LASIK Emergencies

Samir A.
Melki, MD, PhD

Boston Eye Group and Massachusetts Eye and Ear Infirmary
Department of Ophthalmology
Harvard Medical School
Boston, Massachusetts
Ali Fadlallah, MD, MSc, MPH

Faculty of Medicine
Saint Joseph University
Beirut, Lebanon
Eye and Ear Hospital
Naccache, Lebanon
North American LASIK and Eye Surgery Center
Dubai, United Arab Emirates
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Copyright © 2018 by SLACK Incorporated
Dr. Samir A. Melki and Dr. Ali Fadlallah have no financial or proprietary interest in the materials
presented herein.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted
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The procedures and practices described in this publication should be implemented in a manner con-
sistent with the professional standards set for the circumstances that apply in each specific situation.
Every effort has been made to confirm the accuracy of the information presented and to correctly
relate generally accepted practices. The authors, editors, and publisher cannot accept responsibility
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Dedication
To Dr. Dimitri Azar, my refractive surgery mentor, whose deep
analysis, honest assessment, and unequalled passion and energy
always were and will remain the guiding principles in my daily
practice.
To all my fellows who have kept me on my toes and were bold
enough to challenge established viewpoints.
To my wife, Rania, and my children, Philip and Alexi, for their
love, support, and belief in my work.
—Dr. Samir A. Melki
To all my mentors who guided me day-by-day through all my

curriculum.
To my father, Hani, my mother, Maha, my sisters, Laila and
Maryam, my wife, Dana, and my daughter, Bella Maha, for their
love.
To Abdalla Naqi, for giving me the greatest opportunity a
refractive surgeon can receive on his first professional day and for
entrusting me with his eyes for LASIK surgery.
—Dr. Ali Fadlallah
Contents
Dedication ....................................................................................... v
About the Authors ........................................................................... ix
Preface ............................................................................................ xi
Foreword by Dimitri Azar, MD, MBA .......................................... xiii
Chapter 1 The Normal LASIK Procedure: A Step-By-Step Surgical

Approach ...................................................................... 1
Chapter 2 Loss of Suction ........................................................... 19
Chapter 3 Air Bubbles in the Anterior Chamber ....................... 29
Chapter 4 Buttonholed Flaps and Vertical Gas Breakthrough .. 39
Chapter 5 Opaque Bubble Layer ................................................. 53
Chapter 6 Free Flaps ................................................................... 63
Chapter 7 Flap Tears ................................................................... 73
Chapter 8 Incomplete Flaps ........................................................ 83
Chapter 9 Irregular Flaps ......................................................... 105
Chapter 10 Epithelial Defect ...................................................... 117
Chapter 11 Thin and Thick Flaps ............................................... 127
Chapter 12 Decentered Flaps ...................................................... 141
Chapter 13 Subconjunctival Hemorrhage and Bleeding ............ 147
Chapter 14 Special Considerations ............................................. 155
Chapter 15 Management of Postoperative Complications ......... 161
About the Authors
Samir A. Melki, MD, PhD, is the founder and medical director of
the Boston Eye Group. He is an attending physician on the Cornea
and Refractive Surgery Service at the Massachusetts Eye and Ear
Infirmary (Harvard Medical School). Dr. Melki obtained his BSc
from the American University of Beirut followed by an MD, PhD
degree from Vanderbilt University. He completed his residency at
Georgetown University and additional fellowship training at the
Massachusetts Eye and Ear Infirmary. Dr. Melki’s special interests
lie in refractive, corneal, and cataract surgery.
Ali Fadlallah, MD, MSc, MPH, is a fellow of the Harvard Medical
School and holds an ophthalmology specialized diploma from
Paris-Sorbonne University. He became a European board-certified
ophthalmologist after his training in the Hôtel-Dieu de Paris, one
of the oldest hospitals in Europe. He holds a medical diploma from
Saint Joseph University in Beirut, from where he graduated as a lau-
reate and magna cum laude. Dr. Fadlallah is a clinical instructor at
Saint Joseph University, Faculty of Medicine, Beirut, Lebanon, and
a cornea consultant in affiliated hospitals. He is also an attending
LASIK specialist at the North American LASIK Eye Surgery Centre,
Dubai, United Arab Emirates.
Preface
The operating room is the worst place to think!
To all of us who operate on a regular basis, encountering com-

plications is an expected fact of life. They can be stressful to both
patients and their treating physicians. An unexpected intraoperative
event often leads to an adrenaline rush compounded by a sense of
impending failure and uncertainty. The chain of events that fol-
lows is dictated by how well the surgeon prepared to deal with a
particular occurrence, rather than the judgment made in the spur
of the moment. The operating room is the least favorable setting for
calm and poised decision-making. The response to a complication
should be based on a previously rehearsed scenario that is automati-
cally implemented as soon as the event occurs. Poor preparation can
lead to a rushed, sometimes f lawed decision that may result in an
undesirable outcome. The rarity of complications in LASIK surgery
is a mixed blessing. It is in the extraordinary moment when birds
hit an airplane engine that pilot training and preparation become
paramount. We hope that this book will allow the beginning as well
as the advanced LASIK surgeon to help mentally prepare to turn
a complication into a well-managed episode leading to excellent
visual recovery.
This video primer is a collection of intraoperative LASIK compli-
cations collected over a course of 20 years. Each complication can
present with a variety of facets, and we have tried to show as many
as possible. The reader is best served by reviewing the videos and
the corresponding chapters that list our recommended approach to
each of these complications. It has been said that the surgeon who
doesn’t have complications is the retired surgeon. To all others,
anticipation and rigorous preparation is the best way to maneuver
through the unexpected and deliver the expected outcome to our
patients.
—Samir A. Melki, MD, PhD

