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The history of LASIK

Article  in  Journal of refractive surgery (Thorofare, N.J.: 1995) · April 2012

DOI: 10.3928/1081597X-20120229-01 · Source: PubMed

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The History of LASIK

Dan Z. Reinstein, MD, MA(Cantab), FRCSC, FRCOphth;
Timothy J. Archer, MA(Oxon), DipCompSci(Cantab); Marine Gobbe, MST(Optom), PhD

ABSTRACT

Keratomileusis, brainchild of Jose I. Barraquer Moner, was

conceived and developed as the first stromal sculpting
L aser in situ keratomileusis (LASIK) has become the
single most common elective operation with over 35
million procedures performed worldwide by 2010.1
It has evolved into a 10-minute process that can correct 96% of
all refractive errors with minimal discomfort, a recovery time
method to correct refractive error in 1948. The word
“keratomileusis” literally means “sculpting” of the “cornea.” of a few hours, and dramatic visual results overnight. It is the
Barraquer’s first procedures involved freezing a disc of confluence of numerous brilliant ideas and bioengineering
anterior corneal tissue before removing stromal tissue
with a lathe. Over the years, the procedure continued to
accomplishments that have led to what is now one of the most
develop, first through the Barraquer-Krumeich-Swinger miraculous procedures in the history of medicine.
non-freeze technique where tissue was removed from
the underside of the disc by a second pass of the mi- KERATOMILEUSIS
crokeratome. In-situ keratomileusis was later developed The concept that refractive error could be corrected by
by passing the microkeratome a second time directly
on the stromal bed. The procedure became known as
sculpting corneal stromal tissue to change corneal curvature
automated lamellar keratoplasty with the invention of an was the brainchild of Jose Ignacio Barraquer Moner in 1948.2-4
automated microkeratome and was further refined by Barraquer developed a procedure he coined “keratomileusis,”5
replacing the disc without sutures and later by stopping which involved ressecting a disc of anterior corneal tissue
the microkeratome before the end of the pass to create that was then frozen in liquid nitrogen, placed on a modi-
a hinged flap, as first demonstrated in 1989. The history
of the excimer laser dates back to 1900 and the quantum
fied watchmaker’s lathe (Fig 1), and milled to change corneal
theory, eventually leading to the discovery that 193-nm curvature (Fig 2). The word “keratomileusis” literally means
ultraviolet excimer laser pulses could photoablate tis- “sculpting” of the “cornea.”
sue without thermal damage. Ultrastructural and wound The resection was achieved using a manually driven
healing studies confirmed that large area ablation could microkeratome that he designed specifically for this purpose
be performed in the central cornea. This was described
as photorefractive keratectomy in 1986 and the first
sighted eyes were treated in 1988. An excimer laser was
first used to sculpt from the stromal bed under a hinged From London Vision Clinic, London, United Kingdom (Reinstein, Archer,
flap created manually using a trephine and scalpel in Gobbe); the Department of Ophthalmology, Columbia University Medical
1988. The incorporation of a microkeratome in 1990 Center, New York, New York (Reinstein); and Centre Hospitalier National
finally led to laser in situ keratomileusis—LASIK—as we d’Ophtalmologie, Paris, France (Reinstein).
know it today. [J Refract Surg. 2012;28(4):291-298.] The authors have no financial interest in the materials presented herein.
doi:10.3928/1081597X-20120229-01
The authors thank the following for their invaluable contributions of photos,
video, and other materials: Carmen Barraquer, MD; Jose Ignacio Barraquer
Moner, MD; Lucio Buratto, MD; Jose L. Guell, MD; Khalil Hanna, MD; Jairo
E. Hoyos, MD; Jörg H. Krumeich, MD; John Marshall, PhD; Marguerite B.
McDonald, MD; Ioannis G. Pallikaris, MD, PhD; Yaron S. Rabinowitz, MD;
Aleksander Razhev, MD; Luis A. Ruiz, MD; Theo Seiler, MD, PhD; Casimir
A. Swinger, MD; John Taboada, PhD; Stephen L. Trokel, MD; Richard C.
Troutman, MD; Alfred Vogel, PhD; George O. Waring III, MD; James J. Wynne,
PhD; the Medical University of Lublin, Lublin, Poland; and the International
Society of Refractive Surgery.
Correspondence: Dan Z. Reinstein, MD, MA(Cantab), FRCSC, FRCOphth,
London Vision Clinic, 138 Harley St, London W1G 7LA, United Kingdom.
Tel: 44 207 224 1005; Fax: 44 207 224 1055; E-mail [email protected]
Received: November 18, 2011; Accepted: December 7, 2011

