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Up Front | Jul 2010

CHIEF MEDICAL EDITOR’S PAGE: 20 Years of LASIK— What an Impact

The European Year of LASIK celebrates 2 decades of a procedure that has had phenomenal impact on patients, ophthalmologists, and the entire ophthalmic industry. In its current state, LASIK is still conceptually futuristic: quick to perform, using lasers in almost all aspects with rapid visual recovery.

This procedure has established the goal posts for future surgical procedures in terms of visual expectations, rapidity of recovery, and longterm stability. I am astounded when I see patients whom I treated 15 years ago continue to maintain 20/20+ vision, especially considering the technology used in those days—the Automated Cornea Shaper (ACS; Chiron Vision Corp., Irvine, California; now Bausch + Lomb, Rochester, New York) and the broadbeam excimer laser (Technolas 116; Bausch + Lomb)—which seem medieval compared to available technology today.

I recall a small refractive meeting in Dublin, Ireland, in 1995, in which Patrick Condon, Klaus Ditzen, Michael O'Keeffe, Ioannis Pallikaris, and I discussed our LASIK woes, specifically flap complications. We happily exchanged problems and discussed pearls for a variety of scenarios, including deep-set orbits, big noses, and microkeratome blades.

Rapid evolution of the LASIK procedure ensued, with phenomenal improvements in keratomes, starting with the revolutionary Hansatome (Bausch + Lomb), followed by a series of competitive keratomes, and then revolutionized once again by the IntraLase femtosecond laser (Abbott Medical Optics Inc., Santa Ana, California). Now a number of other femtosecond laser manufacturers are involved not only in the refractive surgery market but also in the cataract surgery market. (Editor's Note: Next month's cover focus will evaluate the position of femtosecond lasers in both markets.)

Parallel to the evolution of flap-making technologies, we have also seen a revolution in corneal laser ablation, with all manufacturers converging to flying-spot lasers, customized treatments, and aspheric ablation profiles. The latter could have been adopted earlier if the industry had only communicated with our colleagues who deal with optics. The combination of flap creation and ablative technologies has led to a procedure that is even more predictable; patients now gain lines of vision as well as contrast sensitivity.

LASIK has set the standard for other evolving vision correction procedures in terms of visual outcome and visual rehabilitation. We, the ophthalmic community, in collaboration with the ophthalmic industry, work hard to develop treatments that obtain similar outcomes as LASIK. Currently, a number of new procedures seem to be gaining interest, particularly in the area of presbyopia correction. Presby-LASIK is now here, Intracor (Technolas Perfect Vision GmbH, Munich, Germany) looks promising, multifocal and accommodating lenses continue to get better, and presbyopic implants of various types are about to hit the stage. But will these treatments achieve similar outcomes as LASIK? Perhaps, but, like LASIK, it will depend on the capability to obtain predictable refractive correction and perhaps more reliance on cortical adaptation.

This issue features the nostalgic recollections of some of LASIK's pioneers as well as an up-to-date review of some of the new technologies mentioned above. The economic climate has impacted procedural volumes, which thankfully is improving; however, let us not forget how LASIK has positively impacted the economics of eye care provision and most importantly demonstrated the value of the patient-doctor contract. Nonreliance on third-party reimbursement is liberating.

One more point for those who are frequently dismissive of refractive surgery: LASIK and its development has had many secondary benefits in ophthalmology, including the evolution of wavefront technology, which resulted in improved cataract implants and pushed the boundaries of selective corneal transplantation, in particular Descemet's stripping automated endothelial keratoplasty.

LASIK has made a huge contribution to patients, ophthalmologists, the industry, and ophthalmology as a whole—numerous reasons to celebrate its 20th anniversary— so ladies and gentleman, let us raise our glasses and drink a toast…