—Ali Fadlallah, MD, MSc, MPH
Foreword
An experienced, meticulous, skillful, and highly respected cor-
neal surgeon shares with the readers of this book his vast refractive
surgical experience. Not unlike other top leaders in the field who
manage complex surgical procedures and supervise subspecialty
fellows, Dr. Samir A. Melki has witnessed his share of unexpected
intraoperative events that were managed successfully, transforming
every one of these difficult situations into a teaching moment for
the reader!
He has done this throughout his career as a prolific author and
as a regular speaker at national and international society meetings,
sharing his surgical vignettes with other colleagues and with audi-
ences worldwide. Now, he has collaborated with a meticulous and
thoughtful coauthor, Dr. Ali Fadlallah, to compile and organize
these videos into a series of surgical pearls with unmatched teach-
ing potential for the novice and experienced LASIK surgeon.
Given the rare occurrence of serious complications during LASIK
surgery, preoperative preparation is essential for preventing and
handling those complications; this video primer will help to mini-
mize rushed or f lawed decisions and reduce stress for the patient
and treating physician alike.
The major strength of this primer is its ability to provide read-
ers with an accessible means to rehearse scenarios that they may
encounter in the operating room and prepare them to handle LASIK
complications as soon as they occur.
The educational videos in this book present unique perspectives
of LASIK complications. In Chapter 2, for example, several videos
of suction loss during femtosecond laser ablation are presented,
preparing the reader to handle this complication at various stages of
the laser pass. Similarly, the prevention and treatment of epithelial
defects are explained in detail in Chapter 7, preparing the reader to
properly manage these complications, including the rare occurrence
of a defect prior to the laser pass, and to minimize their potential
deleterious effects.
xiv Foreword
I applaud Dr. Melki’s and Dr. Fadlallah’s efforts in putting
together this impressive compendium. The authors have succeeded
in achieving the goals of preventing complications, improving
intraoperative judgment, and ultimately enhancing the visual out-
comes for patients who experience LASIK complications.
—Dimitri Azar, MD, MBA

Senior Director, Verily Life Sciences
Executive Dean and Distinguished Professor
BA Field Chair of Ophthalmological Research
University of Illinois College of Medicine
Chicago, Illinois
The Normal LASIK
1
Procedure
A Step-By-Step Surgical Approach
LASIK STEPS
Preparing Instruments
LASIK instrument trays can be divided into the following 2 dif ferent
areas: used instruments area and sterile instruments area.
• Used instruments area
º Sterile gloves
º Interface pack (one for each eye)
• Sterile instruments area
º 2 small piles of 4 × 4 gauze
º Eye patch (one 4 × 4 gauze folded with tape)
º Drape: Tegaderm (3M Company; one for each eye or adhesive
plastic)
º 2 balanced salt solution (BSS) tubes per eye
º 2 packs of Weck-Cel sponges (Beaver Visitec)
º Syringe filled with BSS (3 cubic centimeters with 25 grams cannula)
º 2 flap lifters
º Curved forceps
º Skin marker
Melki SA, Fadlallah A.

LASIK Emergencies: A Video Primer (pp 1-17).
1 © 2018 SLACK Incorporated.
2 Chapter 1
Figure 1-1. LASIK tray: 1-Sterile gloves, 2-4 x 4 gauze, 3-Eye patch, 4-Tegaderm, 5-BSS
tubes, 6-Weck-Cel sponges, 7-Syringe filled with BSS, 8-Flap lifters, 9-Eye speculum,
10-Curved forceps, 11-Skin marker, 12-Interface pack.
We advise hanging a photo of the LASIK and photorefractive keratec-

tomy trays in the surgical suite to guide the staff in preparing complete trays
(Figure 1-1). This is especially useful in high-volume environments.
Preparing Patient
• Place the head cover (cover hair and ears).
• Place the gauzes between the head cover and the ears (Figures 1-2 and
1-3).
• Apply anesthetic drops (one drop is instilled in each eye).
• Apply Betadine 5% (Alcon Labs) on the patient’s skin (mainly on eye-
brows, upper eyelid, and lower eyelid).
• Close the contralateral eye.
• Ask the patient to maintain a chin-up position.
º The patient’s hands may rest on his or her chest or he or she may
be given a teddy bear to hold and squeeze instead of squeezing his
or her eyelids.
The Normal LASIK Procedure 3
Figure 1-2. Patient should be asked to maintain

a chin-up position. The gauze pack in this picture
is in the wrong position. The gauze pack should
cover the patient’s hair and ear to protect him or
her from irrigating solutions (see Figure 1-3).
Figure 1-3. Patient in a chin-up position with

