How Has LASIK Evolved?

Key Points

• Iranian-American ophthalmologist Dr. Gholam Peyman invented LASIK in the early 1980s.
• Early LASIK relied on a microkeratome to create the corneal flap and the excimer laser to reshape the cornea.
• The introduction of the femtosecond laser in 1990 reduced the use of microkeratome blades in flap creation.  
• Advanced LASIK procedures, such as custom LASIK, are completely bladeless, although some surgeons still use microkeratome blades.
• LASIK continues to evolve as scientists aim to make the procedure much safer, more accurate, quicker, and more effective.

Throughout history, people with vision issues have sought better methods of improving their eyesight. From eyeglasses to contact lenses and laser treatment, experts have endeavored to keep up with the demand for safer, more comfortable, and more effective solutions. 

Laser In Situ Keratomileusis, commonly referred to as LASIK eye surgery, is one of the revolutionary laser vision correction procedures, with over 99% of treated eyes achieving 20/40 vision or better.¹

Interestingly, the technology has seen significant improvement since its invention, and it’s still evolving. This article examines the LASIK procedure’s origin, current advancements, and future expectations.

What are the Origins of LASIK?

Before LASIK’s development, Spanish ophthalmologist Jose Ignacio Barraquer Moner developed a procedure to sculpt the cornea and treat refractive errors (e.g., nearsightedness, astigmatism, etc.). He developed the microkeratome blade system and is now known as the “father of refractive surgery.”

Dr. Barraquer’s process involved:

• Removing a piece of the cornea
• Freezing it in cryolathe
• Reshaping it
• Reattaching it to correct a refractive error

Unfortunately, the procedure had a significant drawback⁠—the process damaged the corneal tissue.

Later, scientists discovered that laser pulses could shape corneal tissue without heat damage. From here, the excimer laser was developed, setting a foundation for laser eye surgery.

What Was the First Laser Surgery?

Photorefractive keratectomy (PRK) was the first laser surgery performed on human eyes.² The first PRK procedure was done on an elderly woman in early 1988 at the Louisiana State University (LSU) by surgeon Marguerite McDonald. 

This procedure involved peeling off the outermost layer of the cornea and reshaping the underlying layer using an excimer laser. Further trial and error studies to improve the procedure later led to the invention of LASIK, which is associated with fewer complications and a shorter recovery timeline.

Who Invented LASIK Eye Surgery?

Iranian-American ophthalmologist Gholam Peyman invented LASIK eye surgery. Dr. Peyman came up with the LASIK idea in the early 1980s while evaluating the potential use of CO2 lasers to modify the corneas of rabbit eyes.

He later secured the first U.S. patent for the LASIK technology in 1989.³ The following year, in 1990, Dr. Loannis G. Pallikaris performed the first LASIK eye surgery using a traditional microkeratome and the excimer laser.

Other procedures were performed “off-label” until 1999 when LASIK received FDA approval. There have been many LASIK improvements since its invention, all aimed at making the procedure safer and with the best outcomes.

What Was LASIK Like in the Early Days?

Early LASIK relied on an oscillating blade (the microkeratome) to create the corneal flap and the excimer laser to reshape the cornea.

The procedure involved four main steps:

1. Manually slicing a thin flap on the cornea (the flap is left connected to the rest of the cornea by a small tissue hinge)
2. Folding back the flap to expose the underlying corneal layer
3. Reshaping the corneal tissues using the excimer laser device
4. Replacing the flap to allow for healing.

Evolution of the Microkeratome

The microkeratome was invented in 1948 by the father of refractive surgery, Dr. Barraquer. It is a device with a sharp oscillating blade that creates the LASIK flap.

The first microkeratome was a prototype and moved along a ring to make the incision. This version had no guides for the surgeon.

Later, in 1962, Dr. Barraquer developed a more accurate microkeratome. It had a suction ring as a guide to hold the eye in place and create pressure on the cornea for a precise cut.

The Age of Automated Microkeratomes

In 1991, the automated microkeratome was invented. It ensured a constant blade velocity so surgeons could perform smoother cuts.

Several microkeratome designs have been produced since then:

• The first single-use microkeratome (1999). Produced by Moria Surgical, features a disposable head to provide a smooth edge
• Hansatome microkeratome.⁴ Made by Bausch & Lomb Surgical, Inc., known to cut flaps with an upper hinge, preventing flap displacement during blinking
• The Amadeus microkeratome.⁵ Made by Advanced Medical Optics, features a single-hand design to enable easy learning by new surgeons

Although microkeratomes are still in use, they have largely been replaced by femtosecond lasers, which are considered a much safer alternative.

