EyeWorld Asia-Pacific June 2011 Issue

22 June 2011 EW REFRACTIVE Considering femtosecond flap complications by Maxine Lipner Senior EyeWorld Contributing Editor Infrequent intraoperative issues found I ntraoperative complications of flap creation with the IntraLase (Abbott Medical Optics, Santa Ana, Calif., USA) are rare, occurring in just .37% of cases, according to James A. Davison, MD, adjunct associate clinical professor, University of Utah, Salt Lake City, Utah, USA. In the November 2010 issue of the Journal of Refractive Surgery , investigators focused on complications that occurred with the femtosecond laser during the course of 3,009 consecutive LASIK surgeries. Dr. Davison was one of the early users of the IntraLase. “The decision-making process in 2002 was kind of radical,” he An example of the IntraLase procedure Source: Perry S. Binder, MD Views from Asia-Pacific Cordelia CHAN, MBBS(S’pore), FRCS(Ed), MMed(Ophth), FAMS Senior Consultant, Cornea & External Eye Disease and Refractive Surgery Service, Singapore National Eye Centre 11 Third Hospital Avenue, Singapore 168751 Tel. no. +65-62277255 cordelia_chan@snec.com.sg CHANGING MINDSETS IN LASIK: FROM THE MICROKERATOME TO THE FEMTOSECOND LASER FOR FLAP CREATION I was a comfortable microkeratome user for LASIK for many years, starting first with the Hansatome and then the Zyoptix XP microkeratome. Visual outcomes were good, complication rates were low, patients were happy, and so LASIK became a routine, hassle-free procedure in my practice. Thus, when femtosecond flap creation arrived, there was an initial reluctance on my part to switch to this new platform. However, after taking the first steps in making that transition, I have not looked back. There is no room for error in LASIK. LASIK involves surgery on an otherwise normal eye, and on patients with high expectations for good vision. Flap complications like decentered flaps, partial flaps, free caps and button holes are uncommon complications seen with the microkeratome, but when they do occur, the consequences can be devastating, and a nightmare for both the patient and the surgeon. Femtosecond laser flap creation greatly reduces the incidence of these flap-related complications, and in my opinion, this is reason enough to make the transition. In the article “Considering femtosecond flap complications”, Dr. James A. Davison saw femtosecond technology as “an excellent addendum in forestalling LASIK complications”, and I could not agree more. In addition to avoiding disastrous intraoperative complications and providing better flap stability, another important advantage of the femtosecond laser over the microkeratome is better flap thickness predictability. Being able to attain the desired flap thickness more accurately and avoiding thicker-than-intended flaps is crucial in our fight against post-LASIK ectasia. At the Singapore National Eye Centre (SNEC), we have two femtosecond platforms: The IntraLase 60kHz and the VisuMax (Carl Zeiss Meditec, Dublin, Calif., USA/ Jena, Germany) 500kHz systems. Both platforms have excellent safety and efficacy profiles. These days, in SNEC’s LASIK training programme, young LASIK surgeons are introduced to the femtosecond laser before the microkeratome for flap creation. These surgeons perform their first LASIK cases with the femtosecond laser, as the potential for intraoperative complications is much lower. They are subsequently introduced to the microkeratome when they have attained the required level of expertise and competence in LASIK surgery. Editors’ note: Dr. Chan is a consultant for Bausch & Lomb and has received travel support from Carl Zeiss Meditec, but has no direct financial interests related to her comments. said. “We had machine numbers 21 and 22 in the country.” The thinking at the time was that while they had good experiences with mechanical microkeratomes such as the Hansatome (Bausch & Lomb, Rochester, NY, USA) and the ACS (Bausch & Lomb), with no difficulties, it was only a matter of time before a complication occurred. “We knew that our luck might not hold out of not having problems with mechanical microkeratomes because anyone can have problems with them,” Dr. Davison said. “It was a technology issue and we thought that it was going to be better for patients in the long run [to use the IntraLase] if we did continue to do LASIK.” Prospective log From the start, he kept track