fractive keratectomy (PRK). PRK is more accurate than ALK because it makes use of the
6 Glazer and Azar

Figure 1.3 Myopic automated lamellar keratoplasty. (A) A microkeratome is used to create a
hinged flap in the cornea. (B) A second microkeratome is used to remove a parallel-faced disc of tis-
sue from the corneal bed. (C) The initial flap is replaced, leaving a flattened central cornea. (From
Ref. 116.)

193 nm argon fluoride (ArF) excimer laser. Like LASIK, PRK utilizes the excimer laser to
flatten the cornea by ablating the central cornea. Unlike LASIK, no corneal flap is made;
rather, the central corneal epithelium is simply removed with a spatula or with the laser it-
self (Fig. 1.5). While there are three distinct techniques for performing excimer laser PRK
for myopia, the most widely used technique applies wide-area surface ablation with a large-
diameter beam. Most of the published results of PRK are based on PRK performed in this
manner. It is primarily in Europe that PRK is performed with the two other techniques:
scanning slit and flying spot lasers. A modification of PRK, first performed at the Mas-
sachusetts Eye and Ear Infirmary by Azar and Abad in 1996, was the use of 20% alcohol
to create an epithelial flap which was repositioned to cover the stromal ablation bed. Since
then, several investigators have started to use this laser epithelial keratomileusis (LASEK)
technique, but it is not clear whether LASEK offers any advantages over PRK.
PRK has been shown to be safe and efficacious for the treatment of low to moderate
myopia. Several national studies of PRK demonstrated that 90 to 100% of patients had
20/40 or better uncorrected visual acuity, and 78 to 98% had postoperative refractions
within 1.0 D of the target outcome (3234). Refractive results of PRK in patients with more
than 6 D of myopia tend to be highly variable and undergo more regression. Another dis-
advantage of PRK is a prolonged recovery time: while the corneal epithelium is healing,
Refractive Errors and Their Treatment 7

Figure 1.4 Hyperopic automated lamellar keratoplasty. (A) A hinged flap, approximately 70% of
corneal thickness, is created with a microkeratome. (B) Intraocular pressure displaces the very thin
posterior layer and overlying flap anteriorly, causing central corneal steepening. The original shape
of the cornea is shown with dotted lines. (From Ref. 116.)

patients may experience discomfort and blurry vision. In addition, potential complications
include postoperative haze, halos, induced astigmatism, diplopia, and keratitis (32,3537).
Although PRK was the first widely accepted laser vision correction procedure, it has
been largely supplanted by LASIK as the refractive procedure of choice not just for high
myopia but even for low and moderate myopia. This is partly because LASIK provides
faster visual rehabilitation and decreased time for wound healing (3843).
While LASIK is often the refractive procedure of choice for myopes, PRK may be
preferable to LASIK for patients who are hesitant to undergo incisional surgery, or for pa-
tients who have contraindications to LASIK. Such contraindications would include corneal

Figure 1.5 Schematic illustration of photorefractive keratectomy. The excimer laser is used to re-
move anterior stroma (left), causing corneal flattening (middle). The region of tissue subtraction is
designated by the shaded area. (From Ref. 115.)
8 Glazer and Azar

thinning, in which less than 200 to 250 microns of tissue would be left in the corneal bed,
and epithelial anterior basement membrane dystrophy, because this carries the risk of ep-
ithelial ingrowth. PRK is also competitive with LASIK in the arena of treatment for low
hyperopia. A recent review of 65 eyes with
1.00 to
4.00 D of hyperopia documented
that 92% of the eyes were within 1.00 D of the intended manifest SE at 18 months fol-
low-up (44). Other reports support the use of hyperopic PRK (H-PRK) for treating low de-
grees of hyperopia (4548). H-PRK for the treatment of higher degrees of hyperopia is less
predictable and may result in greater regression (45).

2. Biologic and Synthetic Tissue Addition: Epikeratoplasty and ICRS

One can alter the shape, and thus the refractive index, of the cornea by adding material ei-
ther to the surface of the cornea or into the corneal stroma. Epikeratoplasty involves adding
a lenticule with power (i.e., carved donor tissue) to the deepithelialized surface of Bow-
mans layer. Also called epikeratophakia or lamellar keratoplasty, this technique has
proven problematical. First, the refractive results have been disappointing: only 33% of
eyes achieved 20/40 or better uncorrected visual acuity, 15% lost two or more lines of best
corrected visual acuity (BCVA), and regression was more than 2 D in 17.6% of patients at
5 months follow-up (4951). Secondly, 2.53.5% of patients who underwent this proce-
dure had delayed reepithelialization, which in some cases led to infections and graft melt-
ing (49,5255). Almost 8% of grafts had to be removed due to failure of epithelialization,
haze, glare, irregular astigmatism, epithelial ingrowth, epithelial interface cysts, melt, in-
fection, stromal infiltrates, and wound dehiscence (49,5354,5657). After the lenticules
were removed, many patients were left with central corneal scarring and loss of BCVA
(58,59). Because of the disappointing outcomes and unfortunate complications, epikerato-
plasty has been abandoned as a technique for the correction of myopia. However, epiker-
atoplasty is still occasionally used to diminish the myopia and irregular astigmatism of ker-
atoconus or other corneal thinning disorders (60). This procedure is also sometimes used
for the treatment of pediatric and adult aphakia.
Keratophakia is a procedure in which a lens is placed within the corneal stroma to al-
ter the corneas refractive power. While lenses used to be fashioned from donor human
corneas (homoplastic), these lenses had variable outcomes and a high incidence of compli-
cations (61). Keratophakic lenses are now fashioned exclusively from synthetic materials
(alloplastic).
The intrastromal corneal ring segment (ICRS), approved in the United States in April
1999, is a keratophakic technique to correct for low myopia (1.00 to 3.00 D with an
astigmatic component of 1.00 D or less). The ICRS consists of two 160 degree polymethyl
methacrylate (PMMA) segments placed in two pockets of the peripheral stroma, thereby
inducing peripheral steepening and indirectly causing central corneal flattening (Fig. 1.6).
The procedure is unique in that it retains the potential to be adjusted or reversed.
Two-year results of the phase II and phase III FDA trial analyzed 358 patient eyes.
At 24 months after surgery, 97% of the eyes had an UCVA of 20/40 or better, 76% were
20/20 or better, and 55% were 20/16 or better. In addition, 93% were within 1.00 D range,
and 73% were within 0.50 D range (62).
Potential disadvantages with the procedure include accidental perforation into the an-
terior chamber, surface perforation of the epithelium anteriorly, and induced astigmatism,
which can result from postoperative movement of the intracorneal ring segments (63).
Refractive Errors and Their Treatment 9

Figure 1.6 Intrastromal corneal ring segments. (From Ref. 63.)

3. Corneal Surface Remodeling: Incisional Surgery, Thermal Surgery,

and Orthokeratology
a. Incisional Surgery: Radial Keratotomy
Radial keratotomy (RK) is a procedure that treats myopia by making deep and radial
corneal stromal incisions to weaken the peripheral and paracentral cornea and thereby flat-
ten the central cornea (Figs. 1.7 and 1.8). Experimenting on rabbits corneas, Dutch oph-
thalmologist Lendert Jan Lans first demonstrated that nonperforating corneal incisions par-
allel to the limbus cause peripheral bulging and central flattening (Fig. 1.7) (64,65).
Japanese ophthalmologist Tsutomu Sato first performed anterior and posterior kerato-
tomies to treat myopia after observing that patients with keratoconus who had experienced
breaks in Descemets membrane and hydrops subsequently developed corneal flattening
(6667). Sadly, the role of the corneal endothelium was not understood when Sato was per-
forming his keratotomies. Later follow-up showed that of 170 eyes that underwent a kera-
totomy by Satos group, 121 (71%) developed bullous keratopathy, and only 49 eyes (21%)
retained clear corneas. The average time between the procedure and the onset of edema was
20 years (68). The posterior keratotomy was abandoned for anterior keratotomies once the
physiological importance of the corneal endothelium had been established.
In 1960, Svyatoslav Fyodorov of the Soviet Union visited Japan, where Akiyama
taught him Satos technique of radial keratotomy (Sato himself had recently died). Fyo-
dorov improved upon Satos techniques by devising improved instrumentation and by de-
veloping mathematical formulas to improve the reproducibility of RK (6970). Fyodorov
also showed that paracentral incisions were more effective than peripheral, scleral inci-
sions. In addition, he demonstrated that the diameter of the central clear zone is inversely
proportional to the magnitude of refractive correction.
In the United States, the first RK was performed by Bores at the Kresge Eye Institute
in November 1978. It was at about this time that the 20 year follow-up data of Satos pos-
terior keratotomy patients was revealing the 75% incidence of bullous keratopathy. Be-
cause the newer anterior procedure had scarce follow-up data, the National Eye Institute
chose to fund two large nationwide studies to examine RK: the Prospective Evaluation of
Radial Keratotomy (PERK) and the Analysis of Radial Keratotomy.
10 Glazer and Azar

Figure 1.7 The development of radial and astigmatic keratotomy. Illustrations of Lanss studies
showing peripheral corneal bulging (A) and subsequent scarring (B) after astigmatic keratotomy (C)
and radial keratotomy (D). (From Ref. 117.)

The PERK study showed that 10 years after surgery, 53% of the patients had 20/20
or better uncorrected vision, 85% had 20/40 or better, and 63% of patients younger than 40
years old were spectacle-independent. Low myopes did better than moderate myopes: 94%
of patients with low myopia (2.00 to 3.12 D) had an uncorrected visual acuity (UCVA)
of 20/40 or better, while 79% of moderate myopes (3.25 to 4.37) had 20/40 or better
UCVA. The 10-year PERK results also revealed a long-term instability of refractive errors:
Refractive Errors and Their Treatment 11

43% of eyes demonstrated a hyperopic shift of one diopter or more (71). Of note, the PERK
study employed eight-incision surgery (Fig. 1.8). In lower myopes, the four oblique inci-
sions may be sufficient to achieve the desired result.
The concept of standardized RK was introduced by Casebeer in the early 1990s. Us-
ing his cookbook method, even novice surgeons have been able to perform RK, but the
safety and stability of this approach was controversial, for it was not studied with the same
rigor that was used in the PERK study (7275).
Approximately 250,000 RK operations were performed each year in the United
States in the early 1990s (7176). There were advantages of RK over more modern forms
of refractive surgery; RK utilized relatively inexpensive equipment, the procedure did not
involve incisions in the optical zone, and RK had more long-term follow-up data than sev-
eral other contemporary refractive procedures. In the early days of excimer laser surgery,
RK was generally reserved for patients who had low and moderate myopia (up to 5 D) who

Figure 1.8 Eight-incision radial keratotomy. A diagram highlights the optical zone (top) and the
central flattening (middle) after performing an RK with eight incisions (bottom). (From Ref. 117.)
12 Glazer and Azar

were willing to accept initial undercorrections because they had the best long-term results
with RK.
b. Incisional Surgery: Astigmatic Keratotomy
Astigmatic keratotomy (AK) is a procedure that attempts to correct astigmatic refractive er-
rors in patients with greater than 1.5 D of astigmatism. AK involves performing arcuate or
transverse (also called tangential, or T) incisions that parallel the limbus, flattening the
meridian in which they are placed and steepening the unincised meridian 90 degrees away.
The first AK was performed by Schiotz, a Norwegian ophthalmologist, in 1885. He
performed a 3.5 mm penetrating incision at the limbus in the steep meridian of a post
cataract patient. The patients astigmatism was reduced from 19.5 to 7 D (77). Since then,
many incision configurations and techniques have been described, with variable outcomes
(7880). In general, deeper and longer incisions produce greater effect, but cuts greater
than 75 degrees are not recommended. In addition, the effects of the cuts increase with age.
Both new instruments and nomograms for AK such as Lindstroms have improved results
(Fig. 1.9).
c. Incisional Surgery: Hexagonal Keratotomy
The first incisional surgery for the treatment of hyperopia was performed by Mendez in
1985 (8182). Discussion of this procedure is included for historical purposes. Mendezs
hexagonal keratotomy procedure consisted of making circumferential connecting
hexagonal peripheral cuts around a 4.5 to 6.0 mm optical zone (Fig. 1.10). The central
cornea then bulged forward, correcting the hyperopia. Although the procedure was re-
ported to be successful in early studies, it was soon discovered that intersecting incisions
caused corneal instability with poor predictability and fluctuating refractive results. In ad-
dition, many patients experienced excessive scarring at the incisions and induced astig-
matism (83).

Figure 1.9 Lindstroms nomogram for astigmatic keratotomy. (From Ref. 118.)
Refractive Errors and Their Treatment 13

Figure 1.10 Hexagonal keratotomy. (From Ref. 115.)

In 1989, Jensen and Mendez attempted to improve upon the technique with shorter,
nonintersecting hexagonal incisions (84). Despite these modifications, corneal scarring,
optical aberrations, irregular astigmatism, perforation after minimal trauma, keratitis, and
endophthalmitis were complications that plagued this procedure (8587). It was soon de-
termined that hexagonal keratotomy was an unpredictable, unsafe surgical procedure
with a high complication rate . . . (87). As such, the procedure has largely been aban-
doned.
d. Thermal Surgery
Thermal keratoplasty (TK) was first performed by Lans in 1898 to treat astigmatism (64).
Lans applied thermal energy via a cautery to alter the structure of the corneal stromal col-
lagen and change the anterior corneal curvature. Heat was later applied by means of radio
frequency waves with instruments like the Los Alamos thermal keratoplasty probe (88).
Because it was difficult to control the amount of energy applied, TK using simple cauter-
ies and probes resulted in unpredictable results and regression (89,90).
Interest in TK was rekindled with the introduction of lasers that could heat the cornea
in a more controlled manner. In 1990, Seiler first reported the use of the holmium:yttrium
aluminum garnet (Ho:YAG) laser for hyperopia, a technique called laser thermokerato-
plasty (LTK) (91). Ho:YAG LTK delivers infrared radiation that is focused on the mid-
stroma, thereby avoiding damage to the epithelium. Two types of Ho:YAG LTK delivery
systems were developed: contact and noncontact.
Contact LTK was performed by applanating the cornea with a probe that applied en-
ergy pulses to achieve local, peripheral flattening and subsequent central steepening. In the
early 1990s, the procedure underwent Food and Drug Administration (FDA) trials. Re-
gression and undercorrection plagued the procedure, and contact LTK was withdrawn from
US FDA trials (92).
Noncontact LTK is performed by projecting simultaneously up to eight spots onto
the cornea through a slit lamp-mounted fiberoptic delivery system. FDA phase Iia clini-
cal trials with two years of follow-up showed a mean change in refraction of 0.53 to
1.48 D, with UCVA at two years improved by one or more lines of Snellen visual acu-
ity in 19 (73%) of 26 treated eyes (93). The problem with noncontact LTK is regression.
Studies have shown 31.5 to 40% regression (94,95). Another problem apparent with LTK
is the induction of irregular astigmatism (95,96). Despite these imperfections, noncontact
14 Glazer and Azar

Ho:YAG LTK recently received approval by the FDA. Some investigators are attempt-
ing to improve upon the current pulsed Ho:YAG LTK with a new continuous wave diode
laser that can achieve similar effects on the cornea, without the peaks and troughs of the
pulsed laser (97).

e. Orthokeratology
Orthokeratology is the programmed application of contact lenses to reduce or eliminate re-
fractive anomalies, primarily myopia. An orthokeratology lens is flatter, looser, and larger
than a conventional lens. Theoretically, the lens mechanically alters the central corneal
contour over time. In 1963, Grant and May introduced this practice to the United States.
They fitted a rigid PMMA lens that was 0.37 diopters flatter than the patients flattest
corneal median. As the cornea flattened, new lenses were applied, each time 0.37 D flatter
than the flattest meridian. The patients wore their lenses for 12 to 15 hours a day and were
followed at regular intervals. During the first phase of treatment, the adaptive phase, an av-
erage of six pairs of lenses was prescribed over a period of 18 to 24 months. When unaided
vision reached 20/20 or refraction stabilized to plano  0.50 diopters, the retainer phase be-
gan and patients would then wear a retainer lens to maintain the permanence of the proce-
dure (98,99).
While many anecdotal reports describe the myopia-reducing benefits of orthokera-
tology, there are no scientific studies to support claims that this practice is a viable alterna-
tive to refractive surgery. For example, one randomized, controlled clinical trial did demon-
strate an improvement in uncorrected visual acuity from 20/100 to 20/50 in 36.6% of the
orthokeratology group compared with 20.8% of the cosmetic lens wearers who improved
the same amount. However this trial had no long-term follow up; results were from data at
the very end of the 14 month (on average) treatment period (100).

4. Altered Index of Refraction: Phakic IOLs

Most types of refractive surgeries alter the cornea; however, the refractive power of the eye
can also be adjusted by implanting an intraocular lens (IOL), with or without extraction of
the crystalline lens. Barraquer implanted the first phakic intraocular lens in the 1950s (101).
Unfortunately, many of these anterior chamber lenses were poorly finished and had sharp
edges. After Barraquer implanted almost 500 lenses, significant complications such as
corneal edema occurred, and over 300 of the lenses had to be removed (102). Because of
experiences like this, interest in phakic IOLS waned until the labs were better able to guar-
antee the quality of IOLs.
Modern IOLs are of much better quality than those used in the 1950s. A recent study
used a scanning electron microscope to analyze the surface quality of new generation pha-
kic IOLs; the study showed that these lenses did not have any defects that would con-
traindicate their use as phakic IOLs (103). This study examined the three major types of
lenses used as phakic IOLs today: anterior chamber lenses, iris-fixated anterior chamber
lenses, and posterior chamber lenses (Fig. 1.11). Even in IOLs with smooth surfaces, how-
ever, there is still a risk of progressive corneal endothelial cell loss with the use of phakic
IOLs (104108). Other complications include cataract formation, endopthalmitis, and reti-
nal detachments (109112).
While phakic IOL implantation does have risks, this procedure enjoys many advan-
tages for the correction of refractive errors: the procedure is both highly predictable and re-
Refractive Errors and Their Treatment 15

versible, it can correct higher refractive errors than LASIK and other types of refractive
surgeries, and it can be performed by most ophthalmologists. In addition, phakic IOLs,
while currently used to treat myopia, may soon be approved to correct hyperopia. A recent
Phase I trial of silicone plate posterior chamber lenses, implanted in hyperopes, reported
100% of patients with 20/40 or better UCVA, and 70% with 20/20 or better UCVA (113).
The field of refractive surgery has changed significantly since Sato introduced radial
keratotomy and Barraquer performed his first cryolathe keratomileusis. Advances in instru-
mentation, and in research and understanding of the eye and wound healing, and constant
surgical innovation, will surely keep the field changing and improving as the years progress.
In the twenty-first century, LASIK has crossed the genre from medical procedure to
star-endorsed miracle treatment. The public is familiar with the litany of celebrities who
have had success with the procedure. When a sports celebrity or an eye surgeon is willing
to bet with such high stakes, perhaps the general public feels more comfortable taking a risk
as well. More than one million Americans have had LASIK procedures, and predictions es-
timate that 1.2 million Americans will undergo LASIK in the year 2001 (2).
Some decry LASIK as a shift from disease-driven to demand-driven procedures.
There are, however, individuals (such as athletes, firefighters, and military personnel) for
whom spectacles or contact lenses are hindering or even dangerous. In addition, people
with a high degree of myopia may find glasses to be inadequate due to image minification,
or they may be intolerant of contact lenses. The visual disability of high myopes can reduce
their quality of life so much that some studies suggest that refractive surgery for high my-
opes should be provided under health plans like Great Britains National Health Service.

Figure 1.11 Phakic IOLs. Drawings illustrating the three major types of phakic intraocular lenses
in use today. (From Ref. 119.)
16 Glazer and Azar

REFERENCES
1. SG Farah, DT Azar, C Gurdal, J Wong. Laser in situ keratomileusis: literature review of a de-
veloping technique. J Cataract Refract Surg 1998;24:9891006.
2. K Chang. Laser Eye Surgerys Turf War. The New York Times. August 1, 2000; F1, F5.
3. JI Barraquer. Queratoplastia refractiva. Estudios Inform Oftal Inst Barraquer 1949;10:221.
4. JI Barraquer. Queratomileusis para la correcion de la myopia. Arch Soc Am Oftalmol Optom
1964;5:2748.
5. JI Barraquer. Keratomileusis for myopia and aphakia. Ophthalmology 1981;88:701708.
6. RC Troutman, C Swinger. Refractive keratoplasty: keratophakia and keratomileusis. Trans
Am Ophthalmol Soc 1978;76:329339.
7. JI Barraquer. Keratomileusis. Int Surg 1967;48:103117.
8. JI Barraquer. Results of hypermetropic keratomileusis, 19801981. Int Ophthalmol Clin
1983;23:2544.
9. C Barraquer, AM Gutierrez, A Espinosa. Myopic keratomileusis: short-term results. Refract
Corneal Surg 1989;5:307313.
10. L Nordan. Myopic keratomileusis: 74 consecutive non-amblyopic cases with one year follow-
up. J Refract Surg 1986;2:12241228.
11. CA Swinger, BA Barker. Prospective evaluation of myopic keratomileusis. Ophthalmology
1984;91:78592.
12. SL Trokel, R Srinivasan, B Braren. Excimer laser surgery of the cornea. Am J Ophthalmol
1983;96:710715.
13. GA Peyman, C Beyer, J Kuszak, B Khoobehi, M Shahsavari, R Badaro. Long-term effect of
erbium-YAG laser (2.9 microns) on the primate cornea. Int Ophthalmol 1991;15:249258.
14. IG Pallikaris, ME Papatzanaki, EZ Stathi, O Frenschock, A Georgiadis. Laser in situ ker-
atomileusis. Lasers Surg Med 1990;10:463468.
15. L Buratto, M Ferrari, C Genisi. Myopic keratomileusis with the excimer laser: one-year fol-
low up. Refract Corneal Surg 1993;9:1219.
16. BS Maller. Market trends in refractive surgery. Int Ophthalmol Clin 2000;40(3):1119.
17. M Montes, A Chayet, L Gomez, R Magallanes, N Robledo. Laser in situ keratomileusis for
myopia of 1.50 to 6.00 diopters. J Refract Surg 1999;15:106110.
18. RD Stulting, JD Carr, KP Thompson, GO Waring III, WM Wiley, JG Walker. Complications
of laser in situ keratomileusis for the correction of myopia. Ophthalmology 1999;106:1320.
19. SA Melki, CE Proano, DT Azar. Optical disturbances and their management after myopia
laser in situ keratomileusis. Int Ophthalmol Clin. 2000;40(1):4546.
20. RD Sperduto, D Seigel, J Roberts, M Rowland. Prevalence of myopia in the United States.
Arch Ophthalmol 1983;101:405407.
21. A Sorsby. Biology of the eyes as an optical system. In: Duane TD, Jaeger EA, eds. Clinical
Ophthalmology, rev ed. Philadelphia: Lippincott, 1988.
22. RC Donders, WD Moore, trans. On the Anomalies of Accommodation and Refraction of the
Eye. London: New Sydenham Society, 1864, pp 415417.
23. ESS Duke, D Abrams. Ophthalmic optics and refraction. In: System of Ophthalmology. St.
Louis, MO: Mosby, 1970, Vol. 5, pp 274295.
24. RL Lindstrom. The surgical correction of astigmatism: a clinicians perspective. Refract
Corneal Surg 1990;6:441454.
25. L Ruiz, J Rowsey. In situ keratomileusis. Invest Ophthalmol Vis Sci 1988;29 (suppl):392.
26. WA Lyle, GJ Jin. Initial results of automated lamellar keratoplasty for correction of myopia:
one-year follow-up. J Cataract Refract Surg 1996;22:3143.
27. FW Price Jr., WE Whitson, JS Gonzales, CR Gonzales, J Smith. Automated lamellar ker-
atomileusis in situ for myopia. J Refract Surg 1996;12:2935.
28. R Lindstrom. Minimally invasive radial keratotomy: mini-RK. J Cataract Refract Surg
1995;21:2734.
Refractive Errors and Their Treatment 17

29. TP Werblin, GM Stafford. The Casebeer system for predictable keratorefractive surgery. One-
year evaluation of 205 consecutive eyes. Ophthalmology 1993;100:10951102.
30. WA Lyle, GJ Jin. Hyperopic automated lamellar keratoplasty: complications and visual re-
sults. Arch Ophthalmol 1998;116:425428.
31. GO Waring III. A cautionary tale of innovation in refractive surgery. Arch Ophthalmol 1999;
117:10691073.
32. PS Hersh, RD Stulting, RF Steinert, GO Waring III, KP Thompson, M OConnell, K Doney,
OD Schein. Results of phase III excimer laser photorefractive keratectomy for myopia. The
Summit PRK Study Group. Ophthalmology 1997;104:15351553.
33. SC Schallhorn, CL Blanton, SE Kaupp, J Sutphin, M Gordon, H Goforth Jr, FK Butler Jr. Pre-
liminary results of photorefractive keratectomy in active-duty United States Navy personnel.
Ophthalmology 1996;103:522.
34. SI Shah, PS Hersh. Photorefractive keratectomy for myopia with a 6-mm beam diameter. J Re-
fract Surg 1996;12:341346.
35. T Seiler, A Holschbach, M Derse, B Jean, U Genth. Complications of myopic photorefractive
keratectomy with the excimer laser. Ophthalmology 1994;101:153160.
36. T Seiler, PJ McDonnell. Excimer laser photorefractive keratectomy. Surv Ophthalmol
1995;40:89118.
37. RF Steinert, S Bafna. Surgical correction of moderate myopia: which method should you
choose? PRK and LASIK are the treatments of choice. Surv Ophthalmol 1998;43:157179.
38. MA El Danasoury, GO Waring, A El Maghraby, K Mehrez. Excimer laser in situ ker-
atomileusis to correct compound myopic astigmatism. J Refract Surg 1997;13:511520.
39. Z Wang, J Chen, B Yang. Comparison of laser in situ keratomileusis and photorefractive ker-
atectomy to correct myopia from 1.25 to 6.00 diopters. J Refract Surg 1997;13:528534.
40. DG Kent, KD Solomon, Q Peng, SB Whiteside, SJ Brown, DJ Apple. Effect of surface pho-
torefractive keratectomy and laser in situ keratomileusis on the corneal endothelium.
J Cataract Refract Surg 1997;23:386397.
41. T Latvala, C. Barraquer-Coll, K Tervo, T Tervo. Corneal wound healing and nerve morphol-
ogy after excimer laser in situ keratomileusis in human eyes. J Refract Surg 1996;12:677683.
42. Q Peng, KD Solomon, DG Kent, OF Ahmad, DJ Apple. Comparison of keratocyte activation
in laser in situ keratomileusis and photorefractive keratectomy. Invest Ophthalmol Vis Sci
1996;37(3):S63.
43. K Tervo, JJ Perez-Santonja, JL Alio-Sanz, T Latvala, T Tervo. Nerve morphology after
LASIK in rabbit corneas. Invest Ophthalmol Vis Sci 1996;37(3):S64.
44. WB Jackson, E Casson, WG Hodge, G Mintsioulis, PJ Agapitos. Laser vision correction for
low hyperopia. An 18-month assessment of safety and efficacy. Ophthalmology 1998;105:
17271738; discussion 17371738.
45. D Dausch, R Klein, E Schroeder. Excimer laser photorefractive keratectomy for hyperopia.
Refract Corneal Surg 1993;9:2028.
46. D Dausch, Z Smecka, R Klein, E Schroder, S Kirchner. Excimer laser photorefractive kerate-
ctomy for hyperopia. J Cataract Refract Surg 1997;23:169176.
47. DP OBrart, CS Stephenson, K Oliver, J Marshall. Excimer laser photorefractive keratectomy
for the correction of hyperopia using an erodible mask and axicon system. Ophthalmology
1997;104:19591970.
48. SM Daya, FR Tappouni, NE Habib. Photorefractive keratectomy for hyperopia: six-month re-
sults in 45 eyes. Ophthalmology 1997;104:19521958.
49. MB McDonald, HE Kaufman, JV Aquavella, DS Durrie, DA Hiles, JD Hunkeler, RH Keates,
KS Morgan, DR Sanders. The nationwide study of epikeratophakia for myopia. Am J Oph-
thalmol 1987;103(3 Pt 2):375383.
50. WR Schlichtemeier, KD Arbegast. Long-term loss of effect of myopic epikeratophakia. J Re-
fract Surg 1987;3:4649.
18 Glazer and Azar

51. JT Woodhams. Regression of myopic epikeratophakia effects [letter]. J Cataract Refract Surg
1987;13:343344.
52. TP Werblin, HE Kaufman. Epikeratophakia: the surgical correction of aphakia. II. Preliminary
results in a non-human primate model. Curr Eye Res 1981;1:131137.
53. PS Binder, EY Zavala. Why do some epikeratoplasties fail? Arch Ophthalmol 1987;105:63
69.
54. MB McDonald, HE Kaufman, JV Aquavella, DS Durrie, DA Hiles, JD Hunkeler, RH Keates,
KS Morgan, DR Sanders. The nationwide study of epikeratophakia for aphakia in adults. Am
J Ophthalmol 1987;103(3 Pt 2):358365.
55. KS Morgan, MB McDonald, DA Hiles, JV Aquavella, DS Durrie, JD Hunkeler, HE Kaufman,
RH Keates, DR Sanders. The nationwide study of epikeratophakia for aphakia in children. Am
J Ophthalmol 1987;103(3 Pt 2):366374.
56. DS Durrie, DL Habrich, TR Dietze. Secondary intraocular lens implantation vs. epiker-
atophakia for the treatment of aphakia. Am J Ophthalmol 1987;103(3 Pt 2):384391.
57. M Busin, A Cusumano, M Spitznas. Epithelial interface cysts after epikeratophakia. Ophthal-
mology 1993;100:12251229.
58. PS Musco, JV Aquavalla. Reversibility of epikeratoplasty. J Refract Surg 1988;4:1517.
59. FW Price Jr, PS Binder. Scarring of a recipient cornea following epikeratoplasty. Arch Oph-
thalmol [Link].
60. DJ Schanzlin, EM Sarno, JB Robin. Crescentic lamellar keratoplasty for pellucid marginal de-
generation. Am J Ophthalmol [Link].
61. RC Troutman, C Swinger, M Goldstein. Keratophakia update. Ophthalmology 1981;88:3638.
62. EJ Linebarger, D Song, J Ruckhofer, DJ Schanzlin. Intacs: the intrastromal corneal ring. Int
Ophthalmol Clin 2000;40(3):199208.
63. B Cochener, G Savary-LeFloch, J Colin. Effect of intrastromal corneal ring segment shift on
clinical outcome: one year results for low myopia. J Cataract Refract Surg 2000;26:978986.
64. LJ Lans. Experimentelle Untersuchungen ber Entstehung von Astigmatismus durch nicht-
perfoririende Corneawunden. Arch fur Ophthalmologie 1898;45:117152.
65. BH Schimmelpfennig, GO Waring. Development of refractive keratotomy in the nineteenth
century. In: Waring GO, ed. Refractive Keratotomy for Myopia and Astigmatism. St, Louis:
Mosby-Year Book, 1992, p 174.
66. T Sato. Treatment of conical cornea (incision of Descemets membrane). Acta Soc Ophthal-
mol Jpn 1939;43:544555.
67. T Sato, K Akiyama, H Shibata. A new surgical approach to myopia. Am J Ophthalmol 1953;
36:823829.
68. K Akiyama, H Shibata, A Kanai, S Akiyama, T Yamaguchi, A Nakajima, GO Waring. De-
velopment of radial keratotomy in Japan, 19391960. In Waring GO, ed. Refractive Kerato-
tomy for Myopia and Astigmatism. St Louis: MosbyYear Book, 1992, p 212.
69. SN Fyodorov, Durnev VV. Operation of dosaged dissection of corneal circular ligament in
cases of myopia of mid degree. Ann Ophthlmol 1979;11:11851190.
70. SN Fyodorov, AA Agranovsky. Long-term results of anterior radial keratotomy. J Ocular
Therapy Surg 1982;1:217223.
71. GO Waring III, MJ Lynn, PJ McDonnell. Results of the prospective evaluation of radial ker-
atotomy (PERK) study 10 years after surgery. Arch Ophthalmol 1994;112:12981308.
72. JC Casebeer. New techniques for radial keratotomy. Eur J Implant Refract Surg 1994;6:
237238.
73. TP Werblin, GM Stafford. The Casebeer system for predictable keratorefractive surgery. One-
year evaluation of 205 consecutive eyes. Ophthalmology 1993;100:10951102.
74. TP Werblin, GM Stafford. Hyperopic shift after refractive keratotomy using the Casebeer sys-
tem. J Cataract Refract Surg 1996;22:10301036.
75. TP Werblin, GM Stafford. Three year results of refractive keratotomy using the Casebeer sys-
tem. J Cataract Refract Surg 1996;22:10231029.
Refractive Errors and Their Treatment 19

76. GO Waring, MJ Lynn, A Nizam, MH Kutner, JW Cowden, W Culbertson, PR Laibson, MB

McDonald, JD Nelson, SA Obstbaum. Results of the evaluation of radial keratotomy (PERK)
study five years after surgery. Ophthalmology 1991;98:11641176.
77. LJ Schiotz. Hinfall von hochgradigem Hornhautsastigmatismus nach Staarextraction,
Besserung auf operativem Wege. Arch Augenheilkd 1885;15:178181.
78. LT Nordan. Quantifiable astigmatism correction: concepts and suggestions. J Cataract Refract
Surg 1986;12:507518.
79. EG Faktorovich, RK Maloney, FW Price Jr. Effect of astigmatic keratotomy on spherical
equivalent: results of the Astigmatism Reduction Clinical Trial. Am J Ophthalmol 1999;127:
260269.
80. RL Lindstrom. The surgical correction of astigmatism: a clinicians perspective. Refract
Corneal Surg 1990;6:441454.
81. A Mendez. Correco da hipermetropia pela ceratotomia hexagonal. In: Guimarares R, ed.
Cirugia Refractive. Rio de Janeiro, Brazil: Piramide Livro Medic Editora Ltda, 1987, pp.
267279.
82. A Mendez. Advances in hyperopic correction with hexagonal keratotomy. Presented at the
American Society of Cataract and Refractive Surgery Meeting, April 1986, Los Angeles, CA.
83. A Neumann, G McCarty. Hexagonal keratotomy for correction of low hyperopia: preliminary
results of a prospective study. J Cataract Refract Surg 1988;14:265269.
84. JC Casebeer, SG Phillips. Hexagonal keratotomy. An historical review and assessment of 46
cases. Ophthalmol Clin North Am 1992;5:727744.
85. R Jensen. Hexagonal keratotomy: clinical experience with 483 eyes. Int Ophthalmol Clin
1991;31:6973.
86. P McDonnell, J Lean, D Schanzlin. Globe rupture from blunt trauma after hexagonal kerato-
tomy. Am J Ophthalmol 1987;103:241242.
87. WL Basuk, M Zisman, GO Waring III, LA Wilson, PS Binder, KP Thompson, HE Gross-
niklaus, RD Stulting. Complications of hexagonal keratotomy. Am J Ophthalmol 1994;
117:3749.
88. JJ Rowsey, JD Doss. Preliminary report of Los Alamos keratoplasty technique. Ophthalmol-
ogy 1981;88:755.
89. H Stringer, J Parr. Shrinkage temperature of eye collagen. Nature 1964;204:1307.
90. AC Neumann, D Sanders, M Raanan, M DeLuca. Hyperopic thermokeratoplasty: clinical
evaluation. J Cataract Refract Surg 1991;17:830838.
91. T Seiler, M Matallana, T Bende. Laser thermokeratoplasty by means of a pulsed holmium:YAG
laser for hyperopic correction. Refract Corneal Surg 1990;6:335339.
92. DS Durrie, DJ Schumer, TB Cavanaugh. Holmium:YAG laser thermokeratoplasty for hyper-
opia. J Refract Corneal Surg 1994;10:S277280.
93. DD Koch, T Kohnen, PJ McDonnell, R Menefee, M Berry. Hyperopia correction by noncon-
tact holmium: YAG laser thermal keratoplasty: U.S. phase IIA clinical study with 2-year fol-
low-up. Ophthalmology 1997;104:19381947.
94. JL Alio, MM Ismail, JL Sanchez Pego. Correction of hyperopia with non-contact Ho:YAG
laser thermal keratoplasty. J Refract Surg 1997;13:1722.
95. MK Tutton, PKM Cherry. Holmium: YAG laser thermokeratoplasty to correct hyperopia: two
years follow-up. Ophthalmic Surg Lasers 1996;27(5 suppl):S521S524.
96. DS Durrie, DJ Schumer, TB Cavanaugh. Holmium:YAG laser thermokeratoplasty for hyper-
opia. J Refract Corneal Surg 1994;10(2 suppl):S277S280.
97. T Bende, B Jean, T Oltrup. Laser thermal keratoplasty using a continuous wave diode laser. J
Refract Surg 1999;15:154158.
98. SC Grant, CH May. Orthokeratologycontrol of refractive errors through contact lenses. J
Am Opt Assoc 1971;42:12771283.
99. CH May, SC Grant, J Norlan. Orthokeratology, a Synopsis of Techniques. San Diego: Inter-
national Society of Orthokeratology, 1972.
20 Glazer and Azar

100. KA Polse. Corneal changes accompanying orthokeratology. Arch Ophthalmol. 1984;101:

18731878.
101. J Barraquer. Anterior chamber plastic lenses. Results of and conclusions from five years of ex-
perience. Trans Ophthalmol Soc UK 1959;79:393424.
102. RC Drews. The Barraquer experience with intraocular lenses. 20 years later. Ophthalmology
1982;89:386393.
103. T Kohnen, M Baumeister, G Magdowski. Scanning electron microscopic characteristics of
phakic intraocular lenses. Ophthalmology 2000;107:934939.
104. M Landesz, JGR Worst, G van Rij. Long-term results of correction of high myopia with an iris
claw phakic intraocular lens. J Refract Surg 2000;16:310316.
105. F Mimouni, J Colin, V Koffi, P Bonnet. Damage to the corneal endothelium from anterior
chamber intraocular lenses in phakic myopic eyes. Refract Corneal Surg 1991;7:277281.
106. JJ Saragoussi, J Cotinat, G Renard, M Savoldelli, A Abenhaim, Y Pauliquen. Damage to the
corneal endothelium by minus power anterior chamber intraocular lenses. Refract Corneal
Surg 1991;7:282285.
107. JJ Perez-Santonja, MT Iradier, L Sanz-Iglesias, JM Serrano, MA Zato. Endothelial changes in
phakic eyes with anterior chamber intraocular lenses to correct high myopia. J Cataract Re-
fract Surg 1996;22:10171022.
108. JL Menezo, AL Cisneros, V Rodriguez-Salvador. Endothelial study of iris-claw phakic lens:
four-year follow-up. J Cataract Refract Surg 1998;24:10391049.
109. F Trindade, F Pereira. Cataract formation after posterior chamber phakic intraocular lens im-
plantation. J Cataract Refract Surg 1998;24:16611663.
110. PH Brauweiler, T Wehler, M Busin. High incidence of cataract formation after implantation
of a silicone posterior chamber lens in phakic, highly myopic eyes. Ophthalmology
1999;106:16511655.
111. JM Ruiz-Moreno, JL Alio, JJ Perez-Santonja, F de la Hoz. Retinal detachment in phakic eyes
with anterior chamber intraocular lenses to correct severe myopia. Am J Ophthalmol 1999;
127:270275.
112. JJ Perez-Santonja, JM Ruiz-Moreno, F de la Hoz, C Giner-Gorriti, JL Alio. Endophthalmitis
after phakic intraocular lens implantation to correct high myopia. J Cataract Refract Surg
1999;25:12951298.
113. K Rose, R Harper, C Tromans, C Waterman, D Goldberg, C Haggerty, A Tullo. Br J Oph-
thalmol 2000;84:10311034.
114. DR Sanders, RG Martin, DC Brown, J Shepherd, MR Deitz, M DeLuca. Posterior chamber
phakic intraocular lens for hyperopia. J Refract Surg 1999;15:309315.
115. MD Mead, DT Azar. Terminology, Classification, and Definitions of Refractive Surgery.
Connecticut: Appleton and Lange, 1997, pp. 318.
116. CA Swinger, A Chou. History and principles of automated lamellar keratoplasty and laser in
situ keratomileusis. In: RS Brightbill, ed. Corneal Surgery: Theory, Technique and Tissue. 3rd
ed. New York: Mosby, 1999, pp. 762770.
117. EW Kornmehl. Radial keratotomy: operative techniques. In: DT Azar, ed. Refractive Surgery.
Connecticut: Appleton and Lange, 1997, pp. 255272.
118. YR Chu, DR Hardten, RL Lindstrom. Concepts in astigmatic keratotomy. In: Brightbill RS,
ed. Corneal Surgery: Theory, Technique and Tissue. 3rd ed. New York: Mosby, 1999, pp.
650655.
119. H Leibowitz, G Waring. Corneal Disorders. Philadelphia: Saunders, 1998.
 2
History of LASIK

IOANNIS PALLIKARIS
University of Crete Medical School and University Hospital of Heraklion
Heraklion, Crete, Greece
THEKLA PAPADAKI
Vardinoyannion Eye Institute of Crete, University of Crete Medical School
Heraklion, Crete, Greece

A. INTRODUCTION

Modern lamellar refractive surgery has its roots in the pioneer work of Professor Jos Ig-
nacio Barraquer of Colombia. In 1949, Barraquer suggested that by adding or removing
corneal tissue, it was possible to manipulate surgically the curvature of the air/tear film in-
terface, where the two thirds of the refractive power of the eye is located (1). From the very
beginning, he realized the importance of preserving each layer of the cornea, and so corneal
lamellar techniques started to develop.
During the past 50 years, lamellar corneal refractive surgery has undergone a long
evolutionary process. Various different methods have been suggested to remove and/or
shape corneal tissue, in order to enhance the accuracy and predictability of lamellar proce-
dures. Laser in situ keratomileusis (LASIK) is the most recent step in this process and com-
bines well-established lamellar surgical techniques with the precision of excimer laser pho-
toablation. Although it enjoys, at present, great popularity among refractive surgeons,
LASIK is still a developing procedure in terms of technique and perioperative patient man-
agement.
In this chapter we are going to follow the steps that led from Barraquers first exper-
iments to LASIK. Reviewing the history of refractive surgery is essential, because it pro-
vides the fundamental principles which form the basis for better understanding and
refining the currently used techniques.

