レーザー角膜切削形成術 laser in situ keratomileusis

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/12/07 06:54:36」(JST)

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レーシック手術

レーシック（英語: LASIK）とは角膜屈折矯正手術の一種で、目の表面の角膜にエキシマレーザーを照射し、角膜の曲率を変えることにより視力を矯正する手術である。LASIKは、正式名称である「LASER(-assisted) in situ κερατόμῑλευσις^[1]」（英語・ラテン語・ギリシア語からなる）の略であり、「レーザー照射を本来の場所に収まったままの眼球に施し、角膜を彫り整えること」の語意がある。

近視を補正する場合、眼鏡やコンタクトレンズ等の道具を使用することが一般的だが、レーシックでは角膜を矯正手術することにより正視の状態に近づける。これにより、裸眼視力を向上することができる。1990年代にアメリカを中心にその手術方法が認知されるようになった。

概要

レーザー機器もしくは、マイクロケラトームと呼ばれる眼球用カンナで角膜の表面を薄くスライスし、フラップ（ふた状のもの）を作り、めくる。表出した角膜実質層にエキシマレーザーを照射し、一部を削る（蒸散させる）。その後、フラップを元の状態に戻し、フラップが自然に吸着する。角膜中央部が薄くなるため、角膜の曲率が下がり（凹レンズを用いたのと同じ効果）、近視が矯正される。視力は術後直後から1日程度で矯正される。視力が安定するには1週間から1ヶ月程度を要し、90%以上の人が裸眼視力1.0以上になる。

フラップは時間の経過とともに安全な強度に近づくが、元には戻らない。強い外圧がかかるとフラップがずれる場合がある。このため格闘技の選手等、顔面に衝撃を伴う職種には向かない。フラップを作らずに角膜上皮から削ることで屈曲率を矯正するPRKや、フラップを再生させることが出来るラセックと呼ばれる同種の手術もあるので、特にスポーツ選手はこちらを選ぶこともある。

角膜に一定の厚さが必要なため、角膜が薄い場合や眼に疾患等を抱えている場合は、手術が受けられない。また、近視の進行する10代などの若年者は手術を受けられない。日本眼科学会のガイドラインでは18歳以上の者でなければ手術を受けられない。米国FDAでも同様に18歳以上としているのに加えて、二十歳代の始めのうちも度数変動のリスクから望ましくないとしている。^[2]。近視遠視乱視を矯正するための手術であるので、加齢により進行する老眼には有効でない。モノビジョンと呼ばれる片方を遠視用、もう片方を近視用とする手術も存在する。

角膜屈折矯正手術後、角膜上皮の再生・治癒反応に伴い、ヘイズ（英: haze）と呼ばれる角膜の混濁が現れる可能性がある。

世界初のレーシックは1990年にギリシャで行われた。1995年にアメリカ食品医薬品局がエキシマレーザーの使用認可を出し、アメリカでは1998年以降レーシックが屈折矯正手術の主流となった。日本では、2000年1月に厚生省（現・厚生労働省）がエキシマレーザーの使用認可を出してから受けられるようになっている。歴史が浅いため、長期に渡る安全性が実証されていないとも言われるが、2009年、アメリカの医学誌「Archives of Ophthalmology（眼科学）」11月号にて近視に対するレーザー手術は長期的に見ても安全であるという研究結果が発表された^[3]。

問題点

術後合併症等のリスクが存在する（詳細は後段）。
日本の場合、レーシックなどの屈折矯正手術を受けた者は航空機操縦士の受験資格がない^[4]。メガネによる矯正では、±8D以内という度数制限を満たしていれば通常に受験が可能である^[5]。
日本の場合、団体信用生命保険等の保険加入時にリスクのひとつとして取られるため、不利になる場合がある。

合併症

レーシックは角膜を手術するため、患者個人による差異はあるものの、合併症が伴う場合がある。中には深刻な合併症となる場合があり、後遺症として残る場合もある。良い条件の患者に有能かつ経験豊富な医師が手術を施した場合、深刻な合併症の起こる確率は1%未満と言われる^[6]。

深刻でないものを含めれば合併症の起こる確率はもっと高い。手術による合併症で最も多いドライアイは深刻な合併症には当たらないが、American Journal of Ophthalmologyの2006年3月の発表によれば、レーシック後6か月の術後治療期間の後にドライアイに罹患している割合は33.36%である^[7]。アメリカ食品医薬品局のウェブサイト^[8]によれば、このドライアイは、後遺症として残る場合がある。人工涙液や涙点プラグなどが必要になる例もある。

消費者庁は2013年12月4日、事故情報データバンクに登録された情報に基づき、安易なレーシック手術を避けるよう注意を呼びかけた^[9]。事故情報データバンクとは消費者庁が国民生活センターと連携し、関係機関から事故情報や危険情報を収集し、事故防止に役立てるためのデータ収集・提供システム。この注意によれば、2013年11月8日までに登録された情報のうち、レーシック手術を受けて危害が発生した件数は80に及んだ。最も多かったのが過矯正による遠視と頭痛、吐き気などによる体調不良だった。その他、乱視、光をまぶしく感じること、ドライアイ、目の痛みが含まれていた。重大な身体被害に至った事例としては、手術直後から2カ月間、目の表面に激しい痛みがあり、寝たきりの状態に至った40歳代の女性の例がある。

手術前の屈折異常の度合いにより、術後に、暈（かさ）が見えたり、ものが二重に見えたり、コントラストが低下したり、グレアが現れる場合がある。^[10]このため、一律の基準で手術を施すのではなく、個々の患者ごとに状況を判断し、手術を行うことが重要であると言われている^[11]。

以下は、その他に報告されているレーシックの合併症の一部である^[12]^[13]。

術前より矯正視力が低下^[14]
過剰矯正^[15]および矯正不足
視力の変動
ゴースト像^[16]

フラップのしわ^[17]
フラップの下の塵や腫瘍
フラップの穴^[18]

照射のずれによる乱視
角膜拡張
飛蚊症

上皮侵食
後部硝子体剥離^[19]
黄斑円孔^[20]

角膜感染症

レーシックは角膜を手術するため感染症を引き起こす場合がある。屈折矯正手術に伴う角膜感染症の発生頻度は5,000例に1例程度とされる^[21]。通常、レーシックを行う場所では、手術道具の消毒等が徹底的に行われている^[22]が、2008年から2009年にかけ、東京・銀座にある眼科でレーシックによる近視の矯正手術を受けた患者67人が、感染性角膜炎などに集団感染していたことが判明した。中央区などによると、2008年9月から2009年2月にかけ、「銀座眼科」でレーシック手術を受けた患者639人のうち1割に当たる67人というかなりの高い割合で感染性角膜炎などを発症し、うち2人が入院。レーシック手術に適応するかチェックせず即日に手術を行うなどずさんな事前検査の体制や、日常的に手術室が待合室から見えるほど衛生的に隔離されておらず、また医療機器の滅菌消毒が不十分だったことが集団感染の原因と見られたため、2009年2月に入って3回の立ち入り調査が行われ^[23]、2010年12月7日に元院長が業務上過失傷害の容疑で警視庁に逮捕されるに至った^[24]。

現状

日本

日本での歴史は、2000年にエキシマレーザー装置が医療機器の承認をうけ、販売が許可されたことから始まっている。日本国内での手術名称は「角膜切削剥離焼灼矯正手術」である。現在のところ治療には健康保険が適用されず、自由診療である事から手術費用は診療所や医院によって幅がある。普及当初は両目で60万円以上するのが通常であったが、手術数や手術医院等の増加等に伴い、現在は両眼で8万円から50万円程度まで開きがある^[25]。そのため、その料金表示をめぐって、不祥事になった例もある。2009年8月6日、公正取引委員会は、ウェブサイトの料金表示が不当景品類及び不当表示防止法第4条第1項第2号に規定する有利誤認のおそれがあるものとして、品川近視クリニックと神奈川クリニック眼科に対し誤認するような表示を行わないよう警告を行った^[26]。神奈川クリニックは2010年5月に破産し、神戸クリニックに吸収された。

手術者数は、2000年に年間2万人程度で、2008年に年間40万人程度であった^[27]^[28]。

先述のとおり、施術の方法にはレーザー機器もしくは、マイクロケラトームによる方法がある。

刑事・民事訴訟

2011年9月 - 業務上過失傷害罪で起訴された銀座眼科の医師に対して、禁固2年の実刑判決が言い渡された。事件内容は、手術器具による細菌感染防止の手順を怠ったために、患者70人が集団感染し、細菌性角膜炎などを発症した^[29]。
2014年10月 - 被害者ら15人による、クリニックを相手取った集団訴訟に踏み切り。過剰矯正による遠視、眼精疲労、痛み、視力障害などの訴え^[30]。

一般的な手術の流れ

ハードコンタクトレンズ1週間前、ソフトコンタクトレンズは3日前から裸眼状態にする必要がある。
検査は、散瞳検査で約1時間　適応検査に約10分、診察に約5分、相談および説明に約20分、そして手術待ち時間が付加される。瞳孔を目薬で開けさせ検査するため、検査状態後2-3時間は、瞳孔が開いた状態のため、まぶしく感じる。
手術時間は15分程度。その後は手術直後の休憩に15分程度掛かる。
当日以降の検査は翌日、1週間後、2週間後、1ヶ月後、3ヵ月後、6ヵ月後、1年後…と手術後も定期的に通う必要がある。

視力矯正手術の種類

レーシック
Zレーシック
アマリスZレーシック

イントラレーシック（iレーシック）
エピレーシック
カメラインレー

ラセック
ウェーブフロント
フェイキック IOL

PRK
フレックスPRK
放射状角膜切開術（PK）

出典

^ κέρατο（角膜）+ σμῑλεύω（彫刻する）+ σις（～すること）
^ http://www.fda.gov/medicaldevices/productsandmedicalprocedures/surgeryandlifesupport/lasik/ucm061366.htm
^ ^[リンク切れ] 近視レーザー手術は長期的にも安全
^ [1]一般社団法人航空医学研究センターによる航空身体検査マニュアル
^ [2]一般社団法人航空医学研究センターによる航空身体検査マニュアル
^ レーシック後の合併症
^ De Paiva CS, Chen Z, Koch DD, et al. (March 2006). “The incidence and risk factors for developing dry eye after myopic LASIK”. Am. J. Ophthalmol. 141 (3): 438–45. doi:10.1016/j.ajo.2005.10.006. PMID 16490488.
^ http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm061354.htm
^ [3]消費者庁による2013年12月4日の報道発表資料「レーシック手術を安易に受けることは避け、リスクの説明を十分受けましょう！」（PDF）
^ Pop M, Payette Y (January 2004). “Risk factors for night vision complaints after LASIK for myopia”. Ophthalmology 111 (1): 3–10. doi:10.1016/j.ophtha.2003.09.022. PMID 14711706.
^ "Individual Risk Factors of Halos, Loss of Contrast Sensitivity, Glare and Starbursts after LASIK." operationauge.com
^ "The most common complications of refractive surgery.". USAEyes.org
^ Knorz MC (March 2006). “[Complications of refractive excimer laser surgery]” (German). Ophthalmologe 103 (3): 192–8. doi:10.1007/s00347-006-1314-y10.1007/s00347-006-1314-y (inactive 2009-07-10). PMID 16465507.
^ http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm061354.htm
^ "Lasik Overcorrection - Unexpected, Unwanted, Desired, and Planned.". USAEyes
^ "Ghost or double vision after Lasik and similar vision correction surgery.". USAEyes
^ "Macro-striae and micro-striae complication of Lasik and All-Laser Lasik." USAEyes
^ "Buttonhole Incomplete Flap in Lasik and All-Laser Lasik". USAEyes
^ Mirshahi A, Schöpfer D, Gerhardt D, Terzi E, Kasper T, Kohnen T (February 2006). “Incidence of posterior vitreous detachment after laser in situ keratomileusis”. Graefes Arch. Clin. Exp. Ophthalmol. 244 (2): 149–53. doi:10.1007/s00417-005-0002-y10.1007/s00417-005-0002-y (inactive 2009-07-10). PMID 16044328.
^ Arevalo JF, Mendoza AJ, Velez-Vazquez W, et al. (July 2005). “Full-thickness macular hole after LASIK for the correction of myopia”. Ophthalmology 112 (7): 1207–12. doi:10.1016/j.ophtha.2005.01.046. PMID 15921746.
^ 屈折矯正手術合併症の実態調査報告
^ 日本眼科学会：レーシック術後の角膜感染症多発事件について
^ 読売新聞
^ 山本太一; 内橋寿明; 小泉大士 (2010年12月7日). “レーシック手術：「銀座眼科」元院長を逮捕実態の解明へ”. 毎日新聞 2010年12月7日閲覧。
^ 例えば2012年10月現在、品川近視クリニック（千代田区ほか）では7.5万円から、新宿近視クリニック（新宿区ほか）は8万円から、1996年に日本で初めてレーシックを実施した錦糸眼科（港区ほか）でも8万円からレーシック手術を実施している。吉野眼科クリニック（台東区）では43万円から。大規模な病院では慶應義塾大学病院（新宿区）は231，000円から。医療機関によっては別途検査費用が必要な場合がある。
^ 公正取引委員会 - 広報
時事通信「視力回復手術大手に警告＝「限定割引」実態なし－公取委」2009年8月6日
^ J-CASTニュース
^ 神戸新聞
^ レーシック手術集団感染事件で銀座眼科医師に実刑判決
^ レーシック被害　提訴へ

外部リンク

日本眼科学会：目の病気屈折矯正手術
日本眼科手術学会

wiki en

[Wiki en表示]

LASIK or Lasik (Laser-Assisted in situ Keratomileusis), commonly referred to as laser eye surgery or laser vision correction, is a type of refractive surgery for the correction of myopia, hypermetropia, and astigmatism. The LASIK surgery is performed by an ophthalmologist who uses a laser or microkeratome to reshape the eye's cornea in order to improve visual acuity.^[1] For most patients, LASIK provides a permanent alternative to eyeglasses or contact lenses.^[2]

LASIK is most similar to another surgical corrective procedure, photorefractive keratectomy (PRK, similar to LASIK), and both represent advances over radial keratotomy in the surgical treatment of refractive errors of vision. For patients with moderate to high myopia or thin corneas which cannot be treated with LASIK and PRK, the phakic intraocular lens is an alternative.^[3]^[4] As of 2011, over 11 million LASIK procedures had been performed in the United States^[5] and as of 2009 over 28 million have been performed worldwide.^[6]

1 History
- 1.1 Barraquer's early work
- 1.2 Application of medical laser to refractive surgery
2 Introduction of LASIK
- 2.1 Patent
3 Implementation in U.S.
4 Further developments
- 4.1 Experimental techniques
5 Procedures
- 5.1 Preoperative procedures
  - 5.1.1 Contact lenses
  - 5.1.2 Pre-operative examination and education
- 5.2 Operative procedure
  - 5.2.1 Flap creation
  - 5.2.2 Laser remodelling
  - 5.2.3 Repositioning of the flap
- 5.3 Postoperative care
6 Wavefront-guided LASIK
7 Effectiveness
- 7.1 Patient satisfaction
- 7.2 Patient dissatisfaction
8 Risks
- 8.1 Vision loss as a result of an infection
- 8.2 Higher-order aberrations
- 8.3 Dry eyes
- 8.4 Halos
- 8.5 Other complications
9 Onset of presbyopia
10 LASIK versus photorefractive keratectomy
11 FDA's position on LASIK
- 11.1 LASIK Quality of Life Study
12 See also
13 References
14 External links

History

Barraquer's early work

In the 1950s, the microkeratome and keratomileusis technique were developed in Bogotá, Colombia, by the Spanish ophthalmologist Jose Barraquer. In his clinic, he would cut thin (one hundredth of a mm thick) flaps in the cornea to alter its shape. Barraquer also investigated how much of the cornea had to be left unaltered in order to provide stable long-term results.^[7] This work was followed by that of the Russian scientist, Svyatoslav Fyodorov (1920-2000), who developed radial keratotomy (RK) in the 1970s and designed the first posterior chamber implantable contact lenses (phakic intraocular lens) in the 1980s.

Application of medical laser to refractive surgery

In 1980, Rangaswamy Srinivasan, at the IBM Research laboratory, discovered that an ultraviolet excimer laser could etch living tissue, with precision and with no thermal damage to the surrounding area. He named the phenomenon "ablative photo-decomposition" (APD).^[8] Five years later, in 1985, Steven Trokel at the Edward S. Harkness Eye Institute, Columbia University in New York City, published his work using the excimer laser in radial keratotomy. He wrote,

"The central corneal flattening obtained by radial diamond knife incisions has been duplicated by radial laser incisions in 18 enucleated human eyes. The incisions, made by 193 nm far-ultraviolet light radiation emitted by the excimer laser, produced corneal flattening ranging from 0.12 to 5.35 diopters. Both the depth of the corneal incisions and the degree of central corneal flattening correlated with the laser energy applied. Histopathology revealed the remarkably smooth edges of the laser incisions."^[9]

Together with his colleagues, Charles Munnerlyn and Terry Clapham, Trokel founded VISX USA inc.^[10] Marguerite B. MacDonald MD performed the first human VISX refractive laser eye surgery in 1989.^[11]

Introduction of LASIK

Patent

A number of patents have been issued for several techniques related to LASIK. First patent came from German inventor Josef Bille. For example, Samuel E. Blum filed a patent application in 1982. Later, on 20 June 1989, Gholam A. Peyman was granted a US patent for LASIK (US4840175). It was,

"A method and apparatus for modifying the curvature of a live cornea via use of an excimer laser. The live cornea has a thin layer removed therefrom, leaving an exposed internal surface thereon. Then, either the surface or thin layer is exposed to the laser beam along a predetermined pattern to ablate desired portions. The thin layer is then replaced onto the surface. Ablating a central area of the surface or thin layer makes the cornea less curved, while ablating an annular area spaced from the center of the surface or layer makes the cornea more curved. The desired predetermined pattern is formed by use of a variable diaphragm, a rotating orifice of variable size, a movable mirror or a movable fiber optic cable through which the laser beam is directed towards the exposed internal surface or removed thin layer."^[12]

The patents related to so-called broad-beam LASIK and PRK technologies were granted to US companies including Visx and Summit during 1990-1995 based on the fundamental US patent issued to IBM (1983) which claimed the use of UV laser for the ablation of organic tissues. In 1991, J.T. Lin was granted a US patent (US5520679) for a new technology using a flying-spot for customized LASIK that has been used worldwide. The first US patent (in 1993) using an eye-tracking device to prevent decentration in LASIK procedures was granted to S. Lai.

Implementation in U.S.

The LASIK technique was implemented in the U.S. after its successful application elsewhere. The Food and Drug Administration (FDA) commenced a trial of the excimer laser in 1989. The first enterprise to receive FDA approval to use an excimer laser for photo-refractive keratectomy was Summit Technology (founder and CEO, Dr. David Muller).^[13] In 1992, under the direction of the FDA, Greek ophthalmologist Ioannis Pallikaris introduced LASIK to ten VISX centres. In 1998, the "Kremer Excimer Laser", serial number KEA 940202, received FDA approval for its singular use for performing LASIK.^[14] Subsequently, Summit Technology was the first company to receive FDA approval to mass manufacture and distribute excimer lasers. VISX and other companies followed.^[14]

The excimer laser that was used for the first LASIK surgeries by I.Pallikaris

Pallikaris suggested a flap of cornea could be raised by microkeratome prior to the performing of PRK with the excimer laser. The addition of a flap to PRK became known as LASIK.

Further developments

Since 1991, there have been further developments such as faster lasers; larger spot areas; bladeless flap incisions; intraoperative corneal pachymetry; and "wavefront-optimized" and "wavefront-guided" techniques. However, use of the excimer laser risks damage to the retina and optic nerve. The goal of refractive surgery is to avoid permanently weakening the cornea with incisions and to deliver less energy to the surrounding tissues.

Experimental techniques

"plain" LASIK: LASEK, Epi-LASIK,
Sub-Bowman’s keratomileusis (thin flap LASIK),
Wavefront-guided PRK,
advanced intraocular lenses.
Femtosecond laser intrastromal vision correction: using all-femtosecond correction, for example, Femtosecond Lenticule EXtraction, FLIVC, or IntraCOR),
Keraflex: a thermobiochemical solution which has received the CE Mark for refractive correction.^[15] and is in European clinical trials for the correction of myopia and keratoconus.^[16]
Technolas FEMTEC laser: for incisionless IntraCOR ablation for presbyopia,^[17] with trials ongoing for myopia and other conditions.^[18]

Procedures

Play media

Video of a complete LASIK-treatment

The planning and analysis of corneal reshaping techniques such as LASIK have been standardized by the American National Standards Institute, an approach based on the Alpins Method of astigmatism analysis. The FDA website on LASIK states,

"Before undergoing a refractive procedure, you should carefully weigh the risks and benefits based on your own personal value system, and try to avoid being influenced by friends that have had the procedure or doctors encouraging you to do so."^[19]

The procedure involves creating a thin flap on the eye, folding it to enable remodeling of the tissue beneath with a laser and repositioning the flap.