appropriate gauze position.
4 Chapter 1
Flap Procedure
Femtosecond LASIK
• Preoperative checklist
º Recheck the patient’s name, date of birth, eye being treated, and
refractive correction (Table 1-1).
• Explain to the patient that the part of the surgery involving a femtosec-
ond laser will probably be the most uncomfortable for him or her, as he
or she may feel pressure and/or black out.
• Initiate the laser platform (Figures 1-4 and 1-5).
º Enter the patient’s name, the patient’s date of birth, and the sur-
geon’s name.
º Choose the procedure: Flap (with the IntraLase [Abbott Medical
Optics]).
º Choose the following flap parameters:
■ Pattern of ablation: Raster cut vs spiral cut (variable; depends on
the laser platform and factory recommendation)
■ Hinge position: Usually superior
■ Depth: Between 100 microns (μm) and 110 μm (depends on abla-
tion and residual stromal bed)
■ Flap diameter: Our default preference is 9.1 mm; we prefer a dia-
meter of 8.8 mm in small eyes to avoid air bubbles in the anterior
chamber and a minimum of 9.1 mm for hyperopic ablations.
■ Bed energy and spot separation (depends on the laser platform
and factory recommendation)
■ Side cuts: Between 60 and 90 degrees (variable; depends on the
laser platform and factory recommendation)
■ Side cut energy: Variable (depends on the laser platform and fac-
tory recommendation)
■ Pocket
◆ Parameters as set by factory.
◆ ON decreases the risk of opaque bubble layer (OBL).
◆ OFF increases the flap diameter when needed.
◆ Initiate the laser.
º Verify glass cone integrity (Figures 1-6 and 1-7).
TABLE 1-1
Identification of Sources of Error Specific
to Laser Vision Correction*
Error# Sources of Error Specific to LVC
1 Patient name
2 Date of birth
3 Type of procedure (LASIK, PRK)
4 Aim (distance, near)
5 Optical zone
6 Preoperative sphere: plus or minus
7 Preoperative sphere power: first digit
8 Preoperative sphere: first decimal
9 Preoperative sphere: second decimal
10 Preoperative cylinder power: plus or minus
11 Preoperative cylinder power: first digit
12 Preoperative cylinder power: first decimal
13 Preoperative cylinder power: second decimal
14 Preoperative cylinder axis: first digit
15 Preoperative cylinder axis: second digit
16 Preoperative cylinder axis: third digit
17 Wavescan or laser input sphere: plus or minus
18 Wavescan or laser input sphere: first digit
19 Wavescan or laser input sphere: first decimal
20 Wavescan or laser input sphere: second decimal
21 Wavescan or laser input cylinder power: plus or minus
22 Wavescan or laser input cylinder power: first digit
23 Wavescan or laser input cylinder power: first decimal
24 Wavescan or laser input cylinder power: second decimal
25 Wavescan or laser input cylinder axis: first digit
26 Wavescan or laser input cylinder axis: second digit
27 Wavescan or laser input cylinder axis: third digit
28 Nomogram adjustment
LASIK = laser in situ keratomileusis; LVC = laser vision correction; PRK = photorefractive
keratectomy
* This list of 28 items relates to each eye having refractive surgery.
6 Chapter 1
Figure 1-4. IntraLase FS60 (Abbott Medical Optics) platform. Please note the sticker at
the bottom right corner of the screen. This has been devised to facilitate communica-
tion between the surgeon and the laser operator when indicating in which direction
to move a decentered flap. Instead of pointing to the desired direction, the surgeon
requests a certain number of clicks in the direction of a certain clock hour.
Figure 1-5. WaveLight FS200 (Alcon Labs) platform.

Figure 1-6. IntraLase cone.
Figure 1-7. WaveLight FS200 cone.

8 Chapter 1
Figure 1-8. IntraLase FS60 suction ring.
• Ensure proper head positioning: Depends mainly on eye and nose

configuration.
º Ask the patient to look in the middle of the rings of lights for the
IntraLase platform and toward the green light for the WaveLight
FS200 (Alcon Labs).
º Deep set orbit and large nose: Tilt the patient’s head to get access to
the cornea and avoid the applanation cone being hindered by the
nose bridge.
º Ask the patient to maintain a chin-up position to optimize eye
exposure.
• Applying the suction ring
º May be done under an excimer or femtosecond laser microscope.
º With speculum
■ Depends on surgeon preference.
■ Use in case of deep set orbit and excessive eyelids squeezing.
º Without speculum
■ Depends on surgeon preference.
■ May be helpful sometimes in small palpebral fissure cases.
º Ring should be decentered to provide 1 mm to 2 mm beyond the
superior limbus in the area where the hinge will be made.
■ > 2 mm: This may increase the risk of hemorrhage (from limbal
vessels) and air bubbles in the anterior chamber.
■ < 1 mm: This may induce a decentered flap.
■ IntraLase FS60 (Abbott Medical Optics) suction ring presents
marks that can be used for alignment with the pupil (Figure 1-8).
º After correct ring position is established, apply firm pressure before
applying suction.
Figure 1-9. Syringe should range between 2 mL and 3 mL (maximum 4 mL) when suc-
tion is applied manually.
Figure 1-10. Green light on screen (suction 1 and suction 2) indicates appropriate
suction pressure.
º Apply suction
■ Manually for IntraLase platform: Syringe piston should indicate
a maximum of 4 mL during suction (Figure 1-9).
■ Automatically in WaveLight FS200: Accomplished by pressing
the suction pedal. Green light on screen indicates appropri-
ate suction pressure (Figure 1-10). Some signs of good suction
include mydriasis and blackout.
10 Chapter 1
■ Suction may be repeated 3 to 4 times if unsuccessful. Closing the
eye for 3 to 4 minutes is needed before any extra attempt (this
may decrease chemosis and the risk of extensive subconjunctival
hemorrhage). The suction ring can drift due to excessive
chemosis. Decentering the suction ring superiorly may facili-
tate centration while reapplying suction, as the ring tends to slide
back into the previously created groove. Consideration can be
given to applying a drop of naphazoline to minimize chemosis,
but that may lead to pupillary dilation.
• Applying the cone
º Insert the cone firmly in the femtosecond laser tray without touch-
ing the glass (loose cone insertion may end up with difficult dock-
ing and a decentered flap).
º Raise the patient to the glass.
º Fit the cone in the suction ring.
■ WaveLight FS200
◆ The 2 red lights focused on the cornea should cross to be
slightly defocused to allow good applanation.
◆ Move bed up and laser down to fit the cone inside of the ring.
Slight suction ring rotation around the cone may initiate laser
activation.
■ IntraLase: 3 dif ferent ways are possible
◆ Suction ring lock ON: This happens simply by introducing the
cone inside of the ring and then releasing the lock (to block
cone movement).
◆ Suction ring lock OFF: Press on the suction ring when
glass touches the upper surface of the ring. Further upper
bed movement and laser down movement are needed for
applanation.
◆ Suction ring lock OFF: Allow 5 to 6 seconds of continuous
laser down movement after the glass touches the upper sur-
face of the ring. Then press on the suction ring to allow cone
movement inside of the ring. Usually, no further movement is
needed for applanation.
º Hard docking (Figure 1-11)
■ No liquid interface is seen in periphery (between the glass and
the cornea).
■ Increases the risk of OBL, but decreases the risk of uncut flap
zones.
º Soft docking (Figure 1-12)
Figure 1-11. Hard docking. No liquid meniscus is seen at glass edges (red arrow).
Figure 1-12. Soft docking. Liquid meniscus seen at glass edges (red arrow).
■ Liquid interface is seen in the periphery (between the glass and

