Twenty years after the first laser eye operation, here is a
look at the history of the procedure
In November 1989 a junior ophthalmic surgeon at St Thomas'
Hospital in London fired a laser into the eye of a blind man,
inaugurating one of the greatest innovations in his field since the
invention of spectacles. The laser had been designed to cut
microchips and the surgeon, David Gartry, was performing the
operation as part of his PhD research. "I thought it was an
interesting project," he said. "I would get my PhD and move
on."
Instead, this first clinical trial of laser eye surgery in the
UK paved the way for a revolution in optometry. There would be a
huge fuss; stories of people left half blind, eyes weeping, no
longer able to endure bright lights. The operation seemed
horrifying: submit to this butchery just to be rid of the bother of
wearing spectacles? Critics were incredulous.
But quietly, over the past two decades, it has become one of the
most commonly performed surgeries. Every year in Britain 100,000
people lie on a couch to have their eyes cut open and their corneas
resculpted with a laser. More than 20 million people have been
treated worldwide and Professor Gartry himself has performed 14,000
operations.
The strange tale of how all this came about begins six years
before Gartry's trials. In 1983 Dr Stephen Trokel, a New York eye
surgeon, was firing lasers into eyes taken from the cadavers of
cows, seeking a more precise means of refractive surgery -
reshaping of the cornea to correct myopia (short sight). At the
time surgeons used a diamond scalpel or a razor blade.
A computer scientist suggested that he should try the excimer
laser, developed to carve circuit boards. "Others had not worked,"
Dr Trokel says, but this one "cooked away the material with minimal
radial effects" and the cuts left no scars.
In New Orleans a newly qualified surgeon, Dr Margeurite
McDonald, began testing the procedure on monkeys. Then a Louisiana
housewife who was about to have cancer surgery offered her own eye.
"She said, 'I'm going to lose it anyway, you may as well do
something with it'," says Dr McDonald. "I said, 'We've got this
laser . . .' "
The test was a success and sped up the process of gaining
approval for human testing, which was given sooner in Europe than
in the US. In London, under the supervision of the leading eye
surgeon John Marshall, Gartry tested 16 people in late 1989.
When approval came in America, Dr McDonald took ten volunteers
who were blind in one eye and treated each as though he or she had
degrees of myopia. "We offered them no money," she says. "In my
opinion, some did it to advance science and others did it for the
attention. Doctors and scientists flew from all over the world to
see them and they became like rock stars. One even changed his name
to Excimer. One or two started dating doctors whom they met on
their way. Later, when excimer became widely known, they felt like
forgotten movie stars and became depressed."
Among the ten was Carolyn Henry, a young African-American who
had lost her sight in one eye after surgery for a brain tumour.
Bright xenon lights shone directly into her eye elicited no
reaction, and specialists pronounced the eye blind. Three months
after Dr McDonald's trials, Henry had some news: she could see
perfectly. It turned out that she had been suffering from
"hysterical blindness" brought on by the trauma of surgery and,
quite by chance, had been given exactly the right corrective
treatment for her slight myopia.
"My stomach turned," says Dr McDonald. "On the one hand it was a
breakthrough, on the other a huge professional setback." Critics
and the regulatory authorities were incredulous. In
the American Journal of Ophthalmology a famous
surgeon accused her of charging ahead recklessly to secure a place
in history.
The research was still thought frivolous. "People kept saying:
'Why aren't you trying to cure blindness?' " says Dr McDonald. It
was privately funded, and her backers could not secure permission
to use a state research clinic. Instead, trials took place in a
trailer outside the ophthalmology department at Louisiana State
University, next to a largerubbish compactor.
"It didn't smell great and the whole area shook like crazy when
the compactor was on," she says. "Occasionally it would start
without warning and the trailer shook. But we found that the people
treated while it was on did better. The slight vibration seemed to
act like polishing." A slight wobble was later built into the
technology.
When clinical trials proved successful, companies raced to bring
the technique to the high street. Dr Trokel watched with unease.
"This has been a big money-maker for a lot of people," he says,
noting that in Britain there was "a rather energetic adoption of
the technology and some rather unhappy patients in the early
years".
Julian Stevens, a surgeon at Moorfields Eye Hospital, recalls
that in the early days the lasers were quite crude and surgeons
were still learning the technique. "To some extent it was burn and
learn," he says.
Patients complained of dry eyes, blurred vision, glare at night
and, in some extreme cases, loss of sight. There are still concerns
that the procedure is sometimes mis-sold. This
year, Which?magazine claimed that high street clinics
underplayed the risks and understated the price of surgery in
advertising. When a researcher from this newspaper called three
large clinics in September (Optical Express, Optimax and Ultralase)
he found it difficult to obtain a comparable price from any of
them.
But even critics allow that safety has improved greatly. A
voluntary examination and assessment process has been instituted by
the Royal College of Ophthalmologists. Tracking technology helps to
guide the laser and Wavefront, the system used to correct the
Hubble telescope, allows surgeons to map the topography of the eye.
Professional sportsmen, particularly golfers, have had the
procedure to improve their performance, as have members of the
Special Forces.
At Queensland University, Professor Nathan Efron, a former
critic of laser eye surgery, cautions that the refractive surgery
technique "severs fine nerves in the cornea that may take up to
five years to recover fully" but concedes that overall "there is
about a 1 in 50 risk of complications leaving you with more vision
problems than you started with, so the odds are in your
favour".
Some of the fullest assessments of the surgery have been made by
the US military, thanks in part to the work of Captain Steven
Schallhorn, a fighter pilot and instructor turned ophthalmic
surgeon. As a pilot he wrote papers on visual search in air combat;
in his second career he compiled research on laser eye surgery for
the military. Young men with myopia can now have the surgery and
learn to land fighter jets on aircraft carriers, while older pilots
can extend their flying time.
Captain Schallhorn then carried out studies for Nasa.
"Astronauts were having problems with contact lenses," he says (in
space, glasses do not stay on and eye drops tend to float away).
"In September 2007 the surgery was approved by the board."
Dr Trokel regards the sum of these achievements as a huge
advance in a field that had not progressed much for some nine
centuries, since glasses arrived to save the myopic from their
blurred world.
Some still worry that we cannot be sure of the longevity of a
treatment that has been used on people for only 20 years. Dr
McDonald dismisses their concerns. "My monkeys are still doing
fine," she says.
RELATED NEWS: