LASIK-Basics and

Microkeratome Theory

Dr. Rupal Shah

LASIK India,
LASIK Information India,
Blade Free LASIK India
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LASIK
■ “Laser In Situ Keratameleusis”
■ Followed from the procedure known as
ALK or MLK
■ Basic theory is decades old

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Automated Lamellar
Keratomeleusis(ALK)
■ Consists of two incisions
■ First, a slice of cornea 160 microns
thick and a diameter of 8 mm is
removed
■ Second, a thin slice of cornea
corresponding to the refractive error is
removed
■ The first slice is replaced back
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Problems with ALK
■ There are limits to the accuracy of a
mechanical instrument
■ The second slice could never be
accurate or precise enough to compete
with other forms of refractive surgery

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Excimer Laser
■ Can ablate tissue with great accuracy
■ Since the first cut is not critical, that is
done with the microkeratome
■ The refractive lenticle is removed with
the excimer laser
■ Refractive change can occur with the
excimer laser without disturbing the
epithelium
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LASIK-Technique
■ The microkeratome makes a horizontal
cut on the cornea
■ Slice is not excised completely
■ A tongue like flap is removed to one
side
■ The laser is applied in the usual manner
■ The flap is replaced and sticks in place
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Horizontal-First Cut

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Horizontal-First Cut

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Horizontal-First Cut

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Flap is lifted to a side

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Laser is applied under the flap

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Flap is replaced

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Microkeratomes-History
■ Basic Theory was evolved by Jose
Barraquer decades ago
■ First Used for ALK/MLK
■ In the 90’s, modified for use in the
procedure that has come to be known
as LASIK

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 Microkeratomes
■ Used for making thin lamellar slices of
the cornea

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Microkeratomes Used in LASIK
■ Capable of creating thin lamellar slices
of the cornea of fixed or adjustable
depth
■ The Slice interface should be smooth,
and free of spherical aberrations
■ The slice should have an appropriate
diameter along with an appropriate
hinge size.
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Principle of Microkeratomes
■ Work on the principle of a carpenter’s
plane or ‘randho’
■ The blade is at a fixed distance from an
applanation plate, which determines the
thicknessBlade
of the slice

Plane
Blade to Plate Gap

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Problem of applanation
■ The cornea is a spherical object, and
unlike wood, will not be in contact with
the applanation plate at all or any points
along the blade motion
■ Therefore, very high suction is applied
all around the cornea, to ensure high
IOP, and thereby pressure of the
cornea against the applanation plate
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■ The suction ring will induce a rise in
intraocular pressure.
■ An adequate vacuum will induce
pressure greater than 65mm Hg, which
is the recommended minimum
requirement.
■ Insufficient vacuum will not provide the
optimum positioning of the eye within
the suction ring. If this occurs, an
irregular flap may
New be produced.
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First Component of a
Microkeratome
■ A Suction ring and a vacuum pump, to
ensure adequate applanation of the
cornea by the applanation plate
■ If the cornea is not applanated
perfectly, we would get thin flaps, no
flap or a small free lamella of the
Plate
cornea Blade

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■ 8.5 mm ring
– Steep corneas (K > 45), thinner flaps
– Small diameter corneas (prevent dissection of blood
vessels)
■ 8.8 mm ring
■ 9.0 mm ring
– Standard myopic ring
■ 9.5 mm ring
■ 10.0 mm ring
– All hyperopes and flat corneas (K < 40)
– Extremely steep corneas (K > 47)
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■ Ring selection closely corresponds to the
desired flap diameter
– Slightly larger with steeper K’s
– Slightly smaller with flatter K’s
180 EYES

Ring/K’s <40 >40<44 >44<46 >46

8.5 N/A 8.25 9.3 9.0
9.0 N/A 9.2 9.37 9.37
10.0 9.0 10.2 10.2 9.8
Final Averages – Flap Diameter (mm)

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Second Component
■ A means to arrive at a conclusion
whether there is sufficient applanation
or not
■ Indirect Way: Through an applanation
tonometer, measuring IOP
■ Direct Way: Through a transparent
applanation plate

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■ The applanators are used to verify
the cut diameter prior to flap
creation.

■ The applanator does not replace,

or function as a tonometer.
• Diameter check vs.
pressure check

■ IOP measurement is
recommended for every eye prior
to flap creation
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Applanation of the Cornea

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Flap Interface Should be Smooth
■ An ordinary knife would lead to lot of
scarring on the cornea
■ A special blade is used which oscillates
at a high speed to and fro in the
direction orthogonal to the direction of
forward motion
■ Higher the oscillation speed, the
smoother is the cut
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Oscillation of the blade
■ A rotating shaft with an eccentric tip is
used. The shaft is rotated by a turbine
motor, either gas driven (faster
oscillation) or electrically driven

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Third Component
■ A means of forward translation of the
blade, along with oscillation in an
orthogonal direction
■ Forward Motion should be smooth,
uniform and independent of load
■ Can be done by hand (manual
machines), a cable drive or gears

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■ BLADE SPEED (12,000 rpm)
■ BLADE ANGLE AND SHARPNESS (25 degrees)
■ SPEED OF TRANSITION ACROSS THE CORNEA
(4.0 mm/sec)
■ DISTANCE BETWEEN THE BLADE AND THE
PLATE
■ IOP (>65mmHg)
■ PRESSURE DURING TRANSITION
■ NASAL DECENTERING (0.5mm)

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■ Pressure exerted by the surgeons hands on the
instrument during the surgery could effect the
outcome of the procedure.

– Too much downward pressure will create

a thicker flap.
– Not enough downward pressure, a thin
flap or loss of suction may occur.

■ The weight of the keratome has been adapted to the

speed of the keratome head across the cornea.
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Cable Drives for rotational and
axial motion

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Fourth Component
■ The thickness of the flap is determined
by the blade to plate gap
■ This gap can be varied by physically
increasing the gap, or by using different
thickness applanation plates

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■ Stainless Steel Construction

■ Available in multiple depths:

– 130 µm
– Thin corneas (500u – 530u), high myopes

– 160 µm
– Moderate corneas (530u – 560u)

– 180 µm
– All thick corneas (>560 µm)
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Four Essential Components
■ Suction ring and Vacuum pump
■ Applanation plate with means of
checking applanation
■ A means of oscillating the blade at high
speed and a mechanism for forward
translation of the blade
■ An adjustable plate to blade gap
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Fully assembled, no on eye assembly required

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 Blade Change
Vacuum Level
Test
Vacuum Adjust
Battery
Indicator

On/Off
Pedal Connect
Handpiece
Vacuum Port Connect

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Other Microkeratomes
■ Suction Ring is first applied on the eye.
■ The Handpiece is then placed later

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■ Your success is dependent on close
attention to detailed:
» assembly
» operation
» maintenance
■ The device is a precisely manufactured
instrument designed to cut precise
corneal lenticules. Damage to any part
of the instrument may lead to undesired
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■ Always follow the recommended
cleaning regimen

■ Failure to use the proper cleaning

technique or cleaning agents may:

» Damage the components

» Lead to undesired clinical
outcomes
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Laser Microkeratomes
■ Intralase, Femtec 20/20
■ All laser procedure
■ Uses Photodisruption

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 Thank You

Rotational Cable
App.Plate
Axial Cable
Hinge Stop

Blade Suction Ring

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