21
22 Pallikaris and Papadaki

B. FROM KERATOMILEUSIS TO ALK

In order to describe lamellar techniques, Barraquer used the term keratomileusis, which is
derived from the Greek roots keras (hornlike  cornea) and smileusis (carving).
Myopic keratomuleusis (MKM) was introduced in 1949 (1). The initial procedure in-
volved creating a lamellar corneal disc approximately 300 m in depth (lamellar keratec-
tomy) and removing tissue from the residual stromal bed or the disc (refractive keratec-
tomy). When the disc was replaced, the anterior corneal curvature was flattened, thus
reducing the refractive power of the eye and correcting myopia (Fig. 2.1). Both keratec-
tomies were initially performed freehand with a Paufique knife. Removing stroma from the
bed freehand proved to be so difficult technically and so inaccurate that Barraquer tem-
porarily abandoned the in situ technique.
Instead, he focused on refining the lamellar keratectomy and perfecting the carving
of the lamellar disc. He discovered that the relation between IOP and resection diameter di-
rectly affected the depth of keratectomy (2). Based on this knowledge, Barraquer designed
the first manual microkeratome, applanator lenses, and suction rings of various heights. He
also discovered that a slow passage speed and constant contact between the microkeratome
and the suction ring during the cut were essential for a smooth, even keratectomy (3). He
was now able to achieve lamellar discs of predetermined thickness and diameter (2). Bar-
raquers early work provided the principles of lamellar keratectomy and set the basis for the
development of the modern automated microkeratomes.
In order to achieve more precise shaping of the resected corneal disc, Barraquer
thought of freezing the tissue and carving it using a modified contact lens cryolathe in a pro-
cedure named freeze-myopic keratomileusis (F-MKM) (2). After the disc was excised with
the microkeratome, its thickness was determined using an American Optical radiuscope.
Using a certain formula, Barraquer could calculate the required curvature to correct the
ametropia, given the original corneal radius of curvature and the dioptric correction (4).
The lathe was preground for the required radius of curvature. The disc was stained with Ki-
ton green 0.5%, to allow visualization during the procedure, and placed epithelial side-
down on the lathe lap. The lap and disc were frozen to 30C by liquid nitrogen. The stro-

Figure 2.1 Myopic keratomileusis (MKM). A lamellar corneal disc approximately 300 m in
depth is created (lamellar keratectomy) and tissue is removed from the residual stromal bed (refrac-
tive keratectomy). Once the disc is replaced, the anterior corneal surface is flattened, thus reducing
the refractive power of the eye and correcting myopia. (Reprinted with permission from D. T. Azar.
Refractive Surgery. Appleton & Lange, 1997.)
History of LASIK 23

Figure 2.2 Free keratomileusis. The dyed corneal disc is placed on the lathe, epithelial side down,
and frozen by liquid nitrogen (A). A frozen tool is then used to lathe the disc (B). (Courtesy of Dr.
Jos Ignacio Barraquer.)

mal surface was then lathed with more tissue removed from the center than the periphery
in the myopic cases so as to flatten the central corneal curvature (Fig. 2.2). For hyperopic
correction the disc was treated in the opposite way to achieve steepening of the central
corneal curvature (Fig. 2.3). After thawing, the carved disc was placed back on to the
cornea and held in place with sutures. This was the first time a part of a human organ was
removed from the body to alter its function and then returned.
Barraquer also thought he could achieve steepening of the central corneal curvature
more effectively by implanting a preprocessed stomal tissue lenticle (allograft) within the
recipients stroma (5). To create the lenticle, a lamellar corneal disc was resected from fresh
or preserved donors cornea, using a microkeratome. The epithelium, Bowmans layer and
the anterior stroma were removed. The remaining stromal tissue was preserved by a vari-
ety of means (refrigeration, freezing, and freeze drying) and processed on the lathe in a way

Figure 2.3 Freeze keratomileusis for myopia and hyperopia. As more tissue is removed centrally
than peripherally (A), the plano corneal disc is converted to a concave (negative) lens, capable of
correcting myopia. For hyperopic correction, more tissue is removed from the periphery of the disc
to achieve steepening of the central curvature (B). (Courtesy of Dr. Jos Ignacio Barraquer.)
24 Pallikaris and Papadaki

Figure 2.4 Keratophakia (KF) is the procedure in which a corneal lenticle is removed from a
donors cornea. After a lamellar resection is performed on the recipients cornea, the lenticule is in-
serted underneath the resected corneal cap. As the cap is sutured back, a new steepend anterior
corneal curvature is formed. (Reprinted with permission from D. T. Azar. Refractive Surgery. Ap-
pleton & Lange, 1997.)

similar to that in F-KM, to create a converge lenticle capable of correcting aphakia and high
hyperopia. Keratophakia (KF) was the term employed to describe the procedure in which
a lamellar keratectomy was performed on the recipients cornea, the lenticle was placed in-
trastromally, and the lamellar disc was sutured in place (Fig. 2.4). The lenticle diameter and
thickness varied, depending on the initial refractive error and the target correction. KF was
first reported in 1958 as having the potential to correct aphakia (5). With this report Barra-
quer introduced his work to the ophthalmic community.
The first report on F-MKM followed in 1967 (2). First results revealed visual im-
provement in 80% of the patients and indicated that refinement of the procedure should pro-
ceed. Over the next decade significant advantages in the cutting and shaping of the tissue
improved the predictability of the procedure but could not help overcome its major draw-
backs. These were the use of very complicated technology and the steep learning curve re-
quired for the procedure, together with the prolonged visual recovery time and the high rate
of complications such as scarring and irregular astigmatism (6).
Troutman and Swinger brought the concepts of KF and KM to the United States in 1978
(7). KF attracted the attention of the ophthalmic community as a possible solution for the
treatment of aphakia after cataract extraction (810). However, with the advent of IOL tech-
nology, interest in KF subsided. Though early results on MKM were encouraging (11,12), the
technical difficulty, the steep learning curve, and the potential of sight-threatening complica-
tions, which were attributed mainly to tissue damage during freezing and lathing (1215), dis-
couraged many ophthalmic surgeons, and the technique failed to be popularized.
In an attempt to simplify lamellar refractive surgery and make it safer, Kaufman,
Werblin, and Klyce of the Louisiana State University Eye Center introduced epiker-
atophakia (epikeratoplasty or epi) in 1979 (1618). The procedure involved deepithelial-
ization of the recipient cornea and preparation of a peripheral annular partial-thickness ker-
atotomy. A lyophilized preshaped corneal tissue lenticle (consisting of Bowmans layer
and the anterior stroma) was reconstituted and sutured into the keratotomy site, creating a
new shape for the anterior corneal surface (Fig. 2.5). The major advantage of this proce-
dure was that it avoided the problems of using a microkeratome to cut across the optical
zone and lathing the corneal tissue intraoperatively (19). Epi was intended for use in the
History of LASIK 25

treatment of aphakia, high myopia, or hyperopia (20,21). Plano epilenticles were also em-
ployed to flatten the cornea in keratoconus and provide a more regular surface for contact
lens wear (22). Unfortunately, the initial reports proved that the procedure was neither pre-
dictable nor safe (2324). The most common complications of epi included irregular astig-
matism, persistent epithelial defects, and delayed visual recovery (2527). These were
mainly attributed to the heavy processing of the graft tissue (28). Several modifications of
the initial procedure were employed (2930), among them the application of nonfreezing
techniques to shape the graft lenticle (31). Altman reported on using a spot excimer laser
beam to shape the corneal tissue, mounted on a movable platform (32). Buratto and Ferrari
used the BarraquerKrumeichSwinger technique (described below) to shape epilenticles
without freezing. Predictability was still low, but visual recovery was significantly faster
than with regular freezing techniques (33). Despite the efforts, epi never gained approval
from the FDA and was withdrawn from the market (34). However, the ease of epi compared
to MKM prompted the development of nonfreeze keratomileusis techniques.
The BarraquerKrumeichSwinger (BKS) refractive system was introduced in 1985
(35). This included an improved microkeratome (the BKS 1000), a set of dies, and a suc-
tion stand. The microkeratome was used to excise a lamellar corneal disc. The disc was then
placed epithelial side down on one of the suction dies, and the second refractive cut was
performed on the stromal aspect of the disc, using the microkeratome. The curvatures of the
dies varied, depending on the amount of the attempted correction of myopia or hyperopia
(Figs. 2.6 and 2.7). When a convex die was used, the keratome removed a central part of
the stroma, thus flattening the anterior surface of the cornea. For hyperopia correction, the
lenticle was placed on a concave die, and the microkeratome removed a peripheral portion
of the stroma, steepening the central cornea. The sculptured lamellar disc was finally su-
tured back to the bed. Despite its technical difficulty, nonfreeze keratomileusis proved to
have a major advantage: the rapid and comfortable visual recovery of the patients. This was

Figure 2.5 Epikeratophakia or epikeratoplasty. A preprocessed donor lenticle is fixed onto the
corneal surface. A peripheral circumferential keratectomy allows fixation of the lenticle into the host
cornea. For correction of hyperopia (right), a positive lens is used to steepen the anterior corneal cur-
vature. A negative lens (left), on the contrary, would flatten the anterior corneal curvature, resulting
in correction of myopia. (Reprinted with permission from D. T. Azar. Refractive Surgery. Appleton
& Lange, 1997.)
26 Pallikaris and Papadaki

Figure 2.6 The BarraquerKrumeichSwinger (BKS) nonfreeze keratomileusis technique. Apart

from the microkeratome, the BKS system includes a set of suction dies (left) and a suction stand. Af-
ter the corneal cap is resected it is placed, epithelial side down, on the proper suction die, selected ac-
cording to the amount of attempted correction of myopia or hyperopia. The die bearing the corneal
cap is then fixed onto the suction stand for the refractive, second, cut to be made at the stromal side
of the cap (right).

attributed to the preservation of fibroblasts and corneal epithelium. However, significant

amounts of irregular astigmatism could not be avoided, as the refractive cut could not be
centered with precision, and there was always the risk of trauma to the disc during manip-
ulation. More important, the thickness of the lamellar disc determined completely the ac-
curacy of the technique, which was ineffective for more than 16 diopters of myopia (36). It
was now evident that carving of the corneal disc should be eliminated, in order to reduce
the complication rate and achieve more predictable corrections of high myopia. Thus re-
search turned once again towards keratomileusis in situ.

Figure 2.7 The BarraquerKrumeichSwinger (BKS) system for nonfreeze keratomileusis. The
BKS microkeratome and the suction stand.
History of LASIK 27

As mentioned previously, Barraquer introduced KM in situ in the late 1940s (1) but
had to abandon the technique very soon due to the many technical difficulties inherent in
the use of a manual microkeratome. Ruiz and Rowsey revised the idea of KM in situ in the
late 1980s, taking advantage of the BKS system cutting properties (37). The initial kerate-
ctomy was performed as in the BKS technique. Subsequently, by using suction rings of dif-
ferent heights, Ruiz would perform the refractive cut on the stromal bed instead of the stro-
mal aspect of the disc. The thickness of the cut was proportional to the degree of myopia to
be corrected and was calculated using a nomogram that Ruiz proposed. The advantage of
the procedure, compared to classic KM, was that carving the stromal bed allowed for larger
optical zones and widened the range of potential correction (38,39). In 1987, Leo Bores
performed the first KM in situ in the US (40) and initiated the investigation of the tech-
nique. KM in situ with the use of a manual microkeratome, however, was reported as be-
ing not technically safe, precise, or predictable and was adopted by a very small number of
surgeons (38,39). The desire to improve the reproductability and accuracy of the in situ
technique prompted research in developing new improved microkeratomes (41).
In the late 1980s, Luis Ruiz gave impulse to lamellar refractive surgery, by develop-
ing an automated geared microkeratome (Fig. 2.8). A suction device stabilized the ker-
atome head on the eye, and the speed of the keratome passage could be controlled using a
foot pedal, so that more even, consistent cuts were obtained. The microkeratome would
also automatically reverse at the end of the procedure, without disturbing the lamellar cut.
This automatic corneal shaper (ACS) led to the introduction of automated lamellar kerato-
plasty (ALK) in the field of lamellar refractive corneal surgery. The procedure involved re-
section of the initial lamellar disc using ASC. For myopic corrections a second, plano re-
fractive cut was subsequently performed on the bed. The depth of the second cut was
adjusted by altering the height of the suction ring. In the end the anterior lamellar disc was
replaced on the stromal bed, with or without sutures (Fig. 2.9). In hyperopic ALK no re-
fractive cut was performed, as the initial cut generated ectasia of the residual stroma ade-
quate to correct up to 6 diopters of hyperopia. This ectasia was maintained after the ante-
rior lamellar disc was replaced. For higher hyperopic corrections, homoplastic ALK was

Figure 2.8 The Ruiz automated microkeratome is geared, so that the same motor that moves the
blade also drives the microkeratome across the eye.
28 Pallikaris and Papadaki

Figure 2.9 The Automated Lamellar Keratoplasty (ALK) is based on the same concept as ker-
atomileusis in situ. The use of the automated microkeratome has increased dramatically the safety and
effectiveness of the procedure. This photo shows the actual corneal bed after the two lamellar resec-
tions. The even sharp concentric borders of the lamellar cuts, as well as the smooth surface of the re-
maining stroma, are evident. (Reprinted with permission from J. Machat. Excimer Laser Refractive
Surgery. Slack, 1996.)

invented (42). The procedure involved excision of a small, very thin anterior lamellar disc,
which was discarded and replaced by a 300400 m thick donor lenticle (processed also
using ACS).
ALK has been a breakthrough in lamellar surgery. The total operative time was re-
duced, and the procedure could be safely performed under topical anesthesia. Recovery time
improved. ALK became very popular, as many surgeons who found it difficult to use the
manual microkeratomes adopted ACS. The first clinical trials on ALK revealed its advan-
tages: ease of use, rapid visual recovery, stability of refraction, and efficacy in th correction
of high myopia (43). There were major disadvantages, however; a relatively high rate for
irregular astigmatism (2%) and poor predictability of the procedure (within 2 D) (44). The
latter was attributed to the imprecision of the depth obtained with the second lamellar
resection. It became obvious that ALK could never overcome its inherent drawback: the re-
fractive cut was not truly refractiveit was resection of a plano disc from the stromal bed.
Investigators now started exploring ways to improve the accuracy of the second refractive
cut. That time coincides with the beginning of the excimer laser era in ophthalmology.

C. THE DEVELOPMENT OF THE EXCIMER LASER

Excimer is a term used to describe lasers with output in the ultraviolet (UV) range of the
electromagnetic spectrum. In 1973, Charles Brau, James Ewing, and Donald Setser started
working on using rare gashalide mixtures to produce laser action. Two years later, in
1975, Stuart Searles produced the first excimer laser action by bombarding a medium of
History of LASIK 29

xenon bromide with an electron beam gun. In 1976, argon fluoride (ArF) was found to lase
at 193.3 nm when excited in an electron beam (45).
The first laboratory excimer lasers required a great amount of energy to excite the
rare gashalide complex. Therefore their usefulness for biological experiments was lim-
ited. Later on, it was shown to be possible to achieve laser action in a more compact device,
using a transverse electrical discharge as the energy source. Tachisto made the first com-
mercial system in 1979 (45). Within only a year, excimer lasers improved in reliability and
output energy and became suitable for general laboratory use. As a consequence, research
on the possible applications of excimer lasers and their potential hazards started to evolve.
The United States Air Force (USAF) School of Aerospace Medicine started investi-
gating the use of these new lasers on the eye. In 1981, Taboada reported that ArF laser light
produces an immediate but temporary indentation of the corneal epithelium, which takes
on the shape of the beam, without causing any opacification to the adjacent epithelium or
stroma (46,47).
IBM researcher R. Srinivasan further studied the interaction of a 193 nm laser with
organic materials. He suggested the term photoablative decompensation (later referred to
as photoablation) to describe the mechanism of ablation with the 193 nm excimer lasers,
and by creating grooves in human hair he demonstrated the high precision of the ablation
technique. He suggested the possibility of optical control of the corneal surface by remov-
ing tissue and set the basis for further studies (48).
Stephen Trokel first experimented on the cornea with excimer photoablation and de-
scribed its surgical potential. In 1983 Trokel reported, UV light at 193 nm, ablated corneal
tissue at a predictable rate, producing minimal thermal damage to the surrounding tissues
(49). These properties of excimer laser photoablation are the foundation of excimer laser
refractive surgery. Separate patents on photorefractive keratectomy (PRK) were filed by
Stephen Trokel and Francis LEsperance. Studies on animal corneas as early as 1984 re-
vealed that only 5 m of corneal tissue had to be removed to lower the refractive power
of a 4 mm corneal optical zone by 1 D (50). Early attempts to perform phototherapeutic ker-
atectomy (PTK) showed that the ablated surface would heal without scarring (51,52).
Thus the ophthalmologic community overcame the belief that the preservation of Bow-
mans membrane was essential to preserve corneal topography and clarity. Based on that
evidence, the use of the excimer laser to alter directly the cornea curvature was made pos-
sible and PRK was introduced. In 1985, Theo Seiler of Germany was the first to perform
excimer laser PTK in a sighted eye (53). Laser companies such as Meditec GmbH (Ger-
many), VISX (Santa Clara, CA), and Summit Technologies (Waltham, MA) began to
emerge. In 1987 Francis LEsperance performed the first PRK in the U.S. on a blind eye
(53). In 1988, FDA clinical trials on PRK began. Marguerite McDonald achieved the first
successful refractive correction with PRK in a normally sighted myope, as part of an FDA
trial (54). At the same time, C. Munnerlyn and his colleagues published a computer-based
algorithm that relates ablation zone diameter and thickness to the required amount of diop-
tric change (50).
In 1995 FDA issued approval of the Summit and VISX lasers for PTK and the Sum-
mit laser for PRK. In 1996 FDA approved the VISX laser for PRK (53).
As the use of the 193 nm excimer laser in refractive surgery increased, it was revealed
that, for the correction of more than 6 D of myopia, PRK resulted in significant central
corneal haze, regression of the refractive effect, and poor predictability (55). To achieve
more accurate corrections of high myopia, investigators began to use the excimer laser in
combination with intrastromal techniques.
30 Pallikaris and Papadaki

D. LASIK DEVELOPMENT
As a modality, LASIK was designed and developed at the University of Crete. In 1988,
Ioannis Pallikaris and colleagues introduced the term laser in situ keratomileusis (LASIK)
to describe excimer laser ablation performed under a hinged corneal flap (Fig. 2.10) (56).
Pureskin first suggested the idea of raising a corneal flap and removing stromal tissue from
the bed, back in 1967. He attempted to create the flap manually and cut out the in situ part
with a trephine in a procedure that he termed stromectomy (57).
In LASIK the automated microkeratome is used to create a hinged corneal disc (i.e.,
flap), which consists of epithelium Bowmans layer and anterior stroma. The laser beam is
then applied directly to the stroma, to remove a predetermined amount of tissue, depending
on the target correction. Once ablation is completed, the flap is repositioned and held in
place with the action of the endothelial pump (Fig. 2.11).
The idea for the LASIK procedure was based on the histological observation that dur-
ing surface photoablation (PRK) the corneal neural network is also ablated and takes sev-
eral months to reconstitute (58). The initial hypothesis was that destruction of both Bow-
mans layer and the superficial corneal nerves during PRK would have an adverse effect on
the healing response. It was thus theorized that creation of a flap instead of a lamellar disc
would assure better fitting of tissues after the ablation and would not affect the anatomic
integrity of the cornea mainly by preserving Bowmans layer and the superficial corneal
nervous net. Other important advantages would be reduction of surgical manipulations and
total time required for the operation (56).

Figure 2.10 The first published diagram for LASIK. (Pallikaris 1989.)
History of LASIK 31

Figure 2.11 In laser in situ keratomileusis (LASIK) for hyperopia, the automated microkeratome
is used to create a hinged corneal disc (i.e., flap), which consists of epithelium and anterior stroma.
The laser beam is then applied directly to the stroma to remove a predetermined amount of tissue, de-
pending on the target correction. Once ablation is completed, the flap is repositioned and held in place
with the action of the endothelial pump. (Reprinted with permission from D. T. Azar. Refractive
Surgery. Appleton & Lange, 1997.)

To support this hypothesis, animal studies to determine wound-healing reactions af-

ter LASIK began in 1987. A Lambda Physik excimer laser was used, along with a manual
microkeratome that was designed to produce a 150 micron flap instead of a total cup (Fig.
2.12). The first published results regarding wound-healing reactions after LASIK on rabbit
eyes revealed that the neural network is reestablished within a month after the procedure
and no significant haze was present (58). These findings suggested that stromal ablation
could avoid the regression of effect and stromal haze related to PRK, as the epithelium re-
mains intact and the ablated area is hidden from the normal healing process of the eye that
takes place at the epithelium/stromal interface. Gholam Peyman reported in 1989 an ani-

Figure 2.12 The first animal studies to determine wound healing after LASIK. University of
Crete, 1987.
32 Pallikaris and Papadaki

Figure 2.13 Excimer laser intrastromal keratomileusis. After the lamellar cap is harvested (A), it
is positioned, epithelial side down, under the laser beam for photoablation (B). The ablated disc (C)
is then sutured back in place (D). (Courtesy of Dr. Lucio Buratto.)

mal study in which an erbium-Yag laser was successfully used to remove the stroma from
a lamellar bed as well as the corneal surface. Peymans work, however, focused on the use
of the erbium-Yag laser for experimental PRK (59).
In 1990 Lucio Buratto independently attempted to use the excimer laser to perform the
second cut in KM. He introduced the technique of excimer laser intrastromal keratomileusis
or photokeratomileusis (PKM), in which a 300 m thick lamellar disc was excised, inverted,
and ablated on its stromal aspect (Lucio Buratto, personal communication: First International
Meeting on Keratomileusis, Venice, Italy, June 1990) (Fig. 2.13). First results on a large
series of human eyes proved that this technique was effective for myopia up to 25 D, yet not
safe (60). The complication rate was comparable to that of MKM, and so PKM was finally
abandoned in favor of LASIK.

E. LASIK MILESTONES

In June 1989, the first LASIK on a blind human eye was performed in the University of
Crete, as part of an unofficial blind eye protocol. A specially modified BKS 1000 micro-
keratome was used for the operation.
Human studies begun in 1990 (61,63). The first blind eye study accessed the effect
of flap creation on both the corneal healing response and the topographic pattern. It was re-
History of LASIK 33

vealed that, three months following the flap technique, corneal transparency was main-
tained and no significant irregular astigmatism was noted on corneal topography. The
safety of sutureless LASIK was also suggested at that time (61). It was recognized that ad-
equate adhesion between the flap and the stromal bed was possible even without sutures.
The absence of irregular astigmatism, the elimination of sutures, and the invention of the
automated geared microkeratome by Luis Ruiz (described previously) were the three most
important developments that made LASIK widely accepted.
In 1992, Stephen Slade and Stephen Brint performed the first LASIK in the U.S.
In 1993, Slade used the automated microkeratome to create the flap. He termed the
procedure excimer ALK (E-ALK) or flap and zap (64).
In 1994, Pallikaris and colleagues published their early experience in the use of
LASIK on sighted eyes, as well as the first study comparing LASIK and PRK (65,66).
LASIK proved superior to PRK in terms of stability and predictability for the correction of
myopia greater than 10 diopters.
In 1997, Buratto suggested the downup LASIK, which involves positioning the flap
hinge superiorly instead of nasally. This modification of the procedure was thought to min-
imize the risk for flap dislodgment during the early postoperative term. A superior hinge
would also allow for wider ablation profiles, which are crucial in cases of hyperopic and
astigmatic corrections. The advantages of downup LASIK over the classic technique are
currently under investigation (67).
In 1999, the FDA approved the Summit Excimer Laser (Summit Technologies,
Waltham, Mass.) for use in LASIK (68).

F. LASIK VS. PRK

As the use of the excimer laser in refractive surgery increased, it became obvious that wide
area surface PRK was neither predictable nor accurate for the correction of more than 6
diopters of myopia (55). Thus, in the beginning, LASIK was suggested as a more precise
alternative for the correction of high myopia. To date, several clinical studies published in
peer-reviewed journals point out its advantages over PRK (6990). These include:
1. Early recovery of visual function
2. Minimal postoperative pain
3. Lack of adverse healing phenomena such as haze formation
4. Increased range of efficacy over PRK in high myopia, hyperopia, and astigmatism
5. The ability to combine with previous refractive surgery, such as PRK, PTK, or RK.
However, the technique has also well-recognized disadvantages and limitations. These in-
clude:
1. Expense and complexity of instrumentation
2. Lack of a standardized nomogram for tissue ablation
3. Steep learning curve and potentially sight-threatening complications for the be-
ginning surgeon
The refractive results of LASIK are far from optimum. A review of the current bibliogra-
phy on LASIK by Farah and coauthors suggests that LASIK is, up to now, the best proce-
dure to correct myopia greater than 6 D (91). It has acceptable visual outcomes and com-
plication rates. It also appears effective for lower levels of hyperopia below 6 D. Its role in
the treatment of low myopia and astigmatism remains to be investigated.
34 Pallikaris and Papadaki

G. FUTURE TRENDS
For the foreseeable future, LASIK should remain the surgical treatment of choice for low
and moderate refractive errors. The most serious alternative to LASIK may be the use of
phakic intraocular lenses for high and moderate myopia.
For LASIK to be the first-choice procedure in the correction of high ametropias, its
accuracy and postoperative quality of vision must improve to reach that of an IOL implan-
tation (93). Continuous evolution in the field of microkeratome and excimer laser technol-
ogy is the only way to achieve that goal.
Currently there is great interest in refining refractive surgery by identifying and re-
ducing optical aberrations that degrade the optical image and limit visual acuity potential
(94). Corneal topography guided ablations and wavefront technology are used to develop
customized laser ablation patterns in an effort to improve optical performance after pho-
toablation. The primary results of their application are encouraging (95, 96). Possibly, as
the use of customized ablation increases, we will be able to improve the best-corrected
visual acuity in many eyes.
It has been suggested recently that many variables play a role in the surgical effect
obtained after LASIK (91). Currently used nomograms are far from perfect, as they con-
sider only the depth and the diameter of the ablation zone. Improved nomograms that in-
corporate multiple variables are under development and will soon be available in clinical
practice. We hope that their application will increase the accuracy of the procedure.
One area of advancement in LASIK may also be the development of nonexcimer
lasers to cut corneal flaps, which could reduce or eliminate microkeratome-related compli-
cations.
Furthermore, intrastromal ablation with picolasers may eliminate the need for the mi-
crokeratome. Solid-state picosecond lasers are infrared lasers that can penetrate tissues
without being absorbed. Thus such lasers can theoretically achieve intrastromal ablation
without disturbing the overlying epithelium and Bowmans layer. Animal studies are by far
encouraging, but extensive investigation is required before picosecond laser intrastromal
ablation becomes an acceptable keratorefractive procedure (97).
Continuing evolution in the current techniques is the only way to approach the ultimate
goal, which should be to offer our patients better vision in terms of quality and quantity.

REFERENCES
1. JI Barraquer. Oueratoplastia refractiva. Estudios Inform 1949;10:221.
2. JI Barraquer. Keratomileusis. Int Surg 1967;48:103107.
3. JI Barraquer. Results of myopic keratomileusis. J Refract Surg 1987;3:98101.
4. H Littman. Optic of Barraquers keratomileusis. Arch Oftal Optom 1966;6:1.
5. JI Barraquer. Method for cutting lamellar grafts in frozen corneas: new orientations for refrac-
tive surgery. Arch Soc Am Ophthalmol 1958;1:237.
6. JI Barraquer. Keratomileusis for myopia and aphakia. Ophthalmology 1981;88:701708.
7. RC Troutman, CA Swinger. Refractive keratoplasty: keratophakia and keratomileusis. Trans
Am Ophthalmol Soc 1978;76:329339.
8. D Taylor, A Stern, K Romanchuck. Keratophakia: clinical evaluation. Ophthalmology 1981;
88:11411150.
9. MH Friedlander, TP Werblin, HE Kaufman. Clinical results of keratophakia and keratomileu-
sis. Ophthalmology 1981;88:716720.
10. JV Jester, MM Rodrigues, RA Villasenor, DJ Schanzlin. Keratophakia and keratomileusis:
histopathologic, ultrastructural and experimental studies. Ophthalmology 1984;91:793805.
History of LASIK 35

11. CA Swinger, BA Barker. Prospective evaluation of myopic keratomileusis. Ophthalmology

1984;91:785792.
12. LT Nordan, MK Fallor. Myopic keratomileusis: 74 consecutive nonamblyopic cases with one-
year follow-up. J Refract Surg 1986;2:124128.
13. LJ Maquire, SD Klyce, H Sawelson, MB McDonald, HE Kaufman. Visual distortion after my-
opic keratomileusis: computer analysis of keratoscope photographs. Ophthalmic Surg
1987;18:352356.
14. LT Nordan. Keratomileusis. Int Ophthalmol Clin 1991;31:712.
15. C Barraquer, A Guitierrez, A Espinoza. Myopic keratomileusis: short term results. Refract
Corneal Surg 1989;5:307313.
16. HE Kaufman. The correction of aphakia. XXXVI Edward Jackson Memorial Lecture. Am J
Ophthalmol 1980;89:110.
17. TP Werblin, SD Klyce. Epikeratophakia: the correction of aphakia. I. Lathing of corneal tissue.
Curr Eye Res 19811982;1:591597.
18. JI Barraquer. Modification of refraction by means of intracorneal inclusions. Int Ophthalmol
Clin 1966;6:5378.
19. TP Werblin. Epikeratophakia: techniques, complications and clinical results. Int Ophthalmol
Clin 1983;23:4558.
20. TP Werblin, HE Kaufman, MH Friedlander, KL Sehon, MB McDonald, NS Granet. A prospec-
tive study of the use of hyperopic epikeratophakia grafts for the correction of aphakia in adults.
Ophthalmology 1981;88:11371140.
21. TP Werblin, JE Blaydes, HE Kaufman. Epikeratophkia: the correction of astigmatismpre-
liminary experimental results. CLAO J 1983;9:6163.
22. HE Kaufmann, TP Werblin. Epikeratophakia: a form of lamellar keratoplasty for the treatment
of keratoconus. Am J Ophthalmol 1982;93:342347.
23. MB McDonald, HE Kaufman, JV Aquavella, DS Durrie, DA Hiles, JD Hunkeler, RH Keates,
KS Morgan, DR Sanders. The nationwide study of epikeratophakia for aphakia in adults. Am J
Ophthalmol 1987;103:350365.
24. MB McDonald, HE Kaufman, JV Aquavella, DS Durrie, DA Hiles, JD Hunkeler, RH Keates,
KS Morgan, DR Sanders. The nationwide study of epikeratophakia for myopia in adults. Am J
Ophthalmol 1987;103:375383.
25. JJ Reidy, MB McDonald, SD Klyce. The corneal topography of epikeratophakia. Refract
Corneal Surg 1990;6:2631.
26. DR Wilson, AH Keeney. Corrective measures for myopia. Surv Ophthalmol 1990;34:294
304.
27. JD Goosey, TC Prager, CB Goosey, ME Allison, TL Marvelli. Stability of refraction during two
years after myopic epikeratoplasty. Refract Corneal Surg 1990;6:48.
28. MH Friedlander, LF Rich, TP Werblin, HE Kaufman, N Granet. Keratophakia using preserved
lenticles. Ophthalmology 1980;87:687692.
29. JD Goosey, TC Prager, TL Marvelli, ME Allison, SR Hook, KA Carlson. Epikeratophakia
without annular keratectomy. Ann Ophthalmol 1987;19:388391.
30. SG Slade, GH Strauss. Use of tissue adhesive (Tisseel) in epikeratophakia. Invest Ophthalmol
Vis Sci 1990;31:30.
31. EY Zavala, J Krumeich, PS Binder. Laboratory evaluation of freeze vs. non freeze lamellar re-
fractive keratoplasty. Arch Ophthalmol 1987;105:11251128.
32. J Altmann, G Grabner, W Husinsky, S Mitterer, I Baumgartner, F Skorpik, T Asenbauer.
Corneal lathing using the excimer laser and a computer-controlled positioning system. Part I
lathing of epikeratoplasty lenticles. Refract Corneal Surg 1991;7:377384.
33. L Buratto, M Ferrari. Retrospective comparison of freeze and non-freeze myopic Epiker-
atophakia. Refract Corneal Surg 1989;5:9497.
34. American Academy of Ophthalmology. Ophthalmic procedure assessment: epikeratoplasty.
Ophthalmology 1996;103(6):983988.
36 Pallikaris and Papadaki

35. CA Swinger, J Krumeich, D Cassiday. Planar lamellar refractive keratoplasty. J Refract Surg
1986;2:1724.
36. J Colin, F Mimouni, A Robinet. The surgical treatment of high myopia: comparison of epiker-
atoplasty, keratomileusis and minus power anterior chamber lenses. Refract Corneal Surg
1990;6:245251.
37. L Ruiz, J Rowsey. In situ keratomileusis. Invest Ophthalmol Vis Sci 1988;29(suppl):392.
38. E Arenas-Archila, JC Sanchez-Thorin, JP Naranjo-Uribe, A Hernandez-Lozano. Myopic ker-
atomileusis in situ: a preliminary report. J Cataract Refract Surg 1991;17:424435.
39. M Bas, H Nano. In situ keratomileusisresults in 30 eyes at 15 months. Refract Corneal Surg
1991;7:223231.
40. L Bores. Lamellar refractive surgery. In: L Bores, ed. Refractive Eye Surgery. Boston: Black-
well, 1993, pp 324392.
41. RF Hofmann, SJ Bechara. An independent evaluation of second-generation suction microker-
atomes. Refract Corneal Surg 1992;8:348354.
42. JH Krummeich, CA Swinger. The planar non-freeze lamellar refractive keratoplasty tech-
niques. In: BF Boyd, ed. Highlights of Ophthalmology, 30th anniversary ed. Refractive Surgery
with the Masters. Coral Gables, FL, 1987, pp. 228.
43. SG Slade et al. Keratomileusis in situ: a prospective evaluation. Ophthalmology 1993;
100(suppl).
44. SG Slade, SA Updegraff. Complications of automated lamellar keratectomy (comment). Arch
Ophthalmol 1995;113(9):10921093.
45. S Trokel. History and mechanism of action of excimer laser corneal surgery. In: JJ Salz, ed.
Corneal Laser Surgery. St Louis: Mosby - Year Book, 1995, pp 17.
46. J Taboada, GW Mikesell, RD Reed. Response of corneal epithelium to KrF excimer laser
pulses. Health Phys 1981;40:677683.
47. J Taboada, CJ Archibald. An extreme sensitivity in the corneal epithelium to far UV ArF ex-
cimer laser pulses, Proceedings of the Scientific Program of the Aerospace Medical Associa-
tion, San Antonio, 1981.
48. R Srinivasan. Kinetics of the ablative photodecomposition of organic polymers in the far ultra-
violet (193 nm). J Vac Sci Technol Bull 1983;4:923926.
49. S Trockel, R Shrinivasan, B Braren. Excimer laser surgery of the cornea. Am J Ophthalmol
1983;94:125.
50. CR Munnerlyn, SJ Koons, J Marshall. Photorefractive keratectomy: a technique for laser re-
fractive surgery. J Cataract Refract Surg 1988;14:4652.
51. RR Krueger, SL Trokel, HD Schubert. Interaction of ultraviolet light with the cornea. Invest
Ophthalmol Vis Sci 1985;26:14551464.
52. SL Trokel. The cornea and ultraviolet laser light. Laser in der Ophthalmologie, Vol. 113.
Stuttgart: Bucherei des Augenarztes. Ferdinand Enke, 1988.
53. J Talamo. Excimer laser landmarks. In: J Talamo, RR Krueger, eds. The Excimer Manual. Lit-
tle, Brown. Boston, MA, 1997, p. xxv.
54. MB McDonald, HE Kaufman, JM Frantz, S Shofner, B Salmeron, SD Klyce. Excimer laser ab-
lation in a human eye. Arch Ophthalmol 1989;107:641642.
55. T Seiler, PJ Mc Donnell. Excimer laser photorefractive keratectomy. Surv Ophthalmol
1995;40(2):89118.
56. I Pallikaris, M Papatzanaki, EZ Stathi, O Frenschock, A Georgiadis. Laser in situ keratomileu-
sis. Lasers Surg Med 1990;10:463468.
57. N Pureskin. Weakening ocular refraction by means of partial stromectomy of the cornea under
experimental conditions. Vestn Oftalmol 1967;80:17.
58. I Pallikaris, M Papatzanaki, A Georgiadis, O Frenschock. A comparative study of neural re-
generation following corneal wounds induced by argon fluoride excimer laser and mechanical
methods. Lasers Light Ophthalmol 1990;3:8995.
59. G Peyman, C Beyer, J Kuszak, B Khoobehi, M Shahsavari, R Badaro. Long-term effect of er-
bium-YAG laser (2.9 m) on the primate cornea. Int Ophthalmol 1991;15:249258.
History of LASIK 37

60. L Buratto, M Ferrari, P Rama. Excimer laser intrastromal keratomileusis. Am J Ophthalmol

1992;113:291295.
61. IG Pallikaris, ME Papatzanaki, DS Siganos, MK Tsilimbaris. A corneal flap technique for laser
in situ keratomileusis. Arch Ophthalmol 1991;109(12):16991702.
62. IG Pallikaris, ME Papatzanaki, DS Siganos, MK Tsilimbaris. Tecnica de colajo corneal para la
queratomileusis in situ mediane laser. Estudios en humanos. Arch Ophthalmol (ed esp).
1992;3(3):127130.
63. DS Siganos, IG Pallikaris. Laser in situ keratomileusis in partially sighted eyes. Invest Oph-
thalmol Vis Sci 1993;34(4):800.
64. T Salah, G Waring, A El-Maghraby. Excimer laser keratomileusis. In: JJ Salz, ed. Corneal
Laser Surgery. St Louis: MosbyYear Book, 1995, pp. 187189.
65. IG Pallikaris, DS Siganos. Excimer laser in situ keratomileusis and photorefractive keratectomy
for the correction of high myopia. J Refract Corneal Surg 1994;10(15):498510.
66. IG Pallikaris, DS Siganos. Corneal flap technique for excimer laser in situ keratomileusis to cor-
rect moderate and high myopia: two-year follow-up. Best papers of sessions. ASCRS Sympo-
sium on Cataract, IOL and Refractive Surgery, 1994, pp. 917.
67. L Buratto, M Ferrari. Indications, techniques, results, limits and complications of laser in situ
keratomileusis. Curr Opin Ophthalmol 1997;8(4):5966.
68. [Link]
69. AM Bas, R Onnis. Excimer laser in situ keratomileusis for myopia. J Refract Surg 1995;
11(suppl):S229S233.
70. DC Fiander, F Tayfour. Excimer laser in situ keratomileusis in 124 myopic eyes. J Refract Surg
1995;11(suppl):S234238.
71. MC Knorz, A Liermann, H Steiner. Laser in situ keratomileusis to correct myopia of 6 to 29
diopters. J Refract Surg 1996;12:575584.
72. T Salah, GO Waring III, A El Maghraby, K Moadel, SB Grimm. Excimer laser in situ ker-
atomileusis under a corneal flap for myopia of 2 to 20 diopters. Am J Ophthalmol 1996;121:
143155.
73. JL Guell, A Muller. Laser in situ keratomileusis (LASIK) for myopia ranging from 7 to 18
diopters. J Refract Surg 1996;12:222228.
74. JJ Perez-Santonja, P Bellot Claramonte, MM Ismail, J Alio. Laser in situ keratomileusis to cor-
rect high myopia. J Cataract Refract Surg 1997;23:372385.
75. MA El Danasoury, GO Waring, A El Maghraby, K Mehrez. Excimer laser in situ keratomileu-
sis to correct compound myopic astigmatism. J Refract Surg 1997;13:511521.
76. A Marinho, MC Pinto, R Pinto, F Vaz, MC Neves. LASIK for high myopia: 1-year experience.
Ophth Surg Lasers 1996;27:S517S520.
77. JC Casebeer, GM Kezirian. Outcomes of spherocylinder treatments in the comprehensive re-
fractive surgery LASIK study. Semin Ophthalmol 1998;3(2):7178.
78. CJ Argento, MJ Cosentino. Laser in situ keratomileusis for hyperopia. J Cataract Refract Surg
1998;24(8):10501058.
79. JD Carr, RD Stulting, Y Sano, KP Thompson, W Wiley, GO Waring III. Prospective compari-
son of single-zone and multizone laser in situ keratomileusis for the correction of low myopia.
Ophthalmology 1998;105(8):15041511.
80. MC Knorz, B Wiesinger, A Liermann, V Seiberth, H Liesenhoff. Laser in situ keratomileusis for
moderate and high myopia and myopic astigmatism. Ophthalmology 199;105(5):932940.
81. JM Davidorf, R Zaldivar, S Oscherow. Results and complications of laser in situ keratomileu-
sis by experienced surgeons. J Refract Surg 1998;14(2):114122.
82. O Ibrahim. Laser in situ keratomileusis for hyperopia and hyperopic astigmatism. J Refract
Surg 1998;14(2 suppl):179182.
83. F Lavery. Laser in situ keratomileusis for myopia. J Refract Surg 1998;14(2 suppl):177178.
84. AS Chayet, R Magallanes, M Montes, S Chavez, N Robledo. Laser in situ keratomileusis for
simple myopic, mixed and simple hyperopic astigmatism. J Refract Surg 1998;14(2 suppl):
175176.
38 Pallikaris and Papadaki

85. A Maldonado-Bas, R Onnis. Results of laser in situ keratomileusis in different degrees of my-
opia. Ophthalmology 1998;105(4):606611.
86. S Goker, H Er, C Kahvecioglu. Laser in situ keratomileusis to correct hyperopia from
4.25 to

8.00 diopters. J Refract Surg 1998;14(1):2630.
87. R Zaldivar, JM Davidorf, S Oscherow. Laser in situ keratomileusis for myopia from 5.5 to
11.50 diopters with astigmatism. J Refract Surg 1998;14(1):1925.
88. DJ Salchow, ME Zirm, C Stieldorf, A Parisi. Laser in situ keratomileusis for myopia and my-
opic astigmatism. J Cataract Refract Surg 1998;24(2):175182.
89. RL Lindstrom, DR Hardten, YR Chu. Laser in situ keratomileusis (LASIK) for the treatment of
low, moderate, and high myopia. Trans Am Ophthalmol Soc 1997;95:285296; discussion
296306.
90. GO Waring III, JD Carr, RD Stulting, KP Thompson. Prospective, randomized comparison of
simultaneous and sequential bilateral LASIK for the correction of myopia. Trans Am Ophthal-
mol Soc 1997;95:271284.
91. SG Farah, DT Azar, C Gurdal, J Wong. Laser in situ keratomileusis: literature review of a de-
veloping technique. J Cataract Refract Surg 1998;24(7):9891006.
92. LJ Maguire. Topographical principles in keratorefractive surgery. Int Ophthalmol Clin 1991;
31:16.
93. JT Holladay, TC Prager, RS Ruiz, JW Lewis, H Rosenthal. Improving the predictability of in-
traocular lens power calculations. Arch Ophthalmol 1986;104:539541.
94. SM MacRae. Supernormal vision, hypervision, and customized corneal ablation. J Cataract Re-
fract Surg 2000;26(2):154157.
95. G Alessio, F Boscia, MG La Tegola, C Sborgia. Topography-driven photorefractive keratec-
tomy: results of corneal interactive programmed topographic ablation software. Ophthalmology
2000;107(8):15781587.
96. M Mrochen, M Kaemmerer, T Seiler. Wavefront-guided laser in situ keratomileusis: early re-
sults in three eyes. J Refract Surg 2000;16(2):116121.
97. M Ito, AJ Quantock, S Malhan, DJ Schanzlin, RR Krueger. Picosecond laser in situ ker-
atomileusis with a 1053-nm Nd:YLF laser. J Refract Surg 1996;12:721728.
 3
Lasers in LASIK
Basic Aspects

RODRIGO TORRES
Massachusetts Eye and Ear Infirmary and Harvard Medical School,
Boston, Massachusetts, U.S.A.
ROBERT T. ANG
Massachusetts Eye and Ear Infirmary and Harvard Medical School,
Boston, Massachusetts, U.S.A., and Asian Eye Institute, Makati, The Philippines
DIMITRI T. AZAR
Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute,
and Harvard Medical School, Boston, Massachusetts, U.S.A.