Journal of Refractive Surgery • Vol. 28, No. 4, 2012 291

History of LASIK/Reinstein et al

Figure 1. Jose I. Barraquer Moner using his first cryolathe to mill the under- Figure 2. Close-up of the corneal milling showing tissue being removed
side of a ressected disc of anterior corneal tissue. This original lathe was a from the underside of the frozen ressected disc. (Image courtesy of
modified watchmaker’s lathe. (Image courtesy of Carmen Barraquer, MD.) Carmen Barraquer, MD.)

Figure 4. Trigonometric diagram that formed the basis of the calculations

for Barraquer’s Law of Thicknesses on which keratomileusis and all future
corneal tissue removal/ablation procedures were based. The diagrams
demonstrate the tissue that needs to be removed in a myopic (left) and
hyperopic (right) correction. (Reprinted with permission from Barraquer JI.
Queratomileusis y Queratofaquia. Bogota, Colombia: Instituto Barraquer
de América; 1980:125. Copyright © 1980.)

Figure 3. Photograph (above) and technical diagram (below) of the first flattens when tissue is removed from the center and
manually driven microkeratome developed by Barraquer for corneal disc steepens when tissue is removed from the periphery.”
resection in keratomileusis. (Image courtesy of Carmen Barraquer, MD.)
His earliest patients were treated in the early 1960s
at the Clinica de Marly in Bogota, Colombia, where he
based on a carpenter’s plane (Fig 3). Barraquer then had to leave the patient on the operating table after res-
used trigonometric calculations to derive the volume secting the corneal disc while he hurried 3 km across
of tissue removal required for a particular refractive town to where he had set up the lathing workshop in
error correction. In his 1964 thesis on the “Law of his home. After reshaping the corneal disc with his
Thicknesses”6 (Fig 4), he described that “the cornea cryolathe, he would drive back to the hospital to

292 Copyright © SLACK Incorporated

 History of LASIK/Reinstein et al

suture the thawed and reshaped corneal disc back

onto the patient’s eye (Carmen Barraquer, MD, personal
communication, May 11, 2010). During the process
of developing the keratomileusis procedure, he also
invented a number of instruments and techniques to
make his ideas a reality. His inventions included the
torque anti-torque suture, the operating microscope,
and many other microsurgical instruments commonly
used in ophthalmic surgery today.
Around that time others were experimenting with Bar-
raquer’s ideas. In Poland, Krwawicz7,8 published a paper
in 1964 describing a series of three highly myopic eyes in
which he had performed a “stromectomy.” He manually
made two stromal cuts at different depths with a flat knife
and removed the thin lamella of intervening stroma.
In Russia, Pureskin9 described in 1967 the concept
of an incomplete anterior corneal resection to leave a
naturally hinged flap, after which a stromal disc was
removed by trephination (Fig 5). He reported a series
of 71 rabbit eyes and described the power change
achieved for discs with different diameters.
Several thousand keratomileusis procedures were
performed at the Instituto Barraquer de America in
the 1970s and early to mid 1980s and surgeons from
around the world came to learn this difficult but
miraculous technique.

