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What is LASIK?

The eye and vision errors

The parts of the eye. Indicated are the conjunctiva, sclera, choroid, optic nerve, retina, chamber angle, lens, cilary body, vitreous humor, aqueous humor, iris, pupil, cornea. The cornea is a part of the eye that helps focus light to create an image on the retina. It works in much the same way that the lens of a camera focuses light to create an image on film. The bending and focusing of light is also known as refraction. Usually the shape of the cornea and the eye are not perfect and the image on the retina is out-of-focus (blurred) or distorted. These imperfections in the focusing power of the eye are called refractive errors. There are three primary types of refractive errors: myopia, hyperopia and astigmatism. Persons with myopia, or nearsightedness, have more difficulty seeing distant objects as clearly as near objects.  Persons with hyperopia, or farsightedness,  have more difficulty seeing near objects as clearly as distant objects.  Astigmatism is a distortion of the image on the retina caused by irregularities in the cornea or lens of the eye. Combinations of myopia and astigmatism or hyperopia and astigmatism are common. Glasses or contact lenses are designed to compensate for the eye's imperfections. Surgical procedures aimed at improving the focusing power of the eye are called refractive surgery. In LASIK surgery, precise and controlled removal of corneal tissue by a special laser reshapes the cornea changing its focusing power.

(See the animation of the LASIK procedure and what should I expect before, during, and after surgery.)

Other types of refractive surgery

Radial Keratotomy or RK and Photorefractive Keratectomy or PRK are other refractive surgeries used to reshape the cornea. In RK, a very sharp knife is used to cut slits in the cornea changing its shape. PRK was the first surgical procedure developed to reshape the cornea, by sculpting, using a laser. Later, LASIK was developed. The same type of laser is used for LASIK and PRK. Often the exact same laser is used for the two types of surgery. The major difference between the two surgeries is the way that the stroma, the middle layer of the cornea, is exposed before it is vaporized with the laser. In PRK, the top layer of the cornea, called the epithelium, is scraped away to expose the stromal layer underneath. In LASIK, a flap is cut in the stromal layer and the flap is folded back.

Another type of refractive surgery is thermokeratoplasty in which heat is used to reshape the cornea. The source of the heat can be a laser, but it is a different kind of laser than is used for LASIK and PRK. Other refractive devices include corneal ring segments that are inserted into the stroma and special contact lenses that temporarily reshape the cornea (orthokeratology).

Anatomy, Physiology & Pathology of the Human Eye

Snellen Acuity ChartVisual acuity often is referred to as “Snellen” acuity.  The chart and the letters are named for a 19th-century Dutch ophthalmologist Hermann Snellen (1834–1908) who created them as a test of visual acuity.

One’s visual acuity is an indication of the clarity or clearness of one’s vision.  It is a measurement of how well a person sees.  The word “acuity” comes from the Latin acuitas, which means sharpness.

20/20 or 6/6 visual acuity

The reason that the number “20” is used in visual acuity measurements is because, in the United States, the standard length of an eye exam room (that is, the distance from the patient to the acuity chart) is about 20 feet.

In Great Britain, where meters are used instead of feet, a typical eye exam room is about 6 meters long.  Six meters is 19.685 feet, which is close to 20 feet, and usually is considered to be “close enough” to optical infinity.  Therefore, instead of using 20/20 for normal vision, a notation of 6/6 is used in Britain.

Someone with 20/20 or 6/6 vision (visual acuity) is just able to decipher a letter that subtends a visual angle of 5 minutes of arc (written 5') at the eye.  (5' of arc is 5/60 of a degree, because there are 60' of arc in 1 degree.)  What this means is that if you draw a line from the top of a 20/20 letter to the eye and another line from the bottom of the letter to the eye, the size of the angle at the intersection of these two lines at the eye is 5' of arc.

