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THE ANATOMY AND PHYSIOLOGY OF
EYE
In order to understand the mechanism of refractive
surgery and its complications, it is necessary to be
familiar with the anatomy and physiology of the
ocular system, with a particular emphasis on the
cornea as it is the sole part of the eye operated
upon by refractive surgeons.
The human eye is similar to a camera where a system
of lenses focuses a picture onto a light-sensitive
film.
The eyeball itself is essentially an opaque globe,
encapsulated with a tough, protective white sheath,
the sclera, and filled with a gel-like fluid called the
vitreous. In the front of the eyeball, the sclera gives
way to a transparent dome known as the cornea.
The cornea is similar to the crystal of a wristwatch
and vaults over the anterior chamber of the eye,
much as the crystal vaults over the watch-face. The
cornea is a clear membrane which has the dual
purpose of protecting the eye and focusing light as
it enters the eye. It is maintained in a perfectly
transparent state with a constant curvature. After
light passes through the cornea, it then passes
through the pupil, an opening in the iris (the
colored part of the eye).
Once through the pupil, light then passes through the
crystalline lens, which along with the cornea is
responsible for the focusing of the eye.
Light then passes though the gel-like vitreous and
falls upon the retina, the light-sensitive tissue at
the back of the eyeball (functioning much like the
film in a camera) that converts the light into
electrical signals. The retina contains cells, called
rods and cones, which serve the task of detecting
the intensity and the frequency of the incoming
light. The rods and cones then send nerve
impulses through the optic nerve to the brain,
where translation of the impulses into vision takes
place.

THE CORNEA
The cornea is approximately 500 microns thick (.5
millimeter) and is responsible for 80% of the
focusing (refracting) of the light entering the eye.
The cornea consists of five cell layers, which
moving from the front of the eye inward are the
epithelium, Bowman’s Membrane, Stroma,
Descemets Membrane, and Endothelium.
The Epithelium is the outermost layer of the cornea
and is the eyes first barrier to infectious
organisms.
Riding on the very outside of the corneal epithelium is
a very thin film of water and other chemicals (salt,
antibiotics, etc.) Known as the tear film.
The tear film lubricates the cornea and keeps it moist.
A problem with the tear film causes the sensation
of dry eye.
Coursing through the epithelium are a tremendous
number of nerve cells with bare ends. If these
nerve endings become exposed to the air by the
slightest defect in the epithelial surface, a corneal
abrasion is created which is usually accompanied
by exquisite pain.

REFRACTIVE ERRORS
In order for our eyes to be able to see, light rays must
be bent or “refracted” so they can precisely focus
upon the retina. A refractive error means that the
optics of the eye do not refract the light properly,
so that the image formed on the retina is blurred.
While refractive errors are called eye disorders,
they are not diseases. There are three primary
refractive errors which are addressed by refractive
surgery: myopia, hyperopia, and astigmatism.
Myopia (nearsightedness) is where the distance vision
is blurred at all times while near vision is often
excellent within a certain range. In the myopic eye,
the image ultimately comes to a focus at a point in
front of, rather than directly on, the retina. Myopia
is due to an excessively long eyeball and/ or a
cornea that is too steeply curved, creating an
excessive amount of focusing. It is this corneal
curvature which is altered in the various refractive
surgery techniques to be discussed.
Conversely, hyperopia, (farsightedness) is the
refractive condition where near objects may appear
blurred while distant objects typically appear clear.
The third refractive error deal with through refractive
surgery is astigmatism.
Refractive errors are measured in Diopters. Myopia is
measured in terms of minus “-“diopters, hyperopia
in “+” diopters.

REFRACTIVE SURGERY MODALITIES

The intent of refractive surgery is to change the
natural curvature of the cornea in order to alter the
eyes focusing power… to make a myopic cornea
flatter or a hyperopic cornea steeper.
In the early 80s, eye surgeons became aware of the
Excimer laser, then being used in the computer
chip industry. While most surgical laser beams
affect tissue by producing heat, the Excimer laser
uses a charged mixture of argon and fluorine gases
to produce a cool beam of ultraviolet light. The
beam breaks the molecular bonds between cells
and vaporizes tissue, one microscopic layer at a
time. The Excimer laser was formally approved for
use in PRK in 1995, although many eye surgeons
were flying their patients to Mexico or Canada prior
to that to circumvent the FDA prohibition.
In PRK, the Excimer laser is used to reshape the
cornea in an effort to effect a change in the
refractive characteristics of the eye and thereby
correct or lessen myopia, hyperopia, and/or
astigmatism. Before the laser is applied, the
epithelial layer of the cornea is removed by either
mechanical means (simply scraped away) or
chemical (application of alcohol solution). The
laser is then used to photoablate (vaporize) several
microns of tissue from the central and mid cornea.
Usually from 3% to 15% of the central corneal
tissue is utilized for corneal reshaping for myopic
corrections from -1.00 to -7.00.
The epithelium usually regrows over the treated area
within several days. To reduce the amount of
myopia in the eye, the cornea is flattened by
removing more tissue from the center of the cornea
than from the midzone cornea. The resultant
central corneal flattening moves the focus point
farther back toward its desired spot on the retina.
To reduce hyperopia, more tissue is removed from
the midzone cornea, thereby steepening the central
cornea.
The LASIK procedure is similar to PRK
(photorefractive keratectomy) but does not treat or
alter the very front surface of the cornea
(epithelium). In the LASIK procedure, a liquid
anesthetic is dropped into the patients eye,
numbing it for surgery. The surgeon then props the
eyelids open and marks the cornea with water
soluble ink to guide in the later repositioning of the
flap. A suction ring is placed on the eye to secure
the eye and maintain pressure within the eye while
the cornea is drawn outward.
Simultaneously, a microkeratome (similar to a
carpenters plane, but automated) is placed in the
track of the suction ring . The blade of the
microkeratome then moves across the cornea,
creating a flap of corneal tissue some 20-25% of
the total corneal thickness. This layer(down into
the corneal stroma) is not cut away completely, but
remains attached at one side and is then opened
like a door on a hinge to reveal the stroma beneath.
Once the upper corneal flap has been folded back, the
excimer laser is then employed to ablate (vaporize)
the amount of underlying corneal tissue necessary
to reshape the corneal curvature to the desired
degree. To correct myopia, the laser trims the
corneas center, making it flatter. For hyperopia, a
doughnut-shaped ring of tissue is removed. The
laser is programmed to ablate the necessary
amount with a modified version of the patients
glasses or contact lens prescription. The corneal
flab is then repositioned to its original position on
the stromal bed where it adheres over the next
several months. As in the other procedures , the
eye is then treated with antibiotics, covered with a
shield, and the patient is sent home to recover.
Dr. Sami Ata Dassan
Medics Index Member
http://medicsorg.tripod.com/drsamiadassan/index.htm