The excimer laser offers entirely new corneal surgery procedures. In this paper, we describe conditions for one such procedure, photorefractive keratectomy, the direct reshaping of the cornea's central optical zone using tissue ablation with far ultraviolet radiation. We present equations for the required tissue ablation to achieve required refractive corrections. Conditions for beam uniformity are presented and a method of achieving better beam uniformity using beam integration by rotation is demonstrated. The healing of rabbit corneas after area ablation was observed. Five days after treatment, the surface quality of deep cuts was very irregular; the shallow cuts produced more regular results, as predicted by our calculations of beam characteristics.

Photorefractive keratectomy: A technique for laser refractive surgery

Laser myopic keratomileusis (photorefractive keratectomy) was performed on 29 rhesus monkey corneas with an argon fluoride (193-nm) excimer laser and a computer-controlled, moving slit delivery system. The 4-mm-diameter central ablation zone ranged in depth from 11 microns (-2 diopters effect) to 46 microns (-8 diopters effect). Corneas were studied for the 9 months postoperatively by clinical slit-lamp microscopy, and periodically with light and transmission electron microscopy. By 6 weeks, mild to moderate subepithelial haze was apparent in 93% of the corneas, with considerable variability in density. Progressive clearing occurred so that by 6 to 9 months 12 of 13 surviving corneas (92%) were either completely clear (4 corneas) or trace hazy (8 corneas). The epithelium was thickened at 21 days after ablation and returned to normal thickness by 3 months. At 3 weeks, subepithelial fibroblasts were three times the density of normal keratocytes and returned to nearly normal numbers by 9 months. We concluded that the anterior monkey cornea demonstrated a mild, typical wound healing response after excimer laser keratomileusis.

Wound healing after excimer laser keratomileusis (photorefractive keratectomy) in monkeys.

Laser-tissue interactions

Balanced pH, hyperosmotic, hypoosmotic, or isoosmotic gels are ideal vehicles for drug delivery. They are especially suited for topical body cavity or injection application of drugs or diagnostic agents; for drug or diagnostic agent delivery to the eye of a mammal; as protective corneal shields; or as ablatable corneal masks useful in laser reprofiling of the cornea. The compositions without the addition of a drug or diagnostic agent are useful as medical devices, for instance, in separating surgically or otherwise injured tissue as a means of preventing adhesions.

Medical uses of in situ formed gels

Excimer laser photorefractive keratectomy.

Excimer Laser Radial Keratotomy

Intraocular metallic-appearing foreign bodies in the anterior segment were seen in six eyes after cataract extraction by two-handed phacoemulsification. These fragments produced no symptoms and had no clinically significant effect on visual function. Similar-appearing foreign bodies were experimentally produced by applying ultrasound power with a phacoemulsification handpiece to the surface of a cyclodialysis spatula in vitro. Microscopic examination of the phaco handpiece tip and cyclodialysis spatulas revealed numerous surface irregularities, suggesting a possible source of these fragments. These results suggest that instrument touch during phacoemulsification may be the cause of the fragments. Long-term follow-up of these patients is required to determine the overall effect of the fragments.

Intraocular metallic-appearing foreign bodies after phacoemulsification

Applying the scleral pocket incision to insertion of the Cardona nut and bolt keratoprosthesis was found to facilitate wound closure and permit better device centration.

Arthur M. Cotliar

Papers

Excimer Laser Radial Keratotomy

Intraocular metallic-appearing foreign bodies after phacoemulsification

Scleral pocket incision applied to insertion of the nut and bolt keratoprosthesis.