A. BASIC LASER PHYSICS

1. Definitions
Irradiance, mJ/cm2. Energy/surface area. A measurement of the amount of light en-
ergy striking a given surface area. Conceptually it is the energy density transferred
onto a surface from a laser pulse. Irradiance is a useful term, frequently correlated
with corneal ablation rate in refractive surgery.
Fluence, mJ/cm3. Energy/volume. Often confused with irradiance. In refractive
surgery, fluence is not usually used to describe a laser. When fluence is mentioned,
irradiance is often what is truly implied.
Energy, joule (J). Kgm2/s2. Also measured in electron volts (eV). A force through a
distance, or work. Energy is what is required for breaking chemical bonds.
Power, watt (W). J/s. Kgm2/s3. Energy/time. The rate at which energy is delivered.
Intensity, Watt/surface Area. W/cm2. Power density along a surface.
Homogeneity, the distribution of energy within the cross section of a laser beam. If a
39
40 Torres et al.

beam is perfectly homogeneous, the distribution of energy within the beam is uni-
form.
Coherence, monochromatic light waves perfectly in phase and parallel.
femtosecond, 1015 seconds; picosecond, 1012 seconds; nanosecond, 10-9 seconds.

2. Brief History of Lasers

Laser technology is just over forty years old. The theory of visible frequency lasers was first
proposed by Schawlow and Townes in 1958 when they expanded upon an existing theory
of microwave masers (1). In 1960, Maiman demonstrated the first experimental laser, a
ruby crystal laser powered by a flashlamp (2). Since then, laser technology has grown ex-
ponentially.
The word laser comes from the acronym LASER, standing for light amplification by
stimulated emission of radiation. The theory of stimulated emission is central to the gener-
ation of the laser beam. With stimulated emission, when a photon interacts with an excited
atom capable of emitting an identical photon, the atom is stimulated to emit the photon so
that it goes in the same direction and perfectly in phase with the incident photon. In this
fashion, order is introduced to the normally chaotic process of electromagnetic emission. If
enough of these coherent photons are recruited from the excited atoms, a beam of
monochromatic, unidirectional, and in-phase photons is produced.

3. Laser Properties Relevant to Photorefractive Surgery

a. Frequency
The frequency of light determines where it falls within the electromagnetic spectrum
(Fig. 3.1). The frequency of laser light determines what molecules or atoms are able to

Figure 3.1 The electromagnetic spectrum. The 193 nm argon fluoride (ArF) excimer laser falls in
the ultraviolet portion of the spectrum. (From Ref. 62.) [Color in original.]
Lasers in LASIK 41

Figure 3.2 The argon fluoride excimer laser demonstrates high absorption and low penetration
properties within the corneal surface. (From Ref. 63.)

absorb the radiant energy (Fig. 3.2). Other atoms are simply unaffected by the photons and
let them pass by. By manipulating the frequency of light, we can choose whether we want
the energy to affect water or biological tissue. Effectively, we can pick our molecular
targets.
Lasers used in LASIK utilize ultraviolet wavelengths around 200 nm (0.2 m),
falling in the UV-C range of the spectrum. The dominant chromophore in cornea for the
193 nm and 213 nm wavelengths within this range is the peptide bond linking adjacent
amino acids in collagen (3). Photons at these wavelengths carry in the range of 6.4 eV of
energy each, an amount exceeding that in typical peptide bonds. The bonds are broken by
the photon interaction. Ideally this process occurs with very little thermal generation, be-
cause the energy is used primarily in breaking bonds. The resulting fragments occupy a
greater volume than the single polymer from which they originated and are imparted some
kinetic energy from the irradiation. Both of these factors contribute to supersonic ejection
of the material from the corneal surface (4,5). This process has been referred to as photo-
chemical ablation, ablative photodecomposition (6), and photoablation (79). The choice
of frequency determines whether photovaporization, photothermal shrinkage, or photo-
chemical ablation occurs.
b. Homogeneity
A uniform distribution of energy in the beam cross section is termed beam homogeneity.
Because no laser leaves the resonator with a uniform distribution, it is important to charac-
terize the beam homogeneity. In the absence of homogeneity, ablation rates are expected to
vary over the treatment zone, resulting in irregular tissue removal (10). Prior to beam ma-
nipulation, a gaussian distribution for the excimer laser is expected. With gaussian beam
profiles, central overcorrection and peripheral undercorrection within the ablation zone
have been reported (1113). These distortions have been associated with the use of small
ablation diameters and a nonuniform gaussian beam profile which is hotter centrally
(12,14).
42 Torres et al.

c. Irradiance
Irradiance is central to studies of ablative threshold and ablative rate. The photoablative
threshold at 193 nm wavelength is a minimum irradiance of 50 mJ/cm2. At values lower
than this, appreciable ablation is not observed.
Photoablative rate is also a function of the irradiance. The relationship between ab-
lation rate and irradiance differs for different electromagnetic wavelengths. At 193 nm, the
photoablative rate increases appreciably as the irradiance increases from 50 mJ/cm2 (the
photoablative threshold) to 150 mJ/cm2; at irradiances greater than 150 mJ/cm2, the pho-
toablative rate tends to plateau for this wavelength (15). At 249 nm, however, the pho-
toablative rate does not plateau but continues to increase logarithmically as the irradiance
increases (Fig. 3.3).
The relationship between ablation rate and irradiance is important in refractive
surgery. Because there is significant pulse-to-pulse variation in irradiance, the ablation rate
must be fairly consistent despite this variability. The ablation rate to irradiance curve for
the 193 nm wavelength is favorable because this curve plateaus at an irradiance of 150
mJ/cm2.
Another important property related to ablation rate is ablation efficiency, which is the
ablation rate divided by the irradiance. Maximizing ablation efficiency minimizes excess
energy, which would otherwise contribute to shock waves, photochemical effects, and
heating of sites local and distant to irradiation (16). The 160180 mJ/cm2 irradiance range
is efficient for corneal ablation. At this range, ablation rates of 0.210.27 m per pulse for
the VISX laser and 0.26 m per pulse for the Summit laser have been confirmed (17).
d. Intensity
Irradiance is a measure of the amount of energy imparted onto a surface area, and intensity
is a measure of the rate at which energy is imparted onto a surface area. Imparting energy
at a rate greater than the rate at which it is absorbed by photoablation results in heating of

Figure 3.3 At irradiances greater than 150 mJ/cm2, the curve plateaus for the 193 nm wavelength.
The ablation rate remains fairly consistent despite a variability in irradiance. (From Ref. 15.)
Lasers in LASIK 43

collateral tissue. This heating can result in energy transduction into corneal surface shock
waves, an undesirable outcome.

B. APPROACHES TO ABLATIVE DECOMPOSITION

Currently there are three approaches to refractive photoablative decomposition: scanning
slit, wide area (broad beam), and flying spot (Fig. 3.4). A large diameter allows for the sim-
pler wide area ablation approach, while smaller diameters rely on the scanning slit and fly-
ing spot approaches.

1. Wide Area (Broad Beam) Ablation

The wide area ablation method requires the use of a large-diameter beam and allows for si-
multaneous treatment of the entire operating field in a pulsatile fashion. By using di-
aphragms, a certain area of the operating field can be shielded from laser ablation, allow-
ing for control of myopic and astigmatic correction patterns of ablation when using the
wide area approach. This method has been in use longer than the other two and has gener-
ated the most clinical data.
Advantages of wide area ablation include a short operating time (often less than 30
seconds for low myopic photorefractive keratectomy), obviating the need for eye tracking.
Also, because the entire treatment area is ablated simultaneously, there is no need for so-
phisticated scanning technology. Only a computer-controlled variable iris diaphragm is
needed, which is simple to operate for the treatment of myopia and astigmatism.
Disadvantages of wide area ablation center on the need to produce a stable, homoge-
neous gaussian beam of large (about 6 mm) diameter in order to cover as much of the
optic zone (treatable area) as possible. This requires the use of an excimer laser head be-
cause, to date, solid-state lasers cannot achieve ablative thresholds with homogeneous gaus-
sian beams at such a large diameter (18). Excimer laser heads are large and bulky and use
argon fluoride (ArF) gas, a toxic gas combination that introduces the risk of exposure. Fur-
thermore, maintaining beam uniformity and homogeneity at such large beam diameters ne-
cessitates higher energy outputs, which translates to higher cost of operation. Greater acous-
tic shock waves are associated with the higher energy output. Higher energy output also puts
increased strain on laser optics, increasing optical maintenance needs. Correction of hyper-
opia with the wide area approach has been technically challenging. Asymmetric astigma-
tisms cannot be corrected. Wide field ablation has also been known to carry some risk of
steep central islands, in contrast to scanning slit and flying spot approaches.
Models available utilizing the wide field ablation approach include the VISX Star S2,
Summit Apex Plus, Apex/OmniMed, and ExciMed; the Chiron-Technolas Keracor 116;
and the Coherent-Schwind Keratom.

2. Scanning Slit Ablation

Scanning slit ablation uses a rectangular beam of light that is passed unidirectionally over
the face of the cornea as laser pulses are passed through a slit-shaped diaphragm. In this
fashion, a uniform layer of tissue can be removed from the cornea over the course of sev-
eral pulses and slit positions. This is in contrast to the wide area ablation, which can treat
the entire optical zone with each pulse.
Advantages of the scanning slit approach result from the fact that the beam energy
does not have to be distributed over the entire treated area with each pulse. Specifically, the
44 Torres et al.

Figure 3.4 The three approaches to excimer laser photoablation. (a) Scanning slit. (b) Large or
broad beam. (c) Flying spot. (From Ref. 64.)
Lasers in LASIK 45

smaller beam allows for ablation to occur at energy outputs less than those required for
wide field ablation. Reduced acoustic shock waves and smoother ablative surfaces are pos-
sible compared with wide area ablation. Beam uniformity and homogeneity are much im-
proved because of the smaller beam cross section. The incidence of steep central islands is
much lower using the scanning slit approach. In contrast to wide area ablation, there are no
optical zone (the size of the treated area) limitations for photorefractive keratectomy (PRK)
or phototherapeutic keratectomy (PTK) with the scanning slit approach.
Disadvantages of the scanning slit technique include increased dependence upon
complicated scanning systems and a longer operating time, compared with wide field ab-
lation. Consequently, eye tracking and fixation become a concern with the scanning slit.
Some systems using this approach include the Nidek EC-5000 and the Meditec MEL
60.

3. Flying Spot Ablation

This approach utilizes a tightly focused beam to ablate very small areas of the cornea at a
time. The small beam is redirected with x and y axis mirrors. Unlike the scanning slit ap-
proach, which requires scanning across the cornea in one direction, the flying spot is very
versatile and can be maneuvered in multiple directions.
The small focal area of the flying spot permits ablation at lower energy outputs.
This allows for smaller laser cavity size and reduced need for maintenance. Acoustic
shock waves are reduced by lower energy outputs. Homogeneity requirements are less
stringent, and fewer optics are needed for flying spot ablation. Spot placement is versa-
tile, allowing for complicated sculpting of the cornea. This allows custom-designed pat-
terns, permitting treatment of asymmetric astigmatism. Hyperopic correction is facilitated
by this approach owing to the ease of creating peripheral annular ablation patterns. As
with the scanning slit approach, there are no optical zone limitations for PRK or PTK.
Another advantage of the flying spot approach is the flexibility in laser heads. Because a
wide area beam is not necessary for ablation, it is possible to achieve ablation using solid-
state laser heads. This offers the option of avoiding the risk of toxic gas exposure asso-
ciated with excimer gas lasers.
Disadvantages associated with the flying spot approach include a longer operating
time and consequently the need for a sophisticated eye-tracking device, in addition to the
need for laser delivery (scanning) capability. Longer operating time also results in varia-
tions of corneal hydration, which has deleterious effects on surgical results.
Overall, flying spot technology is young but shows great promise for the future in that
it allows for precise sculpting of the cornea. If current disadvantages can be minimized with
technological advances, this may become the approach of choice.
Some of the flying spot lasers include the Bausch & Lomb Chiron Technolas 217,
LaserSight Compak-200 Mini-Excimer Laser, Alcon Autonomous T-PRK and LadarVi-
sion 4000, and Novatec LightBlade (a solid-state laser).

C. TYPES OF LASER HEADS IN LASIK AND PRK

Laser heads can come in solid, liquid and gas phases. Liquid lasers have no immediate ap-
plication to photorefractive refractive surgery. Gas lasers investigated for refractive surgery
include the CO2 and the excimer lasers, the latter being the most useful for refractive
surgery.
46 Torres et al.

1. Gas LasersExcimer Lasers

Excimer lasers, developed for their ability to produce ultraviolet laser frequencies, are a
subclass of the gas laser heads. In 1975, excited xenon (Xe) atoms and halogen gas mix-
tures were found to emit ultraviolet radiation following the dissociation of an unstable
xenon halide intermediary. By 1976, this type of interaction was noted with XeF, XeCl,
XeBr, krypton fluoride (KrF), and (ArF) (1922). The word excimer is a contraction of ex-
cited dimer. Strictly speaking, a dimer is formed by two atoms of the same element. Be-
cause it was first thought that the intermediary structure for the excited state of these laser
heads involved the formation of dimers (two atoms of the same element bound together),
the term excimer was applied to these laser types. Now it is recognized that the activated
intermediary is a rare gas halide, not a dimer. The name grew popular, however, and is uni-
versally accepted.
The ArF excimer laser has a wavelength of 193 nm, which imparts an energy of 6.4
eV per photon. This photon energy is adequate to break covalent bonds through the process
of ablative decomposition. Krueger and colleagues compared the tissue effects of the ArF,
KrF, XeF, and XeCl lasers and found that the 193 nm ArF wavelength provided for
smoother results, more precise ablation, and decreased thermal damage to adjacent tissue
(23). For these reasons the excimer ArF laser is the laser of choice for LASIK and PRK.

a. Safety of ArF Excimer Lasers

Mutagenicity of the 193 nm wavelength. Some frequencies of ultraviolet light carry muta-
genic potential. Cyclobutyl pyrimidine dimers in DNA have been produced by irradiation
with wavelengths under 280 nm, making the question of mutagenicity of excimer radiation
a valid one (24). Results of a number of experimental studies have demonstrated that 193
nm radiation does not cause cytotoxic damage to DNA and mutagenicity (2529).
In human skin, 193 nm ArF excimer radiation has led to no unscheduled DNA syn-
thesis activity, in contrast to 248 nm KrF irradiation, which does induce such activity (30).
Unscheduled DNA synthesis activity can be suggestive of activated excision repair mech-
anisms, commonly considered the most important mechanisms for removing damaged
DNA. In comparison with the 248 and 254 nm wavelengths, the 193 nm wavelength results
in little damage to DNA, and damage in 193 nm irradiated cornea is comparable to that in
unirradiated cornea (26). It has been suggested that the potential for cataractogenicity is
also very low, following the calculation of a very small lens exposure to excimer-induced
ultraviolet fluorescence (31).
An explanation for the sparing of DNA damage by the 193 nm wavelength as op-
posed to other far-UV wavelengths lies in the high absorption of this wavelength by cyto-
plasm. A corneal epithelial cell has 1.53.0 m of cytoplasm between the cell wall and the
nucleus (27). After traveling through 1 m of cytoplasm, 90% of the 193 nm radiation is
absorbed, effectively shielding the nucleus from damage. Speculation of secondary UV ex-
posure is not of great concern because this level of exposure is 10,000 times lower than the
annual exposure to solar UV radiation (32).
Collateral damage by 193 nm wavelength ablative decomposition. Because the
193 nm wavelength is such an accurate tool for photoablation, collateral damage is medi-
ated through indirect effects of the lasertissue interaction. Shock waves, particulate ejec-
tion, and surface heating are the primary concerns in efforts to minimize collateral damage.
Shock waves result from high-pressure, high-temperature, expanding gas clouds
above the surface of the cornea. They are estimated to travel at about 1 km/s, with varia-
Lasers in LASIK 47

tions in velocity dependent on the energy of ablation and the wavelength of the radiation.
Pressures of up to 100 atmospheres can be generated, making corneal damage possible
from shock waves. Thermal denaturation of surface collagen can result in pseudomem-
brane formation, currently considered a local protective effect (33). Structural changes be-
neath the corneal surface following ablation include stromal vacuoles and an increased
number of keratocytes in later stages of wound healing (34).
Particulate ejection occurs as ablative decomposition renders polymers into multiple
heated polymeric fragments that occupy a larger volume (Fig. 3.5). This forces particles
into the air in a supersonic expanding plume (35) (Fig. 3.6). Particles in the plume include
H2O radicals, simple carbons, hydrocarbons, and some alkanes (36,37). The plume ejection
results in a recoil surface wave that travels at several meters per second, although as yet this
wave has not been demonstrated to induce corneal injury (38).
Corneal surface heating occurs secondary to ablative decomposition. Theoretically,
ablative decomposition channels energy into breaking peptide bonds and not into heat, but
the average corneal temperature has been observed to increase by 20C during ablation
(39). In theory, this increase in temperature could induce keratocyte injury.
Accuracy of the 193 nm excimer beam ablation. The 193 nm wavelength has subcel-
lular levels of accuracy for photoablative decomposition. Typical ablation rates are
0.210.27 m per pulse, which translates to roughly one twenty-eighth of the diameter of

Figure 3.5 As laser energy is absorbed (a) peptide bonds are broken (b), resulting in increase in
volume and subsequent ejection of particles (c). (From Ref. 7.)
48 Torres et al.

Figure 3.6 During excimer laser ablation of the cornea, the ejection of particles into the air is vis-
ible as an expanding plume. (From Ref. 35.)

a red blood cell (7 m) of ablation per pulse. In a dramatic demonstration of the precision
of the excimer laser, Srinivasan in 1983 used the ArF excimer to create grooves in a human
hair strand (Fig. 3.7). Light microscopy of ablated areas show clean edges with no de-
tectable traces of cellular injury other than in pale-staining cytoplasm of cells bordering the
ablation.
One feature of this subcellular ablation is the formation of a pseudomembrane, which
can be about 100 nm thick and is present at the ablation site. There is no cell membrane at
this site, but the pseudomembrane is thought to provide a barrier to the passage of water as
well as possibly provide a scaffolding for wound reepithelialization. On electron mi-
croscopy the pseudomembrane appears as a condensation of electron-dense material (40).

Figure 3.7 The clean, sharp edges of the grooves created by the excimer laser on a human hair
demonstrate the accuracy and precision of the laser. (From Ref. 5.)
Lasers in LASIK 49

Not all corneas form pseudomembranes. It is not known what causes pseudomembrane for-
mation, but the thermal effect and the uncoupling of organic double bonds during pho-
toablation have been proposed as contributing to the phenomenon (41).
The 193 nm wavelength has the useful property of a relatively constant ablative rate
at irradiances near the commonly used values of 160180 mJ/cm2. Because of this plateau,
pulse-to-pulse variability in irradiance does not drastically affect the ablative rate, allow-
ing for predictable ablative depths.
b. Other Advantages of the Excimer: Strong Beams with Large
Diameters
An important advantage of the excimer ArF laser is the ability to produce a homogeneous,
large-diameter beam (~6 mm), at ablative irradiances, capable of treating the entire optical
zone simultaneously. This was especially important earlier in photorefractive surgery when
eye tracking, eye fixation, and beam scanning made scanning slit and flying spot technolo-
gies more challenging to develop. As these technologies improve, reliance on large beam
diameters may diminish, opening the door to nonexcimer laser types that initially were im-
practical for refractive purposes.
c. Disadvantages of Excimer Systems
Nonexcimer laser systems are desirable in the future owing to the several potential disadvan-
tages of excimer laser systems. One disadvantage is the risk of toxic gas exposure. The gases
are consumed by laser utilization and must be changed frequently, increasing the risk. The
large size of the laser head and high energy requirements are also undesirable. Optics for
beam homogenization can be complex and require frequent replacement. Finally, because the
193 nm wavelength is absorbed so avidly by cornea, the laser does not allow for intrastromal
refractive surgery. This necessitates mechanical flap lifting for LASIK. Although there is cur-
rently no widely used alternatives to this approach for keratomileusis, in the future it would
be desirable to minimize the invasiveness of the procedure with intrastromal keratomileusis.

2. Solid-State Lasers
Although the excimer gas lasers have made by far the most important contribution to
photorefractive surgery, some solid-state lasers are showing promise for use in this capac-
ity. Keeping in mind that the goal for refractive surgery is to change the shape of the cornea
with precision and little collateral damage, it is important to remember that ablative
decomposition is only one way to attain this goal. Any tissue-altering modality (photodis-
ruption, photovaporization, collagen shrinking, photospallation) that alters tissue struc-
ture in a precise, localized, and predictable fashion has potential as a tool for refractive
surgery.
a. Wavelength-Modulated Nd:YAG and Nd:YLF Lasers
The Nd:YAG and Nd:YLF lasers are infrared solid-state lasers. The active media are the
neodymium-doped crystals of either yttrium-aluminum-garnet or yttrium-lithium-fluoride.
The Nd:YAG and Nd:YLF lasers have fundamental wavelengths of 1064 nm and 1053 nm,
respectively. When raised to the fifth harmonic, the wavelengths become 213 nm and 211
nm, respectively. These are very close to the 193 nm ArF excimer wavelength, suggesting
that these lasers may be suitable for photoablative decomposition. Histological studies
show that the damage zone created by the 213 nm Nd:YAG laser is less than 1 m, which
50 Torres et al.

is similar to the results with the ArF laser (42). Furthermore, PRK with the 213 nm laser
produces smooth surfaces and transitions, with a reepithelialization rate and histopatho-
logical findings similar to the results with the 193 nm excimer laser PRK in rabbit studies
(43). This evidence supports the possibility that 213 nm photoablative decomposition is
feasible and safe.
b. Mutagenicity of the 213 nm Wavelength
The question of mutagenicity at the 213 nm wavelength has been addressed by in vitro stud-
ies (44). These studies measured free radical production in bovine corneas and in vitro bac-
terial survival following 193 and 213 nm irradiation at subablative irradiances. Evidence
suggests that free radical production and species were identical for the two lasers, but the
213 nm wavelength clearly demonstrated increased bacterial cytotoxicity. If the differences
in cytotoxicity apply to mammalian cells, corneal fibroblasts responsible for collagen re-
pair would be much more affected by 213 nm irradiation (45). In vivo studies in rabbits do
not provide clear evidence as to the safety of the 213 nm wavelength in PRK. In one study,
the 213 nm radiation was found comparable to the 193 nm radiation (43), but in another
study, the results were significantly worse at 213 nm (46). Increased postoperative compli-
cations observed in the latter study could be partially explained if the 213 nm wavelength
were cytotoxic to mammalian keratocytes. More studies on the mutagenicity of the 213 nm
wavelength will be an interesting area of future work.
In summary, the frequency-quintupled solid-state lasers do show promise as tools for
refractive surgery. A solid-state laser on the market functioning at the 211 to 213 nm wave-
length range is the Novatec Lightblade flying spot laser. Although these lasers are not
as energy efficient as excimers, they show comparable ablative efficiency. As energy
efficiencies of these systems improve, they may become available as wide-area ablation
lasers, which would decrease operative time, improve intraoperative corneal hydration, and
possibly produce superior surgical results. Also, as flying spot and eye tracking technology
develop further, low-energy, small-beam solid-state lasers can also be expected to produce
superior results. Although not as clinically developed, solid-state lasers have several ad-
vantages over the excimers. The frequency-quintupled Nd:YAG laser is less expensive and
more compact than the ArF laser and does not require the use of toxic gases. Furthermore,
solid-state lasers can provide increased reliability, robustness of design, safety, and lower
operating costs than gas or dye lasers.
c. Nd:Glass (Femtosecond) Lasers
The Nd:glass lasers have been investigated for their ability to generate femtosecond pulses.
The technology for such generation has only recently become feasible. Because these
pulses provide a much higher power output and a much shorter exposure time, they require
only one-fourth to one-tenth the energy to produce corneal photodisruption compared with
picosecond and nanosecond infrared laser pulses (47,48). By utilizing less radiant energy,
the secondary shock wave and cavitation bubble size are reduced, allowing for closer pack-
ing of laser pulses and more contiguous photodisruption.
In a study using femtosecond pulses from a Nd:glass laser to produce an intrastromal
spiral ablation in porcine and primate cadaver eyes, the pulses were focused 150200 m
below the surface epithelium of the cornea and scanned in a spiral pattern to create a plane
(49). The plane was extended to the surface to create a flap, and mechanical tissue plane
separation was used to grade the contiguity of the intrastromal ablation. The results indi-
cated that many of the shortcomings of picosecond technology (including incomplete tis-
Lasers in LASIK 51

sue cutting, poor dissection, and surface quality) are significantly improved when the pulse
duration is further reduced into the femtosecond region. The femtosecond pulses allow for
very small cavitation bubbles, approximately 12 m, which in turn allow for closer place-
ment of pulses and smoother tissue dissection (47). Although results are encouraging, in
vivo systems that closely reproduce the clinical situation must be investigated to establish
clinical efficacy. An in vivo study in rabbits concluded that intrastromal photodisruption
with femtosecond lasers produced consistent changes in corneal thickness without loss of
corneal transparency (50). The study did not evaluate changes in corneal topography or
specular microscopy, although no damage to the corneal endothelium was seen on histo-
logic sections. This laser is now being used to create LASIK flaps in patients undergoing
LASIK surgery with good results.
Advances in ultrafast laser design and the development of powerful laser diodes have
finally made low-cost, reliable, diode-pumped, femtosecond laser systems possible (51).
Femtosecond lasers are solid-state, enjoying all of the advantages of solid-state lasers over
excimer lasers. Because infrared radiation is transmitted by corneal tissue (unlike excimer
193 nm radiation), infrared femtosecond lasers could allow for intrastromal refractive
surgery that obviates the need for mechanical flap creation or epithelial disruption (50). It
will be exciting to follow the advances in femtosecond laser technology and the applica-
tions it offers for corneal flap cutting, laser keratomileusis, corneal implant placement, and
possible intrastromal keratectomy.

D. CALIBRATION AND ABLATION WITH THE EXCIMER LASER

SYSTEMS
1. Causes of Beam Degradation
Excimer laser systems are high-maintenance systems that require frequent calibration
to ensure high performance. Unlike other ophthalmic lasers, there is no modification of
the laser energy based on any clinical indication of tissue response to ablation. This
feature makes preoperative calibration an essential step in photorefractive surgery with the
excimer (52).
a. Optics Degradation
Optics degradation is a natural consequence of laser energy interaction with the lens and
mirror coatings. This leads to deterioration of beam quality and irradiance. Beam quality
can be decreased by a reduction in beam homogeneity. A beam that loses its homogeneity
is no longer an ideal surgical tool. Hot spots within the beam reduce ablation surface
smoothness and can lead to poor refractive outcomes. Because broad beam systems have
large beam diameters and high energy requirements to maintain beam homogeneity, their
optical components can degrade fairly quickly. Furthermore, broad beam systems rely on
complex optics (compared with scanning systems). On the other hand, scanning systems
must use far more pulses to ablate a corneal surface than the broad beam lasers, which taxes
the optics of the scanning systems. For these reasons, it is important to monitor the condi-
tion of optics with both broad beam and scanning systems.
b. Gas Impurities
Laser action releases contaminants into the laser head cavity. The fluorine gas reacts with
contaminants within the laser cavity, further contaminating the cavity and reducing the
52 Torres et al.

availability of fluorine for stimulated emission. This reduces laser action. To maintain pu-
rity, the gas must be either constantly cleaned or frequently replaced. Cleansing of the gas
involves precipitation of contaminants using a cryogenic device and liquid nitrogen. Alter-
natively, the chamber can be cleansed by flushing it with fresh gas to replace the contami-
nated gas. Improvements in laser construction have reduced the need for cryogenic gas pu-
rification and prolonged the lifetime of a single gas fill (6).

2. Calibration Techniques
It is important to check the laser ablation rate prior to surgery because if the output is too
high, overcorrection is likely. If the output is compromised, undercorrection is a risk. This
checking process is referred to as calibration. Calibration methods are generally based on
measurement of energy (energy models) or measurement of ablation (ablation models). En-
ergy models use direct measurement of the energy output of the laser with meters, which is
accurate only within 15% due to the extraordinarily high output of lasers (53). Further-
more, calibration of these meters requires sophisticated equipment that is difficult to use
routinely in the field. For these reasons, the ablation models (ablation of Wratten filters,
PMMA blanks, scanning profilometry) are used most frequently.
One approach to calibration involves ablation of a piece of plastic, forming a lens.
The plastic used is PMMA, or polymethyl methacrylate, the plastic used for contact lenses.
The power of the formed lens can be tested with a lensometer to assess laser irradiance,
laser alignment, and laser beam profile. Distortions of the lens can indicate poor laser light
distribution within the beam (6). Another approach to calibration involves counting the
number of pulses necessary to perforate a plastic Wratten filter. This approach can be mod-
ified to ablate only 90% of the thickness of the plastic. The quality of light transmission
through the plastic can be grossly assessed for uniformity.
The VISX laser is calibrated based on preoperative ablations performed on a PMMA
block. Then the laser is reprogrammed to adjust the ablation rate to the desired value. The
Summit laser can be checked by doing a 90% gelatin film ablation. The Chiron-Technolas
laser is reprogrammed after counting the number of pulses needed to perforate a special
foil. The Coherent-Schwind laser also uses a gelatin film for calibration, with reprogram-
ming based on the number of pulses required for 1090% perforation of the film. The
LaserSight laser uses a patented device, ex-calibur, which employs commercially available
corneal topography systems (54).
Broad beam excimer laser ablations are usually characterized by a relatively uniform
distribution of surface power within the treated zone (55). Nonetheless, the hypothesis that
corneal stromal ablation shape exactly matches the laser beam profile has been shown to be
invalid (56). Rather, in uniform beams the ablation rate varies with the ablation diameter.
This fact must be taken into account when attempting to calibrate by an energy model ap-
proach. Failure to correct for this variance can lead to central undercorrections and periph-
eral overcorrections, a phenomenon termed steep central islands. The underlying causes for
spatially variable ablation rates across a uniform beam are unclear but may include differ-
ential hydration of the cornea, redeposition of ablated material as it lifts from the surface,
photospallation effects, dependence upon proximity to an unablated area, and persistent ab-
lation fog overlying the stromal surface.
Modifying the ablation algorithm to accommodate the spatial variance of corneal ab-
lation has produced spherical enucleated eye PRK ablations. By analyzing the postopera-
tive topography of PRK patients, the ablation algorithm was modified to produce a more
spherical ablation in situ (56).
Lasers in LASIK 53

E. LASERS IN EYE TRACKING SYSTEMS FOR LASIK, LASEK, AND

PRK
Eye tracking is of fundamental importance to the various ablation approaches because it al-
lows for superior control of the surgical field. By tracking eye motion, the laser path can be
redirected to ablate the desired portions of the cornea, regardless of involuntary saccades.
This is especially important for the flying spot approach, where the beam is focused to ab-
late only a very small portion of the cornea at a time and where ablation of the entire cornea
can take several minutes. Eye tracking is also especially important for complex asymmet-
rical ablation patterns, where each cornea can be custom-corrected based on regional ir-
regularities as opposed to gross topographic irregularities. Furthermore, solid-state lasers,
which show some promise of eventually replacing the bulkier, more dangerous excimer
lasers, will most likely depend on flying spot approaches to ablation because of their lim-
ited beam diameter. In the future they will most likely rely heavily on adequate eye track-
ing technology to produce clinically maximized results. For these reasons, excellent eye
tracking technology is a gateway to significant advances in photorefractive surgery.
Eye tracking can be active, passive, or a mixture of the two. Active eye tracking in-
volves detection of a change in eye position. It also involves compensating for the change
by redirecting the ablation laser beam to ablate the desired area, in its new location. Passive
eye tracking is much simpler. Here a change in eye position is detected, and if the change
is greater than a maximum acceptable limit, the laser ablation ceases until the eye is recen-
tered. Then, ablation resumes where it had ceased. The speed at which changes in eye po-
sition can be detected and corrected is dependent upon the frequency at which the eye po-
sition is sampled and monitored. Frequency of sampling is determined by the type of
technology used to monitor eye position.
Lasers can play an important role in the eye tracking systems used for LASIK,
LASEK, and PRK. The laser head used for eye tracking is not any of the types we have con-
sidered previously for corneal ablation, quite simply because no ablation action is
necessary. All the laser must do is detect changes in the eye position; no special laser-
tissue interactions are necessary. By using a laser to monitor eye position, the frequency of
sampling is very high, and eye tracking is much faster.
Traditionally, eye tracking has been performed by infrared video cameras. The fre-
quency of sampling with this approach is limited by the camera frame capacity (images of
the pupils location are produced 60120 times per second). Because lasers are capable of
such high-frequency pulsing, the sampling frequency of a laser-based approach is much
greater. One system, the Autonomous LADARVision excimer laser, uses this approach for
eye tracking. The term LADAR stands for laser radar. This system uses a 905 nm diode
laser to measure the position of the dilated pupillary edge at a sampling rate of 4,000 times
per second (57). This signal is then conveyed to x and y axis tracking mirrors. Together the
laser and mirrors can react with a response time of 600 radians per second. This means that
redirection of the ablation beam to hit the desired target on the cornea can occur within 10
to 25 milliseconds of the change in eye position. This allows even the highest speed sac-
cadic eye movements (up to 700/s or approximately 150 mm/s) to be tracked with a peak
position error of about 30 m (58,59). Furthermore, this laser radar tracking system can de-
tect and initiate a response over 50 times during a saccade and redirect the beam to its ap-
propriate location before a new change occurs. This eye tracking feature is distinct from
others in that it is mandatory for laser ablation function with the Autonomous LADARVi-
sion excimer laser. A disabled tracker will cause ablation to cease. In other tracking sys-
tems, the tracking function is optional. Similar tracking systems are available on most cur-
54 Torres et al.

rent laser systems, but the tracking is based on lower sampling frequencies, and with
equally good outcomes.
A recent study used the LADARVision system to treat one eye of each of 102 patients
with 1.5 to 6.25 D of spherical myopia (60). There was a 93% 1-year follow-up. The
follow-up results reported uncorrected visual acuity of 20/40 or better in 99% of eyes,
20/20 or better in 70% of eyes, and BCVA of 20/25 in 100% of eyes. One eye lost two lines
of BCVA (20/12.5 preoperative to 20/20 postoperative). No eyes lost more than two lines
of BCVA, and corneal haze was trace or better for all patients. Results were within 0.50
D of desired correction in 75% of eyes and within 1.00 D in 93% of eyes. The results of
this study were at least comparable, if not better, than those of a previous wide beam ex-
cimer laser clinical trial in which 63% of myopic eyes (baseline 1 to 6 D; n  342)
achieved visual acuity of 20/20 and 68% were within 0.50 D of the desired refraction
(57,61). The tracking systems on other laser platforms have also shown improved centra-
tion and improved visual outcomes (See ch. 14).

REFERENCES
1. AL Schawlow, CH Townes. Infrared and optical masers. Phys Rev 1958;112:19401949.
2. TH Maiman. Stimulated optical radiation in ruby. Nature 1960;187:493494.
3. S Lerman. Radiant Energy and the Eye. New York: Macmillan, 1980, pp 4359.
4. BJ Garrison, R Srinivasan. Microscopic model for the ablative photodecompensation of poly-
mers by far ultraviolet radiation (193 nm). Appl Phys Lett 1984;44:849.
5. HH Jellinek, R Srinivasan. Theory of etching of polymers by far-ultraviolet, high-intensity
pulsed laser and long-term irradiation. J Phys Chem 1984;88:3048.
6. S Trokel. History and mechanism of action of excimer laser corneal surgery. In: JJ Salz, ed.
Corneal Laser Surgery. St. Louis: Mosby, 1995, pp 110.
7. R Srinivasan. Kinetics of the ablative photodecomposition of organic polymers in the far ultra-
violet (193 nm). J Vac Sci Technol B 1983;1:923926.
8. T Keyes, RH Clarke, JM Isner. Theory of photoablation and its implications for laser pho-
totherapy. J Phys Chem 1985;89:41944196.
9. JM Krauss, CA Puliafito, RF Steinert. Laser interactions with the cornea. Surv Ophthalmol
1986;31:3753.
10. PS Hersh, MD Wagoner. Excimer Laser Surgery for Corneal Disorders. New York: Thieme,
1998, p 5.
11. GM Kawesch, RK Maloney, M Derse, GO Waring, T Seiler. Contour of the ablation zone after
photorefractive keratectomy. Invest Ophthalmol Vis Sci 1992;33(suppl):1105.
12. PS Hersh, BH Schwartz-Goldstein, The Summit Photorefractive Keratectomy Topography
Study Group. Corneal topography of phase III excimer laser photorefractive keratectomy: char-
acterization and clinical effects. Ophthalmology 1995;102:963978.
13. T Seiler, A Holschbach, M Derse, B Jean, U Genth. Complications of myopic photorefractive
keratectomy with the excimer laser. Ophthalmology 1994;101:153160.
14. Summit Technology, ExciMed UV200LA Laser System Users Manual. Waltham, MA: Sum-
mit Technology, 1991, pp 525.
15. RR Krueger, SL Trokel. Quantitation of corneal ablation by ultraviolet laser light. Arch Oph-
thalmol 1985;103:17411742.
16. EA Davis, JC Abad, DT Azar. Excimer laser physics and biology. In: DM Albert, FA Jakobiec,
eds. Principles and Practice of Ophthalmology. 2nd ed. Philadelphia: WB Saunders, 2000, pp
588600.
17. HJ Huebscher, U Genth, T Seiler. Determination of excimer laser ablation rate of the human
cornea using in vivo Scheimpflug videography. Invest Ophthalmol Vis Sci 1996;37:4246.
18. GT Dair, WS Pelouch, PP van Saarloos, DJ Lloyd, SM Paz Linares, F Reinholz. Investigation
of corneal ablation efficiency using ultraviolet 213-nm solid state laser pulses. Invest Ophthal-
mol Vis Sci 1999;40:27522756.
Lasers in LASIK 55

19. SK Searles, GA Hart. Stimulated emission at 281.8 nm from XEBR. Appl Phys Lett
27:243245, 1975
20. JJ Ewing, CA Brau. Laser action on Sigma 2
12] Sigma 2
12. Appl Phys Lett
1975;27:350352.
21. CA Brau, JJ Ewing. 354-nm laser action on XEF. Appl Phys Lett 1975;27:435437.
22. JM Hoffman, AK Hays, GC Tisone. High-power UV noble-gashalide lasers. Appl Phys Lett
1976;28:538539.
23. RR Krueger, SL Trokel, HD Schubert. Interaction of ultraviolet laser light with the cornea. In-
vest Ophthalmol Vis Sci 1985;26:14551464.
24. BM Sutherland, LC Harber, IE Kochevar. Pyrimidine dimer formation and repair in human
skin. Cancer Res 1980;40:31813185.
25. S Jain, TW Hahn, RL McCally, DT Azar. Antioxidants reduce corneal light scattering after ex-
cimer keratectomy in rabbits. Laser Surg Med 1995;17(2):160165.
26. RC Nuss, CA Puliafito, E Dehm. Unscheduled DNA synthesis following excimer laser ablation
of the cornea in vivo. Invest Ophthalmol Vis Sci 1987;28:287294.
27. J Trentacoste, K Thompson, RK Parrish II, A Hajek, MR Berman, P Ganjel. Mutagenic
potential of a 193-nm excimer laser on fibroblasts in tissue culture. Ophthalmology 1987;94:
125129.
28. CE Van Mellaert, L Missotten. On the safety of 193-nanometer excimer laser refractive corneal
surgery. Refract Corneal Surg 1992;8:235239.
29. IE Kochevar. Cytotoxicity and mutagenicity of excimer laser radiation. Lasers Surg Med
1989;9:440445.
30. HA Green, R Margolis, J Boll, IE Kochevar, JA Parrish, AR Oseroff. Unscheduled DNA syn-
thesis in human skin after in vitro ultraviolet-excimer laser ablation. J Invest Dermatol
1987;89:201204.
31. MN Ediger. Excimer-laser-induced fluorescence of rabbit cornea: radiometric measurement
through the cornea. Lasers Surg Med 1991;11:9398.
32. HR Taylor, SK West, FS Rosenthal, B Muoz, HS Newland, H Abbey, EA Emmett. Effect of
ultraviolet radiation on cataract formation. N Engl J Med 1988;319:14291433.
33. J Marshall, S Trokel, S Rothery, H Schubert. An ultrastructural study of corneal incisions in-
duced by an excimer laser at 193 nm. Ophthalmology 1985;92:749758.
34. J Marshall, S Trokel, S Rothery, RR Krueger. Photoablative reprofiling of the cornea using an
excimer laser: photorefractive keratectomy. Lasers Ophthalmol 1986;1:21.
35. CA Puliafito, D Stern, RR Krueger, ER Mandel. High-speed photography of excimer laser ab-
lation of the cornea. Arch Ophthalmol 1987;105:12551259.
36. O Kermani, HJ Koort, E Roth, MV Dardenne. Mass spectroscopic analysis of excimer laser ab-
lated material from human corneal tissue. J Cataract Refract Surg 1988;14:638641.
37. G Kahle, H Stdter, T Seiler, T Wollensak. Gas chromatographic and mass spectroscopic anal-
ysis of excimer and erbium: yttrium aluminum garnet laser-ablated human cornea. Invest Oph-
thalmol Vis Sci 1992;33:21802184.
38. Z Bor, B Hopp, B Rcz, G Szab, I Ratkay, I Sveges, A Fst, J Mohay. Plume emission, shock
wave and surface wave formation during excimer laser ablation of the cornea. Refract Corneal
Surg 1993;9(suppl):S111S115.
39. MW Berns, LH Liaw, A Oliva, JJ Andrews, RE Rasmussen, S Kimel. An acute light and elec-
tron microscopic study of ultraviolet 193-nm excimer laser corneal incisions. Ophthalmology
1988;95:14221433.
40. J Marshall, S Trokel, S Rothery, RR Krueger. A comparative study of corneal incisions induced
by diamond and steel knives and two ultraviolet radiations from an excimer laser. Br J Oph-
thalmol 1986;70:482501.
41. S Trokel. Evolution of excimer laser corneal surgery. J Cataract Refract Surg 1989;15:373383.
42. Q Ren, RP Gailitis, KP Thompson, JT Lin. Ablation of the cornea and synthetic polymers us-
ing a UV (213 nm) solid-state laser. IEEE J Quant Electron 1990;26:22842288.
43. Q Ren, G Simon, J-M Legeais, J-M Parel, W Culbertson, J Shen, Y Takesua, M Savoldelli. Ul-
traviolet solid-state laser (213-nm) photorefractive keratectomy: in vivo study. Ophthalmology
1994;101:883889.
56 Torres et al.