the cornea).
■ Decreases the risk of OBL and the risk of air in the anterior
chamber, but increases the risk of uncut flap zones (especially on
side cut areas).
12 Chapter 1
Figure 1-13. Moving the flap outside of the central circle (red
arrow) may shrink the flap diameter.
Figure 1-14. Moving the flap outside of the central circle may
shrink the flap diameter.
º Look for any contact between the cone and the nose. If there is any,
redock with the head now tilted further to the opposite side.
• Flap centering
º Look on the screen to check how well the cornea is being applanated.
º Appropriate adjustment on the LASIK flap is done on the laser
computer software.
º Center the flap planned on the computer with the pupil center.
■ With the IntraLase platform, moving the flap outside of the cen-
tral circle (Figures 1-13 and 1-14) may shrink the flap diameter.
Turning the pocket off may help to increase the size of the flap
(Figure 1-15).
Figure 1-15. Turning the pocket off may help to increase the size
of the flap.
■ Using a small dial pad (see Figure 1-4) may facilitate communi-

cation between the surgeon and the assistant to specify move-
ment directions (eg, to move flap inferiorly, ask assistant to press
on arrow corresponding to number 6).
º Apply the laser.
■ 10 seconds to 12 seconds with the IntraLase FS150 (Abbott
Medical Optics)
■ 10 seconds to 12 seconds with the WaveLight FS200
■ 20 seconds to 30 seconds with the IntraLase FS60
º Release suction (manually for the IntraLase and by pressing the suc-
tion pedal in the WaveLight FS200) and move the laser up.
º Repeat the same procedure on the other eye and move the bed
under the excimer laser.
º Remove the speculum if used.
Microkeratome LASIK
• Preoperative checklist
º Recheck the patient’s name, date of birth, eye being treated, and
refractive correction.
• Explain to the patient that the part of procedure involving a
microkeratome will probably be the most uncomfortable for him or
her, as he or she may feel pressure and/or black out.
• Head positioning: Depends mainly on eye and nose configuration.
º Deep set orbit and large nose: Tilt the patient’s head to get access to
the cornea.
14 Chapter 1
º Ask the patient to maintain a chin-up position to optimize eye
exposure.
• Instill an anesthetic in the eye.
• Instruct the patient to keep both eyes open.
• Place a plastic drape (Tegaderm) on the upper and lower eyelids.
º Lashes should be isolated for sterility and to prevent them from
jamming the microkeratome.
• Apply speculum on the eye.
º Maximum exposure is needed to ensure a clear path for the
microkeratome.
• Center the eye under the laser by asking the patient to look at the red
blinking light (VISX STAR S4 IR [Abbott Medical Optics]) and the
green blinking light (WaveLight EX500 [Alcon Labs]).
• Mark the eye inferiorly using a 3 mm marked well: Place 2 to 3 asym-
metric marks.
• An anesthetic can be reinstilled.
• Applying the suction ring.
º Choice of ring depends on factory nomogram (eg, keratometry,
pachymetry, ablation zone).
º Confirm microkeratome readiness prior to suction.
º Check the microkeratome blade.
º In deep set orbits, gentle pressure on the speculum may proptose the
globe and facilitate suction ring placement.
■ A chin-up position may be helpful.
º The suction ring should be centered in a way to provide 1 to 2 mm
beyond the superior limbus in the area where the hinge will be
made.
■ > 2 mm: This may increase the risk of hemorrhage.
■ < 1 mm: This may induce a decentered flap.
º After establishing the correct ring position, apply firm pressure
before applying suction.
º Apply suction.
■ Signs of good suction include mydriasis and blackout.
■ Check intraocular pressure (fixed tonometer or
pneumotonometer).
■ Fix any decentration, buy releasing suction and restarting the
procedure.
• Applying the keratome
º The head is dropped on the pivot prior to engagement.
º Look for any contact between the head and the eyelids.
º In cases of a prominent lower cheek, the surgeon may use his or her
finger or may ask an assistant to retract the skin.
º The head is activated by pressing the forward pedal.
º After complete rotation, press the backward pedal.
º Release suction.
º If the head stops prematurely, an attempt at continued forward is
accepted. Never go backward and then forward. Best practice is to
go forward and abort the procedure.
º Release suction.
Excimer Procedure
• Reinstill the anesthetic in the eye.
• Instruct the patient to keep both eyes open.
• Place plastic drape (Tegaderm) on the upper eyelids (for microkeratome
LASIK use the same drape).
• Center the eye under the laser by asking the patient to look at the red
blinking light (VISX STAR S4 IR) and green blinking light (WaveLight
EX500).
• Mark the eye inferiorly using the marking pen; a small marking
between the flap and the peripheral cornea is enough for guiding
flap repositioning in the femtosecond laser. This step is not needed in
microkeratome LASIK.
• An anesthetic can be reinstilled at this step.
• Rinse the surface of the eye with one BSS tube.
• Dry the surface of the eye with a Weck-Cel sponge.
• Lift the flap.
º Step 1: The flap lifter is introduced perpendicularly at the flap/
stroma intersection. The flap interface is penetrated.
º Step 2: Release the first adherence between the flap and the stroma
at the hinge area and then exit at the side cut on the opposite side.
º Step 3: Flap/stroma adherence is then released by 3 consecutive wip-
ing movements from the hinge toward the inferior flap area. The
third wipe movement happens by overlapping at the exit created
during step 2.
º Flap lifting is more simple in microkeratome LASIK because adher-
ence is inexistent.
16 Chapter 1
Figure 1-16. Drying with a Weck- Cel sponge between the flap and the cornea
gives a symmetrical “ring of light.”
• Dry the bed in case of excessive fluid at the stroma interface.