BARRAQUER-KRUMEICH-SWINGER TECHNIQUE
Two of Barraquer’s disciples, Krumeich and Swinger,
worked on a refinement of the technique to perform
keratomileusis without freezing, referred to as the Figure 5. Diagram (top) and intraoperative photograph (bottom) of
Pureskin’s technique of creating a hinged flap followed by trephination of
Barraquer-Krumeich-Swinger (BKS) technique, which a stromal disc. (Reprinted with permission from Pureskin NP. Weakening
was published in 1986.10,11 This BKS non-freeze tech- ocular refraction by means of partial stromectomy of cornea under
nique involved placing the ressected disc epithelial experimental conditions [Russian]. Vestn Oftalmol. 1967;80(1):19-24.
side down onto a curved suction die or mold where a Copyright © 1967. Izdatelstvo Meditsina.)
second pass of the microkeratome removed tissue from
the exposed posterior stromal surface according to the stromal bed (Luis Ruiz, MD, personal communication,
shape of the die (Fig 6). The BKS technique aimed to April 13, 2010). This was called in situ keratomileusis
reduce surgical trauma to the tissues and improve (Fig 7).
visual recovery time.
AUTOMATED LAMELLAR KERATOPLASTY
IN SITU KERATOMILEUSIS Ruiz was responsible for designing a gear system to
Around the same time, another non-freeze technique automate the passage of the microkeratome head (Luis
called in situ keratomileusis12 was developed. The pro- Ruiz, personal communication, April 13, 2010). This
cedure was first performed by Ruiz, who having com- eased the technical challenges of using a manual micro-
pleted his residency at the Barraquer Institute, was per- keratome, as the head could be passed with a constant
forming up to 20 keratomileusis procedures a day. Ruiz and reproducible speed, thereby avoiding irregular re-
was interrupted in his flow by a corneal disc resection sections and improving the accuracy. The procedure
that was found to be too thin for the required stromal became known as automated lamellar keratoplasty
tissue removal. With the patient on the table, he came (ALK). Automated lamellar keratoplasty was further
up with the idea of passing the microkeratome a second refined by replacing the disc without a suture and ad-
time using a different suction ring with the height ad- hesion was aided by drying, after which the eye was
justed to resect the required lenticule directly from the patched overnight until the epithelium sealed the disc

Journal of Refractive Surgery • Vol. 28, No. 4, 2012 293

History of LASIK/Reinstein et al

Figure 7. Intraoperative photograph of the stromal bed after two passes of

the microkeratome. The first pass created the corneal disc resection while
the second pass removed stromal tissue from the stromal bed in a smaller
diameter to achieve the refractive correction. The resected corneal disc
was then sutured back onto the eye. The calipers in the photograph show
the diameter of the second pass, and the larger diameter of the first pass
can also be seen. (Image courtesy of Jairo E. Hoyos, MD.)

that the energy released by an electron moving from an

outer orbital to a lower energy inner orbital could be
initiated by an external source, which he called stimu-
lated emission.16
It was not until 1952 that Einstein’s theory was made
Figure 6. Diagrams (above) and photographs (below) of a myopic (left) a reality when microwaves were used as the external
and hyperopic (right) suction die used in the Barraquer-Krumeich-Swinger
source to produce Microwave Amplification of Stim-
non-freeze technique. The ressected corneal disc was placed epithelial
side down onto the die and a second pass of the microkeratome removed ulated Emission of Radiation (MASER). The MASER
the required stromal tissue. For myopic corrections, the shape of the die was pioneered by Townes and Schawlow17 (Bell Labo-
exposed central stroma, whereas the shape of the die exposed periph- ratories, Murray Hill, New Jersey) and simultaneously
eral stroma for hyperopic corrections. A set of suction dies with different by Basov and Prokhorov18 (Lebedev Physical Institute,
curvatures were available to treat a wide range of different refractions.
Moscow, Russia). Later, the microwave was replaced
(Image courtesy of Jörg H. Krumeich, MD.)
by light, and MASER became LASER (Light Amplifica-
tion of Stimulated Emission of Radiation), as first de-
into place (Luis Ruiz, MD, personal communication, fined (in his lab notebook) by Gordon Gould in 1957.
April 13, 2010). The breakthrough ideas were the use of optical
In 1989, Ruiz presented a paper demonstrating how pumping to initiate the process and amplification of
a flap could be produced by stopping the microkera- the emission by using parallel mirrors, one of which
tome before the end of the pass.13 The flap would then was semi-reflective, to partially reflect photons back
be tucked under the second microkeratome ring ap- and forth through the active medium.
plied for the stromal resection thus leaving a hinge to In 1970, the term excimer laser was introduced to
simplify the replacement of the cap and reduce cap- describe a laser built by Basov using a xenon dimer
related complications. gas, the name excimer coming from an abbreviation of
“excited dimer.” The argon-fluoride excimer laser was
EXCIMER LASER developed in 1976.19,20
In the early 1990s, in situ keratomileusis was com- It was not until 1981 when an argon-fluoride ex-
bined with the emerging technology of excimer lasers cimer laser (193 nm) was fired on organic tissue when
for corneal tissue ablation to finally become LASIK as Srinivasan, Wynne, and Blum, who were researchers
we know it today.14 But the excimer laser has a history at IBM, made an incision in the leftover cartilage of
of its own starting in 1900. After Max Planck had de- a turkey from Thanksgiving dinner and found no evi-
scribed the quantum theory,15 Albert Einstein predicted dence of damage to the surrounding tissue unlike the

294 Copyright © SLACK Incorporated

 History of LASIK/Reinstein et al

Figure 9. Photograph of the plume immediately after an excimer laser

pulse. (Reprinted with permission from Noack J, Tönnies R, Hohla K,
Birngruber R, Vogel A. Influence of ablation plume dynamics on the
formation of central islands in excimer laser PRK. Ophthalmology.
1997;104(5):823-830. Copyright © 1997. Elsevier.)

the potential of corneal applications for the excimer

laser (Stephen L. Trokel, MD, personal communica-
tion, August 18, 2010; John Taboada, PhD, personal
Figure 8. Photographs of incisions into turkey cartilage made by a solid- communication, August 16, 2010). Trokel was intro-
state 532-nm laser (left incision) and an argon-fluoride 193-nm excimer duced to Srinivasan at IBM, who agreed to work with
laser (right incision). The charring can be seen with the solid-state laser,
him to investigate the potential of using an excimer
whereas the incision appears clean with no damage to the surrounding
tissue with the excimer laser. (Image courtesy of James J. Wynne, PhD; laser to improve the accuracy of radial keratotomy
Rangaswamy Srinivasan; and Samuel Blum.) incisions.25,26 Marshall began working with Trokel to
study the ultrastructural aspects of corneal photoabla-
charring seen around an incision made with a solid- tion.27 They compared the quality of the wounds made
state laser with a wavelength of 532 nm (James J. Wynne, by an excimer laser at 193 nm with one at 248 nm as
PhD, personal communication, December 9, 2011) (Fig 8), well as wounds made by steel and diamond blades (Fig
which they presented at the Conference on Lasers and 10). The quality of the wounds was best with 193 nm.28
Electro-Optics in May 1983.21,22 They demonstrated This finding was in agreement with similar studies by
that complex patterns could be made at a micronic other groups29-32 at that time.
level with each pulse removing a fraction of a micron. The wound quality suggested to Marshall that large
This research was an outgrowth of excimer lasers be- area ablation could be performed in the central cornea,
ing used for direct photoetching of polymers, with po- rather than just for peripheral linear incisions (John
tential application to IBM’s microchip packaging tech- Marshall, PhD, personal communication, May 30,
nology. 2010). Marshall described this in 1986 as photore-
At the same time, Taboada also found no thermal fractive keratectomy (PRK).33 For PRK to become a
damage to the remaining tissue after a 248-nm excimer feasible procedure in human eyes, the following cri-
laser pulse on corneal epithelium. 23 Thus, it was teria needed to be satisfied. First, the depth of tissue
established that excimer laser–tissue interaction removal required for a given refraction change must
was effectively non-thermal, but rather direct splitting be known. Munnerlyn proposed an algorithm adapted
of molecular bonds with minimal adjacent heating. from Barraquer’s earlier formulae to calculate the abla-
This process was coined “photoablation”24 (Fig 9). tion profile as a function of refractive error and optical
Trokel had been evaluating the possibility of using zone diameter.34 Second, the quality and clarity of the
different lasers (such as carbon dioxide and Nd:YAG ablated surface must be preserved. Earlier studies in
lasers) for radial keratotomy incisions, but none that rabbit corneas demonstrated only limited haze after a
he had tried were suitable for corneal application. large area ablation.33 Myopic ablation on a donor eye
Trokel first learned of excimer lasers after reading also showed that the ablated surface was clean and
Taboada’s paper, which encouraged him to investigate smooth.35 Third, the wound-healing process must not

Journal of Refractive Surgery • Vol. 28, No. 4, 2012 295

History of LASIK/Reinstein et al

Figure 11. Image of a myopic ablation performed using a broad-beam

laser and a moving iris diaphragm. The diameter of the iris diaphragm
was gradually reduced, which created a series of small steps. The number
of steps was increased to better approximate a curved surface. (Image
courtesy of John Marshall, PhD.)