Preoperative procedures

Contact lenses

Patients wearing soft contact lenses are instructed to stop wearing them 5 to 21 days before surgery. One industry body recommends that patients wearing hard contact lenses should stop wearing them for a minimum of six weeks plus another six weeks for every three years the hard contacts have been worn.^[20] The cornea is avascular because it must be transparent to function normally. Its cells absorb oxygen from the tear film. Thus, low-oxygen-permeable contact lenses reduce the cornea's oxygen absorption, sometimes resulting in corneal neovascularization—the growth of blood vessels into the cornea. This causes a slight lengthening of inflammation duration and healing time and some pain during surgery, because of greater bleeding. Although some contact lenses (notably modern RGP and soft silicone hydrogel lenses) are made of materials with greater oxygen permeability that help reduce the risk of corneal neovascularization, patients considering LASIK are warned to avoid over-wearing their contact lenses.

Pre-operative examination and education

In the United States, the FDA has approved LASIK for age 18 and over.^[21] More importantly the patient's eye prescription should be stable for at least one year prior to surgery. The patient may be examined with pupillary dilation and education given prior to the procedure. Before the surgery, the patient's corneas are examined with a pachymeter to determine their thickness, and with a topographer, or corneal topography machine,^[1] to measure their surface contour. Using low-power lasers, a topographer creates a topographic map of the cornea. The procedure is contraindicated if the topographer finds difficulties such as keratoconus^[1] The preparatory process also detects astigmatism and other irregularities in the shape of the cornea. Using this information, the surgeon calculates the amount and the location of corneal tissue to be removed. The patient is prescribed and self-administers an antibiotic beforehand to minimize the risk of infection after the procedure and is sometimes offered a short acting oral sedative medication as a pre-medication. Prior to the procedure, anaesthetic eye drops are instilled. Factors that may rule out LASIK for some patients include large pupils, thin corneas and extremely dry eyes.^[22]

Operative procedure

Flap creation

A soft corneal suction ring is applied to the eye, holding the eye in place. This step in the procedure can sometimes cause small blood vessels to burst, resulting in bleeding or subconjunctival hemorrhage into the white (sclera) of the eye, a harmless side effect that resolves within several weeks. Increased suction causes a transient dimming of vision in the treated eye. Once the eye is immobilized, a flap is created by cutting through the corneal epithelium and Bowman's layer. This process is achieved with a mechanical microkeratome using a metal blade, or a femtosecond laser that creates a series of tiny closely arranged bubbles within the cornea.^[23] A hinge is left at one end of this flap. The flap is folded back, revealing the stroma, the middle section of the cornea. The process of lifting and folding back the flap can sometimes be uncomfortable.

Laser remodelling

The second step of the procedure uses an excimer laser (193 nm) to remodel the corneal stroma. The laser vaporizes the tissue in a finely controlled manner without damaging the adjacent stroma. No burning with heat or actual cutting is required to ablate the tissue. The layers of tissue removed are tens of micrometres thick. Performing the laser ablation in the deeper corneal stroma provides for more rapid visual recovery and less pain than the earlier technique, photorefractive keratectomy (PRK). During the second step, the patient's vision becomes blurry, once the flap is lifted. They will be able to see only white light surrounding the orange light of the laser, which can lead to mild disorientation. The excimer laser uses an eye tracking system that follows the patient's eye position up to 4,000 times per second, redirecting laser pulses for precise placement within the treatment zone. Typical pulses are around 1 millijoule (mJ) of pulse energy in 10 to 20 nanoseconds.^[24]

Repositioning of the flap

After the laser has reshaped the stromal layer, the LASIK flap is carefully repositioned over the treatment area by the surgeon and checked for the presence of air bubbles, debris, and proper fit on the eye. The flap remains in position by natural adhesion until healing is completed.

Postoperative care

Patients are usually given a course of antibiotic and anti-inflammatory eye drops. These are continued in the weeks following surgery. Patients are told to rest and are given dark eyeglasses to protect their eyes from bright lights and occasionally protective goggles to prevent rubbing of the eyes when asleep and to reduce dry eyes. They also are required to moisturize the eyes with preservative-free tears and follow directions for prescription drops. Occasionally after the procedure a bandage contact lens is placed to aid the healing, and typically removed after 3–4 days. Patients should be adequately informed by their surgeons of the importance of proper post-operative care to minimize the risk of complications.^[25]

Wavefront-guided LASIK

Wavefront-guided LASIK^[26] is a variation of LASIK surgery in which, rather than applying a simple correction of only long/short-sightedness and astigmatism (only lower order aberrations as in traditional LASIK), an ophthalmologist applies a spatially varying correction, guiding the computer-controlled excimer laser with measurements from a wavefront sensor. The goal is to achieve a more optically perfect eye, though the final result still depends on the physician's success at predicting changes that occur during healing and other factors that may have to do with the regularity/irregularity of the cornea and the axis of any residual astigmatism. Another important factor is whether the excimer laser can correctly register eye position in 3 dimensions, and to track the eye in all the possible directions of eye movement. If a wavefront guided treatment is performed with less than perfect registration and tracking, pre-existing aberrations can be worsened. In older patients, scattering from microscopic particles (cataract or incipient cataract) may play a role that outweighs any benefit from wavefront correction. Therefore, patients expecting so-called "super vision" from such procedures may be disappointed.^[27]^[28]^[29]^[30]

One method of planning and analyzing the results of LASIK surgery (as well as cataract/IOL, corneal, and other refractive surgical procedures) uses vector analysis, and in the case of LASIK, may be combined with a wavefront-guided approach.^[27]^[28]^[29]^[30] Many people undergoing LASIK have preexisting astigmatism, which may be regular or irregular, and is caused by some combination of external (corneal surface) and internal (posterior corneal surface, human lens, fluids, retina, and eye-brain interface) optical properties. In some patients, the external optics may have the greater influence, and in other patients, the internal optics may predominate. Importantly, the axes and magnitudes of external and internal astigmatism do not necessarily coincide, but it is the combination of the two that by definition determines the overall optics of the eye.

When treating a patient with preexisting astigmatism, most wavefront-guided LASIK lasers are designed to treat regular astigmatism as determined externally by corneal topography. In patients who have an element of internally induced astigmatism, therefore, the wavefront-guided astigmatism correction may leave regular astigmatism behind (a cross-cylinder effect). If the patient has preexisting irregular astigmatism, wavefront-guided approaches may leave both regular and irregular astigmatism behind. This can result in less-than-optimal visual acuity compared with a wavefront-guided approach combined with vector planning, as shown in a 2008 study.^[31] Thus, vector planning offers a better alignment between corneal astigmatism and laser treatment, and leaves less regular astigmatism behind on the cornea, which is advantageous whether irregular astigmatism coexists or not.