• Measure bed pachymetry (ultrasound measure for VISX STAR S4 IR
and optical biometry for WaveLight EX500).
• Tracking is activated (difficult tracking is discussed in upcoming
chapters).
º Tracking for WaveLight EX500: Foot pedal activation.
º Tracking for VISX STAR S4 IR: Manual activation.
• Align reticules with eye marking in case of astigmatism correction to
avoid errors induced by cyclotorsion.
• Take a side view to ensure appropriate centration.
• Center the laser treatment on the pupil center.
• Press the laser pedal to activate the excimer laser treatment.
• Holding the head and giving timing update may reassure the patient.
• Irrigate the flap interface with BSS and replace the flap (using 25 grams
cannula).
• Irrigate the eye surface with one BSS tube to remove all debris.
• Irrigate the flap interface a second time with BSS using 25 grams can-
nula and apply some firm pressure on the flap to expel excessive water
from under the flap.
• Use a Weck-Cel sponge to dry the intersection between the flap and the
cornea to get a symmetrical “ring of light” (Figure 1-16).
º Asymmetric “ring of light” is an indirect sign of flap tilt. Flap
refloating is warranted to avoid flap striae.
• Instill one antibiotic drop and one steroid drop on the surface of the
flap.
• Prepare for the next eye.
• Placing contact lenses or eye shields is not mandatory.
SUGGESTED READING
Carr JD, Stulting RD, Thompson KP, Waring GO III. Laser in situ keratomileusis: surgical
technique. Ophthalmol Clin North Am. 2001 Jun;14(2):285-94.
Maldonado MJ, Nieto JC, Piñero DP. Advances in technologies for laser-assisted in situ
keratomileusis (LASIK) surgery. Expert Rev Med Devices. 2008 Mar;5(2):209-29.
Robert, MC, Choi, CJ, Shapiro FE, Urman RD, Melki S. Avoidance of seri-
ous medical errors in refractive surgery using a custom preoperative checklist.
J Cataract Refract Surg. 2015 Oct;41(10):2171-8.
Please see videos on the accompanying website at
www.healio.com/books/lasikvideos
2
Loss of Suction
ETIOLOGY AND INCIDENCE OF

LOSS OF SUCTION
Loss of suction can occur during flap creation, either with a femtosecond
laser or with a microkeratome.1 Loss of suction can be due to the following:
• Inadequate initial suction
• Patient movement, eye rotation, and/or head tilt
• Flat corneas with dioptric readings of less than 42 diopters (D)
• Smaller palpebral fissure
• Deep set eyes
• Incarcerated conjunctiva
With femtosecond laser, reported loss of suction incidence varies
between 0.3% (IntraLase [Abbott Medical Optics]) and 4.4% (VisuMax
[Carl Zeiss Meditec Inc]). With microkeratome, loss of suction incidence
varies between 0.3% (Amadeus [Abbott Medical Optics]) and 1.2% (Chiron
Corneal Shaper [Chiron Vision]).2,3

20 Chapter 2
FEMTOSECOND LASIK COMPLICATIONS

AND IMMEDIATE SOLUTIONS
Complication #1: Loss of Suction

(During Raster Cut)
Video section: 1 minute 20 seconds
Platform: IntraLase FS60 kilohertz (kHz) (Abbott Medical Optics)
Flap diameter: 9.3 mm
Flap target depth: 100 microns (μm)
The initial surgery on the right eye resulted in an incomplete flap con-
struction due to suction loss occurring at two-thirds the distance across the
planned cut (video 2; time: 1 minute 20 seconds; Figures 2-1 and 2-2).
Some practical measures are as follows:
• Lift up your foot from the laser pedal immediately. This is impor tant to
avoid cutting the rest of the flap at a dif ferent depth.
• Press “Cancel” on the IntraLase platform or the equivalent on other
platforms.
• Do not change the applanation cone to ensure that the repeat cut is at
the same depth.
• You may consider changing the suction ring after 2 to 3 unsuccessful
attempts.
• Femtosecond laser cut may be repeated.
• The vertical limbal pocket typically created to absorb the cavitation
bubbles should be deactivated if already created during the first pass.
• Once a new successful flap is created, start the mechanical flap dissec-
tion from the section of the flap that has had one raster pass (ie, the
most distal portion from the hinge). This will avoid the possibility of
dissecting an area where 2 dissection planes could be present.
Loss of Suction 21
Figure 2-1. Initial surgery resulted in an incomplete flap construction due to

suction loss occurring at two-thirds the distance across the planned cut.
Figure 2-2. Suction ring was reapplied, and the raster pass resulted in com-
plete flap creation. Ablation was subsequently performed on both eyes.
Intraoperative corneal pachymetry revealed a flap thickness of 87 μm. On the
first day after surgery, the patient had an uncorrected distance visual acuity of
20/25 in each eye, with LASIK flaps clear and well-centered on slit lamp exami-
nation. At the 2-month follow-up visit, uncorrected distance visual acuity was
20/20 in each eye.
22 Chapter 2
Figure 2-3. Initial surgery resulted in an incomplete flap construction due to suction

loss occurring after the raster cut and before the side cut.
Complication #2: Loss of Suction