44. MN Ediger, GH Pettit, LS Matchette. In vitro measurements of cytotoxic effects of 193 nm and
213 nm laser pulses at subablative fluences. Lasers Surg Med 1997;21:8893.
45. DM Maurice. The cornea and sclera. In: H Davson, ed. The Eye. Vol. 1. New York: Academic
Press, 1962, pp 289368.
46. PG Soderberg, T Matsui, F Manns, J-H Shen, J-M Parel, J-M Legeais, M Savoldelli, I Drubaix,
M Menashe, G Renard, Y Pouliquen. Three month follow up on changes in the rabbit cornea
after photoablation with a pulsed scanning beam at 213 nm. In: JM Parel, Q Ren, KM Joos, eds.
Ophthalmic Technologies V Proc. 1995;SPIE 2393:5560.
47. T Juhasz, GA Kastis, C Surez, Z Bor, WE Bron. Time-resolved observations of shock waves
and cavitation bubbles generated by femtosecond laser pulses in corneal tissue and water.
Lasers Surg Med 1996;19:2331.
48. RM Kurtz, X Liu, VM Elner, JA Squier, D Du, GA Mourou. Photodisruption in the human
cornea as a function of laser pulse width. J Refract Surg 1997;13:653658.
49. RM Kurtz, C Horvath, H-H Liu, RR Krueger, T Juhasz. Lamellar refractive surgery with
scanned intrastromal picosecond and femtosecond laser pulses in animal eyes. J Refract Surg
1998;14:541548.
50. KR Sletten, KG Yen, S Sayegh, F Loesel, C Eckhoff, C Horvath, M Muenier, T Juhasz, RM
Kurtz. An in vivo model of femtosecond laser intrastromal refractive surgery. Ophthalmic Surg
Lasers 1999;30:742749.
51. A Braun, H Liu, C Harvath, X Liu, T Juhasz, G Mourou. All solid-state, directly diode-pumped
chirped-pulse amplification laser system. OSA Technical Digest 1997;11:323324.
52. RR Krueger. Excimer laser: a step up in complexity and responsibility for the ophthalmic laser
surgeon? J Refract Corneal Surg 1994;10:8386.
53. JD Gottsch, EV Rencs, JL Cambier, D Hall, DT Azar, WJ Stark. Excimer laser calibration sys-
tem. J Refract Surg 1996;12:401411.
54. P Asbell, CF Beyer, MP Nevitt. LaserSight Compak-200 Mini-excimer laser. In: JH Talamo,
RR Krueger, eds. The Excimer Manual: A Clinicians Guide to Excimer Laser Surgery. Boston:
Little, Brown, 1997, pp 341353.
55. SD Klyce, MK Smolek. Corneal topography of excimer laser photorefractive keratectomy. J
Cataract Refract Surg 1993;19:122130.
56. JK Shimmick, WB Telfair, CR Munnerlyn, JD Bartlett, SL Trokel. Corneal ablation profilom-
etry and steep central islands. J Refract Surg 1997;13:235245.
57. RR Krueger. In perspective: eye tracking and autonomous laser radar. J Refract Surg 1999;
15:145149.
58. M McDonald, LC Van Horn. Autonomous T-PRK. In: JH Talamo, RR Krueger, eds. The Ex-
cimer Manual: A Clinicians Guide to Excimer Laser Surgery. Boston: Little, Brown, 1997, pp
355368.
59. D Boghen, BT Troost, RB Daroff, LF DellOsso, JE Burkett. Velocity characteristics of normal
human saccades. Invest Ophthalmol Vis Sci 1974;13:619623.
60. IG Pallikaris, KI Koufala, DS Siganos, TG Papadaki, VJ Katsanevaki, V Tourtsan, MB Mc-
Donald. Photorefractive keratectomy with a small spot laser and tracker. J Refract Surg
1999;15:137144.
61. VISX Excimer Laser System PRK Professional Use Information Manual, 1998.
62. DS Gartry. The development of excimer laser corneal surgery: beam tissue interactions. In: CNJ
McGhee, HR Taylor, DS Gartry, SL Troke, eds. Excimer Lasers in Ophthalmology: Principles
and Practice. Boston: Butterworth-Heinemann, 1997, p 33.
63. DS Gartry. The development of excimer laser corneal surgery: beam tissue interactions. In: CNJ
McGhee, HR Taylor, DS Gartry, SL Trokel, eds. Excimer Lasers in Ophthalmology: Principles
and Practice. Boston: Butterworth-Heinemann, 1997, p 33.
64. PP van Saarloos. Physical principles of excimer laser. In: CNJ McGhee, HR Taylor, DS Gartry,
SL Trokel, eds. Excimer Lasers in Ophthalmology: Principles and Practice. Boston: Butter-
worth-Heinemann, 1997, p 18.
 4
Microkeratomes

SANDEEP KAKARIA
Cornell University Medical Center, New York, New York, U.S.A
THANH HOANG-XUAN
Fondation Ophtalmologique Adolphe de Rothschild, and Paris University,
Paris, France
DIMITRI T. AZAR
Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute,
and Harvard Medical School, Boston, Massachusetts, U.S.A.

A. INTRODUCTION

Microkeratomes have evolved from suction rings and moving blades that were difficult to
operate to more user-friendly devices currently utilized in LASIK refractive surgery. The
early microkeratomes used by Jos Ignacio Barraquer were limited to the treatment of high
myopia. Barraquers technique, involving the creation of a central lenticule with a manual
microkeratome, freezing this section, and carving the deep portion with a lathe, according
to the amount of refractive error, had several technical limitations and was associated with
numerous complications. Complications of this technique resulted from difficulties in mas-
tering the microkeratome and cryolathe and included lenticular damage, persistent corneal
haze, irregular astigmatism, under- and over-correction, and regression (1). Innovations to
address this problem, including Swingers technique, in which he did not freeze the back
side of the lenticule (14), and Ruizs in situ method for manually removing corneal stroma
deep to the flap (5), were particularly important milestones that led to the development of
current microkeratomes.
Burrato used argon-fluoride excimer laser ablation, previously reported for surface
ablation by Trokel (6), in combination with the microkeratome on the deep portion of the
lenticule (7). Pallikaris demonstrated that in situ ablation and refractive correction could be
57
58 Kakaria et al.

performed on the remaining stromal bed (8). With these advances and the increasing pop-
ularity of the excimer laser, the microkeratome still had its place, but it was no longer used
for reshaping. Instead, its primary purpose was the creation of the corneal flap.
The microkeratomes of today have become safer and have been proven successful in
performing corneal lamellar cuts; however, complications with their use continue to occur.
These complications have been decreasing with surgical experience, advancements, and
design elements incorporated into newer microkeratomes. The current microkeratomes are
by no means close to being free of complications, nor do they approximately an ideal mi-
crokeratome, which would optimize the following parameters: safety, ease of use and ster-
ilization, reliability, moderate increase in IOP and minimal structural deformation during
surgery, smooth beds, regular edges, reproducible thickness, sufficient hinge width, suction
ring stability, and reasonable cost of hardware and disposables. Although currently used
microkeratomes incorporate several features of the ideal microkeratome, they nevertheless
sacrifice some obviously useful features in order to achieve others.
Typical components of a modern microkeratome system include the following (9):
Motor
Microkeratome head
Applanator lenses to measure the diameter of the exposed cornea
Vacuum fixation ring used to secure the eye
Flap stop ring, which limits the travel of the microkeratome head through the fixation
ring
Foot switch

B. MICROKERATOME TYPES
Although microkeratomes share several similarities, they can be divided into five basic cat-
egories:
1. Nondisposable horizontal
A. Gear driven
B. Automated sliding
C. Manual
2. Nondisposable vertical
A. Automated
B. Manual
3. Disposable
A. Cable driven
B. Turbine driven
C. Gear driven
4. Water jet
5. Laser microkeratomes (picosecond)

C. NONDISPOSABLE HORIZONTAL MICROKERATOMES

Automated horizontal microkeratomes include the Bausch and Lomb Surgical/Chiron Au-
tomated Corneal Shaper; Summit Krumeich-Barraquer (SKBM); Herbert Schwind; B.B.-
I-T-I, Allergan, and Nidek (similar to Summit), Med-Logics, LaserSight Technologies Ul-
trashaper, and Innovative Optics Innovatome. Manual microkeratomes in this category
Microkeratomes 59

Figure 4.1 Hinge location. (A) Nasal hinge. The keratomileusis occurred in the temporal-to-nasal
direction. (B) Superior hinge.

include the Moria LSK-1, the SCMD Turbokeratome by New United Development Cor-
poration, and the Med-Logics Manual.
The automated sliding microkeratomes (SKBM, B.B.-I-T-I, Allergan, and Nidek)
have virtually displaced all other horizontal microkeratomes in this category because they
are surgeon-independent reliable units that require minimal assembly during surgery and
have relatively high reproducibility of flap thickness.

1. Basics
Horizontal microkeratomes are derived from the original design by Barraquer. During the
keratomileusis procedure, the turbines or electric motors of these instruments are located
horizontally or to the side of the eye. Cuts are usually made with nasal hinges (Fig. 4.1A),
although it is possible to position narrow versions of these microkeratomes to create supe-
rior hinges.

Figure 4.2 Gears vs. sliding mechanism in nondisposable horizontal microkeratomes. (A) The
gears of the ACS head move through the geared tracks of the suction ring. (B) The SCMD slides
through its track without the assistance of gears.
 60

Figure 4.3 Other examples of nondisposable horizontal microkeratomes. Note that the microkeratome motor is not directly above the
operating surface. (A) Moria Lamellar System for Keratoplasty-1. (B) Summit Krumeich-Barraquer. (C) Med-Logics Microkeratome.
(D) Innovative Optics Innovatome. (E) LaserSight Technologies Ultrashaper.
Kakaria et al.
Microkeratomes 61

2. Design
Automated horizontal microkeratomes may advance through the use of rotating gears be-
tween the microkeratome head and the suction ring (Fig. 4.2A) or through gearless sliding of
the microkeratome head on the suction ring. Manual microkeratomes primarily consist of
gearless sliding of the microkeratome head on the suction ring (Fig. 4.2B).
Gear-driven microkeratomes may have an increased likelihood of jamming due to
operative debris and may also be more difficult to clean between procedures. Sliding de-
signs may decrease these complications. The instances of microkeratome head slippage
from the suction ring tracks in the manual microkeratomes have been practically eliminated
in the newer automated sliding horizontal designs.
The ACS is a gear-driven nondisposable horizontal microkeratome, while the other in-
struments in this category utilize the sliding mechanism (Figs. 4.2B and 4.3). The Moria
LSK-1 and the SCMD, both manual microkeratomes, run on a gas-turbine mechanism, while
the others use an electric motor. Multiple flap sizes and depths are available. Technical fea-
tures of individual nondisposable horizontal microkeratomes may be seen in Table 1.

3. Safety Issues
The original SCS microkeratome uses multiple components to ensure appropriate depths
and flap size. Although this may allow flexibility, the incomplete, inappropriate tightening
of this instrument may result in free caps (if stop is not screwed properly) or corneal per-
foration (if the depth plate is not tightened or mistakenly not inserted). Care must be taken

Table 1 Technical Features of Certain Nondisposable Horizontal Microkeratome

Bausch and LaserSight
Manufacturer Lomb/Chiron Summit Med-Logics Technologies

Model Name Automated Krumeich-Barraquer Med-Logics Ultrashaper

Corneal Shaper
Oscillation speed 7,500 rpm 20,000 813,000 7,500
Flap diameter 9.00 mm 8.0 to 10.0 8.00 to 10 7.2 and

Depth 160 and 180 mm 130, 160, 180 160 and 180 160
Mechanism Gear driven Sliding Sliding Sliding
Automated/manual Automated Automated Automated Automated
Advance rate 3.7 mm/s 0.13.0 mm/s 3.5 mm/s
Motor Electric Electric Electric Electric

Manufacturer Moria BD NIDEK ALLERGAN

Model name LSK-1 K-3000 MK-2000 Amadeus

Oscillation speed 15,000 rpm 12,000 rpm 9,000 rpm 9,000 to 20,000 rpm
Flap diameter 7.5 to
9.5 mm 8.510.0 9.0 or 10.0 8.5 or 9.55
Depth 130, 160, 180 m 130, 168, 180 130, 160, 180 140, 160, 180
Mechanism Sliding Track & Reel Dual Motors Proprietary
Automated/manual Manual Automated Automated Automated
Advance rate N/A 4.4 mm/s 2 mm/s 1.54.0 mm/s
Motor Gas Turbine Electric Electric Electric
62 Kakaria et al.

in the use of all microkeratomes to ensure that a variable depth plate is tightened to the
proper level or that fixed depth plates are always inserted prior to keratomileusis.

4. Oscillation and Advancement Rate

Automated microkeratomes allow advancement at a constant, appropriately slow speed
throughout the keratomileusis procedure. Slow advance rates allow the blades to perform
their shearing action with decreased chance of scraping, plowing, or producing areas of
the flap that are thinner than others. When using manual microkeratomes, the surgeon
must maintain a slow, steady advance rate throughout the cut to ensure consistent flap
thickness.
Fast oscillation speeds allow for a cut that has reduced ridges or chatter in the stro-
mal bed, while slow oscillation speeds have increased ridges. Gas turbines have allowed
microkeratomes to oscillate at faster rates; however, they require large gas canisters to re-
main in the operating room.
Postoperative irregular astigmatism may be caused by variation in thickness through-
out a flap or increased ridges created in the corneal stroma. Therefore, to minimize induced
astigmatism, the surgeon should aim for a consistent flap thickness and minimal ridges or
chatter especially when using a manual unit (10,11).
The manual horizontal microkeratomes that we have studied, Moria and SCMD, at-
tempt to decrease the chance of induced astigmatism with a faster oscillation speed, while
the automated microkeratomes decrease the complication by a programmed advance rate.
It may be appropriate to hypothesize that the chance of induced astigmatism can be mini-
mized by combining a fast oscillation with a consistent advance rate, which is the guiding
principle of most of the newer automated sliding units.

D. NONDISPOSABLE VERTICAL MICROKERATOMES

These microkeratomes are available in automated and manual forms. The automated mi-
crokeratomes include the Carriazo-Barraquer and M-2 made by Moria and the Bausch and
Lomb Surgical/Chiron Hansatome. Moria/Schwind also make manual versions of the Car-
riazo-Barraquer microkeratome.

1. Basics
In nondisposable vertical microkeratomes, the motor lies directly vertical or above the eye,
rather than to the side of the eye. This instrument may be used to create a superior hinge
(Fig. 1B). Vertical microkeratomes are equipped with a rotating head that travels to create
the surgical arc (flap).

2. Designs
The primary difference between the two popular vertical microkeratomes is the presence
of a geared track on the Hansatome compared to the smooth track of the Carriazo-Barra-
quer (Fig. 4.4). As with the ACS, the geared track may cause this instrument to be more
susceptible to jamming from debris; however, it provides the microkeratome with more
torque (torqueforce* distance). Greater torque allows the microkeratome to perform its
keratomileusis with minimal assistance from the surgeon. The Carrazo-Barraquers lack
Microkeratomes 63

Figure 4.4 Examples of nondisposable vertical microkeratomes. Note that the microkeratome
motor is directly above the operating surface. (A) The geared outer track of the Hansatome suction
ring. (B) The smooth outer track of the Carriazo-Barraquer suction ring. (C) Fully assembled
Hansatome with suction ring, plate, and head. (D) Fully assembled Carriazo-Barraquer with suction
ring and head. Note the microkeratome head in B is smaller than A. The M-2 Moria Microkeratome
has virtually replaced the Carriazo-Barraquer microkeratome because it avoids the problem of flap
thickness variability.

Table 2 Technical Features of Nondisposable Vertical Microkeratomes

Manufacturer Bausch & Lomb/Chiron Moria and Schwind

Model name Hansatome Carriazo-Barraquer

Oscillation speed 14,000 rpm 15,000 rpm
Flap diameter 8.5 and 9.5 mm 7.0 mm and

Depth 160 and 180 m 130, 160, 180 m

Mechanism Outer gear Only inner drive mechanism
Motor Electric Gas turbine or electric
Automated/manual Automated Both available
Advance rate 6.0 mm/s 3.7 mm/s
Hinge position Superior Anywhere
64 Kakaria et al.

of an outside gear, and hence its inferior torque, may require the surgeon to push the mi-
crokeratome head gently to initiate keratomileusis. This causes the automatic version of
the Carriazo-Barraquer microkeratome to have a manual component.
Both the Hansatome and the Carriazo-Barraquer operate at high oscillation speeds,
close to 15,000 rpm. The Hansatome has a faster advancement rate, while the Carriazo-Bar-
raquer has a greater selection of flap diameters. Technical features of nondisposable verti-
cal microkeratomes appear in Table 2.

3. Safety Issues
The Hansatome has made a few advancements over the ACS. First of all, it will not oper-
ate if the plate is not inserted. Second, the number of gears is reduced and they are better
covered from debris. The Carriazo-Barraquer does not require a plate to be inserted and can
fit in narrower spaces. In addition, it may produce a hinge in any peripheral corneal loca-
tion.

E. DISPOSABLE MICROKERATOMES
These microkeratomes include the Refractive Technologies Flapmaker, the LaserSight
Technologies Unishaper, and the Moria LSK-1 Disposable.

1. Basics
These are horizontal microkeratomes that have the advantage of requiring no assembly, dis-
assembly, or cleaning. Each microkeratome head, blade, and suction ring combination is
sterile, used once, and then discarded.

2. Designs
In disposables, the blade is preassembled in the head, and the head is engaged in the track.
The head and suction ring are made of clear plastic, and the instruments operate by utiliz-
ing a sliding (cable driven or turbine driven) or a gear driven mechanism (Fig. 4.5).
The Moria LSK-1 Disposable is a manual microkeratome and uses the same con-
trol unit as the other Moria microkeratomes. The Flapmaker and Unishaper are auto-
mated and use electric motors. Technical features of disposable microkeratomes appear
in Table 3.

3. Safety Issues
Disposable systems have the advantage of requiring fewer components to be set up by the
surgeon; they also have improved sterility, thus decreasing the chance of operational error
or surgical infection. In addition, the clear plastic of the disposable systems ensures good
visibility for the keratomileusis procedure.

F. WATER JET MICROKERATOMES

These instruments include the Medjet Hydrokeratome, the Medjet Hydrorefractive Kera-
tectomy hydrokeratome, and the Visijet hydrokeratome.
Microkeratomes 65

Figure 4.5 Examples of disposable microkeratomes. Note the pre-engaged plastic suction ring
and head. See the smooth tracks of A and B and the geared track in C. (A) Refractive Technologies
Flapmaker. (B) Moria LSK-1 disposable. (C) LaserSight Unishaper.

Table 3 Technical Features of Disposable Microkeratomes

LaserSight
Manufacturer Refractive Technologies Moria Technologies

Model name Flapmaker LSK-1 disposable Unishaper

Oscillation speed 12,500 rpm 15,000 rpm 7,500 rpm
Flap diameter 8.5 and 10.5 mm 10 mm 8.5 mm and

Depth 220, 200, 180, 160, 160 and 180 m 160 m

and 130 m
Design Sliding Sliding Gear driven
Motor Electric (cable) Gas turbine Electric
Automated/manual Automated Manual Automated
Advance rate 6.8 mm/s N/A 4.5 mm/s
66 Kakaria et al.

1. Basics
The theory behind the water systems is that blades cause collateral tissue damage, while a
beam of water can precisely cut between layers without leaving debris and provoking min-
imal wound response. In addition, the hydrokeratome can perform the cut without requir-
ing an increase in intraocular pressure.

2. Designs
The Medjet Hydroblade Keratome uses a 30 m beam, and advances at 6.7 mm/s. It has a
fixed depth plate and can produce superior, temporal, or nasal hinges. The Medjet Hy-
drorefractive Keratectomy (HRK) System is a water system that makes a bi-hinged flap
with a C-shaped needle. The system attempts to ablate without the need of a laser. Instead,
the shape and pressure of the template can be changed, along with the scan rate, in order to
remove different amounts of tissue. The Visijet Hydrokeratome is also a water jet system
that uses a 36 m beam and advances at 6.7 mm/s. It has a variable depth plate of 120200
m and a clear applanation lens for good visualization.

G. LASER MICROKERATOMES

These instruments include the Novatek Laser Microkeratome and the IntraLase Microker-
atome. The Novatek microkeratome has not been used clinically, whereas the IntraLase
Microkeratome (picosecond MK) has been in clinical use since early 2000 with outstand-
ing results.

1. Basics

Laser systems create a precise flap with a laser or perform an intrastromal cavitation by
carving a corneal lenticule with a laser beam. The vapor and fluid residues from intrastro-
mal ablations dissipate a few hours after surgery.

2. Designs

The IntraLase Laser Microkeratome depends upon femtosecond pulses, so less energy is
needed to photodisrupt corneal tissue, thus allowing more localized effects. It also allows
a wide variety of corneal flap shapes. It also depends on an applanation plate to ensure con-
sistent flap thickness. The Novatec Laser Systems Laser Microkeratome is expected to
have eye tracking systems to monitor eye movements, giving a three-dimensional map for
the lasers location within the cornea. The IntraLase Microkeratome has been continously
upgraded, so as to allow complete versatility and reproducibility, and may become the most
commonly used system for corneal flaps in the future.

H. OTHER MICROKERATOMES

The Ophthalmic Technologies Inc./Loktal Medical Clear Corneal Molder allows for cor-
rection without photoablation. It can perform convex or concave cuts, thus correcting for
 Microkeratomes 67

myopia and hyperopia. It has minimal vibration, allowing use of steel or diamond blades.
It also has gearless tracks, is a manual microkeratome, and has separate motors for oscilla-
tion and advancement. It is adjustable, 1500 m in depth, and the standard is fixed at 180
m. Its blade speed is also adjustable to 24,000 rpm. It has a viewing window and auto-
matically stops if suction is lost. In addition, it only cuts in forward motion.
Mastel Precision Surgical Instruments Buzard Barraqueratome has a diamond blade
and needs no assembly. It provides good visualization of the flap and is compact, so it can
fit small eyes. It has a two-chambered vacuum, which acts on the cornea and sclera to al-
low for a lower IOP. The depth plate is fixed at 160 m and the instrument makes nasally
oriented flaps.
Hanna also makes a microkeratome. This instrument relies upon rotational motion
and is known for the formation of a smooth bed.

I. DISCUSSION

Each of the above-mentioned microkeratomes attempts to decrease complications seen in

LASIK surgery. Although no microkeratome is ideal, certain features are desirable in mi-
crokeratome systems and physicians should be encouraged to ask manufacturers about them:
Low level of flap complications
Consistent flap thickness
Good visibility
Fits into small eyes
Fixed depth plate
Loss of suction indicators

Table 4 Flap Combinations (Numbers indicate percent complication rates).

Percentages

Micro- # of Incomplete Perorated Short Sliding wrinkles Free Flap Thin Decentered
First author keratome eyes cut lenticule flap flap (striae) cap melt flap flap Cumulative

Brint ACS 47 4.3 4.3

Bas ACS 97 2.1 2.1
Fiander ACS 124 9.7 9.7
Kremer ACS 5 20 20.0
Guell ACS 43 2.3 2.3
Helmy ACS 40 0 0.0
Marinho ACS 34 2.9 5.9 2.9 11.8
Salah ACS 88 3.4 3.4
Condon ACS 51 3.9 3.9
Perez- ACS 143 0.7 3.5 0.7 8.0 12.9
Santonja
Steinert ACS 76 2.6 1.3 3.9
Waring ACS 714 0.7 0.6 1.1 0.1 1.1 0.1 3.8
El-Maghraby ACS 33 6.1 3.0 9.1
Stulting ACS 1062 0.8 0.6 1.2 0.2 0.9 0.1 3.8
Gimbel ACS 1000 1.2 0.3 1.2 0.6 0.1 0.3 3.7
Hersh ACS 115 0.9 0.9 0.9 2.6
Dulany ACS 124 2.4 4.8 7.3
Lindstrom ACS 475 0.6 0.2 0.8
Knorz ACS 42 2.4 7.1 9.5
Summary ACS 4313 0.7 0.4 0.02 1.0 0.6 1.0 0.2 0.1 4.0
Velasco- Hansatome 400 1.0 0 0 1.3 2.3 4.5
Martinelli
Rosa Hansatome 40 2.5 2.5 5.0
Summary Hansatome 440 0.9 0 0.2 0 1.1 2.3 4.5
68 Kakaria et al.

First and foremost, a suitable microkeratome should have a low level of flap complications.
These complications depend on a multitude of factors, including experience and microker-
atome safety features. As refractive surgeons know, there is a steep learning curve for
LASIK, and regardless of microkeratome brand complications will decrease with time.
However, complications may be more apt to occur in certain microkeratomes
(1238). Farahs work quantitates flap complications, and by including data from further
studies, one may see the number of flap complications that have occurred with different mi-
crokeratome designs (1), specifically the ACS and the Hansatome (Table 4). In these stud-
ies, serious flap-related complications occurred in 4% of the ACS cases and 1% of the
Hansatome cases. The Hansatome studies contained less severe complications. There were
no free caps in the 440 eyes analyzed, and 10 of the 20 complications were a decentered
flap. Flap decentration appears to be an inherent possibility in the Hansatome cases. Of-
tentimes, suction ring application causes movement of the globe. The suction must be
stopped and the area recentered. However, in some cases, scleral indentation occurs when
the ring fixes on the globe on the first cut attempt and the indentation may prevent adjust-
ment (12). In these cases, a different suction ring or repeated attempts at recentration will
solve the problem.
Consistent flap thickness is also important in performing LASIK. Most surgeons aim
to leave a minimum of 250 m of residual cornea after ablation to prevent irreversible
corneal edema. For patients whose residual corneal thickness is predicted to be close to 250
m, according to refractive correction and preoperative pachymetry, a predictable flap
thickness is essential. Many microkeratome companies have performed studies to indicate
consistent flap thickness. Summits two studies showed varied results on flap thickness.
A 12 eye study with the Summit KrumeichBarraquer microkeratome indicated a 190 
17 m cut with the 160 m head, while a 24 eye study indicated a 164  13 m cut with
the same head. One study involving 93 eyes that underwent LASIK with the Moria LSK-1
microkeratome indicated that the 160 m head averaged 159  28 m (13). Pinedas work
on 25 eyes reveals a 117  17 m cut with the ACS, and his 21 eye study shows a 127
 29 m cut with the Hansatome; both studies attempted a 160 m cut (14). Pinedas work
and our experience indicate that the ACS and Hansatome provide cuts that are more often
thinner than expected.
In addition to consistent flap thickness, design features that offer good visibility are
an asset to all surgeons, especially those who are still in the steep portion of the learning
curve (1538). Proper visibility allows the beginner to learn correctly the positions and
technical details of microkeratome operation and aids the expert in avoiding debris in the
surgical path. Also, designs that are slim have benefits, since they can fit into the widest va-
riety of patients, such as those with narrow eyes or redundant eyelid skin.
Microkeratomes that rely on fixed depth plates, rather than heads that can achieve
variable depths, are preferable. First, if a surgeon needs to cut at a different depth, he or she
may still do so using a different head. Second, human error may occur when inserting the
depth plate into variable depth systems, thus leading to corneal perforation with high in-
traocular pressure. Such a complication may cause damage to various structures in the eye,
including the iris, the ciliary body, and the lens (37).
Finally, safety features such as alarms, automatic shut-sown buttons, or suction dis-
plays are very beneficial. If the microkeratome continues forward progress after suction is
lost, an irregular cap can occur with a cut through the central cornea. Scarring in this loca-
tion would be in the visual axis.
As for future methods to perform lamellar cuts, more accurate blades with consistent
Microkeratomes 69

depths can be expected, along with laser systems that may cause less corneal disturbance.
Time will tell where the future of microkeratomes lies, but one can be assured that micro-
keratome advances will continue (3638).

REFERENCES
1. SG Farah, DT Azar, C Gurdal, J Wong. Laser in situ keratomileusis: literature review of a de-
veloping technique. J Cataract and Refract Surg 1998;24(7):9891006.
2. O Gris, JL Guell, A Muller. Keratomileusis update. J Cataract Refract Surg 1996;22:620623.
3. CA Swinger, J Krumeich, D Cassiday. Planar lamellar refractive keratoplasty. J Refract Surg
1996;2:1724.
4. SF Brint, DM Ostrick, C Fisher, SG Slade, RK Maloney, R Epstein, RD Stulting, KP Thomp-
son. Six-month results of the Multicenter Phase I Study of Excimer Laser Myopic Ker-
atomileusis. J Cataract Refract Surg 1994;20:610615.
5. L Buratto, M Ferrari. Indications, techniques, results, limits, and complications of laser in situ
keratomileusis. Curr Opin Ophthalmol 1997;8(4):5966.
6. SL Trokel, R Srinivasan, B Braren. Excimer laser surgery of the cornea. Am J Ophthalmol
1983;96:710715.
7. L Buratto, M Ferrari, C Genisi. Myopic keratomileusis with the excimer laser: one year follow-
up. Refract Corneal Surg 1993;9:1219.
8. IG Pallikaris, ME Papatzanaki, DS Siganos, MK Tsilimbaris. A corneal flap technique for laser
in situ keratomileusis; human studies. Arch Ophthalmol 1991;109:16991702.
9. M Duplessie. Surgical technique for laser-assisted in situ keratomileusis. International Oph-
thalmology Clinics 1996;36(4):4551.
10. DT Azar. Refractive Surgery. In: SW Chang, L Ruiz, M Gomez, eds. Lamellar Refractive
Surgery Instruments. New Jersey: Appleton and Lange, 1997, pp 239251.
11. American Academy of Ophthalmology. Automated lamellar keratoplasty. Ophthalmology
1996;103(5):852861.
12. EJ Velasco-Martinelli, FA Tarcha. Superior hinge laser in situ keratomileusis. J Refract Surg
1999;15(2S):S209S211.
13. BJ Jacobs, TA Deutsch, JB Rubenstein. Reproducibility of corneal flap thickness in LASIK.
Ophthalmic Surgery and Lasers 1999;30(5):350353.
14. R Pineda. Comparative analysis of microkeratome flap thickness in LASIK. 21st Biennial
Cornea Research Conference, Boston, 1999;21:45.
15. AM Bas, R Onnis. Excimer laser in situ keratomileusis for myopia. J Refract Surg 1995;
11S:S229S233.
16. L Buratto, M Ferrari, P Rama. Excimer laser surgery of the cornea. Am J Ophthalmol 1992;
113:291295.
17. PI Condon, M Mulhern, T Fulcher, A Foley-Nolan, M Okeefe. Laser intrastromal ker-
atomileusis for high myopia and myopic astigmatism. Br J Ophthalmol 1997;81:199206.
18. DD Dulaney, RW Barnet, SA Perkins, GM Kezirian. Laser in situ keratomileusis for myopia
and astigmatism: 6 month results. J Cataract Refract Surg 1998;24(6):758764.
19. A El-Maghraby, T Salah, GO Waring III, S Klyce, O Ibrahim. Randomized bilateral compari-
son of excimer laser in situ keratomileusis and photorefractive keratectomy for 2.50 to 8.00
diopters of myopia. Ophthalmology 1999;106(3):447457.
20. DC Fiander, F Tayfour. Excimer laser in situ keratomileusis in 124 myopic eyes. J Refract Surg
1995;11S:S234S238.
21. PS Hersh, SF Brint, RK Maloney, DS Durrie, M Gordon, MA Michelson, VM Thompson, RB
Berkeley, OD Schein, RF Steinert. Photorefractive keratectomy versus laser in situ ker-
atomileusis for moderate to high myopia. A randomized prospective study. Ophthalmology
1998;105(8):15121523.
22. HV Gimbel, EE Penno, JA van Westenbrugge, M Ferensowicz, MT Furlong. Incidence and
70 Kakaria et al.

management of intraoperative and early postoperative complications in 1000 consecutive laser

in situ keratomileusis cases. Ophthalmology 1998;105(10):18391848.
23. MC Knorz, A Liermann, V Seiberth, H Steiner, B Wiesinger. Laser in situ keratomileusis to
correct myopia of 6.00 to 29.00 diopters. J Refract Surg 1996;12:575584.
24. I Kremer, M Blumenthal. Myopic keratomileusis in situ combined with VISX 20/20 photore-
fractive keratectomy. J Cataract Refract Surg 1995;21:508511.
25. RL Lindstrom, DR Hardten, YR Chu. Laser in situ keratomileusis (LASIK) for the treatment of
low, moderate, and high myopia. Trans Am Ophthal Soc 1997;95:285306.
26. A Marinho, MC Pinto, R Pinto, F Vaz, MC Neves. LASIK for high myopia: one year experi-
ence. Ophthalmic Surg Lasers 1996;27S:S517S520.
27. JL Guell, A Muller. Laser in situ keratomileusis (LASIK) for myopia from 7 to 18 diopters.
J Refract Surg 1996;12:222228.
28. JJ Perez-Santonja, J Bellot, P Claramonte, MM Ismail, JL Alio. Laser in situ keratomileusis to
correct high myopia. J Cataract Refract Surg 1997;23:372385.
29. SA Helmy, A Salah, T Badawy, AN Sidky. Photorefractive keratectomy and laser in situ ker-
atomileusis for myopia between 6:00 and 10:00 diopters. J Refract Surg 1996;12:417421.
30. DS Rosa, JL Febbraro. Laser in situ keratomileusis for hyperopia. J Refract Surg 1999;
15(2S):S21S215.
31. T Salah, GO Waring III, A El-Maghraby, K Moadel, SB Grimm. Excimer laser in situ ker-
atomileusis under a corneal flap for myopia of 2 to 20 diopters. Am J Ophthalmol 1996;121:
143155.
32. RF Steinert, PS Hersh. Spherical and aspherical photorefractive keratectomy and laser in-situ
keratomileusis for moderate to high myopia: two prospective, randomized clinical trials. Sum-
mit technology PRK-LASIK study group. Trans Am Ophthalmol Soc 1998;197227.
33. RD Stulting, JD Carr, KP Thompson, GO Waring III, WM Wiley, JG Walker. Complications
of laser in situ keratomileusis for the correction of myopia. Ophthalmology 1999;106(1):1320.
34. HV Gimbel, S Basti, GB Kaye, M Ferensowicz. Experience during the learning curve of laser
in situ keratomileusis. J Cataract Refract Surg 1996;22:542550.
35. Trends in technology: microkeratomes. Ocular Surg News 1998.
36. JI Barraquer. The history and evolution of keratomileusis. Int Ophthalmol Clin 1996;36(4):17.
37. SE Wilson. LASIK: management of common complications. Laser in situ keratomileusis.
Cornea 1998;17(5):459467.
38. GO Waring III, JD Carr, RD Stulting, KP Thompson, W Wiley. Prospective randomized com-
parison of simultaneous and sequential bilateral laser in situ keratomileusis for the correction of
myopia. Ophthalmology 1999;106(4):732738.
 5
Adjunctive Instrumentation in LASIK

ROBERT T. ANG
Massachusetts Eye and Ear Infirmary and Harvard Medical School,
Boston, Massachusetts, U.S.A., and Asian Eye Institute, Makati, The Philippines
DIMITRI T. AZAR
Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute,
and Harvard Medical School, Boston, Massachusetts, U.S.A.

A. STANDARDIZED VISUAL ACUITY CHARTS

The measurement of visual acuity (VA) is an essential part of the ophthalmological exam-
ination, and it represents the most common useful test for assessing visual function. In clin-
ical practice, the primary need is to document the occurrence or evolution of pathology; and
in clinical trials or research projects, the need is to perform a reliable and reproducible base-
line and evaluation of outcome. In refractive surgery, it is relevant to measure the best-cor-
rected VA before and after surgery, to rule out any pathology other than refractive error,
and to analyze differences and changes over time.
Charts with a regular progression of optotype size and spacing, with the same number
of letters per row of approximately equal recognition difficulty (Landolt C or Sloan letters),
are more useful for the standardization requirements. The Landolt ring has been consistently
advocated as a standard test object since 1909 and was eventually adopted as the primary
standard optotype by the National Academy of SciencesNational Research Council (NAS-
NRC) Committee on Vision in 1980 (1). The Sloan and British Standard Institution optotype
sets are substantially equivalent to the Landolt rings in terms of recognition difficulty (1).
Optotype sizes must be reduced in a constant way in order to obtain an equal variation all
over the scale extension. A logarithmic progression in steps of 0.1 logUnits corresponds to a
geometric progression in which each row contains optotypes about 1.26 times smaller than
the preceding one. Optotypes must also be quite far apart to avoid the crowding effect. The

71
72 Ang and Azar

NAS-NRC recommended ten optotypes divided into two rows of five; eight letters per row
is the minimum accepted. The same number of letters at each size level is required (1).
In individuals with normal vision, visual acuity (VA) increases as a function of the
background luminance from mesopic to high photopic conditions until glare is experienced
and VA subsequently decreases. VA increases from a luminance of 0.025 cd/m2 to 60
cd/m2, but above 80 cd/m2 the variation is very slight, and above 500 cd/m2 it becomes
negligible (1, 2). Maximal VA is achieved under photopic conditions. It is advisable to
avoid VA measurement in a dark room, but ambient background lighting should not exceed
one half of the chart background luminance. The ability to identify an optotype is related
not only to its angular width but also to the test target contrast. VA is reduced as the con-
trast between the test target and the background decreases. The maximal VA is achieved
when the contrast between optotypes and background is above 80%. The standard chart
testing distance should be 4 meters. With this distance, there is easy approximation to in-
finity by adding algebraically 0.25 D to the refractive correction; easy conversion of the
Snellen ratio between 4 meters and 20 feet; and maximal acuity and minimal dispersion of
acuity scores at distances close to 4 meters.

1. Distance Charts

The Snellen chart is the most widely used chart for VA testing in all English-speaking coun-
tries. It is based on the assumption that a subject with normal recognition acuity can resolve
an optotype with a visual angle of 5 and a resolution angle (stroke) of 1 (minute of arc). The
VA level is expressed as the ratio between the reading distance and the distance in meters at
which the stroke width of the equivalent Landolt ring subtends 1 minute of arc. It has sev-
eral limitations including a different number of optotypes per row, irregular progression in
letter size, differences in the recognition difficulty of the optotypes, and difference in back-
ground luminance related to different chart manufacturers. The back-illuminated Snellen vi-
sual acuity chart routinely used in a clinic has a luminance of approximately 550 cd/m2.
Snellen is generally credited with inventing letter-chart acuity testing, and although many
variants of his original test exist, the Snellen chart has gained universal clinical acceptance.
The basic principle of measuring visual acuity with letter test charts is that the small-
est level of letters that can be read satisfactorily provides the index of visual acuity. It is
therefore reasonable that each level on the test chart should have an equal degree of diffi-
culty. In 1976, Bailey and Lovie described a chart with the following features: the same
number of symbols used on each line; the between-symbol spacing is proportionally the
same on each line; the vertical spacing between one line and the next is a constant propor-
tion of symbol size; and the ratio of symbol size on a given line to that on the next line is
constant (approximately 1.25) (2,3). The British Standards Institution adopted a series of
ten nonserif letters of equal legibility, based on the findings of Coates and Woodruff as re-
ported by Bennett (2). This was the basis for the optotypes selected by Bailey and Lovie to
give standard legibility to each row of their acuity chart. Ten 55 Sloan letters (S, D, K,
H, N, O, C, V, R, and Z) were subsequently adopted by the NAS-NRC Committee. The
55 format designates that each optotype is constructed on a square framework 5 units
wide by 5 units high and having a stroke width equal to 1 unit (4).
The BaileyLovie distance visual acuity chart was developed to overcome the inac-
curacies of the Snellen chart and has been widely accepted as an accurate and efficient mea-
sure of visual acuity, particularly for assessing patients with low vision (2,5,6). The chart
has approximately equally legible letters (British Standards Institution, 1968) on each row,
Adjunctive Instrumentation in LASIK 73

and the separation of letters within rows and between rows is uniform, so that contour in-
teraction is controlled. The visual task at each level of the chart is therefore the same irre-
spective of acuity or test distance. The BaileyLovie chart employs a logarithmic progres-
sion of sizes and the logMAR visual acuity notation, which has been shown to represent a
good approximation to an equal discriminability scale and has been recognized by many in-
vestigators as the most logical measure of visual acuity (4,5,7). LogMAR charts are theo-
retically superior because interpatient differences and follow-up measurements over time
are objectively and consistently evaluated and measured. The LogMAR design also mini-
mizes the crowding phenomenon because of logical spacing of the optotypes. The Bai-
leyLovie chart or adaptations of it have been used in notable research projects including
the Early Treatment of Diabetic Retinopathy Study, the Macular Photocoagulation Study,
and the Prospective Evaluation of Radial Keratotomy Study (79), among others.
The Early Treatment Diabetic Retinopathy Study (ETDRS) chart, also known as the
Lighthouse Distance Visual Acuity Chart, uses lines of letter combinations determined to be
of equal confusability and not containing words or acronyms (7,10). The chart was intro-
duced by Ferris and is a modification of the Bailey and Lovie chart. It utilizes five Sloan op-
totypes per row with a regular progression of the type size and spacing, following a loga-
rithmic scale in steps of 0.1 logUnits. The reduced number of optotypes may increase the
probability of guessing brought about by easier memorization of the few optotypes. The
background luminance is about 150 cd/m2 without any possibility of regulation. (Fig. 5.1.)