L’Esperance et al40 and Seiler et al41 also began per-

forming PRK in blind eyes.
Central ablation of the cornea was performed using
different methods. L’Esperance suggested small scan-
ning spot excimer lasers, which could be controlled
to ablate in specific patterns.42 Marshall proposed us-
ing a broad-beam laser and a moving iris diaphragm
Figure 10. Light micrographs of rabbit corneas incised by A) an argon fluo-
ride excimer laser (193 nm), B) a krypton fluoride excimer laser (248 nm), to shape the area to be ablated. For a myopic correc-
C) a Micra diamond knife, and D) a Sharpoint steel blade. The wound qual- tion, initially the aperture was sequentially reduced
ity is best with the argon fluoride excimer laser. (Reprinted with permission in diameter to create steps on the corneal surface. The
from Marshall J, Trokel S, Rothery S, Krueger RR. A comparative study of number of steps was gradually increased to improve
corneal incisions induced by diamond and steel knives and two ultraviolet
the smoothness of the curved surface (Fig 11).43 Hanna
radiations from an excimer laser. Br J Ophthalmol. 1986;70(7):482-501.
Copyright © 1986. BMJ Publishing Group Ltd.) et al44 used a rotating-slit laser delivery system; the
shape of the slit was determined mathematically to ob-
tain a parabolic ablation profile that resulted from the
result in scarring. It was already known that no scar- slit rotation.
ring occurred after radial incisions.36,37 Marshall et al38 Larger clinical trials followed with commercial
then demonstrated no changes in corneal transpar- excimer lasers given the encouraging results from
ency 8 months after PRK in 12 monkey corneas, and the first cases. In 1991, McDonald and Kaufman et
McDonald et al39 reported stable dioptric change in a al45 reported that myopic PRK treatment with the
primate cornea with good healing and long-term cor- VISX 20/20 (VISX Inc, Santa Clara, California) sys-
neal clarity up to 1 year after PRK. tem was safe. In the same year, Lindstrom and Sher
In 1985, Seiler et al36 performed the first large area et al46-48 demonstrated the safety and efficacy of the
ablation in a live patient to remove corneal dystrophy Taunton Technologies (Monroe, Connecticut) model LV
scarring, having previously performed T-incisions ear- 2000 excimer laser for myopic PRK. Also at that time,
lier that year with an excimer laser to correct for astig- the Marshall49,50 and Seiler51 groups published out-
matism. With the increasing interest in the possibility comes using the Summit Technology Eximed UV200
of performing refractive correction with an excimer excimer laser (Summit Technologies, Waltham,
laser, the first international workshop on laser corneal Massachusetts). During the same year, Dausch and
surgery was held in Berlin in 1986. Schroeder52 presented results in high myopes with
This led to PRK being performed in humans. In early the Aesculap-Meditec (Jena, Germany) excimer laser
1988, McDonald performed the first PRK on a sighted and later, in 1993, presented the first hyperopic ab-
eye due for enucleation, while at around the same time lation profiles.