(After Raster Cut, Before or During Side Cut)
When this complication occurs, the flap bed is fully created, but the suc-
tion is lost prior to the creation of the side cut. This prevents the flap from
being lifted.
Video section: 4 minutes 32 seconds
Platform: IntraLase FS60 kHz
Flap target depth: 100 μm
struction due to suction loss occurring after the raster cut and before the
side cut (video 2; time: 4 minutes 32 seconds; Figures 2-3 and 2-4).
• Lift up your foot from the laser pedal immediately. This is impor tant to
avoid cutting the rest of the flap at a dif ferent depth.
• The same applanation cone should be used to ensure the same depth
of treatment.
• The vertical limbal pocket and the raster cut should be deactivated
when attempting a new pass.
Loss of Suction 23
Figure 2-4. Second laser pass was done with disabling the raster cut and decreasing
the side cut diameter to 8.7 mm. Ablation was subsequently performed on both eyes.
Intraoperative corneal pachymetry revealed a flap thickness of 101 μm. On the first day
after surgery, the patient had an uncorrected distance visual acuity of 20/20 in each
eye, with LASIK flaps clear and well-centered on slit lamp examination. At the 2-month
follow-up visit, uncorrected distance visual acuity was 20/20 in each eye.
• The subsequent side cut should be created within the already-created

flap. The laser manufacturers recommend shrinking the subsequent
side cut by 0.5 mm. The transient opaque bubble layer pattern remains
visible if the suction ring is immediately reapplied, allowing for the
identification of the border of the first raster pass.
• If you are unable to set the laser to a “side cut only” pattern, it is okay to
repeat the whole treatment while turning off the pocket.
General Practical Measures in Femtosecond

LASIK Surgery
Once suction loss is detected, the following measures should be taken:
• Discontinue the laser treatment immediately. Failure to do so may lead
to the raster ablation being performed at dif ferent depths.
• If suction loss is detected during the raster stage prior to the creation of
the side cut, the femtosecond laser cut may be repeated.
24 Chapter 2
• The same applanation cone should be used to ensure the same depth
of treatment.
• The suction ring may be exchanged if the surgeon suspects a manufac-
turing defect.
• The vertical limbal pocket typically created to absorb the cavitation
bubbles may be deactivated if already created during the first pass.
• Start the mechanical flap dissection from the section of the flap that has
had one raster pass (ie, the most distal portion from the hinge).
• Blunt dissection may result in irregular disrupted flap. Go slower than
usual.
• If the loss of suction occurs while creating the side cut, the surgeon
must ensure that the subsequent side cut is created within the already-
created flap. As stated previously, the laser manufacturers recommend
shrinking the subsequent side cut by 0.5 mm. The transient opaque
bubble layer pattern remains visible if the suction ring is immediately
reapplied, allowing for the identification of the border of the first raster
pass.
• If repeated suction attempts prove unsuccessful or results in an irregu-
lar flap, surface ablation should be considered over the incomplete flap.
This can be performed as early as 1 week after the aborted procedure
with the application of mitomycin-C to avoid scarring.
Multiple vacuum applications may not be permissible in certain situ-
ations (eg, in patients with glaucoma). There is no evidence of an adverse
effect on the retina due to repeated suction application to the globe.
A repeat cut may not be as safe with fast lasers in case the ablation was
not immediately interrupted after the loss of suction. A loss of suction in the
visual axis with lasers such as the WaveLight FS200 (Alcon Labs) and the
IntraLase FS (Abbott Medical Optics) may be best aborted and converted to
a future surface ablation. Faster lasers such as these may have cut at a shal-
lower depth prior to laser interruption by the surgeon.
Loss of Suction 25

loss occurring at one-third the distance across the planned cut. Surgery was aborted,
and surface refractive procedure was planned 1 week later.
MICROKERATOME LASIK COMPLICATIONS

Complication #3: Loss of Suction During

Microkeratome Pass
Platform: Hansatome (Bausch + Lomb)
The initial surgery resulted in an incomplete flap construction due to
suction loss occurring at one-third the distance across the planned cut
(Figure 2-5).
The following are some practical measures:
• Abort the surgery.
• Assess the exposed stromal surface for excimer laser treatment.
• Plan for a future surface refractive procedure if the extent of the stromal
bed created is not adequate to apply the excimer laser treatment.
26 Chapter 2
General Practical Measures in Microkeratome
LASIK Surgery
Once suction loss is detected, the following measures should be taken:
• If suction break occurs before any pass, the suction ring may be
reapplied.
• Abort the surgery if suction break or jamming occurs during
microkeratome pass.
• Assess the available stromal surface for excimer laser treatment.
• If the suction loss occurs beyond the visual access, treatment can be
applied if the stromal bed is adequate for at least 6 mm optical zone
treatment. A 5.5 mm optical zone may be considered in spherical treat-
ments less than 3 D in magnitude.
• Avoid manually extending the dissection with a blade.
• When the laser ablation is performed, the flap should be protected from
laser exposure, especially in hyperopic treatments.
• If suction loss results in an irregular flap, surface ablation should be
considered over the incomplete flap. The timing of the repeat procedure
depends on how quickly the surface epithelium is healed. As with fem-
tosecond LASIK surgery, this should be performed with the application
of mitomycin-C to avoid scarring.
PREVENTION OF LOSS OF SUCTION