2. Near Charts
The near test chart is a 1:10 scaled-down chart that uses a test distance of 40 cm. The range
of sizes on these charts extends from 80 point to 2 point print, and the progression of size
is essentially logarithmic. The Times Roman font was chosen because it is similar in ap-
pearance and legibility to the styles of typefaces customarily used in newspapers and books
and because it has already been adopted by the British as the standard typeface for near-vi-
sion charts (11).
The Snellen near chart is expressed as the ratio between the test distance in centime-
ters and the distance in centimeters at which the stroke of the equivalent Landolt ring sub-

Figure 5.1 ETDRS visual acuity chart. This chart is valuable for LASIK studies, although it may
be less convenient than the Snellen chart for routine measurements of visual acuity.
74 Ang and Azar

tends 1 minute of arc. With the Sloan M system, a 1-M letter is defined as an optotype
whose height subtends a visual angle of 5 at a distance of one meter.
One of the main reasons why near acuity in the consulting room can be misleadingly
good is due to the high luminance of the chart and the high contrast of the print.
Furthermore, standardization in near vision tests has not been established with regard
to using text-reading or optotypes recognition. Test cards using the Jaeger system and the
point system also vary across different manufacturers, making standardization difficult.
The practical near acuity chart (PNAC) offers a quick but accurate way to measure
near acuity and shows a high degree of correlation with distance acuity, contrast sensitiv-
ity, and ability to read newsprint (12). The PNAC encompasses print sizes from large (N80,
such as newspaper headlines) to small (N5, such as telephone directory entries). It has a
regular increasing progression of print size and line spacing (0.1 logMAR). Three words
were used on each line; one three letter word, one four letter word, and one five letter word.
Thus each line has an equivalent task demand having 12 letters split into 3 words. The
words are easy to recognize by children and those with poor language and cognitive skills.
The PNAC uses the Times Roman font, as it is a print type commonly used in newspapers
and books. Paragraphs of the most commonly used print sizes are located on the reverse
side of the chart, so reading a set size of print can be practiced once the near acuity thresh-
old has been established. Although the PNAC only uses three words on each line, it was
shown to be as accurate as the BaileyLovie near chart. Near acuity threshold was mea-
sured in half the time using the PNAC than with the BaileyLovie chart. It was found that
most people can read newspaper headlines with a near acuity of N48 (1.4 logMAR), large
text (such as childrens books) with N20 (1.0 logMAR), and normal newspaper text with
N6 (0.5 logMAR) or better at 25 cm.

B. AUTOREFRACTORS
It is almost half a century since Collins reported the design and construction of the first ob-
jective infrared optometer. However, the first fully automated optometer, the Ophthal-
motron, did not appear until 1970 (13). Automated objective refractors that do not require
any operator or patient judgment have been available since then. These instruments are
easy to use and are much quicker than manual refraction.
An ideal objective refraction technique should be able to determine the actual
ametropia without dilating with cycloplegic agents. To achieve this, modern autorefractors
use fogging techniques to relax accommodation (Fig. 5.2). In most autorefractors, accom-
modation is relaxed only once prior to the start of the measurement (14).
Ghose believed that the automatic fogging system of some autorefractors cannot suf-
ficiently control accommodation (15). It is therefore still necessary to check and refine the
displayed readings by subjective refraction or retinoscopy. Autorefractors can be used as a
preliminary refraction or screening method because they provide a starting point for
retinoscopy or subjective refraction, but they cannot serve as a substitute for it.
During the 1970s and 1980s, several subjective autorefractors were introduced but
were not widely accepted because they were not quick and easy to operate and they did not
provide binocular or near point testing. Among the early models were the Humphrey Vi-
sion Analyzer and the American Optical SR III Subjective Refraction System (16). The
more recent autorefractors are quicker, easier to use, have good reliability and accuracy but
still do not provide for binocular balance or nearpoint testing and therefore could not serve
as substitutes for conventional refraction. Autorefractors have become an integral part of
Adjunctive Instrumentation in LASIK 75

Figure 5.2 Automated refractors are helpful in obtaining a rough idea of the patients refractive
error. They should not be used as the sole basis of LASIK treatments.

ophthalmological practice. They are simple enough to be used by technicians with a mod-
erate degree of training, they save time, and they serve as a complement to subjective re-
fraction.

1. Keratometry, Keratoscopy, and Corneal Topography

The indications for measuring corneal curvature and evaluating corneal topography include
contact lens fitting, biometry for determining the power of an intraocular lens, screening for
refractive surgery, evaluation of pathologies such as keratoconus, irregular astigmatism,
and contact lens warpage, identification of postlaser decentrations, central islands, regres-
sions, and postoperative assessment of astigmatism after penetrating keratoplasty and
cataract surgery. Currently, the corneal curvature can be quantified and assessed using the
manual keratometer, the automated keratometer, and videokeratoscopes such as the
Placido-based topography unit, the rasterphotogrammetry unit, and the scanning slit beam
system.
The anterior corneal surface behaves like a convex mirror and reflects light. This
property allows the keratometer to measure the size of the reflected image and to determine
the radius of curvature of the corneal surface (17,18).
The manual keratometer measures the dimensions of a virtual image from the corneal
reflection in two orthogonal meridians simultaneously. Dials indicating the principal cur-
vatures of a toric surface are adjusted with the end result of focusing and aligning reflective
mires thereby producing a virtual image with the same dimensions (19). The keratometer
has been used as the gold standard to which autokeratometers and corneal topography units
have been compared (20). Examples of manual keratometers are the Haag-Streit/Javal
Schiotz, the Bausch & Lomb (Fig. 5.3), the Carl Zeiss, and the Marco keratometer.
The limitations of the manual keratometer are that it assumes a spherocylindrical
cornea with a major and minor axis separated by 90 degrees; it does not provide informa-
tion about the cornea outside of a circle 2.8 to 4 mm in diameter where the measurements
76 Ang and Azar

Figure 5.3 Manual keratometer.

are taken, and corneal irregularities can distort the mires making measurements difficult or
impossible (17,18).
Autokeratometers utilize the same principles as the manual keratometer but use soft-
ware that electronically projects light onto the cornea and captures the reflections to pro-
duce keratometry readings. The Humphrey automated keratometer (Humphrey Instru-
ments, San Leandro, CA) uses three near-infrared light rays that are reflected off the
cornea. Three photodiode receptors receive the images and utilize vector algebra equations
to analyze and calculate the keratometry parameters. The Canon automated keratometer
projects a single keratoscope ring onto the cornea and analyzes the data in a similar man-
ner.
Several reports have compared the manual and automated keratometer. Tate et al.
found no statistical difference in the accuracy of the manual (Haag-Streit) and the auto-
mated (Humphrey, Canon) keratometers (21). Lusby et al. concluded that both keratome-
ters have been shown to give reproducible results on repeated measurements of the same
eye (22). Binder demonstrated that the Humphrey automated keratometer and the Bausch
& Lomb keratometer are comparable in their ability to measure abnormal corneal surfaces
following radial keratotomy and corneal transplantation (23). Because it is quick and easy
to operate, Nakada et al. recommended that the automated keratometer should be widely
used, especially when examining children (24). Automated keratometers have become
more popular than manual keratometers because they are accurate and reliable; they can
measure a larger range of curvatures and astigmatism, eliminate observer bias, produce a
hard copy of the results, and require less skill and less time to operate (25).
In 1993, Sanders et al. stated that videokeratoscopes were becoming invaluable tools
and predicted that they will replace keratometers in standard clinical practice (26). Their
prediction was based on experience in using keratometers and obtaining misleading ker-
atometric measurements from corneas that had asymmetric astigmatism, asymmetry after
radial keratotomy, and unusual variants of keratoconus. With the growing demand for re-
fractive surgery and increased applications in assessment of pathologies and postoperative
care, corneal topography units have indeed become indispensable diagnostic tools in oph-
thalmological practice. Videokeratoscopes offer several advantages over keratometers;
Adjunctive Instrumentation in LASIK 77

they do not assume that the cornea is spherocylindrical, they allow the assessment of the
peripheral cornea, and the images from the systems are digitized, analyzed quantitatively
with various softwares, and printed in color-coded images for easy interpretation.
Placido-based topography systems use a transilluminated Placido cone, an imaging
system that consists of a lens, a camera, a video grabber, and a computer system (17,18).
Illuminated concentric rings are centered and projected radially from the corneal apex. A
camera focuses on the image plane of the cornea and captures the image of the rings. Anal-
ysis of the size and displacement of the ring segments is used to calculate the slope of the
corneal surface. The accuracy of Placido-based units may be affected by intraobserver vari-
ability, interobserver variability, centration, alignment, calibration, and software errors.
Furthermore, a limitation of Placido systems is that elevation data is generated by fitting
the slope to a predefined mathematical model such as spheric, aspheric, or conic, which
may not be right for abnormal corneas. Systems currently in use may differ in the number,
thickness, and position of the rings, the cone design, the illumination, and the software that
they used. Examples of systems using Placido-based topography are the EyeSys, Tech-
nomed C-Scan, Topography Modeling System, Alcon EyeMap, and Humphrey Atlas (Fig.
5.4).
Rasterphotogrammetry defines elevation points by projecting a grid of known geom-
etry onto the corneal surface and analyzing the distortion from this pattern (17,18,20,27,28).
The PAR Corneal Topography System (CTS, PAR Vision Systems Corp., New Hartford,
NY) uses a stereotriangulation technique by utilizing flourescein on the tear film, project-
ing a grid pattern composed of horizontal and vertical lines spaced about 0.22 mm apart, and
viewing the light pattern from an offset angle. A CCD camera collects the reflected images
and the x, y, and z coordinates are determined from the geometry of the measured grid posi-
tion and instrument optics. The PAR CTS determines surface elevation without using the
shape assumptions necessary in Placido-based systems. It relies on projection on the floures-
cein film and therefore does not require a smooth reflective surface nor precise spatial align-
ment for accurate imaging, making it useful in corneas with scars, epithelial defects, or ir-
regular surfaces.

Figure 5.4 Compact placido-based corneal topographical unit.

78 Ang and Azar

Figure 5.5 An elevation-based topographical unit is useful in detecting substantial changes in the
posterior corneal surface and in measuring corneal pachymetry.

The scanning slit beam system is used by the Orbscan (Bausch and Lomb, Rochester,
NY; Fig. 5.5) to measure corneal surface elevation using stereotriangulation techniques
similar to the PAR CTS system (17,18,20). The examination takes 1.5 seconds wherein two
scanning slit lamps project 20 slit beams from the left and 20 slit beams from the right at
an angle of 45 degrees covering the whole cornea form limbus to limbus. A tracking sys-
tem locks on to the eye to minimize errors from involuntary eye movements during the ex-
amination. The software analyzes up to 240 data points per slit, enabling it to calculate and
produce more data. The Orbscan can provide information on the axial curvature of the an-
terior and posterior cornea, the elevation of the anterior and posterior corneal surface rela-
tive to the best fit sphere, and the corneal thickness on the entire cornea. The system yields
more information than Placido or rasterphotogrammetric systems because it takes mea-
surement of the posterior corneal surface as well (29). The Orbscan and the PAR CTS di-
rectly measure surface elevation and measure topography regardless of the orientation of
the eye, unlike the Placido-based systems.
Previous studies have attempted to determine the most reliable system to use in eval-
uating corneal curvature by comparing keratometers with corneal topography units and
corneal topography units among themselves.
In evaluating normal corneal power measurements, Hannush et al. reported that the
manual keratometer was more reproducible than the Corneal Modeling System and the
Corneascope (30). Moura et al. compared three computerized videokeratoscopy systems
with a manual keratometer and found that the most reproducible was the EyeSys, followed
by the manual keratometer, the PAR CTS, and the C-Scan Technomed (31). Jeandervin and
Barr, on the other hand, found no statistical differences in repeatability when comparing the
Alcon EyeMap, the EyeSys 2000, the Humphrey Mastervue, the Humphrey Atlas, and the
Marco manual keratometer (32). However, they observed that the EyeSys had the highest
repeatability and that the Humphrey Atlas was the most accurate system tested (32). Wil-
son et al. reported that the TMS was statistically more accurate in determining the power
of calibrated spheres at 1 mm from the apex, while the Corneal Analysis System (CAS,
EyeSys Laboratories, Houston, TX) was more accurate at 3 mm from the apex (33). These
Adjunctive Instrumentation in LASIK 79

small differences in accuracy between the EyeSys and the TMS were unlikely to be of clin-
ical significance. Tennen et al. did same-day measurements of the steepest and flattest pow-
ers of the central 3 mm of 200 eyes and found no statistical difference in reliability between
the Haag Streit, the Marco, the Alcon handheld keratometer, and the Corneal Analysis Sys-
tem (EyeSys Laboratories, Houston, TX) (34). With regard to elevation data, Priest and
Munger showed that the PAR CTS presented elevation measurements more accurately than
the TMS-1 (Topography Modeling System, Tomey Corp.). Unlike the PAR CTS, which
provides a direct measurement of elevation, errors made by the TMS-1 are the result of as-
sumptions made regarding the corneal shape and position (28). Schultze made a similar ob-
servation that the PAR CTS accurately provides peripheral elevation data on a model rep-
resenting an eye after PRK (35).
Numerous studies have presented data on the accuracy and reliability of different sys-
tems in evaluating corneal curvature. Perhaps the most significant observation was made
by Moura et al. They stated that whenever a particular system is used, it should be used con-
tinually for that patient, otherwise errors may be seen when interchanging and interpreting
data from one system to another (31).

D. PUPILLOMETRY
Sophisticated pupillometry video equipment, which can determine diameters to hundredths
of a millimeter, have been used in neuro-ophthalmic evaluation (36). In refractive surgery,
assessment of pupil diameters is important because despite excellent visual acuity, a well-
centered ablation zone, a good-looking postoperative topographical map, and the absence
of significant corneal haze, widely dilating pupils at low levels of illumination are prone to
halos, glare, and reduced night vision when the pupil dilates to a size larger than the abla-
tion zone. These symptoms should be anticipated, considered, and explained to the patient
before deciding to proceed with refractive surgery if the pupil size measurements in dim il-
lumination reveal that it can dilate to a size larger than the zone of treatment. Careful mea-
surement of scotopic pupil dilation is therefore an integral part of the preoperative evalua-
tion of the refractive patient.
Comparison pupillometry has been performed using the Rosenbaum card (Cleveland,
OH). It contains a series of increasing half-circle diameters denoted by 1.0 mm intervals
printed on one edge of the card. The examiner held the card temporal to the patients eye
in the corneal plane and matched the horizontal pupil diameter with the appropriate half-
circle. Pupil measurements were made in 1.0 mm steps unless the pupil appeared between
two half-circles on the card, and a 0.5 mm measurement interval was then made (37). The
Rosenbaum method was found to overestimate consistently the pupil diameter by 0.5 mm,
with a standard deviation of 0.6 mm. A conversion factor of subtracting 0.5 mm from the
measurement was found to be sufficient to adjust for this overestimation.
Because of the subjective nature of the measurements using the Rosenbaum card, in-
frared pupillometry is presumed to be more accurate in measuring the pupil, especially in
dark conditions. Hippus of the iris and the emotional state of the patient may sometimes af-
fect the pupil diameter and prevent obtaining the largest natural pupil diameter. But the in-
frared device allows a more objective assessment between examiners.
Infrared pupillometry was previously performed with the Iowa Pupillometer (Henry
Louis, Inc., Iowa City, IA) (37). The device consisted of a charged coupling device (CCD)
camera tuned for infrared detection and two infrared side lamps for pupil illumination. Us-
ing two vertical lines on the video monitor, calibration of the pupillometer was performed
80 Ang and Azar

for each subject before pupil measurements were made. The center of the monitor was used
for measurement because distortions in the peripheral monitor may induce measurement er-
ror. This device measured the horizontal pupils to 0.01 mm increments, and analysis was
performed rounding to the nearest 0.1 mm.
The Colvard pupillometer (Oasis Medical) is a handheld pupillometer that uses light
amplification technology (Fig. 5.6) (38). Low levels of light energy entering the device
stimulate a photocathode, which results in electron excitation. The electrons strike a phos-
phor screen, which intensifies the image. A lens system in the instrument brings the ante-
rior segment into focus, and a bright phosphorescent image of the anterior segment is vi-
sualized through the examiners ocular. A reticle in the device superimposes a millimeter
ruler over the enhanced image of the iris and the pupil to measure pupil diameter in a sco-
topic environment. Using the Colvard pupillometer, pupil dilation at the level of light typ-
ically encountered while driving on a suburban street at night, can be reproduced by turn-
ing off all the lights in a windowless examining room and opening the door 1 to 2 inches.
It was found that mean pupil size at 15 lumens was 5.1 mm (range 2.5 to 8.0 mm) and at 3
lumens was 6.2 mm (range 3.0 to 9.0 mm).
The Video Vision Analyzer (VIVA) pupillometer allows binocular measurement of
the dark adapted pupil (39). The subject sits 1 meter in front of and beneath the device and
fixates on a red light. Both eyes are focused on a rectangular field on the pupillometer dis-
play. Then a button is pressed, and the device automatically takes three images by infrared
light. By digital processing, the pupil diameter under scotopic light conditions is calculated.
Precise measurements within 0.3 mm at 1 meter are possible.
Several studies using the above-mentioned instruments have measured pupil diame-
ters under scotopic light conditions. Evaluation of the pupil size with the Rosenbaum card
detected a mean pupil size of 5.4  1.1 mm, with the IOWA infrared pupillometer 4.95
 1.08 mm, and with the Colvard pupillometer 6.2 mm (range 3.0 to 9.0 mm) (37,38). In a
recent study by Schnitzler, the mean scotopic pupil diameter was reported to be 6.08  1.16
mm with the Colvard pupillometer and 6.24  1.28 mm with the VIVA pupillometer. She
concluded that measurements with the VIVA pupillometer seem slightly overestimated,

Figure 5.6 Colvard pupillometer. Measurement can be optimized by controlling ambient illumi-
nation during pupil measurements.
Adjunctive Instrumentation in LASIK 81

whereas measurements with the Colvard delivered more similar data on scotopic pupil size,
indicating that measurements with the Colvard are more reliable and precise (39).
Pupil diameters have also been measured using topography devices including the
Technomed C-Scan, the Humphrey Masterview, and the Alcon EyeMap. The measure-
ments obtained were 3.35 mm (C-Scan), 2.96 mm (Masterview), 2.34 m (EyeMap), and
5.94 mm (mesopic condition). It was concluded that topography devices gave significantly
smaller pupil measurements than mesopic conditions because of the bright luminance of
the Placido rings. These instruments are not recommended in the determination of pupil di-
ameters prior to refractive surgery (37).

E. PACHYMETRY
Pachymetry is the measure of corneal thickness. It is essential to measure central corneal
thickness in myopic eyes before scheduling for LASIK surgery to ensure that the central
thickness is sufficient to prevent leaving the corneal bed too thin after treatment and prone
to ectasia. The residual bed depth is dependent on both the thickness of the flap and the
depth of laser ablation. The U.S. Food and Drug Administration (FDA) has recommended
that the residual thickness in the bed not be less than 250 m to avoid corneal ectasia (40).
Because of the variability of resection depths of different microkeratomes, calculations by
the surgeon should consider leaving a generous residual bed after resection and planned ab-
lation.
The electronic digital optical pachymeter used a depth measuring attachment for the
900 Haag Streit slit lamp and the 6090 package by Diagnostic Concept. It was calibrated
on PMMA lenses according to the method described by Mandell and Polse (4143). The
angle between the measuring eyepiece (right) and the illumination system of the optical pa-
chometer was set at 47.5. The Haag Streit optical pachymeter emphasized keeping the slit
beam of light perpendicular to the surface of the central cornea. Care was taken to ensure
that the slit of light that passed through the cornea bisected the pupil, both vertically and
horizontally, as seen by the split image during alignment. Ideally, the pupillary axis should
coincide with the pachometric one. Fluorescein was instilled in the eye and the measure-
ment done in darkness to increase contrast and facilitate alignment. Appropriate alignment
was attained when the internal boundary of the endothelium was continuous with the ep-
ithelium seen in the lower field of the pachometer (touch criterion). Alignment was
achieved when the reflecting images of the centration lights were aligned at the projected
slit and in front of the pupil center; 10 readings were then recorded on each eye (44,45).
The MishimaHedbys attachment could be utilized to improve the accuracy of the optical
method (46). The disadvantages of the optical pachymeter with the Haag Streit device are
that it is a subjective measurement wherein the examiner must make sure the slit of light is
perpendicular to the cornea when making the reading and that it requires the cooperation of
the patient in holding fixation during the duration of the measurement.
Ultrasonic pachymetry eliminates the disadvantages of the optical pachymeter since
it can take rapid measurements without asking the patient to hold still for a long time (Fig.
5.7). There is no examiner variability since the machine takes readings upon contact with
the cornea. It is easy to use and allows mapping of corneal thickness. In addition, the ul-
trasonic units are portable with small probe tips making possible intraoperative measure-
ments before proceeding with laser ablation.
The Humphrey ultrasonic pachometer model 8050 uses pulsed ultrasound to evalu-
ate corneal thickness. Although the location of the measurement is arbitrary, it is possible
82 Ang and Azar

Figure 5.7 Ultrasonic pachymetry. To be able to measure intraoperative corneal pachymetry, the
machine may require standardization in the range of 200 m.

to take peripheral measurements by direct touch of the probe to the cornea. The instrument
has automatic alignment properties so that the probe has to be within 3 from normal to the
posterior corneal surface for a thickness to be recorded. Other models (DGH Technology,
Inc., Exton, PA) have since been manufactured with variable features. The probe diameters
range from 1.6 to 3.0 mm. The probes emit and receive pulses with frequencies of 1220
MHz. Most instruments use a calibration speed of 1640 m/s. Some manufacturers sug-
gested 1550 as the correct sound velocity, although it has been reported that 1639 is the ve-
locity of sound through the human cornea at 37C (47). The probe has to be aligned as per-
pendicularly as possible to the cornea. Some pachymeters provide a tone or beep when
proper alignment or a measurement is obtained.
In a study by Salz et al., it was found that the optical pachymeter had two to three
times as much intrasession variation as that of the ultrasound pachymeters, significant in-
terobserver variation (P  0.015), and significant differences between left and right eye
thickness determinations (P  0.005). On the other hand, ultrasonic pachymeters showed
superiority by demonstrating high reproducibility, no interobserver variation, and no
left/right variation, in addition to its user- and patient-friendly features (45).
The Obscan Topography System (Orbtek, Inc.) is an optical scanning slit instrument
that provides both topographic analysis and pachymetric measurements in the same exami-
nation (Fig. 5.5) (48). This instrument is capable of measuring corneal thickness at any point
on the cornea with one procedure. Its sampling method takes into account a broader area of
the cornea than does the ultrasonic pachymeter. A calibrated video and scanning slit beam
system measures the position of several thousand points throughout the thickness of the
cornea. Computer analysis then converts these data into a topographic map of the corneal
surface and provides measurements of corneal thickness over the entire corneal surface, as
well as keratometric measurements and corneal power and elevation maps.
The Orbscan system is noninvasive, requiring no contact for data acquisition, but it
does require the patient to be able to sit at a chin rest while fixating for 1 to 3 seconds. Ul-
trasonic pachymetry, on the other hand, is associated with problems and limitations that the
Adjunctive Instrumentation in LASIK 83

Figure 5.8 A pneumatonometer is used to check the intraocular pressure after application of the
suction ring.

Orbscan system avoids. The ultrasonic pachymeter lacks fixation lights for precise control
of patient gaze during repeated measurements, so probe placement in a reproducible manner
is difficult and is markedly affected by the person performing the evaluation. Also, the speed
of sound may vary in edematous tissue compared with that in normally hydrated tissue.
In a study by Yaylali, it was found that the two devices were quite comparable in their
measurements in the same subjects, with the difference in corneal thickness between the
two devices ranging from 23 to 28 m (48).
Corneal pachymetry can also influence Goldmann tonometry. Use of a pneu-
matonometer (Fig. 5.8) may yield more accurate IOP measurements. See Chapter 27 for
more details.

F. INSTRUMENTATION
1. Eyelid Drape

Plastic disposable eyelid drapes are used to maintain sterility of the surgical field during
LASIK (Fig. 5.9A). The drape is applied after sterilizing the periocular area with a betadine
solution. Aside from sterility, the eyelashes can be moved out of the way and secured when
applying the adhesive on the eyelid. Retracting the adhesive along with the eyelid can aid
the speculum in providing adequate exposure to the globe. Patient comfort is not compro-
mised when breathing under the disposable drape. We have had good experience in using
the 15 inch  15 inch Steri-Drape (3M Healthcare, St. Paul, MN).

2. Speculum
Stable retraction of the eyelids and adequate exposure of the cornea are necessary in refrac-
tive surgery. This is even more critical in laser in situ keratomileusis (LASIK) because a pneu-
matic suction ring is applied on the globe during construction of the corneal flap. The ideal
speculum should provide maximal access to the globe, accommodate the pneumatic suction
 84

Figure 5.9 Intraoperative adjunctive instrumentation. (A) An eyelid drape is applied to ensure sterility and move the eye-
lashes out of the surgical field. (B) A wire speculum is used to provide maximal exposure of the globe for accommodating
Ang and Azar

the suction ring. (C) An RK marker may be used to place asymmetric peripheral corneal marks. The Chayet ring (D) is help-
ful in minimizing deposition of debris into the flap interface.
Adjunctive Instrumentation in LASIK 85

ring within the palpebral opening, allow for temporal and superior surgical approaches, and
provide maximum comfort when fully opened (49). Wire speculums are preferred over solid
blade speculums because they provide more space for applying the suction ring.
After applying the wire speculum, a few minutes are allowed to pass for the eyelids
to adjust to the pressure of the speculum. We have found it helpful to instill one or two ad-
ditional drops of topical anesthesia before completely opening the speculum. These ma-
neuvers minimize patient discomfort and enable the surgeon to maximize the capability of
the speculum in providing adequate exposure. If exposure is still inadequate, the globe can
be proptosed by exerting downward pressure on the arms of the speculum while applying
the suction ring.
Innovations in speculum design have been made to aid in providing better exposure
and added comfort to the patient. Among these are increased angulations in the arms of
the speculum to maximize globe exposure, heavy duty wire bases strong enough to resist
powerful eyelid squeezing, and suction attachments to remove tears and debris from
the surgical area. Popular designs available are the Barraquer wire speculum, the Lieber-
mann Adjustable wire speculum (Fig. 9B), the Machat adjustable speculum (ASICO, West-
mont, IL), the Slade speculum (ASICO), and the Lindstrom-Chu Aspirating speculum
(Rhein).

3. Nonfragmenting Merocel Sponges and Rings

The Chayet ring is an oval sponge with a 10 mm circular opening in the center and a tail in
one of its long ends (Fig. 5.9D). It is placed on the eye after construction of the LASIK flap
with the tail oriented on the opposite meridian across the flap hinge. It has three main uses.
First, it serves as a soft, lint-free bed where the epithelial side of the LASIK flap rests dur-
ing laser ablation. Second, it prevents fluid and debris outside the sponge area from gain-
ing access to the interface during the ablation and flap repositioning steps. Third, it sucks
excess fluid during interface irrigation and floating, preventing flooding of the flap area.
Some surgeons prefer to use a semicircular sponge, which they position in the hinge region
to rest the flap during ablation. The Chayet LASIK drainage rings are manufactured by Vis-
itec (Becton Dickinson and Company, Franklin Lakes, NJ) and Solan (Medtronic, Jack-
sonville, FL).
It is essential to use a nonfragmenting sponge (Merocel, Xomed Surgical Products,
Jacksonville, FL; Fig. 5.10A) throughout the LASIK surgery to avoid any lint fiber from
being left on the flap interface. The Merocel sponge can be used to wipe off any debris,
blood, or fluid on the exposed stroma prior to laser ablation, aspirate excess fluid within the
Chayet ring, and iron the flap during flap repositioning.

4. Markers and Marking Pens

Corneal epithelial marks are placed in the paracentral area of the cornea prior to creation of
the flap with the microkeratome. These marks serve as a guide in realigning the flap after
laser ablation. In the event of a free flap, the marks will help in replacing and repositioning
the flap and aid in orienting which side is epithelial and stromal. The design of optical zone
markers and the marks they create can be circular (Fig. 5.9C), radial, or a combination of both
shapes. Among the popular markers are those designed by Machat, Chayet, Burrato, and
Slade. It is important that the marks be still visible upon flap repositioning but slowly fade a
few hours after the surgery. The marker can be dipped in a gentian violet inkpad (Visitec,
Becton Dickinson and Co., Franklin Lakes, NJ) or painted with a gentian violet marking pen
86 Ang and Azar

Figure 5.10 (A) A Merocel sponge is used to wipe off any blood from the exposed stromal bed
and to sweep the flap during repositioning. (B) A nontoothed forceps is used to lift the flap. (C) A
Machat retreatment spatula and a jewelers forceps are used to locate the interface plane and dissect
the flap edge. (D) A Fechtner conjunctival ring forcep is used to grasp the flap edge and lift the flap.
The same nontoothed forceps can be used to reposition the flap. (E) An irrigating cannula is used to
hydrate the stroma after ablation and to float the flap and avoid wrinkles. Illustrated is a straight dis-
posable cannula. Several surgeons prefer curved cannulae (to conform to the curvature of the corneal
stromal bed). (F) A Pineda iron is helpful to iron flap wrinkles especially during LASIK retreatment
procedures.
Adjunctive Instrumentation in LASIK 87

(Devon Skin Markers, Graphic Controls, Buffalo, NY). The marking pen is also useful when
placing marks on the flap edge prior to lifting during retreatments.

5. Flap Forceps and Spatulae

Forceps are used to elevate and flip over the flap before and after laser ablation. This can
be achieved without grasping the flap, thereby avoiding any unnecessary trauma
(Fig. 5.10B). Virtually any design, whether angled or curved, with or without a tying
platform, can be used, since the ends preferably remain apposed during flap manipulation.
Spatulas are as efficient as forceps in lifting and manipulating the LASIK flap with
minimal trauma.
For retreatment purposes, the Machat LASIK retreatment spatula (ASICO) has a
semisharp angulated tip at one end to lift the LASIK flap edge (Fig. 5.10C). The short, fine
tip on the other end can be used for dissection along the Bowmans layer without excessive
insertion of the instrument underneath the flap. We have found that an ordinary jewelers
forcep can be as effective in dissecting the flap edge and locating the interface plane. For
peeling and lifting the flap, we use a Fechtner conjunctival ring forcep (Moria), which gives
the surgeon a firm grasp of the flap during this maneuver but does not cause perforation or
tearing of tissue even when a gentle pulling force is exerted (Fig. 5.10D).

6. Irrigating Cannulae
An irrigating cannula is used to irrigate under the flap, wash out any interface debris, and
float the flap into the correct position. The diameter of the cannula can range from gauge
26 to 30 and the length and angulation can be variable depending on the designer and man-
ufacturer (Fig. 5.10E). Some cannulas have spatulated or flattened tips to allow for easy in-
sertion underneath the LASIK flap. Other innovations are side ports or multiple openings
for diffuse irrigation and effective floating of the flap. Examples of specialized cannulas are
the 26 gauge Slade cannula (ASICO) with a spatulated tip, the 25 gauge Buratto cannula
(ASICO), and the Kritzinger needle (Storz). Our preference is a 22 mm 30 gauge Rycroft
anterior chamber cannula (Becton Dickinson and Co., Franklin Lakes, NJ), which provides
easy insertion into the flap interface and gentle controlled irrigation (Fig. 5.10E). Excessive
irrigation should be avoided because it can cause delayed flap adherence and stromal
hydration.

7. Intraoperative Tonometry and Pachymetry

To create a smooth flap with suitable thickness, it is believed that the suction ring should
increase the intraocular pressure to at least 65 mmHg. To ensure that this is consistently
achieved, the pressure needs to be checked prior to advancing the microkeratome to resect
the flap. The Barraquer applanation tonometer is a popular instrument that has been used
to evaluate the intraocular pressure (50). The design of this instrument is an inverted
methacrylate cone. It weighs approximately 10 grams and is calibrated according to Mak-
lakovs principle with the Posner scale. The superior surface is convex, with a radius of
22.15 mm to magnify the image obtained on the lower portion, which is flat and has a thin
circular sulcus. When the eye pressure reaches 65 mmHg, the 10 gram tonometer flattens
a circular area 3.8 mm in diameter corresponding to the diameter of the circular mire en-
graved on the applanation surface. An applanated area smaller than the mire on the tonome-
ter indicates a pressure of at least 65 mmHg, which is adequate for flap resection. If the ap-
88 Ang and Azar

planated area is larger than the mire, reflecting an intraocular pressure of less than 65
mmHg, the suction should be discontinued, the tonometer checked to ensure dryness to
avoid false readings, and the ring reapplied. If the readings are still inadequate, the proce-
dure should be aborted and all the instruments checked.
The pneumatonometer (Model 30 Classic, Medtronic, Jacksonville, FL) is an alter-
native, easy-to-use instrument with tonometry functions (Fig. 5.8; also see Fig 12.3.C). It
utilizes a pneumatic sensor, consisting of a piston floating on an air bearing, that is touched
to the anesthetized cornea. A precisely regulated flow of filtered air from an internal pump
enters the piston. A small 5 mm fenestrated membrane (soft silicone tip) at the end of the
piston reacts both to the force of the air blowing through it and to the force represented by
the pressure behind the cornea, against which it is pressed. The balance between these two
forces represents the intraocular pressure, and it is displayed on the screen. The system
records pressures in the range of 5 to 80 mmHg. The pneumatonometer allows us to eval-
uate the adequacy of suction by displaying real-time readings of the progressive rise in in-
traocular pressure. Should the steady rise of pressure falter, the suction can be discontinued
and reapplied right away. There is also no added variable of maintaining a dry cornea,
which could give false readings.
In order to avoid excessive laser ablation and subsequent corneal ectasia, the use of
intraoperative ultrasound or optical pachymetry is increasing in patients with high myopia
or thin corneas (Fig. 5.7). See chapter 10 for details.

8. Iron and Scrapers

Irons are used to exert localized pressure on the corneal surface and flatten folds or wrinkles
on the flap interface. The basic design consists of a smooth metallic stump with a flat sur-
face and rounded edges. A scraper is an instrument with sharpened edges developed to
remove corneal epithelium mechanically. It is used in conjunction with an iron, since it is
believed that if the epithelium above the wrinkle is not scraped and removed, it will not al-
low horizontal expansion and flattening of the area where the wrinkle is localized. Examples
of irons are the Pineda LASIK Iron (Fig. 5.10F) and the Herzig LASIK Depressor (ASICO).

REFERENCES
1. F Ricci, C Cedrone, L Cerulli. Standardized measurement of visual acuity. Ophthalmic Epid
1998;5:4153.
2. IL Bailey, JE Lovie. New design principles for visual acuity letter charts. Am J Optom Phys Opt
1976;53:740744.
3. JB Sprague, LA Stock, J Connett, J Bromberg. Study of chart designs and optotypes for
preschool vision screeningI. Comparability of chart designs. J Pedia Ophthalmol Strab
1989;26:189197.
4. G Strong, GC Woo. A distance visual acuity chart incorporating some new design features.
Arch Ophthalmol 1985;103:4446.
5. LL Sloan. Needs for precise measurements of acuity. Arch Ophthalmol 1980;98:286290.
6. B McAllister. Two distance acuity charts for the partially sighted. J Vis Rehab 1987;1:2732.
7. FL Ferris III, A Kassoff, GH Bresnick, I Bailey. New visual acuity charts for clinical research.
Am J Ophthalmol 1982;94:9196.
8. Macular Photocoagulation Study Group. Argon laser photocoagulation for neovascular macu-
lopathy: three year results from randomized clinical trials. Arch Ophthalmol 1986;104: 694701.
Adjunctive Instrumentation in LASIK 89

9. GO Waring, SD Moffitt, H Gelender. Rationale for a new design of the National Eye Institute
Prospective Evaluation of Radial Keratotomy (PERK) study. Ophthalmology 1983;90:4058.
10. A Arditi, R Cagenello. On the statistical reliability of letter-chart visual acuity measurements.
Invest Ophthalmol Vis Sci 1993;34:120129.
11. IL Bailey, JE Lovie. The design and use of a new near-vision chart. Am J Optom Phys Opt
1980;57:378387.
12. JS Wolffsohn, AL Cochrane. The practical near acuity chart (PNAC) and prediction of visual
ability at near. Ophthal Physiol Opt 2000;20:9097.
13. ICJ Wood. A review of autorefractors. Eye 1987;1:529535.
14. W Wesemann, B Dick. Accuracy and accommodation capability of a handheld autorefractor. J
Cataract Refract Surg 2000;26:6270.
15. S Ghose, BK Nayak, JP Singh. Critical evaluation of the NR-1000F autorefractometer. Br J
Ophthalmol 1986;70:221226.
16. DA Goss, T Grosvenor. Reliability of refractiona literature review. J Am Optom Assoc 1996;
67:619630.
17. EJ Cohen, MW Belin, MJ Mannis. Corneal topography. Ophthalmology 1999;106:1628
1638.
18. DT Azar, M Salvat, A Benson. Curr Opin Ophthalmol 1996;7:8393.
19. PS Binder. Videokeratography. CLAO J 1995;21:133144.
20. B Seitz, A Behrens, A Langenbucher. Corneal topography. Curr Opin Ophthalmol 1997;8:824.
21. GW Tate, A Safir, CZ Mills, JE Bowling, JL McDonald, MR Craig. Accuracy and repro-
ducibility of keratometry readings. CLAO J 1987;13:5058.
22. FW Lusby, JW Franke, JM McCaffery. Clinical comparison of manual and automated ker-
atometry in a geriatric population. CLAO J 1987;13:119121.
23. PS Binder. Measurement of corneal curvature after corneal transplantation and radial kerato-
tomy using standard and automated keratometry. CLAO J 1989;15:201205.
24. S Nakada, M Tanaka, A Nakajima. Comparison of automated and conventional keratometers.
Am J Ophthalmol 1984;97:776778.
25. VN Jarvis, R Levine, PA Asbell. Manual vs. automated keratometry: a comparison. CLAO J
1987;13:235237.
26. DR Sanders, JP Gills, RG Martin. When keratometric measurements do not accurately reflect
corneal topography. J Cataract Refract Surg 1993;19:131135.
27. MW Belin, JL Cambier, JR Nabors, CD Ratcliff. PAR corneal topography system (PAR CTS):
the clinical application of close range photogrammetry. Optom Vis Sci 1995;72:828837.
28. D Priest, R Munger. Comparative study of the elevation topography of complex shapes. J
Cataract Refract Surg 1998;24:741750.
29. Z Liu, AJ Huang, SC Pflugfelder. Evaluation of corneal thickness and topography in normal
eyes using the Orbscan corneal topography system. Br J Ophthalmol 1999;83:774778.
30. SB Hannush, SL Crawford, GO Waring III, MC Gemmill, MJ Lynn, A Nizam. Reproducibil-
ity of normal corneal power measurements with a keratometer, photokeratoscope, and video
imaging system. Arch Ophthalmol 1990;108:539544.
31. RC Moura, BL Bowyer, S Stevens, JJ Rowsey. Comparison of three computerized videoker-
atoscopy systems with keratometry. Cornea 1998;17:522528.
32. M Jeandervin, J Barr. Comparison of repeat videokeratography: repeatability and accuracy. Op-
tom Vis Sci 1998;75:663669.
33. SE Wilson, SM Verity, DL Conger. Accuracy and precision of the Corneal Analysis System
and the Topographic Modeling System. Cornea 1992;11:2835.
34. DG Tennen, RH Keates, C Montoya. Comparison of three keratometry instruments. J Cataract
Refract Surg 1995;21:407408.
35. RL Schultze. Accuracy of corneal elevation with four corneal topography systems. J Refract
Surg 1998;12:100104.
90 Ang and Azar

36. PA Bloom, D Papakostopoulos, Y Gogolitsyn, JA Leenderz, S Papakostopoulos, RH Grey.

Clinical and infrared pupillometry in central retinal vein occlusion. Br J Ophthalmol 1993;
77:7580.
37. BS Wachler, RR Krueger. Agreement and repeatability of infrared pupillometry and the com-
parison method. Ophthalmology 1999;106:319323.
38. M Colvard. Preoperative measurement of scotopic pupil dilation using an office pupillometer.
J Cataract Refract Surg 1998;24:15941597.
39. EM Schnitzler, M Baumeister, T Kohnen. Scotopic measurement of normal pupils: Colvard
versus Video Vision Analyzer infrared pupillometer. J Cataract Refract Surg 2000;26:859866.
40. FW Price, DL Koller, MO Price. Central corneal pachymetry in patients undergoing laser in situ
keratomileusis. Ophthalmology 1999;106:22162220.
41. AC Snyder. Optical pachometry measurements: reliability and variability. Am J Optom Phys-
iol Opt 1984;61:408413.
42. RB Mandell, KA Polse. Keratoconus: spatial variation of corneal thickness as a diagnostic test.
Arch Ophthalmol 1969;82:182188.
43. PS Binder, JA Kohler, DA Rorabaugh. Evaluation of an electronic pachometer. Invest Oph-
thalmol Vis Sci 1977;16:855858.
44. C Giasson, D Forthomme. Comparison of central corneal thickness measurements between op-
tical and ultrasound pachymeters. Optom Vis Sci 1992;69:236241.
45. JJ Salz, SP Azen, J Berstein, P Caroline, RA Villasenor, DJ Schanzlin. Evaluation and com-
parison of sources of variability in the measurement of corneal thickness with ultrasonic and op-
tical pachymeters. Ophthalmic Surg 1983;14:750754.
46. S Mishima, BO Hebdys. Measurement of corneal thickness with the Haag Streit pachymeter.
Arch Ophthalmol 1981;80:710713.
47. DZ Coleman, FL Lizzi, RL Jack. Ultrasonography of the eye and orbit. Philadelphia: Lea and
Febiger, 1977, pp 113114.
48. V Yaylali, SC Kaufman, HW Thompson. Corneal thickness measurements with the Orbscan
Topography System and ultrasonic pachymetry. J Cataract Refract Surg 1997;23:13451350.
49. LE Probst. LASIK instrumentation. In: J Machat, S Glade, L Probst, eds. The Art of LASIK.
Thorofare, NJ: Slack, 1999, pp 7378.
50. L Buratto, S Brint, M Ferrari. Surgical instruments. In: L Buratto, SF Brint, eds. LASIK prin-
ciples and techniques. Thorofare, NJ: Slack, 1998, pp 3568.
 6
LASIK Indications, Contraindications,
and Preoperative Evaluation

RICHARD E. BRAUNSTEIN and MARC WINNICK

Columbia University College of Physicians and Surgeons,
Harkness Eye Institute, New York, New York, U.S.A.
KENNETH A. GREENBERG
Columbia University College of Physicians and Surgeons, New York,
New York, U.S.A.

A. INTRODUCTION

Corneal refractive procedures are currently widely applied to correct ametropia. A suc-
cessful refractive procedure is gauged by many criteria: safety, efficacy, predictability, and
long-term stability. Laser-assisted in-situ keratomileusis (LASIK) is presently the most
widely performed refractive procedure, but it is not appropriate for all patients. Optimal re-
sults are achieved through proper patient selection, education, examination, and consent. A
complete understanding of the risks of the procedure and the effects of pre-existing ocular
conditions are critical in selecting patients for surgery. The ability to recognize subtle ocu-
lar conditions through careful patient examination will reduce the likelihood of complica-
tions. Finally, helping patients have realistic expectations and the ability to say no to pa-
tients who clearly are poor surgical candidates are the keys to building a successful LASIK
practice. This chapter will outline the present refractive indications for LASIK with special
attention given to the preoperative evaluation and patient preparation prior to refractive
surgery. Clinical tips for maximizing refractive outcomes and contraindications to LASIK
will be discussed.

91
92 Braunstein et al.

B. INDICATIONS

Laser in situ keratomilieusis may be considered for patients who are dependent on optical
correction of various refractive errors who desire to reduce or eliminate their dependence
on glasses or contact lenses. In the United States, FDA approval for LASIK is a confusing
issue for surgeons and patients alike. The FDA does not approve procedures, it only ap-
proves drugs and devices. How those drugs and devices are used after approval is up to
physicians under a provision known as the practice of medicine. The FDA labels the de-
vices and drugs according to the information provided by the developers and serves as a
guide for their use. The specific approval guidelines for LASIK are different for each ex-
cimer laser manufacturer based on data from FDA clinical trials. The approval range of re-
fractive errors is only one criterion of judging a prospective candidate, as patients who fall
within the guidelines may not qualify for surgery owing to other conditions (e.g., thin
cornea or flat cornea).
The excimer laser is currently approved for a wide range of myopia, myopic astig-
matism, and hyperopia. Many studies indicate that the predictability of LASIK decreases
with increasing preoperative myopia and astigmatism (1). Hyperopia ranging up to 6
diopters is correctible, but at higher levels of attempted correction, predictability is again
reduced (2). For hyperopia greater than 6 diopters, loss of spectacle-corrected visual acu-
ity occurred in a significant number of eyes in some studies, and accuracy was sufficiently
poor to advise against LASIK in these eyes (3). Approval for treatment of hyperopic astig-
matism and mixed astigmatism is expected in the near future.

C. CONTRAINDICATIONS

Contraindications for LASIK include patients with systemic collagen vascular disease, im-
munodeficiency, autoimmune disease, severe atopy, and diabetes mellitus, diseases all
likely to affect corneal wound healing. Patients who have unstable refractive errors or sig-
nificant pre-existing ocular pathology of the cornea or anterior segment including but not
limited to scarring, severe dry eye syndrome, uncontrolled blepharitis, uveitis, or early
cataract should also not have laser vision correction. Surgery should not be performed on
women who are pregnant or nursing or on patients taking Amiodarone or Acutane. LASIK
is contraindicated in eyes with a history of herpes simplex keratitis or herpes zoster oph-
thalmicus. Special concern should be given to eyes with corneal neovascularization within
1 mm of the ablation zone and those patients with difficult anatomy including small orbital
aperture, narrow interpalpebral fissure or deep-set eyes. Patients with keratoconus or kera-
toconus suspects should not have LASIK surgery. Finally, patients with signs of anterior
basement membrane dystrophy may be better served with photorefractive keratectomy
(surface ablation) rather than LASIK, as the likelihood of an intraoperative epithelial de-
fect may create numerous postoperative management difficulties.
The cornea should not be flattened to less than 33 D or steepened to greater than 52
D, as refractive outcomes in this range are less predictable (4). To determine the postoper-
ative corneal curvature, the preoperative keratometry is reduced or increased by the amount
of desired correction at the corneal plane. All candidates for LASIK procedures should
have a stable refraction for at least 12 months prior to the procedure differing by no more
than 0.50 diopter in manifest sphere or manifest cylinder. For hyperopic patients, manifest
and cycloplegic refraction should not differ more than 0.75 diopter.
LASIK Indications, Contraindications and Preoperative Evaluation 93

D. IATROGENIC KERATECTASIA
LASIK alters both the shape and the structural integrity of the cornea. Preoperative evalu-
ation involves determining what the resultant corneal curvature and residual stromal thick-
ness will be, prior to proceeding with surgery. Preoperative corneal thickness is of particu-
lar concern in preventing iatrogenic keratectasia. Post LASIK keratectasia results in a
progressive central corneal steepening and myopic shift causing irreversible damage by one
year. It occurs in approximately 1 in 1000 eyes (5). Preoperative assessment of corneal
thickness, flap and resultant stromal bed thickness, and amount of desired ablation are es-
sential to prevent such ectasias. The average thickness of the human cornea is 520 microns,
and an average flap created by a microkeratome is from 130 to 160 microns. The keratec-
tomy depth of the excimer laser ablation on average must not exceed 45 to 120 microns
with 325 (conservative case) to 250 microns, respectively, left in the stromal bed (6). This
sparks questions regarding the minimal thickness of residual stroma, which needs to be
maintained to prevent keratectasia. Many LASIK surgeons currently employ a 250 micron
limit to the residual stromal bed following LASIK, but this is only an average value, and
the biomechanical constants of the human cornea vary over a wide range, so that the range
of residual corneal thickness that would prevent keratectasia is unknown. Some advocate
using a percentage of the corneal thickness as a minimal residual stromal thickness rather
than an absolute number, given ultrasound pachymetry measurement errors and biome-
chanical considerations, such as the deeper stroma having less tensile strength compared to
the anterior layers (6). This dilemma can ultimately be resolved when we are better
equipped to measure the biomechanical constants of the cornea in vivo. Promising ap-
proaches such as mechanical spectroscopy and measurement of birefringence of the cornea
can assist in future determination of preoperative stromal bed thickness, which would be
necessary to avoid iatrogenic keratectasia. The residual stromal bed following a LASIK
procedure should be calculated prior to surgery based on a nonnomogram adjusted treat-
ment of the refractive error to be corrected.

E. THE CONSULTATION VISIT

Preoperatively, each patient must have a complete evaluation including a medical, surgical,
and ocular history as well as an ocular examination. A general medical history with em-
phasis on the above-mentioned systemic diseases should be discussed and a medication list
obtained. Past ocular surgery and any previous or existing ophthalmic conditions, such as
glaucoma, dry eye, amblyopia, and past contact lens use, should be reviewed.
An initial preoperative evaluation for LASIK in contact lens wearers should be per-
formed at least two weeks after discontinuation of soft contact lenses or at least three weeks
after discontinuation of soft toric, hard, or rigid gas permeable lenses. Patients wearing
rigid lenses must demonstrate keratometric and refractive stability prior to treatment. It
may be necessary to discontinue contact lenses in these patients at least one month for ev-
ery decade of contact lens use. Previous glasses and contact lens prescriptions should be
compared to the manifest refraction.

F. VISUAL ACUITY AND REFRACTION

Uncorrected and best corrected visual acuity should be assessed. A careful refraction is crit-
ical to maximizing refractive surgery outcomes. Different refraction techniques are appli-
94 Braunstein et al.

cable to different refractive errors. When refracting the myope, a resolution-based refrac-
tion should be performed to avoid overcorrections. A resolution-based end point involves
using the least minus lens to visualize the most letters. The refraction is not terminated at
20/20 if an additional 0.25 diopters yields several letters on the 20/15 line. The Jackson
Cross cylinder is used to determine the maximal amount of cylinder. The correct axis of the
cylinder is easier to determine in eyes with higher degrees of astigmatism. Occasionally,
autorefraction may be helpful in finding the astigmatic axis. Care should be taken to ensure
that the trial lens frame or phoropter is appropriately positioned and level to define the axis
most accurately.
Hyperopic manifest refraction should emphasize a push plus technique. Patients
are encouraged to accept the most plus sphere to see the most letters. Cycloplegic refrac-
tion with 1% cyclopentolate should be performed on all patients because it eliminates ac-
commodation. This is essential to identify the overminused myope and to uncover latent
hyperopia. For patients with hyperopia, manifest and cycloplegic examination should dif-
fer by 0.75 diopter or less. If a large amount of latent hyperopia is identified or if there is a
significant discrepancy between the manifest and cycloplegic refraction in a myope, a post
cycloplegic manifest refraction should be performed with an emphasis on pushing addi-
tional plus power. Occasionally, glasses may be prescribed temporarily to help the patient
accept the additional plus power prior to performing surgical correction.
A clinical workup should include manual keratometry, a pupillary examination, and
a slit lamp examination with emphasis on any lid margin inflammation, corneal epithelial
disease, basement membrane dystrophy, or stromal scars consistent with prior keratitis.
Tonometry should be performed on all patients and gonioscopic examination on all hyper-
opes. Central corneal pachymetry readings should be performed on all patients. A careful,
dilated fundus examination is performed to analyze the optic nerve and retina for any
pathology with careful attention to the peripheral retina in highly myopic eyes that may be
at risk for lattice degeneration. Identified retinal tears or large areas of lattice may require
laser photocoagulation prior to performing LASIK (7).
Special attention should be given to the pupillary examination in myopic and partic-
ularly astigmatic patients. Pupil size should be measured in dim and in bright lighting con-
ditions and recorded. Measurement can be made with a pupil gauge or with an infrared
pupillometer. Patients with higher degrees of refractive error and larger pupils may be at
greater risk for postoperative night vision disturbances, although this remains a subject of
great controversy (3).

G. CORNEAL TOPOGRAPHY

Corneal topography is essential in all patients prior to refractive surgery. Topography is used
to identify patients with corneal curvature abnormalities that are not apparent on slit lamp
examination. True keratoconus is often easy to detect by clinical history and examination,
but subclinical cases may only be apparent by corneal topography. Corneal topography is
necessary to determine whether patients have contact lens related warpage and to help de-
termine when a cornea is stable following contact lens discontinuation. We recommend that
any patient who wears contact lenses have corneal topography repeated 1 week apart to as-
certain stability prior to surgery. Topography is also used to verify postoperative results and
complications such as decentrations, central islands, and irregular astigmatism.
LASIK Indications, Contraindications and Preoperative Evaluation 95

H. DISCUSSION OF SPECIFIC CONDITIONS

1. The Keratoconus Suspect
Keratoconus is a noninflammatory bilateral corneal ectasia that produces irregular astig-
matism and leads to marked refractive error. Clinical signs differ depending on the sever-
ity of the disease. External signs include Munsons sign and the Rizzuti phenomenon. Slit
lamp findings include a Fleischers ring, Vogts striae, stromal thinning and scarring,
prominent corneal nerves, and epithelial nebulae. Retroillumination signs include scissor-
ing on retinoscopy, which is often the first evidence of early keratoconus, and an oil droplet
sign. Early in the disease, many corneas appear normal on slip lamp biomicroscopy. Sev-
eral devices are currently available for detecting early keratoconus. Simple, inexpensive
devices such as a handheld keratoscope can show egg-shaped or inferocentral compression
of mires, which may be indicative of early keratoconus. Ultrasonic pachymetry to demon-
strate central and peripheral corneal thickness has been studied, and although it is highly
accurate and reproducible for measuring corneal thickness, its use has failed to identify a
large percentage of patients with clinically obvious keratoconus, and it should only be used
as corroborative evidence for the diagnosis of keratoconus (8).
Computer-assisted videokeratoscopes, which generate color-coded maps and topo-
graphic indices, are an excellent tool for the diagnosis of keratoconus even when signs of
the disease are not obviously apparent at the slit lamp. Three features of keratoconus are
common to video keratography; a localized area of increased surface power, inferiorsu-
perior power asymmetry, and skewed steep radial axes above and below the horizontal
meridian depicting irregular astigmatism. Much work has been done to quantify the mini-
mal topographic criteria for diagnosing keratoconus. One method is pattern recognition and
one specific topographic pattern, asymmetic bow tie with skewing of the radial axis above
and below the horizontal meridian, was found by Rabinowitz in virtually 100% of patients
with clinical keratoconus. This pattern could represent the earliest sign of irregular astig-
matism and might be a reasonable cutoff point in the transition from normal topography to
keratoconus (9). The second method, the use of quantitative videokeratography derived in-
dices, may represent a more reproducible way to quantify keratoconus and its early pheno-
types. Maeda and coauthors devised an expert system classifier, utilizing an analysis of
eight topographic indices derived from the TMS videokeratoscope. A linear determinant
function is used to determine a composite discriminant value for each map: the KPI. A KPI
value greater than the optimum cutoff is classified as keratoconus (10). Rabinowitz de-
scribed a KISA% index, a quantitative videokeratographic algorithm embodying minimal
topographic criteria for diagnosing keratoconus. Using a combination of four indices: cen-
tral K, an expression of central corneal steepening; the I-S value, an expression of infe-
riorsuperior dioptric asymmetry; the AST index, which quantifies the degree of regular
corneal astigmatism; and the SRAX index, the skewed radial axial index, the KISA index
is derived. Kisa%  K  I-S  AST  SRAX  100 (11). This has been shown to have
excellent preliminary clinical correlation and can be used by surgeons to determine a pa-
tients chance of having early keratoconus. A single index with excellent clinical correla-
tion would be optimal to depict early keratoconus and warn a refractive surgeon of poten-
tial intra- and postoperative risks and complications. The formulation of these indices are
still being altered to improve accuracy and at present should be used with appropriate clin-
ical correlation including slit lamp biomicroscopy, pachymetry, retinoscopy, and keratom-
etry to determine the relative risk of laser refractive surgery. Patients with keratoconus or
96 Braunstein et al.

those who are likely keratoconus suspects are not candidates for LASIK using present al-
gorithms and treatment profiles and should be considered to have a progressive corneal dis-
ease. Patients with asymmetric bow tie astigmatism and inferior steepening who do not ap-
pear to have keratoconus may be treated surgically with appropriate informed consent.

2. The Incipient Cataract

The incipient cataract patient requires special consideration. Cataract extraction should be
viewed as both a media clearing surgery and a refractive surgery. Progression of central vi-
sual axis opacity will decrease the best corrected visual acuity post laser and result in a pa-
tient unhappy with LASIK and in need of a second surgical procedure. It is therefore rec-
ommended that the best corrected visual acuity be assessed preoperatively and the effect of
the incipient cataract on visual acuity be determined. If it is believed that the cataract is sig-
nificant or is progressing rapidly, laser vision correction should not be performed, and con-
sideration may be given to cataract surgery, if appropriate. Although phacoemulsification
can be performed on an eye that has had LASIK, the intraocular lens power calculation can
be problematic, and a more reliable refractive outcome may be achieved with lens extrac-
tion and intraocular lens implantation (12).

3. The Dry Eye Patient

Patients with a history of dry eye symptoms and contact lens intolerance frequently seek
laser vision correction. Dry eye symptoms and corneal epithelial staining are common
problems following LASIK. The mechanism of this disorder following surgery is not well
understood, although alteration of corneal innervation following LASIK is the most likely
cause. Evaluation of these patients includes assessment of tear film quality and breakup as
well as corneal epithelial integrity. Patients with evidence of corneal staining should be
treated preoperatively. Management may include topical lubricants, punctal occlusion, and
occasionally oral doxycycline if the patient has evidence of meibomian gland dysfunction.
Schirmers testing has not been shown to be predictive of postoperative dry eye problems
following LASIK.

4. The Glaucoma Suspect

If preoperative screening identifies a patient with elevated intraocular pressure or optic
nerve head cupping, focal ischemia, or hemorrhage, a 24-2 Humphrey visual field is rec-
ommended, and further testing or consultation is necessary to determine if indeed the pa-
tient has glaucoma. If the patient has glaucoma, LASIK should not be performed. Patients
who are glaucoma suspects by family history, borderline elevated intraocular pressure, or
mild disc asymmetry must be treated cautiously. If the patient does not have glaucomatous
optic neuropathy, and a diagnosis of glaucoma is considered unlikely, they may be consid-
ered for laser vision correction. However, informed consent discussing the potential re-
duced value to tonometry measurement must be discussed with the patient.
In general, the validity of applanation tonometry following laser vision correction is
less accurate and ultimately may limit the ability to treat glaucoma in selected patients.
Falsely low intraocular pressure measurements are obtained by applanation due to easy
compressibility of the fluid-filled space between the corneal flap and the stromal bed and
the direct relationship between corneal thickness and Goldman applanation tonometry (13).
In addition, the intraoperative increase in intraocular pressure following application of the
LASIK Indications, Contraindications and Preoperative Evaluation 97

suction ring during LASIK will further decrease optic nerve head perfusion pressure and
can cause additional damage to an already susceptible glaucomatous optic nerve.

5. The Presbyope
Many LASIK patients are presbyopes. Patients who already wear some reading correction
are easier to counsel than patients who simply remove their glasses to read. Patients need
to be informed that the procedure will not correct distance and near vision completely. An
informed patient can help determine what would be best for them. Patients should be of-
fered various options including distance vision in both eyes, monovision, or slight under-
correction of both eyes. If the patient is a successful contact lens wearer with monovision,
this is likely to be the best route. If the patient does not wear lenses, a preoperative mono-
vision contact lens trial can be used to demonstrate the effects of monovision to the candi-
date for refractive surgery (14). The add power and selection of the distance and near eye
can also be determined with a contact lens trial.

6. The Low Myope

For peripresbyopic and presbyopic lower myopes (1.00 through 3.50 diopters), we fre-
quently treat the dominant eye first and postoperatively determine the correction for the non-
dominant eye, if any. Some patients happily tolerate large amounts of anisometropia, while
others are intolerant of as little as 0.50 diopters. The refractive goal needs to be tailored to
the requirements of the individual patient. Patients who spend most of their time doing near
work without glasses preoperatively need to understand that correcting their distance vision
will necessitate the use of reading glasses. Often, patients have a preconceived notion that
surgery will allow them to throw away their glasses. Occasionally, patients misunderstand
or are misinformed and are disappointed in their postoperative spectacle dependence for
near work when they did not require glasses preoperatively.

7. The Very High Myope

Patients with high degrees of myopia are usually very motivated as they have greater visual
disability. A preoperative evaluation in high myopes must include a careful dilated retinal
examination using indirect ophthalmoscopy to search for peripheral retinal pathology
as well as a careful macular exam. Preoperative retinal consultation is of value to determine
if existing retinal pathology requires any treatment prior to surgery. Additionally, with
higher degrees of myopia, there is an increase in the loss of BSCVA as well as reduced ac-
curacy. Patients need appropriate preoperative counseling to help understand these risks.

8. The Hyperope
LASIK, at present, shows great promise for effective and stable correction for mild to mod-
erate hyperopia. A gonioscopic examination should be performed prior to LASIK in all hy-
peropic patients and a prophylactic peripheral iridotomy may be indicated for an occlud-
able angle. Although there is no cause and effect relation between hyperopic LASIK and
acute angle closure glaucoma, patients with hyperopia and narrow angles should be fol-
lowed for the possibility of angle closure at a later time (15). The ablation profile for hy-
peropia extends out to 9 mm requiring a large corneal flap. Patients with a history of con-
tact lens wear and corneal neovascularization may have significant bleeding with LASIK
surgery, and potential complications of bleeding should be discussed and included in the
consent prior to surgery.
98 Braunstein et al.

9. The Astigmat
A preoperative evaluation of the astigmat is essential for successful refractive surgery.
Astigmatism has a directional component and a magnitude, and sources of astigmatism can
be corneal or lenticular. As the magnitude of cylinder decreases, the ability to measure pre-
cisely the cylinder axis also decreases. Refractive, keratometric, and topographic cylinder
occasionally do not match in axis or magnitude, but treatment is based on refractive cylin-
der. When disparity occurs, proceed cautiously and ascertain stability by repeating mea-
surements over time.

I. PATIENT SELECTION
Selecting the appropriate candidate for refractive surgery requires an understanding of the
patients expectations, desires, and disposition in addition to a clinical ocular examination.
A candidate must have the ability to understand the risks and benefits of LASIK and be able
to give informed consent. The patient must be able to tolerate the procedure and have the
ability to lie flat without difficulty, to tolerate topical anesthesia, and to fixate steadily and
accurately for the duration of the procedure. Patients must be targeted toward their differing
visual needs. A myope prior to laser vision correction enjoyed close and clear visual space
and will be disappointed if overcorrected postoperatively. Some presbyopes desire mono-
vision, while others would rather wear spectacle correction. Patients who demand spectacle
independence all the time and have unrealistic expectations of laser vision correction should
be avoided in addition to all patients with the above-mentioned systemic diseases or ocular
pathology that otherwise jeopardize the efficacy, safety, and stability of LASIK.

J. LASIK CONSENT
A patients understanding of the possible postoperative complications and adverse symp-
tomatology is an essential component of an informed consent. Patients should be given a
copy of the FDA brochure provided from the excimer laser manufacturer citing the results
of clinical trials using the specific laser. Additional statistics may be provided regarding the
doctors own data and experience.
A detailed informed consent document is often helpful in highlighting many of the
known side effects and complications of LASIK surgery. Undercorrection, overcorrection,
and induced astigmatism and the possibility of additional surgery should be discussed.
Complications that could lead to a loss of best corrected visual acuity include but are not
limited to irregular flaps, irregular astigmatism, haze, scarring, infection, central islands,
striae, and epithelial ingrowth; these must be explained to the patient in a manner that they
can understand. Many patients do not appreciate that they do risk a loss in best corrected
visual acuity and possibly blindness due to an infection or retinal vascular event. Patients
who require excellent night vision (e.g., truck drivers) should be cautioned prior to LASIK
surgery regarding their risk of night vision impairment. Night vision impairment has been
reported by Guell and Muller in 23% of patients at 6 months postoperatively, and other re-
ports of night halos occurred in up to 30% of eyes at 6 months (16). Halos around lights and
night vision impairment appear to decrease with larger ablation zones and smaller pupil
size and often improve with time (17). Finally, patients should be advised of the possibil-
ity of dry eye symptoms, which may affect vision following laser vision correction. Prior
to surgery, the patient should be given an opportunity to read all of the materials provided
and to have all of their questions answered by their surgeon.
LASIK Indications, Contraindications and Preoperative Evaluation 99

REFERENCES
1. T Salah, GO Waring III, A El-Maghraby, K Moadel, SB Grimm. Excimer laser in situ ker-
atomileusis under a corneal flap for myopia of 2 to 20 diopters. Am J Ophthalmol 1996;121:
143155.
2. S Esquenazi, A Mendoza. Two year follow-up of laser in situ keratomileusis for hyperopia. J
Refract Surg 1999;15:648652.
3. MC Arbelaez, MC Knorz. Laser in situ keratomileusis for hyperopia and hyperopic astigma-
tism. J Refract Surg 1999;15:406414.
4. DJ Salchow, ME Zirm, C Stieldorf, A Parisi. Comparison of objective and subjective refraction
before and after laser in situ keratomileusis. J Cataract Refract Surg 1999;25:827835.
5. T Seiler. Iatrogenic keratectasia: academic anxiety or serious risk? J Cataract Refract Surg
1999;25:13071308.
6. T Seiler, K Koufala, G Richter. Iatrogenic keratectasia after laser in situ keratomileusis. J Re-
fract Surg 1998;14:312317.
7. TP Werblin. Barraquer Lecture 1998. Why should refractive surgeons be looking beyond the
cornea? J Refract Surg 1999;15:357376.
8. YS Rabinowitz, K Rasheed, H Yang, J Elashoff. Accuracy of ultrasonic pachymetry and
videokeratography in detecting keratoconus. J Cataract Refract Surg 1998;24:196201.
9. YS Rabinowitz. Keratoconus. Surv Ophthalmol 1998;42:297319.
10. N Maeda, SD Klyce, MK Smolek. Comparison of methods for detecting keratoconus using
videokeratography. Arch Ophthalmol 1995;113(7):870874.
11. YS Rabinowitz, K Rasheed. KISA% index: a quantitative videokeratography algorithm em-
bodying minimal topographic criteria for diagnosing keratoconus. J Cataract Refract Surg
1999;25:13271335.
12. B Seitz, A Langenbucher. Intraocular lens calculations status after corneal refractive surgery.
Curr Opin Ophthalmol 2000;11:3546.
13. J Najman-Vainer, RJ Smith, RK Maloney. Interface fluid after LASIK: misleading tonometry
can lead to end-stage glaucoma. J Cataract Refract Surg 2000;26:471472.
14. MM Hom. Monovision and LASIK. J Am Optom Assoc 1999;70:117122.
15. M Paciuc, CF Velasco, R Naranjo. Acute angle closure glaucoma after hyperopic laser in situ
keratomileusis. J Cataract Refract Surg 2000;26:620623.
16. JL Guell, A Muller. Laser in situ keratomileusis (LASIK) for myopia from 7 to 18 diopters.
J Refract Surg 1996;12:222228.
17. SG Farah, DT Azar, C Gurdal, J Wong. Laser in situ keratomileusis: literature review of a de-
veloping technique. J Cataract Refract Surg 1998;24:9891006.
 7
Preoperative Optical Considerations in
LASIK
Refractive Errors, Monovision, and Contrast
Sensitivity

BALAMURALI K. AMBATI
Massachusetts Eye and Ear Infirmary and Harvard Medical School,
Boston, Massachusetts, U.S.A.
LEON STRAUSS
The Wilmer Eye Institute, Johns Hopkins University School of Medicine,
Baltimore, Maryland, U.S.A.
DIMITRI T. AZAR
Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute,
and Harvard Medical School, Boston, Massachusetts, U.S.A.

Preoperative optical considerations in LASIK have gained increased importance, for they
allow interpretation and anticipation of postoperative aberrations and provide a basis for
patient education prior to surgery. This chapter will focus on refractive error evaluation,
monovision, and contrast sensitivity. Subsequent chapters will cover the topics of corneal
topography, wavefront analysis, and corneal biomechanics.

A. REFRACTIVE ERRORS

Emmetropic eyes focus parallel rays from an object point at optical infinity to a point on
the retina. The secondary focal point of such an eye is on the retina, and the far point plane
is at optical infinity. Myopic eyes focus parallel rays anterior to the retina. Thus the focal
point of the eye is in the vitreous, and the far point of the eye is located between the eye and
optical infinity (1). Hyperopic eyes have insufficient power without accommodation to fo-
cus parallel rays of light on the retina; accommodation may produce enough plus power to
bring parallel or even diverging rays to focus on the retina. Astigmatism is due to asym-
101
102 Ambati et al.

metry usually of the cornea and sometimes of the lens. Regular astigmatism is correctable
with a spherocylindrical lens, whereas irregular astigmatism is not correctable with such a
lens. Regular astigmatism is called with the rule when the steepest (most refracting) merid-
ian lies near 90 degrees. It is termed against the rule when the steepest meridian lies near
180 degrees. When regular astigmatism is neither with nor against the rule, it is termed
oblique.

1. Spectacle-Correction of Ametropias

Spectacle lenses placed in front of the eye must have their focal point coinciding with the
far point of the eye, so that parallel rays are focused onto the retina. Drawbacks of this sys-
tem include image distortion, prism effects, anisometropic effects, and field tilt. Minus
lenses minify images by approximately 2% per diopter, while plus lenses magnify the im-
age but create a peripheral scotoma between what is viewed inside and outside the specta-
cle frame. Astigmatic correction produces meridional minification or magnification, dis-
torting the image. Off-axis viewing and lens tilt alter the effective spherocylindrical power
of the lens, while viewing away from the center of the lens produces prism, leading to the
well-known pincushion and barrel distortions of hyperopic and myopic lenses, respec-
tively. Disparity between astigmatic correction of the two eyes produces a perceived tilt of
the object. This can be minimized by decreasing the cylinder power and/or rotating the axis
of the cylinder, albeit at the expense of clarity. All of these effects are heightened in higher
power lenses.

B. PREOPERATIVE CONSIDERATIONS

What should the refractive surgeon aim for in patients whose spectacle usage has entailed
such compromises? The surgeon should still aim for full correction of astigmatism, as cor-
rection at the cornea minimizes distortion effects. Further, surgery may relieve distortion
due to anisometropia. Indeed, patients who are undercorrected with surgery often report
double images not eliminated by monocular patching and other distortion effects not due to
meridional magnification. Some patients who have adapted to spectacle distortion and tilt
may take some time to readapt their binocular spatial sense and appreciate the lack of op-
tical distortion. Refractive surgery in the myope, by removing the minification of the spec-
tacle lens, produces a larger retinal image of objects, improving visual acuity even when
clarity, i.e., optic resolving power, is the same or decreased.
For the same reason that a presbyopic myope has a more remote near point when
wearing contact lenses than when wearing glasses, refractive surgery giving full correction
of myopia may make reading without reading glasses more difficult than it was with glasses
before surgery.

1. Contact Lens Wear

Preoperative evaluation for refractive surgery is influenced by several considerations. Con-
tact lens wearers should discontinue soft contacts for at least 3 days and rigid lenses for at
least 3 weeks so that the cornea can assume its natural shape prior to evaluation. Vertex dis-
tance considerations become significant for refractive error over approximately 5 D; ver-
tex distance should be measured from the rear surface of a corrective lens to calculate the
refractive power at the cornea.
Preoperative Optical Considerations in LASIK 103

2. High Myopia
In patients with unilateral high myopia, placement of a corrective contact lens allows a pre-
operative prediction of the degree of aniseikonia they may experience after refractive
surgery. Patients with bilateral high myopia should be appraised of the possibility of dis-
turbing aniseikonia after one eye has undergone surgery before the other eye: the possibil-
ity of unequal photoreceptor spacing is considered in cases of high refractive errors, in
which case aniseikonia testing should be performed.

3. Cycloplegic Refraction
Cycloplegic refraction allows the examiner to discern the degree of myopia in the manifest
refraction due to accommodative tone; however, pupil dilation leads to a mild myopic shift
due to spherical aberration of the lens. Cycloplegic refractions of hyperopes enables the de-
termination of latent, manifest, and therefore total hyperopia; the surgeon must consider
that the latent portion will gradually become manifest as the patient ages.

4. Diabetes
Diabetic fluctuations in blood sugar can change lens size and curvature. Stability of refrac-
tive error is essential prior to refractive surgery. Further, diabetes is a relative contraindi-
cation to elective corneal surgery, as diabetic corneal epithelium is more prone to persis-
tent epithelial defects, duplication of basement membrane, and recurrent erosions.

5. Pupil Size
Larger pupils allow light rays peripheral to the optical zone to be transmitted to the fovea.
The StylesCrawford effect dampens this somewhat, as photoreceptors are oriented to-
wards reception of light passing through the central cornea.

6. Ocular Motility
Motility examination with measurements of convergence and divergence amplitudes is part
of the preoperative evaluation for refractive surgery, which can increase or decrease ac-
commodative requirements in various circumstances. As mentioned above, the myope pre-
viously corrected with spectacles will lose the near effectivity of distance-corrective minus
lenses. Undercorrection of myopia with surgery relieves the demand for accommodation at
near but increases the need for nonaccommodative convergence at near. Patients with low
reserves of fusional divergence may become symptomatic if surgery overcorrects myopia,
as the resultant hyperopia increases the demand for accomodation and attendant acco-
modative convergence. Thus measuring with prisms the amplitudes of convergence and di-
vergence (far and near, and with or without accomodation) helps predict whether a change
of accomodative demand may create problems of convergence or divergence insufficiency.

7. Accomodation
Accomodative amplitude with the correction mode at the cornea should be measured be-
fore surgery to plan targeting for near vision, i.e., equal correction vs. monovision, full cor-
rection vs. partial. The amplitude of accomodation can be measured several ways, e.g., the
difference in diopters between the least and most spheres accepted with clear vision while
gazing at a distant target. Low amplitudes may be due to medication, oculomotor nerve
104 Ambati et al.

paresis, trauma, lack of effort, incorrect distance refraction, or accomodative spasm. Mea-
surement of the near point while wearing myopic spectacles will overestimate the ampli-
tude of accomodation amplitude, because of the so-called near-effectivity of the myopic
spectacle lens. Correcting the same eye for emmetropia by contact lens or refractive
surgery will yield a more remote near point and smaller amplitude of accomodation.
Myopes who have been overminused with presbyopic symptoms may become less
symptomatic once the extra minus is eliminated. Determination that a patient is overmi-
nused can be performed with cycloplegia or possibly with prolonged fogging with plus
lenses. If the cycloplegic manifest refraction is accepted in new glasses, surgery should be
based on those values. However, it should be borne in mind that some patients who have
had overcorrected myopia for years will not be able to relax completely their accomodative
tone soon after surgery. The surgeon and patient must then be aware of the prospect of
blurred vision in either the short or the long term.

C. REFRACTIVE EVALUATION
Making the central cornea flatter and the peripheral cornea steeper with LASIK produces
blur, which is more pronounced when the pupil is large, as it is in dim light. When the pupil
dilates, the peripheral lens is also more exposed; this part of the lens has greater plus power.
The clinical relevance of peripheral corneal irregularity, scars, decentration, and central
corneal haze are topics of active investigation. The impact of postoperative irregular astig-
matism of the central cornea on uncorrected and spectacle-corrected vision is unclear. Pre-
dictive factors for good spectacle correction remain to be identified.

1. Astigmatism
An objective for surgical correction of astigmatism is a relatively spherical central corneal
zone. The outline of this region is oval, the narrower aspect being the meridian with the
maximum difference in curvature between central and peripheral cornea. When the pupil
dilates, the peripheral cornea becomes more relevant, resulting in blur or monocular
diplopia, especially noticeable when details vary with torsion of the eye or observed object.
As these patients have a clear image from the central zone, the blurred regions of an object
stand in contrast to the sharper portions: this can be more disturbing than preoperative dif-
fuse blur.

2. Retinoscopy
Streak retinoscopy is performed in the standard fashion with attention to the central reflex.
Retinoscopy after refractive surgery may be more easily performed using minus cylinder
techniques to neutralize against motion. The endpoint of retinoscopy is less influenced by
the steeper peripheral cornea if the target is neutralization of any part of the against motion,
generally seen first in the flattest central cornea. A novice depending on complete neutral-
ization of against motion or any part of with motion may overcorrect patients significantly.
Further, when against motion is observed, the patient is fogged and thus less likely to ac-
comodate during retinoscopy.
During retinoscopy, skew, break, and straddling are useful to refine the axis of cor-
rective cylinder. Skew is streak motion not paralleling the motion of the retinoscope and is
helpful in patients with postoperative irregular astigmatism, when break (when the streak
falls on iris, indicating imperfect alignment of the retinoscopic reflex) is not easily ob-
Preoperative Optical Considerations in LASIK 105

served. Straddling involves observing reflexes 45 degrees on either side of the presumed
axis. With motion should be observed with this technique and can be produced by adding
minus sphere or moving closer to the eye.
When using plus cylinders, the correct axis is approached turning towards the thin-
ner, brighter reflex. When using minus cylinders, the correct axis is approached by turning
away from the thinner, brighter reflex. Retinoscopy after dilation may be confused due to
scissoring of the reflex; this is commonly seen after refractive surgery. In this situation, one
should focus on the reflex of the central three millimeters. Further, it should be remembered
that off-axis retinoscopy will give a false measurement of astigmatism.

3. Confirmation of Retinoscopic Findings

Other tools used in refraction include automated refractors, wavefront analyzers, topo-
graphic maps, astigmatic dials, and stenopeic slits. In the final analysis, subjective refrac-
tion, based on these objective methods, is the most important test used for planning refrac-
tive surgery. Automated refractors have little utility after refractive surgery. Topography
may be of use in detecting lenticular astigmatism, as it can be detected preoperatively by a
disagreement between the axis of astigmatism found in topography and manifest refraction.
The astigmatic dial is useful to determine axis and power of cylinder when retinoscopy and
the Jackson cross-cylinder fail. With fogging to 20/40 acuity, the patient is asked to iden-
tify the lines that appear blackest and sharpest. The minus cylinder axis is determined by
multiplying the smaller hour number by 30. Minus cylinder is then added until the lines
are equally blurred. The stenopeic slit, essentially an elongated pinhole, can be used in
manifest refraction of patients with irregular astigmatism with unhelpful retinoscopy. The
patient is first refracted with spheres. The stenopeic slit is then placed in front of the eye
and rotated to the position with best acuity. Sphere is again adjusted, indicating the power
needed at the axis parallel to the slit. The slit is rotated 90 degrees away, and the sphere
once again adjusted, providing an estimate of the power of cylindrical correction. At the
conclusion of these objective methods of refraction, subjective refraction should be per-
formed with relaxed accomodation and/or cycloplegia.
When patients still need spectacles after refractive surgery, the spectacle prescription
of young patients may be overminused 0.25 or 0.40 D to blunt postoperative diurnal fluc-
tuation and aid the patient in tasks requiring sharpest acuity. Cycloplegic refraction can be
done with an aperture blocking peripheral light rays, for reasons noted above.

4. Anisometropia
During the preoperative evaluation, a discussion of the possibility of anisometropia en-
countered postoperatively is valuable. The management of these cases is similar to that of
anisometropes in general, depending on what sensorimotor adaptations the patient has de-
veloped, the presence of amblyopia, etc. A contact lens worn in the unoperated eye can al-
leviate aniseikonia and spectacle-induced vertical prism effects on up and downgaze. Par-
tial correction or a balance lens can be used in spectacle correction in cases where deep
amblyopia is present or symptoms of aniseikonia and anisophoria are severe. Spectacles
may be attempted in the postoperative period to protect a dominant eye when the other eye
is amblyopic.
Monovision (one eye targeted for distance, the other for near) may be given without
compromise when there is good vision but little stereopsis in both eyes. A preoperative trial
with contact lenses can be used to predict whether significant anisophoria or aniseikonia
106 Ambati et al.

would occur in patients after correction for monovision. In patients with high myopia, pre-
existing strabismus and suppression may be present. Surgical overcorrection may lead to
accommodative spasm and esodeviations. In this situation, contact lenses or enhancement
surgery may correct the consecutive hyperopia.

5. Spasm of Accommodation
Convergence and accommodation issues are also encountered postoperatively. Uncor-
rected hyperopes, astigmatics, and overcorrected myopes can develop spasm of accommo-
dation, causing asthenopia, headache, or blurred vision. Exophoria, stress, convergence in-
sufficiency, iridocyclitis, and certain medications (especially anticholinesterase agents) can
worsen this phenomenon. Accommodative spasm can be addressed with reading glasses,
adding plus to spectacles, bifocals, or chronic cycloplegia. Subclinical convergence insuf-
ficiency may be unmasked after refractive surgery for hyperopia, as accommodation-re-
lated convergence is lessened. Spectacle-induced hyperopia usually solves this problem.

6. Optical Requirements for Near Vision

As noted above, the borderline presbyopic myope may lose the near effectivity of minus
spectacles and have increased difficulty at near after refractive surgery. In general, patients
are better served by choosing a lesser add to give a larger range of accommodation and to
not blur middle distances. High-riding progressive adds can be useful in patients with diur-
nal fluctuations in refractive error. Very anisometropic patients may have unequal ampli-
tudes of accommodation, and may need unequal adds. The more myopic eye will need less
plus in its bifocal segment. Horizontal phorias can be aggravated by reading adds; trial frame
evaluation is very useful in this circumstance to judge comfort of focusing and fusion.
Stronger adds will minimize accommodative convergence in esophoric patients, while
weaker adds will stimulate it in exophoric patients. Those with large cylindrical errors may
need cross-cylinder refraction at near, as torsion of the globe can occur with convergence
and downgaze. When prescribing bifocals, surgically undercorrected myopes benefit from
flattop bifocal segments, which minimize image jump (as the optical center of the add is
close to that of the far correction segment) and prism displacement (counterbalanced by the
opposite effect of the underlying minus lens). The overcorrected myope must choose be-
tween the greater image displacement of flattop segments and the greater image jump of
roundtop segments. Vertical prism effects can be minimized by slabbing off prism from the
more myopic lens, lowering the optical centers of the distance correction, or using different
segment types for the two eyes. These problems of off-axis viewing can be avoided by sin-
gle-vision reading glasses. Options for patients with minimal amplitudes of accommodation
include trifocals, progressive-add bifocals, and separate intermediate-zone glasses.