The "leftover" astigmatism after a purely surface-guided laser correction can be calculated beforehand, and is called ocular residual astigmatism (ORA). ORA is a calculation of astigmatism due to the noncorneal surface (internal) optics. The purely refraction-based approach represented by wavefront analysis actually conflicts with corneal surgical experience developed over many years.^[30]

The pathway to "super vision" thus may require a more customized approach to corneal astigmatism than is usually attempted, and any remaining astigmatism ought to be regular (as opposed to irregular), which are both fundamental principles of vector planning overlooked by a purely wavefront-guided treatment plan.^[30] This was confirmed by the 2008 study mentioned above, which found a greater reduction in corneal astigmatism and better visual outcomes under mesopic conditions using wavefront technology combined with vector analysis than using wavefront technology alone, and also found equivalent higher-order aberrations (see below).^[31] Vector planning also proved advantageous in patients with keratoconus.^[32] Additional discussion of wavefront-guided LASIK can be found here.

No good data can be found that compare the percentage of LASIK procedures that employ wavefront guidance versus the percentage that do not, nor the percentage of refractive surgeons who have a preference one way or the other. Wavefront technology continues to be positioned as an "advance" in LASIK with putative advantages;^[33]^[34]^[35]^[36] however, it is clear that not all LASIK procedures are performed with wavefront guidance.^[37]

Still, surgeons claim patients are generally more satisfied with this technique than with previous methods, particularly regarding lowered incidence of "halos," the visual artifact caused by spherical aberration induced in the eye by earlier methods. A meta-analysis of eight trials showed a lower incidence of these higher order aberrations in patients who had wavefront-guided LASIK compared to non-wavefront-guided LASIK.^[38] Based on their experience, the United States Air Force has described WFG-Lasik as giving "superior vision results".^[39]

Effectiveness

In 2006, the British National Health Service's National Institute for Health and Clinical Excellence (NICE) considered evidence of the effectiveness and the potential risks of the laser surgery stating "current evidence suggests that photorefractive (laser) surgery for the correction of refractive errors is safe and efficacious for use in appropriately selected patients. Clinicians undertaking photorefractive (laser) surgery for the correction of refractive errors should ensure that patients understand the benefits and potential risks of the procedure. Risks include failure to achieve the expected improvement in unaided vision, development of new visual disturbances, corneal infection and flap complications. These risks should be weighed against those of wearing spectacles or contact lenses."^[40] The FDA reports "The safety and effectiveness of refractive procedures has not been determined in patients with some diseases."^[41]

Patient satisfaction

Surveys of LASIK find rates of patient satisfaction between 92 and 98 percent.^[42]^[43]^[44] In March 2008, The American Society of Cataract and Refractive Surgery published a patient satisfaction meta-analysis of over 3,000 peer-reviewed articles from international clinical journals. Data from the prior 10 years revealed a 95.4 percent patient satisfaction rate among LASIK patients.^[45]

Patient dissatisfaction

Some patients with poor outcomes from LASIK surgical procedures report a significantly reduced quality of life because of vision problems or physical pain associated with the surgery. A small percentage of patients may need to have another surgery because their condition is over-corrected or under-corrected. Some patients need to wear contact lenses or glasses even after treatment.^[46] Patients who have suffered LASIK complications have created websites and discussion forums where prospective and past patients can discuss the surgery.

In 1999, "Surgical Eyes" was founded in New York city as a resource for patients with complications of LASIK and other refractive surgeries by RK patient Ron Link. "Surgical Eyes" has since been superseded by the "Vision Surgery Rehab Network" (VSRN).^[47]^[48]^[49]^[50]^[51]

Morris Waxler, a former FDA official who was involved in the approval of LASIK, has subsequently criticized its widespread use. In 2010, Waxler made media appearances and claimed that the procedure had a failure rate greater than 50%. The FDA responded that Waxler's information was "filled with false statements, incorrect citations" and "mischaracterization of results".^[52]

Risks

Vision loss as a result of an infection

On October 10, 2006, WebMD^[53] reported on a peer-reviewed study in the Archives of Ophthalmology^[54] in which statistical analysis revealed that vision loss risk as a result of an infection for contact lens wearers is less than vision loss risk as a result of an infection from LASIK. Daily contact lens wearers have a 1-in-200,000 chance of suffering significant vision loss. The researchers calculated the risk of significant vision loss consequence of LASIK surgery to be closer to 1-in-10,000 cases.

Higher-order aberrations

The term "higher-order aberrations" are visual problems that require special testing for diagnosis and are not corrected with normal spectacles (eyeglasses). These aberrations include 'starbursts', 'ghosting', 'halos' and others.^[55] Some patients describe these symptoms post-operatively and associate them with the LASIK technique including the formation of the flap and the tissue ablation.^[56] The advancement of the LASIK technology has reduced the risk of clinically significant visual impairment after surgery.^{[citation needed]} There is a correlation between pupil size and aberrations.^[57] This correlation may be the result of irregularity in the corneal tissue between the untouched part of the cornea and the reshaped part. Daytime post-LASIK vision is optimal, since the pupil size is smaller than the LASIK flap. However, at night, the pupil may dilate such that light passes through the edge of the LASIK flap which gives rise to aberrations. LASIK and PRK may induce spherical aberration if the laser under corrects as it moves outward from the centre of the treatment zone, especially when major corrections are made.^{[citation needed]} Others propose that higher order aberrations are present preoperatively.^[58] They can be measured in micrometers (µm) whereas the smallest laser beam size approved by the FDA is about 1000 times larger, at 0.65 mm. In situ keratomileusis effected at a later age increases the incidence of corneal higher-order wavefront aberrations.^[59]^[60] These factors demonstrate the importance of careful patient selection for LASIK treatment.

A subconjunctival hemorrhage is a common and minor post-LASIK complication.

Dry eyes

Some people experience dry eyes following surgery.^[61] Although it is usually temporary it can develop into dry eye syndrome.^[62]

Underlying conditions with dry eye such as Sjögren's syndrome are considered contraindications to Lasik.^[63]

Treatments include artificial tears, prescription tears and punctal occlusion. Punctal occlusion is accomplished by placing a collagen plug in the tear duct, which normally drains fluid from the eye. Some patients complain of ongoing dry eye symptoms despite such treatments and dry eye symptoms may be permanent.^[64]

Halos

Some post-LASIK patients see halos and starbursts around bright lights at night^[65]^[66]^[67] At night, the pupil may dilate to be larger than the flap leading to the edge of the flap or stromal changes causing visual distortion of light that does not occur during the day when the pupil is smaller. The eyes can be examined for large pupils pre-operatively and the risk of this symptom assessed.

