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In this study, published online in June 2010 in the Journal of Refrac- tive Surgery, Dr. Kymionis investi- gated only a single case report of epithelium-only flap creation. He also mentioned that the femtosec- ond has a "high incidence of repro- ducibility and stability," opening a "new chapter in ophthalmology." Still, potential complications deserve understanding. A case of torn flaps Dr. Kymionis performed LASIK on a 28-year-old man with a corrected distance visual acuity of 20/20 in both eyes but who only had count- ing fingers vision uncorrected at dis- tance in both eyes. Manifest refraction was –6.75 – 0.75 x 5 in the right eye and –7.00 – 0.50 x 180 in the left eye. "Taking into consideration corneal thickness and refractive error, the surgeon decided to pro- ceed with LASIK using the IntraLase iFS System [Abbott Medical Optics, Santa Ana, Calif.]," Dr. Kymionis re- poted. "A corneal flap with a supe- rior hinge was created using the IntraLase iFS laser (150 kHz). The laser parameters in both eyes were: attempted flap thickness 100 μm, flap diameter 8.25 mm, spot/line separation 6 μm/6 μm, bed energy of 1.10 μJ, superior hinge position with hinge angle of 50°, and side-cut energy of 1.05 μJ with side-cut angle of 70°. Pocket was enabled in both eyes at 240 μm. Flap creation was performed uneventfully; however, the created flaps were much thinner than expected in both eyes." The flaps were torn with ease during lifting, and the procedure was turned into a PRK. Mitomycin C (MMC) and a bandage contact lens facilitated that procedure. After a course of antibiotics, steroid drops and artificial tears, the patient achieved 20/25 in the right eye and 20/20 in the left eye with no corneal haze at 3 months post-op. Dr. Kymionis hypothesized that epithelial flap creation may have oc- curred as a result of inadequate corneal applanation related to the glass cone, although he could not confirm this. "A similar case of thin flap cre- ation including stroma suggests … that femtosecond laser flap thick- ness creation is correlated to cone glass thickness, and thicker glass cones may produce thinner than usual flaps," Dr. Kymionis reported. "In our case, we did not measure glass cone thickness and therefore we cannot confirm or exclude this possibility." Dr. Kymionis added that an ep- ithelium-only flap can be managed by conversion to PRK but advised using MMC when doing so. "The use of MMC was necessary to avoid severe postoperative haze formation due to the high at- tempted myopic correction," Dr. Kymionis reported. Francis S. Mah, M.D., co-med- ical director, Charles T. Campbell Ophthalmic Microbiology Labora- tory, University of Pittsburgh School of Medicine, Pittsburgh, wasn't sur- prised that femtosecond lasers could have such hiccups from time to time. "There isn't anything that is 100% foolproof," Dr. Mah said. In order to avoid femtosecond problems, Dr. Mah said it's impor- tant to first advise patients of these issues. Further, be vigilant, he said. "Make sure you're not going through the same motions you've gone through a thousand times be- fore," Dr. Mah said. "Be meticulous." LASIK is highly effective and safe, Dr. Mah said. Just consistently be alert, he reiterated. EW Editors' note: Dr. Kymionis reported no financial interests related to this study. Dr. Mah has no financial interests re- lated to his comments. Contact information Kymionis: kymionis@med.uoc.gr Mah: 412-647-2211, mahfs@upmc.edu February 2011 2 9 7 5 B r o t h e r B l v d B a r t l e t t T N 3 8 1 3 3 8 8 8 . 9 0 5 . 7 7 7 0 o d y s s e y m e d . c o m © 2010 Odyssey Medical, Inc. All rights reser ved. †Market Scope Dr y Eye Report (June 2003) ‡McCabe, C. (2009). Punctal occlusion reduces dr y eye symptoms and improves vision. Review of Ophthalmolog y, 16(11), 55-58 *Some conditions apply; call for details. C A L L F O R A F R E E I N T R O D U C T O R Y T R I A L D E S I G N E D L I K E N O O T H E R . 92% # 1 ‡ AMONG ALL COMPETITORS † IN THE DRY EYE MARKET 92 % 0 O 1 0 © 2 u d e r . d e v r e s e s r t h g i l r l . A c n , I l a c i d e y M e s s y d 0 O † t ( r o p e e R y y E r e D p o c t S e k r a M ( 6 1 , y g o l o m l a h t h p f O w o e i v e R . n o i s i s v e v o r p m i d n s a m o t p m y s e y e y r d s e c u ) 3 0 0 e 2 n u J t ( ‡ n o i s u l c c l o a t c n u . P 9) 0 0 2 . ( , C e b a C c M . s l i a t e d r o l f l a ; c y l p p a s n o i t i d n o c e m o S * 8 5 - 5 5 , ) 1 1 (

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