D. MONOVISION REFRACTIVE SURGERY

An often successful strategy for presbyopia is monovision, which is refractive correction
of one eye for distance and the other for near. In myopes, the dominant eye is generally cor-
rected for distance and the nondominant eye is undercorrected (2). Ideally, such a patient
should see clearly at all distances, without significant functional impairment. Monovision
acceptance rates for contact lens wearers usually range from 60 to 80%.
Definitions of monovision success vary. One commonly used set of criteria is ade-
quate adaptation to 1 to 2 diopters of monocular blur after 3 weeks. The mean success rate
Preoperative Optical Considerations in LASIK 107

of patients reported in 19 articles was 76% (434 out of 573 patients). Failure was due to
contact lens intolerance or poor visual adaptation. If previously contact-lens intolerant pa-
tients are excluded, monovision success rates are approximately 86% (2).
There are several factors determining monovision success: ocular dominance, sight-
ing preference, interocular blur suppression, stereo acuity, and phorias. When the dominant
eye was corrected for distance, overall monovision success rate was 75% (3). These pa-
tients performed better at visual locomotor tasks requiring directional prediction (walking,
driving) and also had lesser esophoric shifts at distance. Patients with alternating domi-
nance (no sighting preference) have interocular blur suppression, another factor predictive
of monovision success. Those with strong sighting preferences had reduced blur suppres-
sion, decreased binocular depth of focus (relative to others), and higher monovision failure
rates; they frequently reported ghosting at near or distance (secondary images that can be
distracting and sometimes affect balance) (4). After monovision correction, unsuccessful
monovision patients had a mean of 50 to 62 seconds of arc less in stereopsis than success-
ful patients (56). Postoperative esophoric shifts were less in successful monovision pa-
tients than in unsuccessful patients, but no differences in fusional vergence ranges have
been documented. Age has yet to be shown to be a factor affecting monovision success.
Monovision affects several visual functions (713). Monovision correction generally
produces a small reduction in high and low-contrast visual acuity, especially in conditions
of low lighting (11). The average visual acuity reduction was 0.05  0.02 logMAR units.
The decrease in high-contrast binocular visual acuity is quite variable and worsens with
larger pupils and greater astigmatic errors. Monovision has no significant effect on binoc-
ular peripheral visual acuity or visual field width (6). Contrast sensitivity is 42% less with
monovision than with binocular vision (12). Thus monovision is not preferable in those
whose occupations require fine, detailed work. Task performance is reduced by less than
6% in activities requiring moderate stereopsis, e.g., card-filing (13). In those with alternat-
ing dominance (no sighting preference), the binocular depth of focus is almost equal to the
sum of monocular depths of focus (9). In those with strong sighting preferences, the binoc-
ular image becomes blurred as the object moves from the dominant eyes clear range to the
nondominant eyes clear range, and thus the binocular depth of focus in these patients is
much less than the sum of the monocular depths of focus. After 3 weeks of monovision
adaptation, a significant recovery of stereo acuity occurs (8). Increasing the ocular blur in-
creases the stereoscopic threshold. In presbyopes, the stereo acuity decreased greatly when
the blur was more than
1.75 D. Monovision reduced secondary fusion in 10 to 20% of pa-
tients but did not affect simultaneous perception or gross stereopsis. The binocular visual
stress created by monovision is thought to cause esophoric shifts. These shifts are greater
when the nondominant eye is corrected for distance. Divergence and convergence ranges
at distance are reduced with monovision, but reductions in fusional vergence ranges are sig-
nificant only when the nondominant eye is corrected for distance. Monovision reduces the
typical exophoria seen in presbyopes at near by 2.5 to 5.2 prism diopters (6). The diver-
gence range is significantly less with monovision at near viewing, but not the convergence
range.
Monovision should be avoided in patients with strong sighting preference, significant
loss of stereoacuity with monocular correction, large esophoric shifts, minimal interocular
suppression, or occupations requiring fine work. Patients must be informed of the reduc-
tion in visual acuity and stereopsis. Spectacle lenses may need to be prescribed for tasks re-
quiring sharp distance vision (aniseikonia is generally acceptable in these circumstances).
Monovision is clearly not a panacea for presbyopia and should be used only in patients who
108 Ambati et al.

have been carefully screened and who are willing to tolerate its attendant visual compro-
mises. Preoperative use of monovision contact lenses may identify those who are likely to
do well with monovision refractive surgery; these should be conducted for at least 3 weeks.
If patients do not improve significantly in their adaptation to monovision over that time pe-
riod, they may not be good candidates. Lastly, it should be noted that there are presently no
published reports of LASIK being used to produce monovision.

E. CONTRAST SENSITIVITY AND GLARE TESTING

Contrast and glare sensitivity are two important parameters of visual function that can be
affected by LASIK (14). Refractive surgery can cause light scatter (due to corneal haze)
and aberrations of the corneal curvature, both of which can affect contrast and glare sensi-
tivity. Light scatter can cause starburst phenomena, while spherical aberration can cause
haloes to appear around bright objects. Pupil size and the size of the treated area are im-
portant factors in the prominence of the starburst and halo effects.
Contrast measures of sensitivity assess how much a pattern must vary in luminance
to be seen; this generally parallels visual acuity in normal, healthy eyes. In various disor-
ders, including cataracts, amblyopia, glaucoma, optic neuritis, cerebral lesions, and dia-
betic retinopathy, the two may not correlate well. Loss of contrast sensitivity can make the
world appear hazy. Loss of low spatial frequency contrast sensitivity hampers face recog-
nition, navigation in unfamiliar environments, and reading of low-contrast text (15).
Contrast sensitivity is traditionally measured by using sine wave gratings that vary in
spatial frequency (bar width) and contrast; a contrast sensitivity function is generated by
measuring the lowest detectable contrast across a range of spatial frequencies. Rubin and
Legge (17) have shown that global changes in contrast sensitivity and changes near the
peak of the function curve are more clinically relevant than subtle variations in the curve.
The Pelli-Robson Letter Sensitivity Chart is a commercially available test that provides a
single, global measure of contrast sensitivity (16). Letters consisting of contrasting lighter
and darker bars are arranged in triplets of decreasing contrast and are equivalent to a 20/720
letter with respect to visual angle subtended. They reliably measure contrast sensitivity for
patients with visual acuity of 20/400 or better.
One of the most common visual side effects of refractive surgery is glare. Disability
glare occurs when light sources in the visual field reduce visibility of a target, and it occurs
when light from the glare source is scattered by the ocular media, forming a veiling illumi-
nance that dampens the contrast and thus the visibility of the target (17). Glare testing uses
contrast or acuity tests in the presence of a glare source (18). The most commonly available
glare test is the Brightness Acuity Test (BAT), a brightly illuminated dome held in front of
the eye through which a standard eye chart is viewed (19).
There have been few studies of the effects of LASIK on contrast and glare sensitiv-
ity. Holladay et al. found that contrast threshold worsened the first postoperative day by a
mean of 0.6  1.0 lines in darkness and 0.8  0.7 lines at high BAT (20). Contrast sensi-
tivity in light conditions recovered by 1 week, but contrast threshold in darkness did not re-
turn to baseline through 6 months. Larger pupil sizes were associated with worse contrast
outcomes. This study speculated that the conversion by LASIK of corneal asphericity to an
oblate shape accounted for this result. El Danasoury compared night glare after using
LASIK in two different ways: a single ablation zone of 5.5 mm in one eye, and an ablation
zone of 5.5 mm with a transition zone of 1.0 mm diameter larger on the other eye (21). Use
of the transition zone significantly decreased night glare in this study. Carr et al. compared
Preoperative Optical Considerations in LASIK 109

single-zone vs. multizone LASIK (22). Multizone eyes were found to have a greater de-
crease in log contrast sensitivity at 12 cycles/degree under undilated conditions. Perez-San-
tonja et al. found that contrast sensitivity 1 month after LASIK decreased significantly only
at low and intermediate spatial frequencies (3 and 6 cycles/degree) (23). By 3 months, there
were no significant differences in contrast sensitivity at all spatial frequencies compared to
baseline. Wang et al. found that LASIK eyes recovered contrast sensitivity by 3 months as
well, a significant difference from their control group, PRK eyes, in whom recovery took
6 to 12 months (24).

F. CONCLUSION
Several preoperative optical considerations are important when evaluating a patient con-
sidering LASIK surgery. In addition to understanding the basics of refractive error evalua-
tion, anticipation of postoperative outcomes and of optical aberrations after surgery are es-
sential for patient education prior to surgery. The use of corneal topography and wavefront
analysis is valuable to achieve this goal. An understanding of certain fundamental princi-
ples of optics will facilitate and optimize clinical application of LASIK. Refractive sur-
geons must be aware of more than spherocylindrical thin-lens first-order optics in order to
make informed decisions. The following chapters will cover additional preoperative con-
siderations that are necessary to optimize LASIK outcomes and improve patient satisfac-
tion.

REFERENCES
1. American Academy of Ophthalmology. Ophthalmology, Optics, Refraction, and Contact
Lenses: Basic and Clinical Science Course. San Francisco, 1998.
2. S Jain, I Arora, DT Azar. Success of monovision in presbyopes: review of the literature and po-
tential applications to refractive surgery. Surv Ophthalmol 1996;40:491499.
3. EC McGill, P Erickson. Sighting dominance and monovision distance binocular fusional
ranges. J Am Optom Assoc 1991;62:738742.
4. C Schor, M Carson, G Peterson, J Suzuki, P Erickson. Effects of interocular blur suppression
ability on monovision task performance. J Am Optom Assoc 1989;60:188192.
5. P Erickson, EC McGill. Role of visual acuity, stereo acuity, and ocular dominance in monovi-
sion patient success. Optom Vis Sci 1992;69:761764.
6. MJ Collins, B Brown, SJ Verne, M Makras, KJ Bowman. Peripheral visual acuity with mono-
vision and other contact lens corrections for presbyopia. Optom Vis Sci 1989;66:370374.
7. JE Sheedy, MG Harris, L Busby, E Chan, I Koga. Monovision contact lens wear and occupa-
tional task performance. Am J Optom Physiol Opt 1988;65:1418.
8. JH McLendon, JL Burcham, CH Pheiffer. Presbyopic patterns and single vision contact lenes.
South J Optom 1968;10:710.
9. A Back, T Grant, N Hine. Comparative visual performance of three presbyopic contact lens cor-
rections. Optom Vis Sci 1992;69:474480.
10. M Collins, A Good, B Brown. Distance visual acuity and monovision. Optom Visc Sci 1989;
66:370374.
11. S Pradhan, J Gilchrist. The effect of monocular defocus on binocular contrast sensitivity. Oph-
thal Physiol Opt 1990;10:3336.
12. MJ Collins, B Brown, KJ Bowman. Contrast sensitivity with contact lens corrections for pres-
byopia. Ophthal Physiol Opt 1989;9:133138.
13. KA Lebow, JB Goldberg. Characteristics of binocular vision found for presbyopic patients
wearing single vision contact lenses. J Am Optom Assoc 1975;46:11161123.
110 Ambati et al.

14. GS Rubin. Contrast sensitivity and glare testing in keratorefractive surgery. In: D Azar, ed. Re-
fractive Surgery. Stamford, CT: Appleton & Lange, 1997, pp 143151.
15. JA Marron, IL Bailey. Visual factors and orientation-mobility performance. Am J Optom Phys-
iol Opt 1982;59:413426.
16. DG Pelli, JG Robson, AJ Wilkins. The design of a new letter chart for measuring contrast sen-
sitivity. Clin Vis Sci. 1988;2:169177.
17. GS Rubin, GE Legge. Psychophysics of readingthe role of contrast in low vision. Vis Res
1989;29:7991.
18. DB Elliott, MA Bullimore. Assessing the reliability, discriminative ability, and validity of dis-
ability glare tests. Inv Ophthalmol Vis Sci 1993;34:108119.
19. JT Holladay, TC Prager, J Trujillo, RS Ruis. Brightness acuity test and outdoor visual acuity in
cataract patients. J Cataract Refract Surg 1987;13:6769.
20. JT Holladay, DR Dudeja, J Chang. Functional vision and corneal changes after laser in situ ker-
atomileusis determined by contrast sensitivity, glare testing, and corneal topography. J Cataract
Refract Surg 1999;25:663669.
21. MA El Danasoury. Prospective bilateral study of night glare after laser in situ keratomileusis
with single zone and transition zone ablation. J Refract Surg 1998;14:512516.
22. JD Carr, RD Stulting, Y Sano, KP Thompson, W Wiley, GO Waring III. Prospective compari-
son of single zone and multizone laser in situ keratomileusis for the correction of low myopia.
Ophthalmology 1998;105:15041511.
23. JJ Perez-Santonja, HF Sakla, JL Alio. Contrast sensitivity after laser in situ keratomileusis. J
Cataract Refract Surg 1998;24:183189.
24. Z Wang, J Chen, B Yang. Comparison of laser in situ keratomileusis and photorefraactive ker-
atectomy to correct myopia from 1.25 to 6.00 diopters. J Refract Surg 1997;13:528534.
 8
Corneal Topography and LASIK
Applications

LI WANG and DOUGLAS D. KOCH

Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, U.S.A.
DIMITRI T. AZAR
Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute,
and Harvard Medical School, Boston, Massachusetts, U.S.A.
ROBERT T. ANG
Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston,
Massachusetts, U.S.A., and Asian Eye Institute, Makati, The Philippines
RENGIN YILDIRIM
Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey

The use of computerized videokeratography (CVK) for the evaluation of the corneal sur-
face has become widespread. CVK is an indispensable tool for refractive surgeons for pre-
operative screening, surgical planning, assessment of surgical outcomes, detection and
management of complications, and refinement and development of surgical techniques.
This chapter reviews the basic principles of CVK, the recognition of corneal topographic
patterns, and the role of corneal topography in refractive surgery.

A. PRINCIPLES OF CORNEAL TOPOGRAPHY

1. Terminology
It is important to introduce some terminology first. The corneal light reflex is in fact an im-
age reflected off the tear film and is the basis for placido-based topographic measurements.

111
112 Wang et al.

The tear film of the anterior corneal surface acts like a convex mirror to form a virtual, erect
image of reflected light. This image is called the corneal light reflex or the first Purkinje
image.
The line of sight is a line connecting a fixation point at optical infinity with the cen-
ter of the entrance pupil (1). The pupillary axis is a line normal to the corneal surface pass-
ing through the center of the entrance pupil, which is usually temporal to the line of sight,
and the angle between them is known as angle lambda and is in the range of 3 to 6.
The topography of the cornea can be arbitrarily broken down into four zones. The
central zone generally refers to the central 3 to 4 mm of the cornea. The paracentral zone is
an annulus with inner and outer diameters of 4 and 7 mm, respectively. The peripheral zone
is an annular region with inner and outer diameters of 7 and 11 mm, respectively. The lim-
bal zone is the border, about 0.5 mm wide, between the cornea and sclera.
A meridian is a line that spans the diameter of the cornea from one point on the lim-
bus to a point on the opposing limbus. Meridians are located by their angular position, in-
creasing counterclockwise from 0 at the 3 oclock position to 180 at the 9 oclock posi-
tion for both the right and left eyes (2). A semimeridian is a radial line on the corneal
surface from its center, and it is located by its angular position from 0 at the 3 oclock po-
sition, increasing counterclockwise around the full 360 for both the right and the left eyes.
In the literature, there is confusion over the terms apex and vertex as applied to the
cornea. Waring defined the apex as the high spot of the corneal (2). Maloney suggested de-
noting the high point of the cornea as the corneal vertex and the apex as the region of great-
est curvature (3). According to Webster, however, both terms refer to a point on a shape
furthest from its base (4). A vertex sometimes also refers to the point where the axis of a
curve intersects the curve itself. It is important to understand that the high point and the re-
gion of greatest curvature often do not coincide. In this chapter, we will use Maloneys def-
initions, referring to the vertex as the high point on the cornea relative to the imaging sys-
tem (and hence the center of the placido disk rings), apex referring to the region of steepest
curvature.

2. Placido Disk System

a. Data Acquisition
Placido disk technology has been most widely accepted, used, and understood. The differ-
ent units share certain components but can differ in data acquisition, processing, and per-
formance (5). All systems contain a transilluminated disc or cone (modified Placido disc),
an imaging system consisting of an objective lens, a black and white (B&W) camera (Tech-
noMed utilizes a color camera and color ring system), a video frame grabber, and a com-
puter system. The number, thickness, color, and position of the rings relative to each other
vary from system to system. Most systems can be divided into near design (Tomey TMS,
TechnoMed C-Scan, and Keratron) and distant design (EyeSys Corneal Analysis Sys-
tem-2000, Humphrey Atlas, Alcon EyeMap EH-290, and Dicon CT-200). The near design
units typically image a greater portion of the cornea and require lower levels of illumina-
tion, but they may be more susceptible to focusing error (unless they are software cor-
rected), and at times the patients brow may interfere with the positioning of the cone. The
distant design systems are less susceptible to focusing error and typically are not affected
by the patients anatomy, but they require brighter illumination and have less corneal cov-
erage. Recently, the additions of new cone designs, more sensitive video cameras, and cor-
recting algorithms have decreased the clinical distinction between near and distant units.
Corneal Topography and LASIK Applications 113

Figure 8.1 The principles of Placido disk technology. The larger the distances between the rings,
the flatter the cornea, and the less dioptric power it has. The reverse is true with a steeper cornea,
which shows smaller distances between the rings and a higher corneal power.

The placido target is projected onto the cornea and reflected off the tear film to form
a smaller upright image that is in focus near the iris plane. This two-dimensional digital im-
age is captured by a CCD camera and analyzed to reconstruct three-dimensional corneal
shapes, using the distances between rings or ring edges as the basis for calculating the ra-
dius of curvature or refractive power. A larger spacing between ring edges indicates a flat-
ter cornea with a greater radius of curvature (Fig. 8.1).
b. Data Processing and Map Display
Three basic formulas exist for calculating corneal power: axial radius of curvature, instan-
taneous (or tangential) radius of curvature, and refractive. Clinically significant differences
exist in the corneal power values calculated by the three formulas (6). The topographic data
may then be represented in a variety of ways. Clinically, the most useful representation to
the clinician is the color-coded map. The warm colors, red and orange, represent relatively
higher powers (steeper curvatures), green and yellow are used for powers associated with
normal corneas, and cool colors, hues of blue, denote relatively lower powers (flatter cur-
vatures). Types of topographic displays include
1. Axial radius of curvature maps. The axial radius of curvature maps are the orig-
inal and most commonly used CVK maps and are derived from the axial radius of curva-
ture. This formula is used by the keratometer and is based on the distance from the corneal
vertex to the center or edge of the ring. This distance is then used to calculate the length
of the radial line connecting this point to the optical (or sagittal) axis. This approach
simplifies the optical principles of the cornea by assuming that the rays of light striking
the cornea are paraxial, i.e., the angles of incidence are small. The simplified paraxial
formula is
n  1
Paxial  (1)
raxial
where n  1.3375 (standardized value for keratometric index of refraction) and raxial the
distance from the corneal surface to a point of intersection on the optical axis (Fig. 8.2A).
The standardized value for keratometric index of refraction, n, is not the true refractive in-
dex of the cornea but an approximated index to yield the total corneal power as a single re-
fracting surface by compensating for the negative power of the posterior surface. Axial
power tends to have a spherical bias because each curvature measured is referred to the op-
tical axis. For aspherical surfaces, this bias gives an accuracy of 0.25 D in the central
cornea, but errors of 3 D or more can be found in the periphery (7).
114 Wang et al.

Figure 8.2 Two approaches for the calculation of the corneal radius of the curvature: (A) axial ra-
dius, (B) instantaneous radius.

The axial radius of curvature map is the standard that may be used by most clinicians.
However, it is less accurate than instantaneous radius of curvature maps in providing detail
regarding corneal curvature, and it is less accurate than refractive maps in portraying the
refractive power of the anterior corneal surface. As a result, it may be less valid than these
other two maps, despite its popularity.
2. Instantaneous radius of curvature maps. The instantaneous radius of curvature
varies from the axial radius of curvature in that it calculates a true radius of curvature in-
dependent of the sagittal axis (Fig. 8.2B):
n  1
Pinst  (2)
rinst
where rinst is the radius of curvature for any given point on the cornea. The difference be-
tween axial radius of curvature and instantaneous radius of curvature maps can be dramatic.
Axial radius of curvature maps tend to appear more uniform because abrupt changes in lo-
cal curvature are underestimated because the calculated radius of curvature must terminate
at the sagittal axis. Instantaneous radius of curvature maps typically show more marked
changes in dioptric power over smaller regions and provide more accurate measurements
of corneal curvature and certainly better representation of local irregularity (7).
Corneal Topography and LASIK Applications 115

Both of these maps, however, have marked limitations in predicting corneal refrac-
tive power. For the central paraxial rays, these formulas can be used to estimate corneal re-
fractive power. Outside of the central region, however, the assumptions and their equations
are not necessarily valid, and in particular they ignore the incident angle of the incoming
light, thereby underestimating the refractive effect of peripheral rays (spherical aberration)
(8).
3. Refractive maps. The appropriate equation for the refractive power (secondary
focal point power) for the incoming parallel rays was first described by Gullstrand (9) and
modified by Klein (10) as
n n
P   (3)
x/tan (i  r)
where is the focal length, defined as the distance from the corneal vertex to the intersec-
tion of the refracted ray with the optical axis, x the corneal zone, i the angle of incidence,
and r the angle of refraction. Maps calculated using this formula attempt to estimate the
refractive power of the anterior corneal surface.
This map best characterizes the image-forming properties of the anterior corneal sur-
face.
4. Elevation maps. Elevation data, which describe the difference between the
height of the cornea and a reference surface, are provided by many of the Placido-based
units. These elevation data are derived from the placido ring measurements, which is an ap-
proach that obviously differs from the projection principle used by elevation-based systems
to obtain direct height measurements (see below).
As will be described below, elevation maps have particular value in assessing post-
operative visual problems, such as central islands.
5. Difference maps. These are typically calculated using axial radius of curvature
maps. They are useful in characterizing the change that has occurred during any interval.
As with any color-coded map, it is important to note the scale for the difference map. In the
authors view, a 0.5 D and 0.25 D interval is often most useful.
6. Other comparative maps. Different devices have a number of color-coded maps
that compare corneal curvature or refractive power to some standard surface. An irregu-
larity map may compare local changes in curvature to an idealized spherical cylindrical sur-
face. A profile map may compare corneal curvature to a standard aspheric corneal surface
as a way of evaluating the asphericity of the cornea. Corneal acuity maps display the esti-
mated visual acuity potential for any given region of the cornea and for the cornea as a
whole.
In viewing a color-coded dioptric map, it is critical first to ascertain the dioptric scale.
A number of different dioptric intervals have been recommended for standardized scales,
but the authors prefer a 0.5 D scale. Scales with intervals greater than 0.5 D are useful for
corneas with large dioptric ranges, such as advanced keratoconus. However, for refractive
surgery, a 0.5 D scale is required to obtain sufficient detail regarding nuances that affect vi-
sual performance. Fortunately, most topographers now offer some type of standardized ab-
solute scale and adjustable scales that allow the clinician to customize the information for
maximal clinical value.

c. Indices

CVK devices provide a number of quantitative indices that can tremendously enhance anal-
ysis of topographic maps. Simulated Keratometry (Sim K), which is provided by all de-
116 Wang et al.

vices, is a value that attempts to mimic conventional keratometry readings. However, there
are differences between Sim K values and standard keratometry. Whereas Sim K values
represent orthogonal curvatures at the 3 mm zone, for the keratometer, the diameter of the
measured zone varies according to corneal curvature: the flatter the cornea the larger the di-
ameter of the zone that is measured (11). In addition, different devices presumably use dif-
ferent formulas for calculating Sim K, depending upon the number of points that are sam-
pled in order to make this calculation.
Many devices offer a number of specialized indices. The Tomey unit (Tomey Cor-
poration USA, Waltham, MA) provides several indices, including the surface regularity in-
dex (SRI) and the surface asymmetry index (SAI) (12). The SRI is a measure of the local
regularity of the corneal surface within the central 4.5 mm diameter. SRI values increase
with increasing irregular astigmatism and approach zero for a smooth corneal surface.
Studies have demonstrated that the SRI is highly correlated with best spectacle-corrected
visual acuity (1215). SAI measures the difference in corneal powers at each ring 180 de-
grees apart as a measure of symmetry. Theoretically, the SAI value would be zero for a per-
fect sphere, a surface with perfectly spherocylindrical regular astigmatism, and for any sur-
face with a power that is radially symmetrical. The potential visual acuity (PVA) is an
estimation of predicted visual acuity based on surface regularity index. Other Tomey in-
dices include those that can be used to estimate the likelihood of the presence of kerato-
conus (see below).
The EyeSys Corneal Analysis System (EyeSys Technologies, Houston, TX) also
provides several numeric indexes in its Holladay Diagnostic Summary Display (16). Ef-
fective refractive power (EffRP) is the calculated mean refractive power of the cornea
over the central 3 mm, including the role of the Stiles Crawford effect. Corneal unifor-
mity index (CUI) is a measure of the uniformity of the distortion of the corneal surface
within the 3 mm pupil, expressed as a percentage. A CUI of 100% indicates that the op-
tical quality of the cornea is perfectly uniform over the 3 mm pupil, and a CUI of 0% in-
dicates the nonuniform optical quality of the cornea. It is important to note that a CUI of
100% does not indicate that the cornea has good optical quality, simply that it is uniform;
it could be uniformly bad or good. Predicted corneal acuity (PCA) measures the extent
of corneal microirregularity by comparing the video-captured image with a best-fit ellipse
(17). It is the estimated range of visual acuity that could be expected if the cornea were
the only factor limiting vision. Weiss and Oplinger found that the PCA appears to be
most useful in predicting the BCVA in patients with normal corneas but is less precise in
patients with corneal abnormalities (18).
In the Humphrey Atlas, the irregularity map displays wavefront error to characterize
the irregularity of anterior corneal surface. Wavefront error is the difference between
the corneal surface and a best fitted toric surface. It describes the condition of the light
rays as they pass through the corneal surface and are refracted onto the retina through the
clear media of the eye. Wavefront error, which closely measures a toric surface, will be dis-
played as green, with red and blue representing positive and negative wavefront errors, re-
spectively.
Early Placido-based systems were susceptible to errors induced by focusing and align-
ment (centration) (19). To minimize these sources of errors, most current units use special
methods, such as correcting algorithms (Tomey, Humphrey, and TechnoMed) or employ-
ing three cameras to measure precisely the distance from the Placido surface to the cornea
(EyeSys). However, the Placido-based topography systems still have some limitations:
Corneal Topography and LASIK Applications 117

1. Missed central zone data have to be interpolated.

2. Calculations are based on assumption that the cornea has sufficient smoothness
in the radial direction; therefore, these systems lose accuracy when used to map
nonspherical and irregular surfaces (2021).
3. Information regarding the corneal contour is only gained through the reflection
of light rays from the tear film; abnormalities of the tear film and corneal surface,
e.g., epithelial irregularities, may result in poor quality mires and misleading re-
sults.

3. Elevation-Based Systems
Elevation-based systems utilize the principle of projection to measure directly corneal ele-
vation. Curvature values are derived from the elevation data.
a. Scanning Slit Imaging System
The Orbtek ORBSCAN (Bausch & Lomb) uses a scanning slit beam and direct stereotrian-
gulation to measure the anterior corneal surface, the posterior corneal surface, and the ante-
rior iris and anterior lens surfaces (Fig. 8.3). It employs a calibrated video and a forty scan-
ning slit beam system (20 from the left and 20 from the right) to measure independently the
x, y, and z locations of several thousand points on each surface with a resolution of 2 m.
Figure 8.4 illustrates the data acquisition by the slit beam system. The cornea is scanned lim-
bus to limbus, and the images are accessed by a calibrated video camera with 240 data points
per slit. These directly measured points are used to construct topographic maps.
Orbscan displays color maps as 3-D, profile, and traditional for elevation, curvature,
and pachymetry. The elevation map shows the difference between the best fit sphere (BFS)

Figure 8.3 Series of surface planes measured with the Orbscan system from anterior corneal sur-
face to anterior lens surface.
118 Wang et al.

Figure 8.4 Data acquisition by the slit beam system. Forty single images are captured by a cali-
brated video camera (240 data points/slit). Resolution and accuracy of the central area (35 mm) are
improved by the overlapped images.

and the eye surface in mm, expressed in distance radially from the center of the sphere (by
default) or sagittal height between the two surfaces. The BFS is used to match best the an-
terior or posterior corneal surfaces, and this match is determined using a least squares
method. Positive elevation measurements indicate that the corneal surface falls above the
BFS and are represented as warm colors, while negative values indicate that the corneal
surface falls below the BFS and are represented as cool colors on the elevation maps. It
should be noted, however, that the elevation display depends on reference surface size,
shape, alignment, fitting zone, and elevation direction (normal or axial) (2223).
Corneal pachymetry is calculated at more than 5000 points from the elevation differ-
ence of the anterior and posterior surfaces. The pachymetry map displays thickness at the
thinnest point and in an array from center to the limbus.
Advantages of the slit beam scanning technology include direct measurement of
corneal height, lack of spherical bias, entire corneal coverage, and information about all
surfaces of the anterior segment. The Orbscan measurement of anterior chamber depth
has been reported to be accurate and reliable in normal eyes, as well as in high myopic
and hyperopic eyes (2425). However, corneal pachymetry measured by Orbscan has
been found to exceed ultrasonic pachymetric measurements (2627). A recent study
found poor accuracy of Orbscan pachymetric readings in corneas that had undergone
LASIK (28).
Elevation data have been used for customized laser ablation to correct irregular astig-
matism due to different causes (2930). Results have been mixed, a relatively high per-
centage of patients do not achieve any improvement in spectacle-corrected visual acuity.
Causes for this may include inaccuracy of the corneal measurements, inaccurate laser al-
gorithms, or difficulty in correctly aligning the laser to the cornea.
A limitation of this device is the relatively long time (1.5 seconds) required for imag-
ing the 40 scanning slits, although the system employs a tracking system that attempts to
minimize the influence of involuntary eye movement. A more significant concern is that
clinical accuracy of this technology has not been fully established, particularly the accuracy
of posterior curvature measurements. One study has shown relative inaccuracy, and Mal-
oney has suggested that measuring the testretest variability is an appropriate method of
controlling the accuracy of posterior curvature measurements(31).
Corneal Topography and LASIK Applications 119

b. Rasterphotogrammetry

The PAR Corneal Topography System (PAR CTS, PAR Vision System Corp., New Hart-
ford, NY) was the first topography system to produce an elevation map of the corneal
surface. The system projects onto the corneal surface a grid composed of horizontal and
vertical lines spaced about 0.2 mm (200 microns) apart and computes elevation data
based on the distortion of the grid. The PAR system requires that a small amount of flu-
orescein be placed in the tear film, and the images are collected using standard fluores-
cence-based photography. Image acquisition is rapid and relatively insensitive to focus-
ing. From the known geometry of the grid projection and imaging system paths, rays can
be intersected in three-dimensional space to compute the x, y, and z coordinates of the
surface (32).
Studies showed that the PAR system was both accurate and reproducible and had the
ability to image irregular, deepithelialized, and keratectomized corneas (3336). On the
other hand, the use of fluorescein staining and limited measurement points (1400) are
among the major drawbacks of this system. Although this technology is intriguing, it is no
longer commercially available.

c. Interferometric System

The KeraMetrics Corneal Laser Analysis System 1000 (CLAS 1000; Kera Metrics Inc.,
Solana Beach, CA) utilizes laser holographic interferometry fringe patterns to depict devi-
ation of the corneal surface. Interferometry records the interference pattern generated on
the corneal surface by two coherent wave fronts (37). Although high accuracy is theoreti-
cally possible here, there have been no detailed studies on the accuracy of topographic mea-
surement using this technology or on specific clinical applications. This device is not com-
mercially available.

d. Moir Interference System

Moir interference occurs when two sets of parallel lines are superimposed at different ori-
entation (38). There are few peer-reviewed data available validating the system.

B. CORNEAL TOPOGRAPHIC PATTERN IN MYOPIA, HYPEROPIA,

AND ASTIGMATISM
1. Myopia

Although myopia is predominantly caused by increased length, a weak but statistically sig-
nificant relation has been shown to exist between the corneal power and refractive error,
i.e., corneal power increases (corneal radius decreases) with increasing myopia (3945).
Two studies have noted that the cornea flattens less rapidly in the periphery with increas-
ing myopia (more negative Q values, see below) (4546).
Using the EyeSys Corneal Analysis System, Budak and colleagues provided a
corneal topographic classification of myopic eyes based on axial, instantaneous, refractive,
and profile difference maps (47). They defined six types of patterns for axial, instanta-
neous, and refractive maps: circular, circular with central bow tie, circular with central ir-
regularity, symmetric bow tie, asymmetric bow tie, and irregular pattern (Fig. 8.5AF)
120 Wang et al.

B
Figure 8.5 Six types of myopic patterns for axial, instantaneous, and refractive maps: (A) circu-
lar, (B) circular with central bow tie, (C) circular with central irregularity, (D) symmetric bow tie, (E)
asymmetric bow tie, and (F) irregular pattern.
Corneal Topography and LASIK Applications 121

Figure 8.5 Continued

122 Wang et al.

F
Figure 8.5 Continued
Corneal Topography and LASIK Applications 123

(Table 1). The circular with central irregularity and irregular patterns were associated with
lower values for Predicted Corneal Acuity and Corneal Uniformity Index.

2. Hyperopia
A study by Strang and coauthors found that hyperopia, like myopia, is predominantly axial
in nature, although in some hyperopes the cornea is abnormally flat and either contributes
to or accounts for the hyperopic refractive error (48). No study has yet been done to classify
the patterns on topographic maps using computerized videokeratography (CVK).

3. Astigmatism
In patients with regular astigmatism, the astigmatic patterns in curvature maps are often
represented as a bow tie or figure eight, with the steepest and flattest axes of curvature of
the cornea lying at right angles to one another (orthogonal) (Fig. 8.6A). On the elevation
map, the astigmatic cornea may appear as a regular, irregular, or incomplete ridge pattern,
with the elevated portion or ridge representing the flatter astigmatic cylinder of the cornea
(Fig. 8.6B).
In patients with irregular astigmatism, corneal topographic patterns include circular
with central irregularity, asymmetric bow tie (characterized by asymmetric powers in or-
thogonal steep and/or flat semimeridians or by nonorthogonal semi-meridians), and irreg-
ular pattern as defined by Budak et al. (47) (Fig. 8.5). In elevation maps, the pattern may
be an irregular ridge, an incomplete ridge, or an unclassified pattern.

C. CORNEAL ASPHERICITY
The anterior corneal surface is asymmetrically aspheric, as the radius of curvature changes
from the center to the limbus and does so at different rates along different semimeridians
(4950). Many authors have tried to describe the complex aspheric asymmetric shape of the
cornea, either mathematically or graphically (49, 5154).
The ellipse is perhaps the most useful shape for describing corneal curvature, and the
profile of the cornea along any meridian can be considered as part of an ellipse. The nor-
mal cornea has a prolate shape, which means that the central zone is steeper than the para-
central and peripheral zones; this is the shape of a section across the steep end of an ellipse

Table 1 Distribution of Topographic Patterns in Axial, Instantaneous, and Auto-Scale Refractive

Maps

Auto-scale
Axial Instantaneous refractive
Pattern map (%) map (%) map (%)

Circular 21.6 8.5 31.4

Circular with central bow tie 28.1 24.2 49.7
Circular with central irregularity 5.2 13.7 2.6
Symmetric bow tie 23.5 14.4 14.4
Asymmetric bow tie 15.0 17.6 1.3
Irregular 6.5 21.6 0.7

Source: Modified from Ref. 47.

 124 Wang et al.

B
Figure 8.6 Patient with regular astigmatism: (A) bow tie pattern on curvature map, (B) irregular
ridge pattern on elevation map.
Corneal Topography and LASIK Applications 125

Figure 8.7 Aspherical corneal shapes.

(Fig. 8.7). The reverse shape is oblate, in which the central zone is flatter than the periph-
eral zone; this corresponds to the flat side of an ellipse and is often seen in corneas that have
undergone myopic refractive surgery.
Usually corneal asphericity is quantitatively described by the Q value. For a sphere,
Q  0. For prolate surfaces, Q  0, and for oblate surfaces, Q
0 (55). For example, a
corneal asphericity with Q  0.26 indicates that, at a distance of 5 mm from the center,
the cornea flattens by about 7% as radius of curvature compared to a sphere. Mean reported
Q values have ranged from 0.15 to 0.30 (5660). Related parameters include eccen-
tricity of the equivalent conic section (e) and shape factor (P), where Q e2, and P  Q

1, respectively.

D. VALUE OF COMPUTERIZED VIDEOKERATOGRAPHY IN

REFRACTIVE SURGERY

CVK plays a critical role in the ongoing evaluation of potential and in all phases of the care
of the refractive surgical patient, including preoperative screening, postoperative monitor-
ing of results, and postoperative planning for retreatment procedures.

1. Preoperative Screening

CVK plays several roles in the preoperative evaluation of refractive surgical patients.
a. Determining Topographic Stabilization Following Discontinuation of
Contact Lens Wear
Contact lens wear can alter the shape of the cornea by a process termed warpage, which re-
sults from direct mechanical pressure of the lens and possibly from metabolic factors, such
as low oxygen tension. Corneal topographic patterns of warpage are characterized by the
presence of central irregular astigmatism, loss of radial symmetry, and frequent reversal of
the normal topographic pattern of progressive flattening of corneal contour from the center
to the periphery (61). Superior-riding lenses produced flattening superiorly and result in a
relatively steeper contour inferiorly that simulates the topography of early keratoconus. Us-
ing the Orbscan topography system, Liu and Pflugfelder found that long-term contact lens
 126

Figure 8.8 Contact lensinduced corneal warpage reversed in 1 month after discontinuation of contact lens wear.
Wang et al.
Corneal Topography and LASIK Applications 127

wear ( 5 years) appeared to decrease the entire corneal thickness and increase the corneal
curvature and surface irregularity (62).
Following discontinuation of contact lens wear, it is important to monitor corneal to-
pographic changes and defer obtaining final refractive measurements until corneal topog-
raphy stabilizes (Fig. 8.8). Using the CVK (EyeSys Corneal Analysis System), Budak and
colleagues evaluated corneal stability after discontinuation of contact lens wear in preop-
erative refractive surgery candidates (63). They found that, if the manifest refraction and
CVK maps were within 0.5 diopters of values obtained 2 weeks earlier, topographic indices
were normal, suggesting return of the cornea to its baseline topographic state. In their study
this was noted after discontinuation of soft contact lenses wear for 2 weeks and of rigid gas-
permeable contact lenses wear for 5 weeks.
b. Detecting Ectatic Corneal Disorders or Other Topographic
Abnormalities
Keratoconus
The detection of keratoconus and keratoconus suspects has assumed greater significance in
light of the development and expansion of refractive surgery over recent years. Patients
with keratoconus do not achieve high-quality vision with either glasses or contact lenses,
and they tend to seek out refractive surgery. The percentage of candidates who were found
to have keratoconus or subclinical keratoconus during the preoperative screening for re-
fractive surgery has been reported to be as high as 33% (64).
Patients with moderate to advanced keratoconus are readily recognizable on the to-
pographic maps and easily diagnosed clinically (Fig. 8.9). The difficulty is to detect the

Figure 8.9 Topographic map of keratoconus on curvature map.

128 Wang et al.

keratoconus in its early stages before obvious topographic and clinical signs are present.
These corneas are sometimes referred to as forme fruste keratoconus or keratoconus sus-
pects, because of the subtle topographic abnormalities that are present. Several quantitative
specific corneal indices and detection programs designed to aid the topographic diagnosis
of keratoconus have been developed.
1. RABINOWITZMCDONNELL INDICES. These investigators described two criteria
for detected keratoconus. The first is the inferiorsuperior value (IS), which is defined as
an average refractive power difference between five inferior points and five superior points
3 mm from the center at 30 intervals (65); it is designed to detect clinically significant in-
ferior corneal steepening. When used alone, an IS value greater than 1.4 D is suggestive of
keratoconus. A disadvantage of the I-S value is that the steepening in keratoconus is not al-
ways limited to the inferior periphery (6667). The second criterion, which is designed to
detect central cones, is central corneal power
47.2 D. Because of the variability of the lo-
cation of the cone, these two diagnostic features should be used in concert, and subjective
interpretation is necessary (68).
2. KERATOCONUS PREDICTABILITY INDEX (KPI). Maeda and colleagues devel-
oped the KPI, which is a single value derived by linear discriminant analysis of eight quan-
titative topographic indices (69). A KPI value greater than 0.23 is indicative of kerato-
conus.
3. KERATOCONUS INDEX (KCI). In addition to the discriminant analysis classi-
fier, the authors (69) developed an expert system classifier. An expert system is a form
of artificial intelligence that comprises an extensive set of decision rules. Decisions by
the expert system are made deductively with step-by-step logical operation. In addition
to the KPI, four indices were used in the binary decision tree. The degree of the kerato-
conus-like pattern is determined and expressed as a percentage, KCI%. A value of zero
is normal, with greater values describing an increasing likelihood of the presence of ker-
atoconus. In their study, the expert classifier system was found to be superior to dis-
criminate analysis in sensitivity and overall accuracy. In a subsequent study, three kera-
toconus detection schemes were compared: keratometry (average simulated keratometry
[SimK] readings
45.7 diopters [D]); the modified RabinowitzMcDonnell test (central
corneal power
47.2 D and/or inferosuperior asymmetry [IS] value
1.4 D); and the
expert system classifier (70). Results showed that for screening candidates for refractive
surgery, where high sensitivity is needed, either the modified RabinowitzMcDonnell test
or the expert system classifier is suitable. For diagnosing keratoconus, where high speci-
ficity is more useful, the expert system classifier is more appropriate than the other two
methods.
4. KERATOCONUS SEVERITY INDEX (KSI). Neural networks can interpolate or pre-
dict complicated data through learning, by simulating human neurological processing
abilities, and have been attracting considerable attention in science, economics, and indus-
try, as well as in many areas of medicine. The first application of a neural network model
to classify corneal topography was reported and tested in 183 topographic maps (71). The
correct classification was achieved by a trained neural network for all 108 maps in the train-
ing set. In the test set, the neural network correctly classified 60 of 75 maps (80%). For ev-
ery category, accuracy and specificity were greater than 90%, whereas sensitivity ranged
from 44% to 100%. The model has subsequently been improved (72) and KSI was pro-
posed, which is a combination of neural network models and decision tree analysis. Kera-
toconus suspicion is interpreted when KSI reaches 0.15. A KSI of 0.30 or higher indicates
clinical keratoconus.
Corneal Topography and LASIK Applications 129

5. KISA% INDEX. The KISA% index is derived from the product of four indices:
K value, IS value, AST index, and skewed radial axis (SRAX) index (73). At a cutoff point
for KISA% of 100, 280 of 281 participants (99.6%) were correctly classified. The KISA%
index set at 100 is highly sensitive and specific for diagnosing keratoconus, and a range of
60% to 100% can be used to designate or label patients as keratoconus suspects with min-
imal fear of significant overlap with the normal population (0.5%).
6. OTHER INDICES. The highest rate of steepening (HRS) is the highest rate
of corneal power changes (in diopters per millimeter) away from the apex (the point of max-
imum curvature) to the periphery measured along its semimeridian (74). The authors found
that a cutoff value of HRS of 1.40 D/mm has a sensitivity of 95.7% (67/70), a specificity of
96.4% (16 false positive cases), and an accuracy of 96.3% for detection of keratoconus.
Langenbucher and colleagues developed a keratoconus detection scheme with
wavefront parameters based on topography height data (75). A decomposition of corneal
topography height data into orthogonal Zernike polynomials was performed using
the corneal topographer TMS-1. This index was found to perform at least as well (sensi-
tivity in mild/severe keratoconus 93.4%/100%, with a specificity of 100%) as keratoconus
detection schemes based on the KlyceMaeda and the RabinowitzMcDonnell indices.
Clinical approach. The authors use two approaches to screen patients for kerato-
conus. First, patients are graded according to the keratoconus-screening chart proposed by
Azar, which accounts for both topographic features and slit lamp findings (for details see
Chap. 10). As a second step, corneas are measured using the Tomey topographer, and val-
ues for the KCI and KSI are obtained; any patient with any likelihood of the presence of
keratoconus by either index is rejected for LASIK surgery.