Also, the individual parts of the letter subtend a visual angle of 1' of arc at the eye.  It does not matter how far away something is from the eye; if it subtends an angle of 5' of arc at the eye, then a person with 20/20 visual acuity will just be able to distinguish what it is.

A person with 20/20 vision could stand 30 feet away from a test chart and just decipher a 20/30 letter on the chart, since at that distance a 20/30 letter would subtend an angle of 5' of arc at the person’s eye.  That same person could stand 80 feet away from the chart and be able to decipher a 20/80 letter, or 200 feet away to be able to decipher a 20/200 letter.

20/20 compared with other acuities

Someone with 20/20 visual acuity does not have “perfect” vision, since it is quite possible to see better than 20/20.  The less the bottom number in the visual acuity ratio, the better the acuity; and the greater the bottom number, the worse the acuity.  Therefore, 20/15 acuity is better than 20/20 acuity, and 20/30 acuity is worse than 20/20 acuity.  Also, 20/15 acuity is equivalent to 6/4.5 acuity, while 20/30 acuity is the same as 6/9 acuity.

As noted before, although 20/20 is "normal" visual acuity for most people, it is possible (and, in fact, very common) to be able to see better than that.  For instance, many people have 20/15 visual acuity.  A person with 20/15 acuity can stand 20 feet away from an object and see it as well as a person with 20/20 acuity moving up to 15 feet away from the object to view it.

If that is true, let’s take a person with 20/15 vision looking at an object from 100 feet away.  Where would a person with 20/20 vision need to stand to see the object just as well?  The answer is 75 feet away from the object.  (That is, 15/20 × 100 feet = 75 feet.)

It even is possible, although not too common, for someone to have 20/10 visual acuity.  Let’s say a person with 20/20 vision can just detect a ship which is 25 miles away out on the ocean.  A person with 20/10 acuity could be 50 miles away from the ship and still be able to just detect it.  That is, if a person with 20/10 acuity can just tell what an object is, a person with 20/20 vision would need to stand half that distance away to be able to see what it is.

You can use the same rationale when considering someone with less than 20/20 acuity.  Consider a person with 20/40 visual acuity (which is what someone needs in most states to acquire a driver’s license).  If a person with 20/20 acuity can just read a sign which is 60 feet down the road, the person with 20/40 acuity would have to be 30 feet away to read the same sign.  Also, a person with 20/15 acuity could be 80 feet away, and a person with 20/10 acuity 120 feet away, to read the same sign.

Compared to a person with 20/20 vision reading a sign 30 feet away, how far do people with various visual acuities need to stand away from the sign to be able to read it as well as the person with 20/20 acuity?  See the following chart:

Visual Acuity   Distance Away
From Object
20/10     60 feet
20/15     40 feet
(“normal” vision)
    30 feet
20/25     24 feet
20/30     20 feet
20/40     15 feet
20/50     12 feet
20/60     10 feet
20/80     7½ feet
20/100     6 feet
20/200     3 feet
20/400     1½ feet

near visual acuity

Besides a person’s visual acuity being tested at a far distance, one’s near acuity also can be tested.  Testing typically is done by holding a nearpoint Snellen acuity card at 40 centimeters (about 16 inches).  Just as on a far acuity chart, a 20/20 letter on a near chart subtends a visual angle at the eye of 5' of arc (5 minutes of arc, or 1/12 of a degree).

Without a lens correction, a myopic (nearsighted) person generally will have better visual acuity at near than at far, while a hyperopic (farsighted) person generally will have better acuity at far than at near.  Until the early to mid-forties, a person with 20/20 distance acuity usually also has 20/20 acuity at near.  However, once presbyopia sets in, one’s uncorrected near visual acuity decreases, creating the need for reading glasses or bifocals.

size of a 20/20 letter

When an eye doctor sets up an examination room, care should be taken in calibrating the size of the letters on the visual acuity chart (which usually is projected onto a highly reflective screen). 