Complications due to LASIK have been classified as those that occur due to preoperative, intraoperative, early postoperative, or late postoperative sources:^[68] According to the UK National Health Service complications occur in fewer than 5% of cases.^[61]

Other complications

flap complications – The incidence of flap complications is about 0.244%.^[69] Flap complications (such as displaced flaps or folds in the flaps that necessitate repositioning, diffuse lamellar keratitis, and epithelial ingrowth) are common in lamellar corneal surgeries^[70] but rarely lead to permanent loss of visual acuity. The incidence of these microkeratome-related complications decreases with increased physician experience.^[71]
"slipped flap" – is a corneal flap that detaches from the rest of the cornea. The chances of this are greatest immediately after surgery, so patients typically are advised to go home and sleep to let the flap adhere and heal. Patients are usually given sleep goggles or eye shields to wear for several nights to prevent them from dislodging the flap in their sleep. A short operation time may decrease the chance of this complication, as there is less time for the flap to dry. .^{[citation needed]}
"Flap interface particles" – are a finding whose clinical significance is undetermined.^[72] Particles of various sizes and reflectivity are clinically visible in about 38.7% of eyes examined via slit lamp biomicroscopy and in 100% of eyes examined by confocal microscopy.^[72]
Diffuse lamellar keratitis (or DLK) – an inflammatory process that involves an accumulation of white blood cells at the interface between the LASIK corneal flap and the underlying stroma. It is known colloquially as "sands of Sahara syndrome" because on slit lamp exam, the inflammatory infiltrate appears similar to waves of sand. The USAeyes organisation reports an incidence of 2.3% after LASIK.^[73]^[74] It is most commonly treated with steroid eye drops. Sometimes it is necessary for the eye surgeon to lift the flap and manually remove the accumulated cells. DLK has not been reported with photorefractive keratectomy due to the absence of flap creation.
Infection – the incidence of infection responsive to treatment has been estimated at 0.4%.^[74]
Ectasia – post-LASIK corneal ectasia^[75] is a condition where the cornea starts to bulge forwards at a variable time after LASIK, causing irregular astigmatism. The condition is similar to keratoconus. If this occurs, the patient may need rigid gas permeable contact lenses, Intrastromal corneal ring segments,^[76] corneal collagen cross-linking with Riboflavin,^[77] or a corneal transplant. A significant risk factor is forme fruste keratoconus, a genetic condition that predisposes the cornea to thinning after surgery. Although this condition is screened for in the preoperative examination, it is possible for the condition to appear later in life (the mid-40s). When cross-linking is performed only after the cornea becomes distorted, vision remains blurry even though the disease is stabilised. As a result, combining corneal collagen cross-linking with LASIK ('LASIK Xtra') aims to strengthen the cornea at the point of surgery and may be useful in cases where a very thin cornea is expected after the LASIK procedure. This would include cases of high spectacle power and patients with thin corneas before surgery. Definitive evidence that the procedure can reduce the risk of corneal ectasia will only become available a number of years later as corneal ectasia, if it happens, usually occurs in the late post-operative period. Some study show that combining LASIK with cross-linking adds refractive stability to hyperopic treatments and may also do the same for very high myopic treatments.^[78]^[79]
subconjunctival hemorrhage – A report shows the incidence of subconjunctival hemorrhage has been estimated at 10.5%.^[74]
Corneal scarring – or permanent problems with cornea's shape making it impossible to wear contact lenses.^[46]
epithelial ingrowth – the incidence of epithelial ingrowth has been estimated at 0.1%.^[74]
traumatic flap dislocations – Cases of late traumatic flap dislocations have been reported up to seven years after LASIK.^[80]
Glaucoma – After LASIK, measurements of intraocular pressure (used to diagnose and treat glaucoma) can be more difficult. The changes also affect the calculations used to select the correct intraocular lens implant for cataract surgery. This is known as "refractive surprise." Preoperative, operative and postoperative measurements can assist.^{[citation needed]}
Retinal detachment: the incidence of retinal detachment has been estimated at 0.36 percent.^[81]
Choroidal neovascularization: the incidence of choroidal neovascularization has been estimated at 0.33 percent.^[81]
Uveitis: the incidence of uveitis has been estimated at 0.18 percent.^[82]
for climbers – Although the cornea usually is thinner after LASIK, because of the removal of part of the stroma, refractive surgeons strive to maintain the maximum thickness to avoid structurally weakening the cornea. Decreased atmospheric pressure at higher altitudes has not been demonstrated as extremely dangerous to the eyes of LASIK patients. However, some mountain climbers have experienced a myopic shift at extreme altitudes.^[83]^[84]
corneal keratocytes – There is a report of decreases in numbers of corneal keratocytes (fibroblasts) after LASIK.^[85]
Late postoperative complications – A large body of evidence on the chances of long-term complications is not yet established and may be changing due to advances in operator experience, instruments and techniques.^[86]^[87]^[88]^[89]

Onset of presbyopia

Myopic (nearsighted) people who are close to the age (mid- to late-forties) when they will require either reading glasses or bifocal eyeglasses may find that they still require reading glasses despite having undergone refractive LASIK surgery. Myopic people generally require reading glasses or bifocal eyeglasses at a later age than people who are emmetropic (those who see without eyeglasses), but this benefit may be lost if they undergo LASIK. This is not a complication but an expected result of the physical laws of optics. Although there is currently no method to completely eradicate the need for reading glasses in this group, it may be minimized by performing a variation of the LASIK procedure called "slight monovision." In this procedure, which is performed exactly like distance-vision-correction LASIK, the dominant eye is set for distance vision, while the non-dominant eye is set to the prescription of the patient's reading glasses. This allows the patient to achieve a similar effect as wearing bifocals. The majority of patients tolerate this procedure very well and do not notice any shift between near and distance viewing, although a small portion of the population has trouble adjusting to the monovision effect. This can be tested for several days prior to surgery by wearing contact lenses that mimic the monovision effect. Recently, a variation of the laser ablation pattern called PresbyLASIK, has been developed to reduce or eliminate dependence on reading glasses while retaining distance vision.^{[citation needed]}

LASIK versus photorefractive keratectomy

There have been a number of studies comparing Lasik to photorefractive keratectomy, or PRK. Lasik is associated with decreased inflammation and quicker recovery, but at the cost of decreased expression of nerve growth factor (NGF) at the surgical bed.^[90] PRK, on the other hand, has longer recovery time with more postoperative discomfort and irritation, but rates of ocular dryness are less,^[91]^[92]^[93] as only the epithelium is denuded in this approach. Lasik, on the other hand, involves creation of a corneal flap.^[94] The medical literature is not uniform, however, regarding their comparative effects on ocular dryness,^[95] although the majority of research supports PRK as causing less reduction in the tear film. Surgical technique has improved with time, and a more recent study has shown no difference in ocular dryness in Lasik or PRK at 12 months, as compared to pre-operative baseline, although interval assessments at months 1, 3 and 6 did show dryness in both groups.^[96] Quantitative changes occurring at the eye surface are more pronounced with Lasik, but more irritation, pain and eyelid sticking are felt with PRK, which could be related to increased denervation with Lasik.^[90]^[97] A Systematic review compared LASIK and PRK and concluded that LASIK may probably have faster recovery time and lower pain in comparison to PRK, however results may be similar in both beyond a period of one year.^[98]

FDA's position on LASIK

On December 6, 2011, FDA posted a video on FDA's YouTube channel and FDA's LASIK web site to help explain the risks of LASIK and other important information to potential patients. The video includes images of what certain visual symptoms may look like to patients experiencing them.^[99]

LASIK Quality of Life Study

In October 2009, the FDA, the National Eye Institute (NEI), and the Department of Defense (DoD) launched the LASIK Quality of Life Collaboration Project (LQOLCP) to help better understand the potential risk of severe problems that can result from LASIK^[100] in response to widespread reports of problems experienced by patients after LASIK laser eye surgery.^[99] This project examined patient-reported outcomes with LASIK (PROWL). The project consisted of three phases: pilot phase, phase I, phase II (PROWL-1) and phase III (PROWL-2).^[101] The last two phases were completed in 2014.

The results of the long-awaited LASIK Quality of Life Study were disclosed in October, 2014.