Other Corneal Ectasias

Pellucid marginal degeneration and keratoglobus may represent variants of keratoconus, as
there is considerable overlap among their clinical and topographic features, and they may
coexist in an individual or in the same family.
In pellucid marginal degeneration, the topographic pattern has a classical butterfly
appearance, demonstrating large amounts of against-the-rule astigmatism (Fig. 8.10) and
inferior corneal steepening (7678). Rare cases of superior corneal thinning in pellucid
marginal degeneration have been reported (7981).
Keratoglobus is a rare disorder characterized by limbus-to-limbus corneal thinning
and a globular protrusion of the cornea evident on profile examination (82,83). The topo-
graphic appearance is diffuse corneal steepening with irregular astigmatism.

Corneal Scarring
The topographic pattern produced by corneal scars depends on the site and size of the scar.
Typically, there is corneal flattening overlying the scar with adjacent corneal steepening.
With larger scars, particularly if they are located in the anterior cornea, the videokerato-
scopic rings may merge into one another and cannot be distinguished well enough for the
topography to be reconstructed accurately, resulting in misleading or absent data (Fig.
8.11A, B).

c. Selecting the optimal surgical procedure

In some patients, the preoperative corneal topographic findings can be used to select the ap-
propriate surgical procedure. For example, one might recommend PRK if there is suspicion
of forme fruste keratoconus. This is certainly an area of controversy, because one could ar-
130 Wang et al.

Figure 8.10 Topographic map of pellucid marginal degeneration.

gue that patients with any form of topographic irregularity should be excluded from un-
dergoing corneal refractive surgery. However, there is growing evidence that patients with
asymmetric inferior steepening may be at risk for developing keratectasia following
LASIK (84), whereas PRK may be a safe option in these instances. Another option in these
patients might be Intacs, assuming that the refractive error is low and there is little pre-ex-
isting refractive astigmatism. Finally, detection of forme fruste keratoconus or other sight-
threatening disorders may not preclude patients from undergoing a noncorneal procedure,
such as implantation of a phakic intraocular lens.
d. Topographically Driven Corneal Ablation
Several studies have addressed the potential role of CVK in determining the ablation pattern
to be employed. Tamayo and Serrano reported promising results performing customized ex-
cimer laser ablation based on the Contoured Ablation Patterns (CAP) software (VISX, Inc.),
which enables the surgeon to control the size, pattern, depth, and location of the ablation
based on the elevation data (85). Alessio and colleagues reported promising results in cor-
recting irregular astigmatism using Corneal Interactive Programmed Topographic Ablation
(CIPTA) (LIGI, Taranto, Italy), which provides customized laser ablation by transferring
programmed ablation from the corneal topography to a flying-spot excimer laser (30).

2. Monitoring Postoperative Outcomes

CVK plays a crucial role in assessing patients postoperative outcome, particularly when
complications occur. Hersh (86) have identified eight postoperative topographic patterns in
 Corneal Topography and LASIK Applications 131

eyes that have undergone laser refractive surgery. Unfortunately, there is no strict correla-
tion between postoperative symptoms and topographic findings.
In evaluating postoperative CVK, the authors find it useful to examine several dif-
ferent kinds of maps, depending upon the circumstances. The axial radius of curvature
map is useful because the patterns are familiar and abnormal patterns are therefore read-
ily detected. To evaluate more precisely local irregularities, the instantaneous radius of
curvature map provides the requisite detail. Refractive maps best correlate with quality of
vision and are therefore useful to supplement the curvature data. Finally, elevation maps
can sometimes provide detail that is not as obvious in examining the other maps. In

B
Figure 8.11 Corneal scarring: (A) power map, (B) ring image.
132 Wang et al.

Figure 8.12 Elevation map on an eye 3 months postoperatively showing decentered ablation. Pa-
tient has lost two lines of spectacle-corrected visual acuity.

elevation maps, the authors look for local variations in height that may suggest asymme-
try that can contribute to loss of quality of vision (Fig. 8.12).
Several types of topographic patterns can be indicative of the sources of postoperative
visual problems. A central island is a region in the central corneal that receives relatively
less ablation. Multiple causes have been implicated for central islands, but these are found
only in diaphragm-based broad-beam lasers and are most likely produced by fluid that col-
lects as a result of the shock wave produced by the laser pulses (87). Central islands are de-
fined by their diameter and height in millimeters or power in diopters. In the authors expe-
rience, central islands tend to be symptomatic if they measure 1 mm or more in diameter and
are greater than 1 diopter in power. Whereas central islands following PRK tend to regress
over time, central islands of LASIK eyes tend to be more stable and therefore may require
treatment (88).
Decentration of the ablation is usually best seen with the instantaneous radius of cur-
vature, elevation, and difference maps. Decentration can produce regular and irregular
astigmatism with loss of best-correct acuity, glare, and halos. Treatment requires topo-
graphically driven or wavefront-guided ablation.
Other types of topographic abnormalities that can be seen include a variety of un-
classifiable irregular patterns that can have multiple etiologies, including epithelial irregu-
larity, irregular ablation, and postoperative wound healing problems. Examples of wound
healing problems would include visually significant haze or scarring following PRK and
Grade 4 diffuse lamellar keratitis, particularly the variant that has alsobeen called central
toxic keratopathy (Robert K. Maloney, personal communication). In central toxic ker-
atopathy, there is a pronounced stromal melting with marked irregular astigmatism, corneal
thinning, and striae (Fig. 8.13). Spectacle-corrected acuity can be reduced to as low as
20/200 and may require corneal transplantation.
 Corneal Topography and LASIK Applications

Figure 8.13 An example of central toxic keratopathy (both eyes), with pronounced stromal melting, corneal thinning, and striae.
Spectacle-corrected visual acuity reducted to 20/32 (right eye) and 20/25 (left eye), respectively.
133
 134

Figure 8.14 Patient with apparent central island 4 months following LASIK (upper left). Elevation (lower left) shows higher ele-
vation inferiorly in shape of a peninsula. A 7 m PTK measuring 2.2 mm optical zone with 0.5 mm transition zone was performed de-
centered 0.4 mm inferiorly; this was calculated using VISX CAP software. Note marked improvement in curvature (upper right) and
elevation (lower right) maps.
Wang et al.
Corneal Topography and LASIK Applications 135

3. Planning for Reoperation

CVK is important for determining when the cornea has stabilized following the initial re-
fractive surgical procedure. CVK can also be used to assist in planning the next surgical
procedure. This is particularly relevant if there is a topographic abnormality such as a cen-
tral island or decentration. Certainly, topographic data are essential in planning treatment
of central islands, and outcomes may be enhanced if the ablation can be customized using
special software such as CAP (Fig. 8.14). In the near future, software and hardware devel-
opments, including wavefront-guided ablation, will permit more precise planning and treat-
ment of a range of pre-existing and surgically induced topographic abnormalities.

REFERENCES
1. H Uozato, DL Guyton. Centering corneal surgical procedures. Am J Ophthalmol 1987;103:
264275.
2. GO Waring. Making sense of keratospeak II: proposed conventional terminology for corneal to-
pography. Refract Corneal Surg 1989;5:362367.
3. RK Maloney. Corneal topography and optical zone location in photorefractive keratomy. Re-
fract Corneal Surg 1990;6:363371.
4. FC Mish, ed. Websters Ninth New Collegiate Dictionary. Springfield, MA: Merriam-Webster,
1984.
5. MW Belin, CD Ratliff. Evaluating data acquisition and smoothing functions of currently avail-
able videokeratoscopes. J Cataract Refract Surg 1996;22:421426.
6. S Bafna, T Kohnen, DD Koch. Axial, instantaneous, and refractive formulas in computerized
videokeratography of normal corneas. J Cataract Refract Surg 1998;24:11841190.
7. C Roberts. Characterization of the inherent error in a spherically-biased corneal topography
system in mapping a radially aspheric surface. J Refract Corneal Surg 1994;10:103111.
8. C Roberts. The accuracy of power maps to display curvature data in corneal topography sys-
tems. Invest Ophthalmol Vis Sci 1994;35:35253532.
9. A Gullstrand. Appendices to part I. II. Procedure of the rays in the eye; imagery-laws of the first
order. In: JPC Southall, ed. Helmholtzs Treatise of Physiological Optics; translated from the
third German edition. New York: Optical Society of America, 1924.
10. SA Klein. A corneal topography algorithm that produces continuous curvature. Optom Vis Sci
1992;69:829834.
11. DD Koch, EA Haft. Introduction to corneal topography. In: JP Gills et al., eds. Corneal topog-
raphy: the state of the art. Thorofare, NJ: Slack Incorporated, 1995, pp 315.
12. SE Wilson, SD Klyce. Quantitative descriptors of corneal topography. A clinical study. Arch
Ophthalmol 1991;109:349353.
13. DT Lin. Corneal topographic analysis after excimer photorefractive keratectomy. Ophthalmol-
ogy 1994;101:14321439.
14. MK Smolek, T Oshika, SD Klyce, N Maeda, DH Haight, MB McDonald. Topographic assess-
ment of irregular astigmatism after photorefractive keratectomy. J Cataract Refract Surg
1998;24:10791086.
15. Y Shiotani, N Maeda, T Inoue, H Watanabe, Y Inoue, Y Shimomura, Y Tano. Comparison of
topographic indices that correlate with visual acuity in videokeratography. Ophthalmology
2000;107:559564.
16. JT Holladay. Corneal topography using the Holladay diagnostic summary. J Cataract Refract
Surg 1997;23:209221.
17. PS Hersh, SI Shah, D Geiger, JT Holladay. Corneal optical irregularity after excimer laser pho-
torefractive keratectomy. J Cataract Refract Surg 1996;22:197204.
18. JS Weiss, NL Oplinger. An analysis of the accuracy of predicted corneal acuity in the Holladay
diagnostic summary program. CLAO J 1998;24:141144.
136 Wang et al.

19. RE Hubbe, GN Foulks. The effect of poor fixation on computer-assisted topographic corneal
analysis. Ophthalmology 1994;101:17451748.
20. C Roberts. Analysis of the inherent error of the TMS-1 topographic modeling system in map-
ping a radially aspheric surface. Cornea 1995;14:258265.
21. MW Belin, CD Ratliff. Evaluating data acquisition and smoothing functions of currently avail-
able videokeratoscopes. J Cataract Refract Surg 1996;22:421426.
22. SE Wilson, SD Klyce. Background of corneal topography. In: HK Wu, VM Thompson, RF
Steinert, PS Hersh, SG Slade, eds. Refractive Surgery. New York: Thieme, 1999, pp 5362.
23. L Wang. Keratoconus evaluation using the Orbscan Topography System. Medical doctoral dis-
sertation, 1999, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany.
24. GU Auffarth, MR Tetz, Y Biazid, HE Volcker, Measuring anterior chamber depth with Orb-
scan Topography System. J Cataract Refract Surg 1997;23:13511355.
25. M Vetrugno, N Cardascia, L Cardia. Anterior chamber depth measured by two methods in my-
opic and hyperopic phakic IOL implant. Br J Ophthalmol 2000;84:11131116.
26. V Yaylali, SC Kaufman, HW Thompson. Corneal thickness measurements with the
Orbscan Topography System and ultrasonic pachymetry. J Cataract Refract Surg 1997;23:
13451350.
27. MW Marsich, MA Bullimore. The repeatability of corneal thickness measures. Cornea
2000;19:792795.
28. NG Iskander, EA Penno, NT Peters, HV Gimble, M Ferensowicz. Accuracy of Orbscan
pachymetry measurements compared to DGH ultrasound pachymetry in primary LASIK and
LASIK enhancement procedures. J Cataract Refract Surg. In press.
29. MC Knorz, T Neuhann. Treatment of myopia and myopic astigmatism by customized laser in
situ keratomileusis based on corneal topography. Ophthalmology 2000;107:20722076.
30. G Alessio, F Boscia, MG La Tegola, C Sborgia. Topography-driven photorefractive keratec-
tomy: results of corneal interactive programmed topographic ablation software. Ophthalmology
2000;107:15781587.
31. Z Wang, J Chen, B Yang. Posterior corneal surface topographic changes after laser in situ ker-
atomileusis are related to residual corneal bed thickness. Ophthalmology 1999;106:406409;
discussion 409410.
32. MW Belin, D Litoff, SJ Strods, SS Winn, RS Smith. The PAR technology corneal topography
system. Refract Corneal Surg 1992;8:8896.
33. MW Belin, P Zloty. Accuracy of the PAR corneal topography system with spatial misalign-
ment. CLAO J 1993;19:6468.
34. OO Ucakhan, G Sternberg, C Bodian, K Kelliher, PA Asbell. Intraoperative PAR corneal to-
pography system (CTS): comparison of its keratometric readings to manual keratometer, auto-
keratometer, EyeSys Corneal Analysis system, and slit lamp PAR CTS in healthy eyes. CLAO
J 2000;26:151158.
35. D Priest, R Munger. Comparative study of the elevation topography of complex shapes. J
Cataract Refract Surg 1998;24:741750.
36. RL Schultze. Accuracy of corneal elevation with four corneal topography systems. J Refract
Surg 1998;14:100104.
37. PC Baker. Holographic contour analysis of the cornea. In: BR Masters, ed.: Noninvative diag-
nostic techniques in ophthalmology. New York: Springer-Verlag, 1990.
38. MC Corbett, DP OBrart, BATh Stultiens, FHM Jongsma, J Marshall. Corneal topography us-
ing a new moir image-based system. Eur J Implant Ref Surg 1995;7:353370.
39. GWHM Van Alphen. On emmetropia and ametropia. Ophthalmologica 1961;142(suppl):192.
40. LF Garner, CK Meng, TP Grosvenor, N Mohidin. Ocular dimensions and refractive power in
Malay and Melanesian children. Ophthalmic Physiol Opt 1990;10:234238.
41. DA Goss, VD Cox, GA Herrin-Lawson, ED Nielsen, WA Dolton. Refractive error, axial length,
and height as a function of age in young myopes. Optom Vis Sci 1990;67:332338.
42. T Grosvenor, R Scott. Role of the axial length/corneal radius ratio in determining the refractive
state of the eye. Optom Vis Sci 1994;71:573579.
Corneal Topography and LASIK Applications 137

43. WSH Goh, CSY Lam. Changes in refractive trends and optical components of Hong Kong Chi-
nese aged 1939 years. Ophthalmic Physiol Opt 1994;14:378382.
44. Z Liu, J Chen, S Li. The differences in corneal shape between myopic and normal eyes. Chung
Hua Yen Ko Tsa Chih 1995;31:282284.
45. K Budak, TT Khater, NJ Friedman, JT Holladay, DD Koch. Evaluation of relationships among
refractive and topographic parameters. J Cataract Refract Surg 1999;25:814820.
46. LG Carney, JC Mainstone, BA Henderson. Corneal topography and myopia: a cross-section
study. Invest Ophthalmol Vis Sci 1997;38:311320.
47. K Budak, AM Hamed, NJ Friedman, DD Koch. Corneal topography classification in myopic
eyes based on axial, instantaneous, refractive, and profile difference maps. J Cataract Refract
Surg 1999;25:10691079.
48. NC Strang, KL Schmid, LG Carney. Hyperopia is predominantly axial in nature. Curr Eye Res
1998;17:380383.
49. RB Mandell, R St. Helen. Mathematical model of the corneal contour. Br J Physiol Opt
1971;26:183197.
50. DM Maurice. The cornea and sclera. In: H Davson, ed. The Eye. New York: Academic Press, 1984.
51. RH Webb. Zernike polynomial description of ophthalmic surfaces. In: Ophthalmic and Visual
Optics Technical Digest. Washington, DC: Optical Society of America, 1992, pp 3841.
52. HC Howland, A Glasser, R Applegate. Polynomial approximations of corneal surfaces and
corneal curvature topography. In: Ophthalmic and Visual Optics Technical Digest. Washing-
ton, DC: Optical Society of America, 1992, pp 3437.
53. C Edmund, E Sjontoft. The central-peripheral radius of the normal corneal curvature: a pho-
tokeratoscopic study. Acta Ophthalmol 1985;63:670677.
54. J Wang, DA Rice, SD Klyce. A new reconstruction algorithm for improvement of corneal to-
pographic analysis. Refract Corneal Surg 1989;5:379387.
55. PS Hersh, SI Shah, JT Holladay. Corneal asphericity following excimer laser photorefractive
keratectomy. Summit PRK Topography Study Group. Ophthalmic Surg Lasers 1996;27(suppl):
S421S428.
56. W Lotmar. Theoretical eye model with aspherics. J Opt Sci Am 1971;61:15221529.
57. PM Kiely, G Smith, LG Carney. The mean shape of the human cornea. Optica Acta 1982;
29:10271040.
58. SG El Hage, B Berney. Contribution of the crystalline lens to the spherical aberration of the eye.
J Opt Sci Am 1973;63:205211.
59. M Townsley. New knowledge of the cornea contour. Contacto 1970;14:3843.
60. M Guillon, DPM Lydon, C Wilson. Corneal topography: a clinical model. Ophth Physiol Opt
1986;6:4756.
61. SE Wilson, DT Lin, SD Klyce, JJ Reidy, MS Insler. Topographic changes in contact lens-in-
duced corneal warpage. Ophthalmology 1990;97:734744.
62. Z Liu, SC Pflugfelder. The effects of long-term contact lens wear on corneal thickness, curva-
ture, and surface regularity. Ophthalmology 2000;107:105111.
63. K Budak, AM Hamed, NJ Friedman, DD Koch. Preoperative screening of contact lens wearers
before refractive surgery. J Cataract Refract Surg 1999;25:10801086.
64. SE Wilson, SD Klyce. Screening for corneal topographic abnormalities before refractive
surgery. Ophthalmology 1994;101:147152.
65. YS Rabinowitz, PJ McDonnell. Computer-assisted corneal topography in keratoconus. Refrac-
tive Corneal Surg 1989;5:400406.
66. GU Auffarth, L Wang, HE Volcker. Keratoconus evaluation using the Orbscan topography sys-
tem. J Cataract Refract Surg 2000;26:222228.
67. RA Eiferman, L Lane, M Law, Y Fields. Superior keratoconus (letter). Refract Corneal Surg
1993;9:394395.
68. DD Koch, SE Husain. Corneal topography to detect and characterize corneal pathology. In: JP
Gills et al., eds. Corneal topography: the state of the art. Thorofare, NJ: Slack Incorporated,
1995, pp 159169.
138 Wang et al.

69. N Maeda, SD Klyce, MK Smolek, HW Thompson. Automated keratoconus screening with

corneal topography analysis. Invest Ophthalmol Vis Sci 1994;35:27492757.
70. N Maeda, SD Klyce, MK Smolek. Comparison of methods for detecting keratoconus using
videokeratography. Arch Ophthalmol 1995;113:870874.
71. N Maeda, SD Klyce, MK Smolek. Neural network classification of corneal topography. Pre-
liminary demonstration. Invest Ophthalmol Vis Sci 1995;36:13271335.
72. MK Smolek, SD Klyce. Current keratoconus detection methods compared with a neural net-
work approach. Invest Ophthalmol Vis Sci 1997;38:22902299.
73. YS Rabinowitz, K Rasheed. KISA% index: a quantitative videokeratography algorithm em-
bodying minimal topographic criteria for diagnosing keratoconus. J Cataract Refract Surg
1999;25:13271335.
74. MH Dastjerdi, H Hashemi. A quantitative corneal topography index for detection of kerato-
conus. J Refract Surg 1998;14:427436.
75. A Langenbucher, GC Gusek-Schneider, MM Kus, D Huber, B Seitz. Keratoconus screening
with wave-front parameters based on topography height data. Klin Monatsbl Augenheilkd
1999;214:217223.
76. JH Krachmer. Pellucid marginal corneal degeneration. Arch Ophthalmol 1978;96:12171221.
77. LJ Maguire, SD Klyce, MB McDonald, HE Kaufman. Corneal topography of pellucid marginal
degeneration. Ophthalmology 1987;94:519524.
78. CH Karabatsas, SD Cook. Topographic analysis in pellucid marginal corneal degeneration and
keratoglobus. Eye 1996;10(pt 4):451455.
79. JA Cameron, MA Mahmood. Superior corneal thinning with pellucid marginal corneal degen-
eration. Am J Ophthalmol 1990;109:486487.
80. KS Bower, DK Dhaliwal, DA Barnhorst Jr, J Warnicke. Pellucid marginal degeneration with
superior corneal thinning. Cornea 1997;16:483485.
81. DP Taglia, J Sugar. Superior pellucid marginal corneal degeneration with hydrops. Arch Oph-
thalmol 1997;115:274275.
82. F Verrey. Kratoglobe aigu. Ophthalmologica 1947;114:284288.
83. V Cavara. Keratoglobus and keratoconus: a contribution to the nosological interpretation of
keratoglobus. Br J Ophthalmol 1950;34:621626.
84. SP Amoils, MB Deist, P Gous, PM Amoils. Iatrogenic keratectasia after laser in situ ker-
atomileusis for less than 4.0 to 7.0 diopters of myopia. J Cataract Refract Surg 2000;26:
967977.
85. GE Tamayo Fernandez, MG Serrano. Early clinical experience using custom excimer laser ab-
lations to treat irregular astigmatism (1). J Cataract Refract Surg 2000;26:14421450.
86. PS Hersh. A standardized classification of corneal topography after laser refractive surgery. J
Refract Surg 1997;13:571575; discussion 575578.
87. T Oshika, SD Klyce, MK Smolek, MB McDonald. Corneal hydration and central islands after
excimer laser photorefractive keratectomy. J Cataract Refract Surg 1998;24:15751580.
88. SW Kang, ES Chung, WJ Kim. Clinical analysis of central islands after laser in situ ker-
atomileusis. J Cataract Refract Surg 2000;26:536542.
 9
Wavefront Technology and
LASIK Applications

NAOYUKI MAEDA
Osaka University Medical School, Osaka, Japan

A. INTRODUCTION
Spherical and cylinder corrections with spectacles for the refractive errors of the eyes have
been performed since the thirteenth and nineteenth centuries. From the latter time, refrac-
tive errors have been measured for sphere and cylinder components in the general oph-
thalmic practice. Although corneal topographic analysis can be performed to evaluate the
corneal irregular astigmatism, and rigid contact lenses can be used to correct corneal irreg-
ular astigmatism, it is still difficult to evaluate the irregular astigmatism components in re-
fraction and to correct for irregular astigmatism with any optical device until recently.
Nevertheless, we will eventually have the means of determining the complete refrac-
tive status including higher-order irregular astigmatism by wavefront sensing and to obtain
supernormal vision (1) with refractive surgery by applying the principle of adaptive op-
tics. In this chapter, the concepts of wavefront analysis and adaptive optics, (2) and the ap-
plication of these to the LASIK procedure, will be presented from an ophthalmologists
point of view.

B. PRINCIPLES OF WAVEFRONT SENSING

1. What Is the Wavefront?
We first need to know what is meant by a wavefront. Figure 9.1 shows how light is ex-
pressed differently in geometrical and physical optics. The rays from a point source of light
radiate out in all directions in geometrical optics. However, in physical optics, light is con-
sidered as a wave and the light wave spreads in all directions as in the widening rings on a
still pond when a stone is thrown into it. The wavefront is a ripple that is in phase.
139
140 Maeda

Figure 9.1 Ray and wavefront.

Similarly, light coming from infinity is considered to be linear bundles of rays in ge-
ometrical optics. In physical optics, the wave from infinity has a plane wavefront, and the
plane of the wavefront is always perpendicular to the direction of the rays.
Although an optical system or lens is usually defined as one that refracts light rays,
it can also be defined as one that transforms the shape of wavefront (Fig. 9.2). If we think
of light emitted from the fovea passing through the lens and cornea towards the outside, the
refractive status, such as myopia, hyperopia, supernormal eyes, and eyes with higher-order
aberrations (irregular astigmatism), can be displayed using wavefronts as shown in Fig. 9.3.
The wavefront of the supernormal eye, that is, an emmetropic eye without any aberrations,
is shown as a perfect plane that is perpendicular to the line of sight. In myopic eyes, the
wavefront has a bowllike shape with the peripheral wavefront more advanced than the cen-
tral wavefront. As the wavefront is perpendicular to the ray, it is easy to imagine that the
peripheral rays go to the primary line of sight and bundles of ray converge on the axis.
The wavefront exiting the hyperopic eye, on the other hand, has a hill shape with the
central wavefront more advanced than the peripheral wavefront. Therefore the rays of a hill
shaped wavefront will diverge. If the measured eye has irregular astigmatism or higher-or-
der aberrations, the wavefront of the eye will have an irregular shape.

2. Wavefront Analysis
The purpose of wavefront analysis is to evaluate the optical quality of the eye by evaluat-
ing the shape of its wavefront. The optical quality of a wavefront is usually expressed as
wavefront aberrations, where wavefront aberration is defined as the deviation between the
wavefront that comes from an ideal optic system and the wavefront that originates from an

Figure 9.2 Optical system and wavefront.

Wavefront Technology and LASIK Applications 141

Figure 9.3 Refractive errors and diagram using wavefront.

actual optical system. The unit used for wavefront analysis is not diopters but microns or
fractions of wavelength, because wavefront expresses the deformity of wavefront shape in
three-dimensional space. It is usually expressed as the root mean square or RMS.
The instruments used for wavefront analysis are called wavefront sensors, and these
instruments are classified into two categories based on their method of measurement, the
ray tracing method and the laser interferometry method. Examples of wavefront sensors
that use ray tracing are the Tscherning aberroscope, the HartmannShack sensor, the cross
cylinder aberroscope, optical path difference, and subjective ray tracing.
Higher-order aberrations in the human eye were measured first by Smirnov (3) in
1961 by a psychophysical method, and he predicted that custom lenses will be made to
compensate for the higher-order aberrations of individual eyes. A modified aberroscope
technique was developed by Howland (4), and Liang and Bille (5) measured the wavefront
aberration of the human eye objectively using the HartmannShack sensor in 1994.
The principle of the HartmannShack sensor is shown in Fig. 9.4. A very narrow
beam of light is projected onto the retina, and the light reflected from the fovea passes
through the lens and cornea and exits from the eye. The HartmannShack sensor has an ar-

Figure 9.4 Principles of HartmannShack sensor.

142 Maeda

Figure 9.5 Spot patterns in normal subject.

ray of lenslets that consist of a matrix of small lenses (2,6). The light emerging from the
eye is focused on a CCD camera by each lenslet to form a spot pattern. The spot pattern of
an ideal subject with a perfect wavefront will be exactly the same pattern as the reference
grid. The spot pattern of a subject with a distorted wavefront will create an irregular spot
pattern. Displacements of lenslet images from their reference position are used to calculate
the shape of the wavefront.
Figures 9.5 and 9.6 show examples of spot patterns from a normal and a keratoconic
subject with the Topcon HartmannShack sensor. Although the spot pattern in the normal
subject is regular, the spot pattern in the patient with keratoconus is markedly distorted. As
the wavefront of each lenslet is perpendicular to the direction of the ray, i.e., displacement

Figure 9.6 Spot patterns in keratoconus.

Wavefront Technology and LASIK Applications 143

Figure 9.7 Equation of Zernike polynomials.

of their focusing spots, the wavefront of the measured subjects can be reconstructed from
these spot patterns.
Wavefront aberrations, the quantitative measure of wavefront distortions, are usually
calculated using Zernike polynomials. The wavefront is expanded into sets of Zernike poly-
nomials to extract the characteristic components of the wavefront. The Zernike polynomi-
als are the combination of trigonometric functions and radial functions, and the terms of the
Zernike polynomials, represented as Z (Fig. 9.7), are useful to show the wavefront aberra-
tions because of their orthogonality (2).
Examples of Zernike polynomials up to the fourth order are shown in Fig. 9.8. The
zero order has one term that represents a constant. The first order represents tilt (two
terms, one for the X axis and another for the Y axis). The second order includes three
terms that represent defocus and astigmatism in the two directions. The third order has
four terms that represent coma and trefoil aberrations. The polynomials can be expanded
up to any arbitrary order unless there are enough numbers of measurements of points for
calculations. Spectacles can correct only second-order aberrations, not the third and
higher orders that represent irregular astigmatism. Using the Zernike coefficients of each
term, monochromatic aberrations can be evaluated quantitatively (7).
The wavefront can also be displayed as color-coded maps as shown in Figs. 9.5 and
9.6. The advancing part of a wavefront is shown by warmer colors and the trailing part of
the wavefront is shown by cooler colors.

3. Adaptive Optics
In general, optical systems, such as cameras, telescopes, fundus cameras, or spectacles,
with lower aberrations have better optical properties. However, even if we minimize the
aberrations in an optical system such as an astronomical telescope or a fundus camera,
the aberrations induced by the atmosphere or the aberrations of normal human eyes are
usually larger than the aberrations in the optic devices, and thus the final resolution of the
images is reduced, i.e., the optical quality is limited by the higher-order aberrations of the
subjects.
Adaptive optics is the concept of intentionally designing the optics of the observatory
system to compensate for the measured aberrations of the subject. As a result, the total aber-
rations of the subject and observatory system are reduced, and one can observe with mini-
mal aberrations.
An example of an adaptive optical system is shown in Fig. 9.9. The wavefront sen-
sor measures the aberrations of the subject, and this information is processed and sent to
actuators. The shape of the deformable mirror is controlled by actuators to reshape the sur-
face of the thin mirror to compensate for the aberration of the subject.
 144

Figure 9.8 Graphic representations of Zernike polynomials.

Maeda
Wavefront Technology and LASIK Applications 145

Figure 9.9 Principles of adaptive optics.

Babcock (8) arrived at the concept of adaptive optics in 1953, and this technology
was used for military purposes for a long time. In 1991, much of the United States mili-
tary work in adaptive optics was declassified, and the astronomical community applied this
technology to their field (9). In 1997, Liang and Williams corrected the monochromatic
aberrations of normal human eyes with adaptive optics and showed that this improved the
contrast sensitivity of the eye, and the imaging of cone cells in the living human retina.
With adaptive optics, images of the cone mosaic (short-, medium-, and long-wavelength-
sensitive cones) in living human eyes were observed (10).
If we use an excimer laser in place of the deformable mirror, we have the potential of
correcting irregular astigmatism and obtaining supernormal vision by eliminating the in-
herent optical aberrations of normal human eyes. Although this might not be classified as
adaptive optics by the strictest definition, this concept has become one of the most dis-
cussed topics in refractive surgery.

C. WAVEFRONT-GUIDED ABLATION IN LASIK

1. Optical Quality in Current LASIK Procedures

The question arises whether the current LASIK procedures are satisfactory. For correcting
refractive changes, current LASIK procedures have reasonably good predictability for mild
to moderate myopia and low hyperopia. As a result, most patients are satisfied with the out-
come. This is the one of the major reasons why LASIK has been accepted by the public in
such a short period. However, we have also noticed that the optical quality of the eye fol-
lowing LASIK is not optimal, and LASIK patients sometimes complain about problems
such as halo, glare, or difficulty with night driving. It is also very difficult to treat irregular
astigmatism with conventional LASIK procedures. Thus we must realize that current tech-
niques, while quite satisfactory, still have room to be improved.
The effect of corneal shape on the optical quality of the eye can be calculated as
corneal wavefront aberrations using corneal topography. It is possible to estimate the sur-
gically induced higher-order aberrations of the eye from the measurement of corneal wave-
front aberrations, because wavefront aberrations of the lens should be stable despite the re-
fractive corneal surgeries. The measurement of corneal aberrations showed that
higher-order aberrations of the cornea increased following PRK (11,12,13) and LASIK
146 Maeda

(12). This trend was more prominent for night vision (large pupil) than for day vision (small
pupil). Also, there is a significant correlation between the surgically induced higher-order
aberrations of the cornea and the attempted correction of the surgery (11,13). With the de-
velopment of wavefront sensors, the increase of higher-order aberrations of the eye fol-
lowing a conventional PRK procedure was confirmed (14).
These results suggest that custom ablation methods that can correct irregular astig-
matism or that can reduce surgically induced higher-order aberrations might reduce some
of the problems of the current LASIK procedures.

2. Wavefront-Guided LASIK
When wavefront-guided refractive surgery is performed, the following requirements
should be satisfied for the wavefront sensing and the photo ablation. For the measurement
of wavefront aberrations, wavefront sensors and softwares that can calculate the aberration
are essential. Since 1999, many prototype wavefront sensor instruments have been intro-
duced (Table 1). Figures 9.10, 9.11, and 9.12 show examples of wavefront sensors and
their outputs. Although all of these instruments are prototypes, they should soon be com-
mercially available.
Based on the measured wavefront aberrations, not only spherical and cylindrical er-
rors but also irregular astigmatism (higher-order wavefront aberrations) should be cor-
rectable with the excimer laser. For that purpose, very fine processing of the corneal shape
is required including asymmetrical or local ablations. Therefore laser instruments should
be equipped with a flying spot scanning system or an equivalent mechanism, and an active
eye tracking system is essential for precise ablation (Table 2). In addition, an algorithm that

Table 1 Examples of Wavefront Sensors

Corneal
Wavefront sensor Company Principle topography Excimer laser

CustomCornea Zeiss Humphrey HartmannShack Alcon/Summit/

wavefront Autonomous
system
WaveScan 20/10 Perfect HartmannShack VISX
Vision
Zywave Technolas HartmannShack Slit scanning Technolas
(Orbscan IIz)
Dresden Technomed Tscherning Wavelight,
wavefront Schwind
analyzer
Ray-tracking Tracey Ray tracing
refractometer Aberrometry
ARK-10000 Nidek Optical path Videokeratoscope Nidek
difference
Wavefront Topcon HartmannShack Videokeratoscope
analyzer
COAS Wavefront HartmannShack Meditec
Sciencies
Wavefront Technology and LASIK Applications 147

Figure 9.10 Alcon/Summit/Autonomous Custom cornea wavefront system. (Courtesy of Alcon/

Summit/Autonomous Inc.)

can perform aberration correction (15) should be provided. The speed of light in the air is
faster than that in the corneal stroma. Therefore the corneal stroma where the wavefront is
delayed should be ablated in order to correct aberrations. The areas that are displayed with
cooler colors in the wavefront map should be cut to reduce the wavefront aberrations in-
cluding sphere, cylinder, and higher-order aberrations.
On June 12, 1999, Seiler and his coworkers reported the first application of wave-
front-guided LASIK. The early results in three eyes (16) were published by his group us-
ing the Wavelight Allegretto excimer laser. The results of this report were promising, as all
148 Maeda

Figure 9.11 VISX WaveScan. (Courtesy of VISX.)

three eyes gained up to two lines of visual acuity, and the wavefront deviations were re-
duced by 27% on the average. In the United States, McDonald started the first wavefront-
guided LASIK with the Autonomous system on October 1999. She has been performing a
comparative study by doing conventional LASIK in one eye and the wavefront-guided
LASIK in the other eye for myopia and hyperopia. Although wavefront-guided LASIK pro-
duced similar uncorrected visual acuity compared to conventional LASIK, a reduction of
higher-order aberrations by wavefront-guided LASIK was found in some cases. Also,
VISX and other laser companies have started clinical trials that evaluate the wavefront-
guided ablations. The safety and the efficacy of this procedure should be reported soon.
Wavefront Technology and LASIK Applications 149

Figure 9.12 Topcon wavefront analyzer. (Courtesy of Topcon Inc.)

Table 2 Examples of Excimer Lasers

Eye tracking
Laser Company Ablation (sampling rate)

LadarVision 4000 Alcon/Summit/ Flying spot (0.80.9 mm) Laser radar tracker
Autonomous (4000 Hz)
Star S3 VISX Broad beam followed by Infrared tracker (60 Hz)
scanning spot
EC-5000CX Nidek Scanning slit followed Infrared tracker (60 Hz)
by scanning spot
MEL 70 G-Scan Asclepion-Meditec 1.5 mm flying spot Infrared tracker (50 Hz)
Technolas 217Z B&L Dual-diameter flying Infrared tracker (120 Hz)
spot (2 and 1 mm)
Allegretto Wavelight 1 mm flying spot Infrared tracker (250 Hz)
ESIRIS Schwind 1 mm flying spot Infrared tracker (300 Hz)
LaserScan LSX Lasersight Flying spot (0.81 mm) Infrared tracker (60 Hz)
150 Maeda

D. SUMMARY
It is reasonable for refractive surgeons to remove pathological irregular astigmatism or sur-
gically induced aberrations that correlate with pupil diameter or attempt correction by re-
fractive surgeries. On the other hand, we will need to know the clinical significance of su-
pernormal vision, and also when we should correct for higher-order aberrations because
aberrations of refractive surgery candidates do change with age (17,18).
Wavefront-guided refractive surgery has just begun. Many aspects must be improved
to obtain better results than the conventional techniques, as many newly developed surgi-
cal procedures have problems for the first time. We need to know that conventional refrac-
tive surgeries induce higher-order aberrations, and custom ablation appears to be the only
solution.

REFERENCES
1. J Liang, DR Williams, DT Miller. Supernormal vision and high-resolution retinal imaging
through adaptive optics. J Opt Soc Am A 1997;14:28842892.
2. RK Tyson. Principles of Adaptive Optics. 2d ed. Boston: Academic Press, 1998.
3. MS Smirnov. Measurement of the wave aberration of the human eye. Biofizika 1961;6:687
703.
4. B Howland, HC Howland. Subjective measurement of high-order aberrations of the eye. Sci-
ence 1976;193:580582.
5. J Liang, B Grimms, S Goelz, JF Bille. Objective measurement of wave aberrations of the hu-
man eye with the use of a HartmannShack wavefront sensor. J Opt Soc Am A 1994;11:1949
1957.
6. LN Thibos, X Hong. Clinical applications of the ShackHartmann aberrometer. Optom Vis Sci
1999;76:817825.
7. J Liang, DR Williams. Aberrations and retinal image quality of the normal human eye. J Opt
Soc Am A 1997;14:28732883.
8. HW Babcock. The possibility of compensating astronomical seeing. Publ Astron Soc Pac
1953;65:229236.
9. RQ Fugate, DL Fried, GA Ameer, BR Boeke, SL Browne, PH Roberts, RE Ruane, LM Wopat.
Measurement of atmospheric wavefront distortion using scattered light from a laser guide star.
Nature 1991;353:144146.
10. A Roodra, DR Williams. The arrangement of the three cone classes in the living human eyes.
Nature 1999;397:520522.
11. CE Martinez, RA Applegate, SD Klyce, MB McDonald, JP Medina, HC Howland. Effect of
papillary dilation on corneal optical aberrations after photorefractive keratectomy. Arch Oph-
thalmol 1998;116:10531062.
12. T Oshika, SD Klyce, RA Applegate, HC Howland, MA El Danasoury. Comparison of corneal
wavefront aberrations after photorefractive keratectomy and laser in situ keratomileusis. Am J
Ophthalmol 1999;127:17.
13. KM Oliver, RP Hemenger, MC Corbett, DPS OBrart, S Verma, J Marshall, A Tomlinson.
Corneal optical aberrations induced by photorefractive keratectomy. J Refract Surg 1997;13:
246254.
14. T Seiler, M Kaemmerer, P Mierdel, HE Krinke. Ocular optical aberrations after photorefractive
keratectomy for myopia and myopic astigmatism. Arch Ophthalmol 2000;118:1721.
15. J Schwiegerling, RW Snyder. Custom photorefractive keratectomy ablations for the correction
of spherical and cylindrical refractive error and higher-order aberration. J Opt Soc Am A
1998;15:25722579.
Wavefront Technology and LASIK Applications 151

16. M Mrochen, M Kaemmerer, T Seiler. Wavefront-guided laser in situ keratomileusis: Early re-
sults in three eyes. J Refract Surg 2000,16:116121.
17. T Oshika, SD Klyce, RA Applegate, HC Howland. Changes in corneal wavefront aberrations
with aging. Invest Ophthalmol Vis Sci 1999;40:13511355.
18. A Guirao, C Gonzalez, M Redondo, E Geraghty, S Norrby, P Artal. Average optical perfor-
mance of the human eye as a function of age in a normal population. Invest Ophthalmol Vis Sci
1999;40:203213.
 10
Preoperative Considerations
Diagnosis, Classification, and Avoidance of
Keratoconus Complications

PAUL CHUNG-SHIEN LU
Chang Gung Memorial Hospital, Taipei, Taiwan, and Harvard Medical School,
Boston, Massachusetts, U.S.A.
DIMITRI T. AZAR
Massachusetts Eye and Ear Infirmary, Schepens Eye Research Institute,
and Harvard Medical School, Boston, Massachusetts, U.S.A.

A. INTRODUCTION
Keratoconus patients have problems with contact lenses and poor visual acuity with
glasses, which contributes to the patients natural tendency to consider refractive surgery.
Keratoconus is a progressive, bilateral, and noninflammatory corneal disease associated
with central and paracentral stromal thinning; it is characterized by anterior and posterior
corneal protrusion, irregular astigmatism, stromal scarring, and decreased visual acuity,
which may reduce the patients ability to achieve 20/20 corrected visual acuity with spec-
tacles (1). Keratoconus may be associated with systemic diseases (Downs syndrome,
Lebers congenital amaurosis, connective tissue disease), trauma (2) (contact lens wear,
eye rubbing), and positive family history (35). Stromal thinning, epithelial iron ring
(Fleischer ring), Vogts striae, and scarring (6) are often noted on slit lamp examination.
Hydrops (Fig. 10.1) is generally associated with advanced keratoconus. Due to the patho-
logic conditions surgical trauma may exacerbate the disease. The corneas may be weakened
by a lamellar cut and cause further corneal instability.
Controversy of diagnosis of keratoconus exists especially in contact lenses wearers
(warpage or molding effects) and in other eye conditions simulating keratoconus, such as
pellucid marginal degeneration, and keratoglobus.
153
154 Lu and Azar

Figure 10.1 The advanced keratoconus with a hydrop in the central cornea. Th