Femtosecond LASIK
The first sign of suction loss is an asymmetric tear meniscus leading to
a partial or full loss of applanation. Careful observation during docking of
the patient interface and reposition if necessary can be helpful. Additionally,
recognizing preoperative risk factors, such as a deep set orbit, and planning
accordingly can also be useful in preventing suction loss. Patients who
forcefully squeeze their lids may benefit from additional sedation or the
placement of a wire lid speculum.
Loss of Suction 27
Microkeratome LASIK
As stated above, recognizing preoperative risk factors (eg, a deep set
orbit) and planning accordingly may also aid in preventing suction loss. As
with femtosecond LASIK, additional sedation or the placement of a wire lid
speculum may be useful in patients who forcefully squeeze their lids. The
incidence of suction loss may be reduced if the surgeon pays attention to the
following guidelines:
• Avoid cutting the flap if the intraocular pressure is low.
• Use larger suction rings in flat corneas.
• Inspect the microkeratome blade under the operating microscope
before engaging it in the suction ring to rule out manufacturing or
other preoperative damage.
If a case is aborted, we do not recommend switching to surface ablation
in the same setting. It may be best to reconsent the patient and proceed with
surface ablation on a dif ferent day.
REFERENCES
1. Muñoz G, Albarrán-Diego C, Ferrer-Blasco T, Javaloy J, García-Lázaro S. Single
versus double femtosecond laser pass for incomplete laser in situ keratomileusis
flap in contralateral eyes: visual and optical outcomes. J Cataract Refract Surg.
2012;38(1):8-15.
2. Rosman M, Hall RC, Chan C, et al. Comparison of efficacy and safety of laser in situ
keratomileusis using 2 femtosecond laser platforms in contralateral eyes. J Cataract
Refract Surg. 2013;39(7):1066-1073.
3. Ang M, Mehta JS, Rosman M, et al. Visual outcomes comparison of 2 femto-
second laser platforms for laser in situ keratomileusis. J Cataract Refract Surg.
2013;39(11):1647-1652.
28 Chapter 2
SUGGESTED READING
Faktorovich E. Femtodynamics. Thorofare, NJ: SLACK Inc; 2009.
Melki S, Azar DT. LASIK complications: etiology, management, and prevention. Surv
Ophthalmol. 2001;46(2):95-116.
Shah DN, Melki SA. Complications of femtosecond-assisted laser in-situ keratomileusis
flaps. Semin Ophthalmol. 2014;29(5-6):363-375.
Syed ZA, Melki SA. Successful femtosecond LASIK flap creation despite multiple suction
losses. Digit J Ophthalmol. 2014;20(1):7-9.
3
Air Bubbles in the
Anterior Chamber
ETIOLOGY AND INCIDENCE OF AIR BUBBLES
IN ANTERIOR CHAMBER
Anterior chamber (AC) gas bubbles are an occurrence specific to the fem-
tosecond laser.1 It is hypothesized that gas bubbles enter through Schlemm’s
canal.2 Some authors believe that the bubbles may be due to misdirected
femtosecond laser pulses on the aqueous3; however, imaging with optical
coherence tomography was performed and does not appear to support the
theory that gas bubbles migrate into the AC through the trabecular mesh-
work.3 This is not consistent with our experience, where gas bubbles invari-
ably enter the AC through the trabecular meshwork.
Studies comparing complication rates between the microkeratome and
femtosecond-created flaps found that gas bubbles were present in the AC
only in the femtosecond group (0.3%).4,5 Air bubbles appear more frequent-
ly in the inferonasal quadrant (> 50%).6 When air bubbles are present, they
will interfere with pupil tracking in 50% of cases.6 Surgery can be completed
later the same day in almost all cases without further complication by allow-
ing the bubble(s) to resorb.

30 Chapter 3
Figure 3-1. Initial surgery resulted in air bubbles in the AC (red arrow).

Complication #1: Air Bubbles in

Anterior Chamber Not Interfering
With Excimer Laser Treatment
The initial surgery resulted in air bubbles in the AC (video 2; time: 2
minutes 9 seconds; Figures 3-1, 3-2, 3-3, and 3-4).
Air Bubbles in the Anterior Chamber 31
Figure 3-2. VISX brand laser was used for the excimer procedure.
Figure 3-3. Dimming the light during the tracker registration was helpful to activate
the tracker.
32 Chapter 3
Figure 3-4. Ablation was subsequently performed. On the left eye, the flap diameter
was decreased to 8.9 mm. No air bubble was seen in the AC, and the excimer proce-
dure was uneventful. On the first day after surgery, the patient had an uncorrected
distance visual acuity of 20/25 in each eye with LASIK flaps clear and well-centered
on slit lamp examination. At his 2-month follow-up visit, uncorrected distance visual
acuity was 20/20 in each eye.
• Decrease flap diameter on the fellow eye by 0.5 mm and turn off the
pocket.
• During excimer laser treatment, dimming the light during the tracker
registration can be helpful to allow more reliable pupil tracking.
Complication #2: Air Bubbles in Anterior

Chamber Interfering With Excimer Laser
Treatment
Platform: Wavelight FS200 (Alcon Labs)
The initial surgery resulted in air bubbles in the AC (video 2; time: 3
minutes 48 seconds; Figures 3-5, 3-6, 3-7, 3-8, and 3-9).
Figure 3-5. Initial surgery resulted in air bubbles in the AC.
Figure 3-6. VISX laser was used for the excimer procedure. Dimming the microscope
light and asking the patient to look down did not lead to successful tracking.
• Decrease flap diameter on the fellow eye by 0.5 mm.

• During excimer laser treatment, dim the microscope light and ask the
patient to look down during the tracker registration to drive the bubbles
superiorly. This may lead to better exposure of the pupil to the tracker.
34 Chapter 3
Figure 3-7. Patient was asked to wait before proceeding with excimer laser treatment.
The air bubble resorbed partially 1 hour later.
Figure 3-8. Ablation was subsequently performed. On the left eye, the flap diameter
was decreased to 8.9 mm. No air bubble was seen in the AC, and the excimer proce-
dure was uneventful. On the first day after surgery, the patient had an uncorrected
distance visual acuity of 20/20 in each eye, with LASIK flaps clear and well-centered
on slit lamp examination. At his 2-month follow-up visit, uncorrected distance visual
Figure 3-9. Photograph taken at the end of the surgery showing that small air bubbles
can be suitable with tracking activation.
• In some cases, the above maneuvers are not successful.

• Waiting for air bubbles to resorb is sometimes the only possible solu-
tion. This can take between 30 minutes and several hours.