The correct size of a 20/20 letter can be calculated using the diagram below, where

  • the letter’s visual angle subtended at the eye is 5' of arc (5 minutes of arc), one-half of which is 2.5' of arc,
  • d is the distance (or virtual distance, if using a mirror), along the line of sight, from the eye to the chart in feet, and
  • h is one-half the height of the 20/20 letter in millimeters.
As an example, let’s say that the viewing distance, d, is 20 feet.


Since a right angle is formed by the line of sight and the plane of the acuity chart, then simple trigonometry can be used:

  1. 2.5' of arc ÷ 60 = 0.04167°
  2. tangent 0.04167° = h ÷ d = h ÷ 20 feet
  3. 0.0007272 = h ÷ 6,096 millimeters
  4. h = 0.0007272 × 6,096 millimeters
  5. h = 4.433 millimeters
  6. 2h = total height of a 20/20 letter at 20 feet = 8.87 millimeters


In general, to find the size of a 20/20 letter (in millimeters), multiply .4433 by d (where d is the viewing distance in feet).  That is:

.4433 mm/ft × d ft = height of 20/20 letter in mm.

optical infinity

When an eye is looking at a far away distance (such as at the horizon or at the moon or at a star).  The rays of light entering the eye are virtually parallel, and the crystalline lens of the eye is thin and relaxed because, essentially, there is zero accommodation.

When an optometrist or an ophthalmologist examines and performs a refraction on someone’s eyes, it is optimal for the object being viewed (presumably an acuity chart) to be as far away as possible from the patient.  This is so that the incoming rays of light are as close to parallel as possible, and the amount of accommodation (increased curvature) of the crystalline lens of the eye will be negligible.

Due to space limitations, though, this viewing distance (= “d” in the diagram above) can be only a few meters away from the patient in an examination room.  Therefore, the goal of an eye doctor should be to position the eye chart at “optical infinity,” or the least distance at which there is no significant accommodation by the crystalline lenses of a patient’s eyes.

Traditionally, optical infinity has been accepted to be 20 feet or, approximately, 6 meters.  However, at this distance, there is an accommodative demand on the eye of about 1/6 D (one-sixth of a diopter), which can be significant.  For many people (such as myself), an accommodative fluctuation during an eye examination of more than 1/8 D can result in a variable endpoint in measuring a person’s refractive error, and 1/6 D is even greater than 1/8 D.

As a result, it is recommended that the viewing distance (d) in an examination room should be long enough to create no more than a 1/8 D accommodative demand on any patient’s eyes.  I maintain, then, that optical infinity, for purposes of examining the refractive error of the human eye, is at least 8 meters or 26¼ feet, rather than merely 6 meters or 20 feet.

If lack of space is a problem, front-surface reflective mirrors usually can be utilized to increase the virtual viewing distance in an exam room.  From the previous section, it can be seen that the height of a 20/20 letter on an acuity chart, located at a viewing distance from a patient’s eyes of d = 26¼ feet, is as follows:

.4433 millimeters/foot × 26¼ feet = 11.63 millimeters.


The human eye is the organ which gives us the sense of sight, allowing us to observe and learn more about the surrounding world than we do with any of the other four senses.  We use our eyes in almost every activity we perform, whether reading, working, watching television, writing a letter, driving a car, and in countless other ways.  Most people probably would agree that sight is the sense they value more than all the rest.

The eye allows us to see and interpret the shapes, colors, and dimensions of objects in the world by processing the light they reflect or emit.  The eye is able to detect bright light or dim light, but it cannot sense objects when light is absent.

process of vision

Light waves from an object (such as a tree) enter the eye first through the cornea, the clear dome at the front of the eye.  The light then progresses through the pupil, the circular opening in the center of the colored iris.

Fluctuations in incoming light change the size of the eye’s pupil.  When the light entering the eye is bright enough, the pupil will constrict (get smaller), due to the pupillary light response.

Initially, the light waves are bent or converged first by the cornea, and then further by the