Many of my Miami patients who return sometime following their LASIK/PRK will enthusiastically relate their life experience as it pertains to their surgery.  Here I want to tell my story which basically charts the entire history of LASIK as I was there at the beginning and have grown with the advancements and re-directions.

In 1986, I was introduced to the excimer laser which had been developed at IBM in New York.  It was a precision cutting device which was only used to demonstrate how you could cut a square in a strand of human hair; a party trick.  Eventually some researcers at Columbia University came up with the idea of aiming the laser at the cornea with the hope of reshaping it and eliminating nearsightedness.  The device which had been developed in New York could not be used in the USA thanks to the FDA so I traveled to London and on to Berlin where the procedures were being done.  The trips were fun and the technology was spectacular.

My first opportunity to actually use the laser was in 1996, when it finally received FDA approval.  Tne LASIK procedure at that time was not in existance.  We were aiming the laser at the surface of the cornea without creating a flap; this was PRK, Photorefractive Keratoplasty.  We could only treat myopia as there was no algorithm for farsightedness or astigmatism.  The procedure worked very nicely for the limited number of patients that were treatable.  The down side was that it was a painful postoperative coarse.  Because of the pain created by lasering the front of the cornea, the notion of cutting a flap and lasering the interior gained popularity.  There turned out to be much less pain with this approach and so began LASIK.

The process of cutting an extremely thin section of cornea became the challenge.  One of the earliest and most popular devices was actually developed in Hialeah.  These cutting devices are called keratomes.  In the early days of LASIK the application and successful use of the various keratomes was a tricky undertaking as the equipment was unforgiving if the operator made the slightest error.  There were dislocated flaps, irregular cuts and partial cuts.  But since the vast majority of folks did very well without pain we forged on.  Ultimately, the keratomes became automated and complications became rare.  Surgeons still had in the back of their minds the ultimate safety of the PRK as there is no flap and therefore no flap related problems.  At the same time there emerged a class of eye drops known as NSAIDS (non-steroidal anti-inflammatory drugs).  These drugs eliminated the postoperative pain following the PRK.  Thus began the swing back to the old days of PRK.  Ofcoarse by now we were treating myopia, hyperopia and astigmatism.

While I watched the excimer laser go through four generational changes, the newest kid on the block is the femtosecond laser.  This laser is used to cut a precise flap with minimal complications. 

All of this brings us to the present.  In my consultations with refractive surgery candidates we discuss these options.  Many people want to reduce the risk factor to as close to zero as is possible and elect PRK.  Some need to have an immediate visual result and short term recovery period and elect LASIK (the return of vision following PRK can be five to six days).  Others have thin corneas wherein PRK is the only option.  So it all comes down to fitting the procedure to the patient and not visa versa.  In the end, personalized care and attention to detail leads to a happy patient and a happy doc and we all sleep well at night.

Most of my patients think that astigmatism is a disease; it is not and it’s time to clear the air.  Astigmatism is a normal condition effecting 80 percent of the population.  Astigmatism is caused by an irregular shape of the cornea; the clear window on the front of the eye is the cornea.  In a non-astigmatic eye it has a round curve in all directions, like a basketball.  In the case of astigmatism, it is shaped like a spoon.  In one direction there is a steep curve and in the other there is a gentle curve.  This is called “regular astigmatism.”  When light passes into the eye it must pass through the cornea.  When there is no astigmatism the light comes to a perfect focus on the retina and the vision is excellent.  When light passes through an astigmatic cornea light from different directions is focused differently and there is a blurry image projected onto the retina.

Regular astigmatism is easily corrected with eyeglasses or contact lenses.  If you hold your glasses out in front  of you and look at a picture on the wall while rotating the glasses you might see some changing distortion; this is the lens correcting your astigmatism.  Rigid gas permeable (hard) contacts are excellent at correcting astigmatism while soft lenses are less effective.

There are excellent surgical techniques for the correction of astigmatism.  The oldest method that I began using in 1982 is astigmatic keratotomy.  Here small straight incisions are made on the cornea across the steeper curve (meridian).  This tends to flatten that meridian and steepen the flatter meridian, ultimately making the cornea more spherical.  Along came LASIK where after several years there emerged an algorithm for the correction of astigmatism along with nearsightedness and eventually along with farsightedness.  Very substantial amounts of astigmatism can be corrected with LASIK.  More recently, we have added a variation of astigmatic keratotomy (AK), known as limbal relaxing incision (LRI).  Here the corneal incision is moved to the outer edge of the cornea and is curved rather than straight.  It is more predictable than AK. 

When patients come for cataract surgery we always evaluate their astigmatism.  This is done so that we can calculate the power of the lens to be implanted at surgery and also to be in the position to offer them an opportunity to have the astigmatism corrected with LRI at the same time.  The purpose is to enable patients to achieve excellent vision without glasses when the cataract surgery is done.  We usually reserve the LRI for small amounts of astigmatism because there now is available the toric lens.  This is an intraocular lens with optics designed to neutralize the astigmatism along with the correction of myopia or hyperopia.  This lens is implanted just as any lens might be then it is rotated into a position to match the steep meridian on the cornea, thus neutralizing the astigmatism.

So don’t be concerned when you learn that you have astigmatism; it could be a lot worse.