296 Copyright © SLACK Incorporated

 History of LASIK/Reinstein et al

LASIK
At this point, the excimer laser story joins the ker-
atomileusis story to become laser in situ keratomileusis,
or LASIK. The idea of using an excimer laser to ab-
late tissue under a flap was springing up in various
parts of the world. In 1988, Razhev et al53-55 in Novosi-
birsk, USSR began using a 5-mm trephine to produce
a central 100-μm deep circular keratotomy and then
a scalpel to create a lamellar hinged flap (Aleksander
Razhev, personal communication, August 23, 2010)
(Fig 12).56 They then used an excimer laser to ablate
the stromal bed before replacing the lamellar flap in
four myopic and five hyperopic eyes. They presented
their results with up to 2-year follow-up in September
1990 at Columbia University, New York.55
At around the same time, Buratto was performing Figure 12. Intraoperative photograph during the first LASIK procedure
classical keratomileusis,57 but in October 1989 he performed by Razhev in 1988. The hinged flap can be seen to have been
lifted and the excimer laser ablation can be visualised by the blue area on
used an excimer laser for ablation on the underside the stromal bed. (Image courtesy of Aleksander Razhev, MD.)
of the cap (instead of a lathe or microkeratome) and
published the results of his first 30 high myopic eyes 3. Barraquer JI. Method for cutting lamellar grafts in frozen cornea.
with few complications and 1-year follow-up in 1992. New orientation for refractive surgery. Arch Soc Am Oftal Optom.
In December 1989, Buratto had a case where the cap 1958;1:271-286.
was too thin for the required tissue removal, much like 4. Barraquer JI. Autokeratoplasty with optical carving for the cor-
rection of myopia (keratomileusis) [Spanish]. An Med Espec.
Ruiz previously with ALK, and so decided instead to 1965;51(1):66-82.
perform the excimer laser ablation directly on the stro-
5. Barraquer JI. Keratomileusis. Int Surg. 1967;48(2):103-117.
mal bed before replacing the cap (Lucio Buratto, MD,
6. Barraquer JI. Conducta de la còrnea frente a los cambios de
personal communication, July 1, 2010). espesor. Arch Soc Am Oftal Optom. 1964;5:81-87.
Pallikaris also produced a hinged flap using a micro- 7. Krwawicz T. Lamellar corneal stromectomy for the operative
keratome he had designed for rabbit studies and per- treatment of myopia. A preliminary report. Am J Ophthalmol.
formed the ablation with an excimer laser on the ex- 1964;57:828-833.
posed bed followed by replacement of the flap without 8. Krwawicz T. Further results of partial lamellar resection of the
sutures. The term “LASIK” was first used to describe corneal stroma for correction of high-grade myopia (stromectomia
corneae lamellaris) [Polish]. Klin Oczna. 1965;35:13-17.
this procedure in his 1990 paper.14,58 Pallikaris treated
9. Pureskin NP. Weakening ocular refraction by means of partial
his first patients in October 1990 (Ioannis G. Pallikaris, stromectomy of cornea under experimental conditions [Russian].
MD, PhD, personal communication, July 1, 2010) and Vestn Oftalmol. 1967;80(1):19-24.
published his results on 10 high myopic eyes with 10. Swinger CA, Krumeich JH, Cassiday D. Planar lamellar refrac-
1-year-follow-up in 1994.59 tive keratoplasty. J Refract Surg. 1986;2(1):17-24.
It is this technique that gave birth to what is now the 11. Krumeich JH, Swinger CA. Nonfreeze epikeratophakia for the cor-
most commonly elective performed surgical procedure rection of myopia. Am J Ophthalmol. 1987;103(3 Pt 2):397-403.
in the world1 and realized the dreams of Jose Ignacio 12. Ruiz LA, Rowsey JJ. In situ keratomileusis. Invest Ophthalmol
Vis Sci. 1988;29(Suppl):392.
Barraquer Moner 40 years in the making.
13. Ruiz L, Rowsey JJ. In-situ keratomileusis with a hinged flap. Pre-
sented at: American-European Congress of Ophthalmic Surgery
AUTHOR CONTRIBUTIONS Dulaney Winter Meeting; February 21-24, 1989; Aspen, CO.
Study concept and design (D.Z.R., T.J.A., M.G.); data collection 14. Pallikaris IG, Papatzanaki ME, Stathi EZ, Frenschock O,
(D.Z.R., T.J.A., M.G.); analysis and interpretation of data (D.Z.R., Georgiadis A. Laser in situ keratomileusis. Lasers Surg Med.
T.J.A., M.G.); drafting of the manuscript (D.Z.R., T.J.A., M.G.); criti- 1990;10(5):463-468.
cal revision of the manuscript (D.Z.R.) 15. Planck M. On the law of distribution of energy in the normal
spectrum [German]. Annalen der Physik. 1901;309(3):553.
16. Einstein A. On the quantum theory of radiation [German].
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