Based on study results:

Up to 45 percent of participants, who had no visual symptoms before surgery, reported at least one visual symptom at three months after surgery.

Participants who developed new visual symptoms after surgery, most often developed halos. Up to 35 percent of participants with no halos before LASIK had halos three months following surgery.

Up to 30 percent of participants with no symptoms of dry eyes before LASIK, reported dry eye symptoms at three months after their surgery.

Less than 1 percent of study participants experienced “a lot of” difficulty with or inability to do usual activities without corrective lenses because of their visual symptoms (halos, glare, et al.) after LASIK surgery.

Participants who were not satisfied with the LASIK surgery reported all types of visual symptoms the questionnaire measured (double vision/ghosting, starbursts, glare, and halos).^[100]

At the American Academy of Ophthalmology (AAO) convention in Chicago on October 17, 2014 the FDA's director of the Division of Ophthalmic Devices, ophthalmologist Malvina B. Eydelman, in conclusion to her presentation about the LASIK study results said: "Given the large number of patients undergoing LASIK annually, dissatisfaction and disabling symptoms may occur in a significant number of patients"^[102]

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^ ^a ^b Vesaluoma M, Pérez-Santonja J, Petroll WM, Linna T, Alió J, Tervo T (1 February 2000). "Corneal stromal changes induced by myopic LASIK". Invest. Ophthalmol. Vis. Sci. 41 (2): 369–76. PMID 10670464.
^ "Diffuse Lamellar Keratitis - DLK and Lasik, All-Laser Lasik, Sands of Sahara". Usaeyes.org. 2010-04-12. Retrieved 2011-12-10.
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^ "Intacs for Mild Nearsighted Vision Correction and Keratoconus". Usaeyes.org. 2006-04-08. Retrieved 2011-12-10.
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^ ^a ^b Ruiz-Moreno JM, Alió JL (2003). "Incidence of retinal disease following refractive surgery in 9,239 eyes". J Refract Surg 19 (5): 534–47. PMID 14518742.
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^ Hammer T, Heynemann M, Naumann I, Duncker GI (March 2006). "Correction and induction of high-order aberrations after standard and wavefront-guided LASIK and their influence on the postoperative contrast sensitivity". Klin Monatsbl Augenheilkd (in German) 223 (3): 217–24. doi:10.1055/s-2005-858864. PMID 16552654.
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External links

What is LASIK? — Food and Drug Administration
Laser Eye Surgery — United States National Library of Medicine

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. レーザー屈折矯正手術 laser refractive surgery
2. ドライアイ dry eyes
3. Treatment of dry eye in Sjögren's syndrome treatment of dry eye in sjogrens syndrome
4. 成人における視覚障害：屈折障害と老視 visual impairment in adults refractive disorders and presbyopia
5. コンタクトレンズの概要 overview of contact lenses

English Journal

Induced De Novo Astigmatism After Hyperopic LASIK Versus Myopic LASIK Surgery in Nonastigmatic Eyes.

Karmona L1, Mimouni M, Vainer I, Sela T, Munzer G, Kaiserman I.
Cornea.Cornea.2017 Sep;36(9):1040-1043. doi: 10.1097/ICO.0000000000001253.
PMID 28777775

Incidence of Posterior Vitreous Detachment After Femtosecond LASIK Compared With Microkeratome LASIK.

Osman MH1, Khalil NM, El-Agha MS.
Cornea.Cornea.2017 Sep;36(9):1036-1039. doi: 10.1097/ICO.0000000000001277.
PMID 28708815

Case of Presumed Transient Light-Sensitivity Syndrome After Small-Incision Lenticule Extraction.

Desautels JD1, Moshirfar M, Quist TS, Skanchy DF, Hoopes PC.
Cornea.Cornea.2017 Sep;36(9):1139-1140. doi: 10.1097/ICO.0000000000001240.
PMID 28644232

Japanese Journal

屈折矯正手術術後不適応症候群 (特集眼科医のための心身医学)

Oculista = オクリスタ (30), 52-56, 2015-09
NAID 40020615516

臨床研究 Laser in situ keratomileusis(LASIK)術後多焦点眼内レンズ挿入眼の術後成績

日本眼科学会雑誌 119(9), 613-618, 2015-09
NAID 40020591375

Laser in situ keratomileusis術後の裂孔原性網膜剝離の検討 (特集第68回日本臨床眼科学会講演集(7))

臨床眼科 69(9), 1353-1356, 2015-09
NAID 40020566536

Related Pictures

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★リンクテーブル★

リンク元	「レーザー角膜切削形成術」「生体内レーザー屈折矯正術」「laser in situ keratomileusis」

「レーザー角膜切削形成術」

LASIK
	Intervention
	LASIK surgery using the Star S4 IR™ excimer at US National Naval Medical Center Bethesda
ICD-9-CM	11.71
MeSH	D020731
MedlinePlus	007018

　　[★]

英: laser in situ keratomileusis LASIK
同: レーシック

「生体内レーザー屈折矯正術」

　　[★]

英: laser in situ keratomileusis、LASIK

「laser in situ keratomileusis」

　　[★] レーザー角膜切削形成術 LASIK

[1] κέρατο（角膜）+ σμῑλεύω（彫刻する）+ σις（～すること）

[2] ttp://www.fda.gov/medicaldevices/productsandmedicalprocedures/surgeryandlifesupport/lasik/ucm061366.htm

[3] [リンク切れ] 近視レーザー手術は長期的にも安全

[4] [1]一般社団法人航空医学研究センターによる航空身体検査マニュアル

[5] [2]一般社団法人航空医学研究センターによる航空身体検査マニュアル

[6] レーシック後の合併症

[7] De Paiva CS, Chen Z, Koch DD, et al. (March 2006). “The incidence and risk factors for developing dry eye after myopic LASIK”. Am. J. Ophthalmol. 141 (3): 438–45. doi:10.1016/j.ajo.2005.10.006. PMID 16490488.

[8] ttp://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm061354.htm

[9] [3]消費者庁による2013年12月4日の報道発表資料「レーシック手術を安易に受けることは避け、リスクの説明を十分受けましょう！」（PDF）

[Pop-10] Pop M, Payette Y (January 2004). “Risk factors for night vision complaints after LASIK for myopia”. Ophthalmology 111 (1): 3–10. doi:10.1016/j.ophtha.2003.09.022. PMID 14711706.

[11] "Individual Risk Factors of Halos, Loss of Contrast Sensitivity, Glare and Starbursts after LASIK." operationauge.com

[12] "The most common complications of refractive surgery.". USAEyes.org

[13] Knorz MC (March 2006). “[Complications of refractive excimer laser surgery]” (German). Ophthalmologe 103 (3): 192–8. doi:10.1007/s00347-006-1314-y10.1007/s00347-006-1314-y (inactive 2009-07-10). PMID 16465507.

