The start of something big

The purpose of my meeting with Dr. Troutman was to find an area of corneal research that would pique my interest. He mentioned several topics with various preceptors, but what I found most exciting was an area called lamellar refractive surgery.

Dr. Troutman mentioned that a brilliant ophthalmologist, Casimir A. Swinger, MD, had just completed his fellowship and was starting a new laboratory committed to the study of lamellar refractive surgery. Dr. Troutman and Dr. Swinger were the first surgeons to perform lamellar refractive surgery in the United States in 1977.

The initial study group of lamellar refractive surgeons in this country was very small. Aside from Drs. Troutman and Swinger, they included Jim Salz, MD; Miles Friedlander, MD; Lee Nordan, MD; Richard Elander, MD; Herbert Kaufman, MD; Ted Werblin, MD; and Perry Binder, MD, among others. Marguerite MacDonald, MD, followed Dr. Werblin at the helm of the Epikeratophakia project. People in this group were certainly pioneers and had to deal with the constant skepticism and criticism of their colleagues. This interest group worked hard to gain recognition and convene with their own session at the Association for Research in Vision and Ophthalmology (ARVO) meeting. Initially these sessions were not well attended.

At the end of a long day at the lab, Dr. Swinger would often write a three-page newsletter that would eventually become the Journal of Refractive Surgery. Dr. Swinger told me one day refractive surgery would be a subspecialty of ophthalmology but only if lamellar surgery could be simplified and made more accessible to more ophthalmologists.

In the mid-1980s Drs. Krumeich and Swinger developed nonfreeze lamellar surgery that paved the way for Louis Ruiz, MD, to develop automated lamellar keratoplasty (ALK). The results of ALK for myopia were reasonably predictable but less so for hyperopia. Other surgeons, including Richard Lindstrom, MD, worked hard to refine this procedure, both in the laboratory and clinical settings.

In the mid-1980s the excimer laser was shown to be a precise method for potentially reshaping the cornea. Dr. Swinger felt this would be the future of refractive surgery and encouraged me to do my corneal fellowship at the Massachusetts Eye and Ear Infirmary (MEEI). My research would focus on excimer laser-corneal interactions under the guidance of Roger Steinert, MD, and Carmen Puliafito, MD. In addition to directing the laser laboratory at MEEI, Dr. Puliafito was also the editor-in-chief of Lasers in Surgery in Medicine. During my tenure in the laser lab, Dr. Puliafito received a manuscript from Dr. Pallikaris regarding la-mellar surgery with a keratome followed by laser ablation with the excimer laser.

Dr. Puliafito, aware of my longstanding interest in lamellar surgery, asked me to review the manuscript. We both immediately appreciated that this could be potentially ground-breaking. Subsequently, many others, particularly George R. Waring, III, MD, and Steve Slade, MD, played a central role to ensure LASIK would be safely adapted and performed in the United States.

It took 42 years for lamellar refractive surgery to evolve from myopic keratomileusis in1949 to LASIK. LASIK was not performed widely in this country for another 10 years. The basic principles of Jose Barraquer, MD, of Colombia, the "father" and developer of lamellar refractive surgery, still serve as the basis for lamellar surgery. It took the ingenuity and perseverance of many pioneers to develop the subspecialty of corneal refractive surgery.

Ernest W. Kornmehl, MD, FACS, editor of Anterior Segment Techniques, is medical director of Kornmehl Laser Eye Associates, Boston, and is on the faculty of Harvard and Tufts medical schools and the Massachusetts Institute of Technology.