he term laser is an acronym for Light Amplification by Stimulated Emission of Radiation — and may be the sexiest acronym in the lexicon of man. It carries with it connotations of unfettered power, and a mystique of benevolent utility. The very nuance of the term is that of something embodying everlasting welfare — “We don't know what it means but it sure sounds great!” It has been made the subject of unprecedented media hype and has acquired a reputation for accuracy and applicability — some of it justified, some not. Many see lasers as the Greek panacea — the universal cure, the ultimate liniment. Or the penultimate snake oil — since the term laser itself has been used to sell everything from trinkets to automobiles.

There is no question that such devices, through the beam of electromagnetic radiation that they emit, are extremely powerful things. They can, in an instant, vaporize the most refractory of substances. Heady stuff this, both to witness and to contemplate. It is, however, this very power that makes them extremely dangerous devices. Dangerous, not only in their manifest (as well as latent) power, but in their ability to fascinate, nay mesmerize, man — perhaps into applying them in ways that may prove to be more harmful than beneficial.

The author once made an unfortunate response to an interview question years ago regarding the application of lasers to refractive surgery when he replied, somewhat tongue-in-cheek, that “lasers are the refractive surgical instrument of the future and are likely to be so for the next 10 years”. This answer was not original, it was in fact, a paraphrasing of something someone else had said about the same subject. It was, however, unfortunate because it was mistaken in some quarters as “sour grapes” and taken in others as a jest. The author's intent, however, was to point out that the routine use of lasers in refractive surgery was not then (1987) — however much some individuals and manufacturers would like it to be — and that considerable research and trial were ahead of us. Considering the power of the term laser to stimulate individuals’ imaginations, the potential for harm if lasers are applied willy-nilly, is still very great — and that is no joking matter. Consider this: some are using the LASIK procedure for low degrees of myopia — down to -1D; more of this anon.

Lest it be said that the author is somehow categorically opposed to the use of such devices in refractive surgery, he will go on record by stating that the potential of the laser for such use is high and some of the early work was promising despite certain disappointments. It is further averred that the author expects lasers will play an important, and possibly dominant, role in such surgery in the future. However, let the record also show that none of the early results reported justified the hype surrounding such application. The public as well as the ophthalmologist, were ill-served by a self-serving media blitz. The question, “cui bono?” can still not yet be answered — the patient. The situation surrounding the laser in refractive surgery does not duplicate that of the introduction of RK but it is ironic that RK is being held up as a standard for the results of laser surgery to emulate. It is even more ironic that many of the self-same individuals who, in the recent past, called for radical controls on RK, have decried controls being laid upon the lasers with which they have a closely held interest; an example of the NIH (Not Invented Here) Syndrome.

We can but try to bring some clarity out of the fog of conflicting claims and data and perhaps inject a modicum of sanity into the still current atmosphere of “laser rapture”. A close cousin to “He-Ne rapture” and just as pernicious. The term, He-Ne rapture, was coined to describe the tendency of the ophthalmic surgeon who — so taken with the sight of posterior capsule being blasted to bits under his He-Ne focus spot — keeps pushing the button on his YAG laser until all remnants of capsule have been totally vaporized.

It is our purpose, not to view lasers — ænigmate (through a glass — darkly) — but to shed some light (no pun intended) on these fascinating devices and their possible application in refractive surgery. To that end, we will outline the physical properties of the laser — what makes it go, as it were — and the effect of such amplified light, good and bad, upon living tissue. In addition, we will share with you some of the techniques currently being applied to the corneal surface to modulate its shape along with their results, as well as provide a glimpse of some laser technology still to come.