A refractive and histopathologic study of excimer laser keratectomy in primates.

Using a 193-nm excimer laser, we produced wide-area, refractive keratectomies on 18 cynomolgus monkey corneas and followed them up for up to 18 months. All corneas developed some subepithelial haze by one month. Electron microscopy disclosed epithelial thickening, absence of Bowman's layer, and subepithelial activated fibroblasts surrounded by disorganized collagen. By six months, the haze faded to a variable degree, the epithelium regained normal thickness, and the collagen was more organized. Persistent corneal haze at 12 months in some corneas correlated with electronlucent spaces in the subepithelial zone. Corneas were 90 microns thinner centrally two weeks after myopic ablation, but returned to preoperative thickness by six months. Myopic flattening and hyperopic steepening of 6 diopters were targeted, and over 7 diopters of each were achieved initially. Regression of induced curvature stabilized over several months. At 18 months, 4.4 diopters of myopic flattening and 5.2 diopters of hyperopic steepening remained.

Experimental corneal studies with the excimer laser.

The excimer laser is potentially capable of achieving wide area central corneal reprofiling because of its extreme precision and limited penetration into adjacent tissues. A beam modifying system designed for this application is described. Initial clinical studies in monkeys and in ten human patients with blind eyes were performed. Long-term clinical data and interim histologic analyses are available from these studies. The results indicate that following ablation with an ultraviolet laser in both humans and primates, the ablated tissue shows a normal healing reaction resulting in a mild to moderate stromal interface haze. The effects of this healing on best corrected vision must be elucidated through additional research. Some loss of refractive effect was seen early in the healing process with apparent stabilization.

Human excimer laser lamellar keratectomy. A clinical study.

The first ten blind human eyes in the United States to receive excimer laser (ArFl 193 nm) lamellar keratectomy (reprofiling) are presented. Seven of these patients were followed 6 to 12 months after ablation. All eyes are grossly clear in the region of ablation. Results of slit-lamp examination of all flattened ablated areas show mild superficial haze at the epithelial/stromal interface. This haze might not interfere significantly with vision in patients 7 to 10. Serial pachymetry and keratometry measurements, refraction, and digital keratoscopy show a progressive filling in of the excavated area by approximately two thirds but a loss of initial diopteric correction of only one third. Histopathologic analysis was obtained for four eyes. Transmission electron microscopy of three eyes enucleated 3 to 12 days after ablation shows 40-microns ablation depths through Bowman's layer and superficial stroma with minimal adjacent tissue damage and no inflammatory cells. The epithelium is increased in thickness by 50%, and firmly attached to the underlying stroma. A 4-month postablation specimen shows keratocyte activation with increased protein synthesis (presumed collagen and ground substance).

Human excimer laser corneal surgery: preliminary report.

The first human trial utilizing the argon fluoride excimer laser at 193 nm to produce a superficial keratectomy in ten human eyes has been described with the histopathological evaluation of four eyes and the longer gross appearance of six eyes at intervals extending to 10 months post-excimer laser treatment. The process of laser superficial keratectomy has proved to be one of the promising areas of surgical intervention for reconstructive or refractive keratoplasty in the future. Intensive investigations need to be undertaken on the corneal wound healing process following laser ablation as well as the nature, and long-term stability of the corneal excisions or induced refractive corrections. It is essential that the optimal laser parameters be established for the various refractive corrections and other corneal surgical techniques, and that pathophysiologic and histopathologic changes that have been induced by the excimer laser-corneal tissue interaction in animals and humans be critically and extensively analyzed.

Scleral flap surgery for modification of corneal astigmatism.

We performed resections and recessions of scleral flaps on human cadaver eyes in order to measure the induced change in keratometric astigmatism. We prepared 3-mm scleral flaps that were 3, 5, 7, or 10 mm long and resected or recessed these flaps up to 1 mm in 0.25-mm increments. Scleral flap resection resulted in up to 10.1 D of net corneal steepening along the meridian of the incision. Scleral flap recessions resulted in up to 7.7 D of net corneal flattening along the meridian of the incision; the effect increased with increasing flap length in the recessed eyes. There was a tendency toward mean corneal flattening with resections and mean corneal steepening with recessions.

Anomalies of retinal architecture in Aicardi syndrome.

Eyes obtained at autopsy from a female infant with Aicardi syndrome (chorioretinal lacunae, agenesis of the corpus callosum, and seizures) were studied by light and electron microscopy. The retinal insertion was displaced anteriorly over the ciliary body, the choroid was attenuated, and the retinal pigment epithelium showed hyperplasia and pigment migration throughout the sensory retina. Rosettes of photoreceptorlike cells and inversion of the photoreceptor layer were found. A hole within a lacuna showed total absence of the sensory retina. Optic disc epipapillary tissue consisted of glial and fibrous elements with a vascular core. The mechanism of photoreceptor folding is considered. The continuity of the external limiting membrane with the retinal pigment epithelium at sites of photoreceptor folding seen in our case suggests defective early development.