[14] ttp://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/SurgeryandLifeSupport/LASIK/ucm061354.htm

[15] "Lasik Overcorrection - Unexpected, Unwanted, Desired, and Planned.". USAEyes

[16] "Ghost or double vision after Lasik and similar vision correction surgery.". USAEyes

[17] "Macro-striae and micro-striae complication of Lasik and All-Laser Lasik." USAEyes

[18] "Buttonhole Incomplete Flap in Lasik and All-Laser Lasik". USAEyes

[Mirshahi-19] Mirshahi A, Schöpfer D, Gerhardt D, Terzi E, Kasper T, Kohnen T (February 2006). “Incidence of posterior vitreous detachment after laser in situ keratomileusis”. Graefes Arch. Clin. Exp. Ophthalmol. 244 (2): 149–53. doi:10.1007/s00417-005-0002-y10.1007/s00417-005-0002-y (inactive 2009-07-10). PMID 16044328.

[Arevalo-20] Arevalo JF, Mendoza AJ, Velez-Vazquez W, et al. (July 2005). “Full-thickness macular hole after LASIK for the correction of myopia”. Ophthalmology 112 (7): 1207–12. doi:10.1016/j.ophtha.2005.01.046. PMID 15921746.

[21] 屈折矯正手術合併症の実態調査報告

[22] 日本眼科学会：レーシック術後の角膜感染症多発事件について

[23] 読売新聞

[24] 山本太一; 内橋寿明; 小泉大士 (2010年12月7日). “レーシック手術：「銀座眼科」元院長を逮捕実態の解明へ”. 毎日新聞 2010年12月7日閲覧。

[25] 例えば2012年10月現在、品川近視クリニック（千代田区ほか）では7.5万円から、新宿近視クリニック（新宿区ほか）は8万円から、1996年に日本で初めてレーシックを実施した錦糸眼科（港区ほか）でも8万円からレーシック手術を実施している。吉野眼科クリニック（台東区）では43万円から。大規模な病院では慶應義塾大学病院（新宿区）は231，000円から。医療機関によっては別途検査費用が必要な場合がある。

[26] 公正取引委員会 - 広報
時事通信「視力回復手術大手に警告＝「限定割引」実態なし－公取委」2009年8月6日

[27] J-CASTニュース

[28] 神戸新聞

[29] レーシック手術集団感染事件で銀座眼科医師に実刑判決

[30] レーシック被害　提訴へ

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[4] Sanders, Donald R.; John A. (May 2003). "Comparison of Implantable Contact Lens and Laser Assisted In Situ Keratomileusis for Moderate to High Myopia". Cornea 22 (4): 324–331. doi:10.1097/00003226-200305000-00009. PMID 12792475. Retrieved June 22, 2012.

[5] Lindfield, Dan; Poole, Tom. "Nd:YAG Treatment of Epithelial Ingrowth". Cataract and Refractive Surgery Today. Retrieved 12 September 2013.

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[8] "Prize for the Industrial Application of Physics Winner - American Institute of Physics". Aip.org. Retrieved 2011-12-10.

[9] Cotliar AM, Schubert HD, Mandel ER, Trokel SL (Feb 1985). "Excimer laser radial keratotomy". Ophthalmology 92 (2): 206–8. doi:10.1016/s0161-6420(85)34052-6.

[10] [1] VISX USA Technology (Last accessed 4th June, 2012)

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[17] [4] IntraCOR for presbyopia.

[18] [5] IntraCOR for myopia

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[20] "Lasik and Contacts". Usaeyes.org. 2010-04-12. Retrieved 2011-12-10.

[21] "Age Issues For Lasik, All-Laser Lasik, PRK, LASEK, Epi-Lasik, CK, P-IOL, RLE, etc". Usaeyes.org. 2010-04-12. Retrieved 2011-12-10.

[22] ttp://www.tlcvision.com/learn-about-laser-eye-surgery/am-i-a-lasik-surgery-candidate/

[23] "All-Laser Lasik - iLasik - IntraLasik". Usaeyes.org. 2010-04-12. Retrieved 2011-12-10.

[24] "Patent: ultraviolet solid state laser". Freepatentsonline.com. Retrieved 2011-12-10.

[dta-25] Dimitri T. Azar , Damien Gatinel (2007). Refractive surgery (2nd ed. ed.). Philadelphia: Mosby Elsevier. ISBN 9780323035996.

[26] "IROC . Institut für Refraktive und Ophthalmo-Chirurgie". Iroc.ch. 2005-04-15. Retrieved 2011-12-10. ^{[dead link]}

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[Walsh2000-28] Walsh MJ. Wavefront is showing signs of success, but can it do it alone? Ocular Surgery News. September 1, 2000, page 41.

[EW2000-29] EW Dialogue: the future of wavefront refraction as a diagnostic tool. "EyeWorld". May 2000, pages 64 and 65.

[Alpins2002Fail-30] Alpins, NA (2002). "Wavefront technology: A new advance that fails to answer old questions on corneal vs. Refractive astigmatism correction". Journal of refractive surgery 18 (6): 737–9. PMID 12458868.

[Alpins2008-31] Alpins, N; Stamatelatos, G (2008). "Clinical outcomes of laser in situ keratomileusis using combined topography and refractive wavefront treatments for myopic astigmatism". Journal of cataract and refractive surgery 34 (8): 1250–9. doi:10.1016/j.jcrs.2008.03.028. PMID 18655973.

[Alpins2007-32] Alpins, N; Stamatelatos, G (2007). "Customized photoastigmatic refractive keratectomy using combined topographic and refractive data for myopia and astigmatism in eyes with forme fruste and mild keratoconus". Journal of cataract and refractive surgery 33 (4): 591–602. doi:10.1016/j.jcrs.2006.12.014. PMID 17397730.

[AAOGuide-33] American Academy of Ophthalmology. "Refractive Laser Surgery: An In-Depth Look at LASIK and Brief Overview of PRK, Epi-LASIK, and LASEK: A Science Writer’s Guide". Accessed January 29, 2012.

[AMO2012-34] Abbott Medical Optics website. "WaveScan WaveFront System". Accessed August 15, 2012.

[Emory-35] Emory Healthcare website. "Wavefront technology". Accessed August 15, 2012.

[CroesAAV-36] Croes K. AllAboutVision website. "Custom LASIK or wavefront LASIK: individualized vision correction". Accessed August 15, 2012.

[37] Liz Segre. "Cost of LASIK eye surgery and other corrective procedures". allaboutvision.com. Retrieved 2012-08-15.

[38] Fares, Usama (2011). "Efficacy, predictability, and safety of wavefront-guided refractive laser treatment: Metaanalysis". Journal of Cataract & Refractive Surgery 37 (8): 1465–1475. doi:10.1016/j.jcrs.2011.02.029. PMID 21782089.

[39] Sue Campbell. "Air Force aims for ‘weapons-grade’ vision". Af.mil. Archived from the original on 2012-07-28. Retrieved 2011-12-10.

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[Bailey-43] Bailey MD, Mitchell GL, Dhaliwal DK, Boxer Wachler BS, Zadnik K (July 2003). "Patient satisfaction and visual symptoms after laser in situ keratomileusis". Ophthalmology 110 (7): 1371–8. doi:10.1016/S0161-6420(03)00455-X. PMID 12867394.

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LASIK
Intervention
LASIK surgery using the Star S4 IR™ excimer at US National Naval Medical Center Bethesda
ICD-9-CM	11.71
MeSH	D020731
MedlinePlus	007018

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LASIK