What are the Advancements in Modern LASIK?

Modern LASIK can now rely solely on laser technology. Developments in this area have made the procedure safer and quicker while producing optimum results.

From relying on the microkeratome blade to create a corneal flap, modern LASIK has moved to using different types of systems. These include the excimer laser, the femtosecond laser, and the wavefront technology.

How Did the Excimer Laser Revolutionize LASIK?

The excimer laser technology, and the existence of the microkeratome, enabled the first PRK surgery in 1988 and the first LASIK eye surgery in 1990. The laser could accurately modify the cornea without scarring or heat damage, revolutionizing the field of laser vision correction.⁶ 

The excimer laser got FDA approval in 1995. Today, there are many versions of the technology, but all operate under the same principle.⁷

How Did the Femtosecond Laser Improve LASIK?

The femtosecond laser eliminates the drawbacks of traditional microkeratomes, like dry eyes, flap buttonholes, and flap detachments (free cap formation).⁸ Instead of a sharp blade, it uses laser pulses to make incisions of various patterns and depths with high precision, predictability, and speed.⁹

The femtosecond laser was developed in 1990 by Dr. Ron M. Kurtz at the University of Michigan and got FDA approval in 2001. As of 2024, femtosecond-assisted LASIK (FS-LASIK) is mainly preferred due to its high precision and safety.

Combination with the excimer laser makes FS-LASIK completely bladeless. However, some surgeons still use microkeratome systems because they cost less and are still very effective.

What Is Wavefront Technology for LASIK?

Wavefront LASIK, also called Custom LASIK, is the most advanced LASIK technology that treats lower- and higher-order imperfections. Using a wavefront device, the surgeon can generate a three-dimensional (3D) eye map and use that data to reshape your cornea based on your unique vision correction needs.

There are two main types of wavefront LASIK:

• Wavefront-optimized LASIK. The surgeon uses the generated data to guide the laser and is always in full control. It cannot correct all higher-order aberrations (decreased contrast sensitivity, glare, shadows, halos, and glare).
• Wavefront-guided or topography-guided LASIK. This is more sophisticated and requires additional expertise. The laser uses the data from the wavefront device and tries to correct all issues, including all higher-order aberrations. 

The benefits of wavefront-assisted LASIK include the following:

• Corrects higher aberrations
• Can treat eyes with a history of failed laser surgery
• There is a higher chance of achieving 20/20 vision or better
• Lower risk of night-vision disturbances
• Lower risk of losing best-spectacle-corrected vision

What is the Difference Between Flap and Flapless LASIK?

Flap-associated LASIK involves slicing and lifting a piece of cornea to expose the underlying layer. An excimer laser is then used to reshape the tissues before replacing the flap.

Flapless LASIK, also known as photorefractive keratectomy (PRK), involves the direct application of the laser on the surface layer. It’s mostly recommended for people with thin corneas.

Flapless LASIK is less popular due to the following:

• Extended recovery timelines 
• Discomfort such as burning or scratchy feeling (may last several days)
• It may take several weeks to achieve visual clarity (compared to 24 hours in flapped LASIK).

Regardless of the above shortcomings, there is no significant difference in the visual outcomes of both procedures.

Is Modern LASIK Safer and More Effective?

Considering improvements like automation and the use of the femtosecond laser instead of sharp blades, modern LASIK procedures are much safer and more effective. However, it’s not a “foolproof” procedure. 

Surgeons still need to be very careful when using the current technologies to achieve the best results and minimize complications such as flap tears, eye perforations, decentered flaps, and more.

What Is the Future of LASIK Surgery?

Today, over 700,000 LASIK surgeries are performed in the U.S. every year, with over 19 million beneficiaries so far—and the future is brighter.¹⁰

Newer procedures are being developed to make LASIK treatment benefit more categories of people and improve safety, effectiveness, and speed of recovery. 

For example, PresbyLASIK (for older adults with presbyopia) can potentially replace multifocal IOLs and monovision LASIK.¹¹ Instead of correcting one eye for distance and the other for near vision, presbyLASIK corrects each eye for near and distant vision.

LASIK for children is also being investigated for FDA approval, with eye doctors indicating a potential benefit for children with severe nearsightedness (myopia) or farsightedness (hyperopia).¹²

What Is the Long-Term Outlook for the LASIK Industry?

Experts indicate that the LASIK market will continue to grow significantly.¹³ According to global market research, it reached 2.6 billion in 2022 and is expected to reach 3.7 billion by 2028.

The future holds a lot of promise for LASIK technology. More people are considering the procedure over eyeglasses and contact lenses, with safer tools, techniques, and experts flooding the market.