LASIK Surgery
Once air bubbles in AC are detected, the following measures should be
taken:
• Continue laser treatment.
• Decrease flap diameter on the fellow eye by 0.3 to 0.5 mm.
• During the excimer procedure, ask the patient during tracker registra-
tion to look down and then up.
• Try dimming the microscope light to enlarge the pupil diameter.
• Disable the tracker only in small ametropia (especially with slower
lasers).
36 Chapter 3
• Do not turn off the tracker in cases of astigmatism and high ametropia
and if using a fast laser avoid a decentered ablation. Waiting for air
bubbles to resorb may be the appropriate solution.
• It may take between 30 minutes and several hours for air bubbles to
resorb.
PREVENTION OF AIR BUBBLES

IN ANTERIOR CHAMBER
Gas bubbles in the AC appear to correlate with femtosecond dissection
that is too close to the limbus, which often occurs in smaller corneas, larger
flaps, and high applanation pressures. The following are some suggestions
to help prevent air bubbles in the AC:
• Select a smaller diameter flap when excessive scleral show is noted after
the application of the suction ring.
• Select a smaller flap for the fellow eye and turn the pocket off to prevent
the complication from occurring again.
REFERENCES
1. Farjo AA, Sugar A, Schallhorn SC, et al. Femtosecond lasers for LASIK flap cre-
ation: a report by the American Academy of Ophthalmology. Ophthalmology.
2013;120(3):e5-e20.
2. Soong HK, de Melo Franco R. Anterior chamber gas bubbles during femtosecond
laser flap creation in LASIK: video evidence of entry via trabecular meshwork.
J Cataract Refract Surg. 2012;38(12):2184-2185.
3. Utine CA, Altunsoy M, Basar D. Visante anterior segment OCT in a patient with gas
bubbles in the anterior chamber after femtosecond laser corneal flap formation. Int
Ophthalmol. 2010;30(1):81-84.
4. Srinivasan S, Rootman DS. Anterior chamber gas bubble formation during femtosec-
ond laser flap creation for LASIK. J Refract Surg. 2007;23(8):828-830.
5. Moshirfar M, Gardiner JP, Schliesser J, et al. Laser in situ keratomileusis flap com-
plications using mechanical microkeratome versus femtosecond laser: retrospective
comparison. J Cataract Refract Surg. 2010;36(11):1925-1933.
6. Robert MC, Khreim N, Todani A, Melki SA. Anterior chamber gas bubble
emergence pattern during femtosecond LASIK-flap creation. Br J Ophthalmol.
2015;99(9):1201-1205.
SUGGESTED READING
Shah DN, Melki S. Complications of femtosecond-assisted laser in-situ keratomileusis
4
Buttonholed Flaps and
Vertical Gas Breakthrough
ETIOLOGY AND INCIDENCE

OF BUTTONHOLED FLAPS AND
VERTICAL GAS BREAKTHROUGH
Femtosecond LASIK
Cavitation bubbles from the femtosecond laser can dissect upwards
toward the epithelium and are called vertical bubble breaks.1-3 The bubbles
may either stay below Bowman’s membrane or break through the epithe-
lium. When the bubbles stay under Bowman’s layer, a focal thinning in the
flap is noted. If the break is through the epithelium, this is considered a
buttonhole.
The following 2 types of bubbles have been described:
• Partial bubble breaks characterized by a gray/white appearance.
• Full breaks characterized by a deep black appearance. They are
thought to occur due to the dissection of cavitation bubbles into the
subepithelial space.
Risk factors include corneal scars, microscopic breaks in Bowman’s
membrane, and thin flaps, which can lead to accidental vertical gas break-
through (VGB). Reported VGB incidence varies between 0% with the

40 Chapter 4
60 kilohertz (kHz) femtosecond laser (IntraLase [Abbott Medical Optics])
and 1.3% with Femto LDV (Ziemer Ophthalmic Systems).4,5
Microkeratome LASIK
A buttonholed flap occurs when the microkeratome blade travels more
superficially than intended and enters the epithelium/Bowman’s complex.
Buttonholes may be partial thickness if they transect Bowman’s layer or full
thickness if they exit through the epithelium. The incidence of buttonholes
ranges between 0.2% and 0.56%.1,6 No clear etiology has been identified for
this complication. Presumed risk factors include the following:
• High keratometric values, although this is not consistent with our
experience.
• Previous incisional keratotomy.
• Pre-existing surface lesion (eg, pterygium, corneal scars).

Complication #1: Black Vertical Gas

Breakthrough in Visual Axis
Platform: IntraLase FS60 (kHz) (Abbott Medical Optics)
The initial surgery on the right eye resulted in black VGB in the visual
axis (video 4; time: 1 minute 58 seconds; Figures 4-1, 4-2, and 4-3).
• Continue the femtosecond laser treatment to avoid a partial flap.
• Assess the position of the VGB within the flap.
• The flap with black VGB affecting the visual axis should not be lifted
and surgery should be aborted.
Buttonholed Flaps and Vertical Gas Breakthrough 41
Figure 4-1. Initial surgery resulted in black VGB in the visual axis

(red arrow).
Figure 4-2. Photograph showing black VGB in the visual axis

(red arrow).
Figure 4-3. Photograph showing black VGB in the visual axis

(red arrow). Surgery was aborted. Surgery in the fellow eye was
uneventful. One month later, the right eye underwent LASIK sur-
gery. At the 2-month follow-up visit, uncorrected distance visual
42 Chapter 4
Figure 4-4. Initial surgery resulted in white/gray VGB in the paracentral

pupillary area (red arrow).
Figure 4-5. Photograph showing white/gray VGB in the paracentral

pupillary area (red arrow).
Complication #2: White/Gray Paracentral

Vertical Gas Breakthrough
The initial surgery on the right eye resulted in white/gray paracentral
pupillary VGB (video 4; time: 2 minutes 10 seconds; Figures 4-4, 4-5, and
4-6).
Figure 4-6. Flap lift did not result in a full-thickness buttonhole (red arrow) (see
Figure 4-15). Excimer laser treatment was uneventful. Surgery was uneventful in the
fellow eye.

• Continue the femtosecond laser treatment.
• Start gentle mechanical flap dissection around the VGB area.
• Assess the position of air bubbles within the flap; white VGB is at lower
risk of tearing during a flap lift.
• Consider using flap forceps to lift the flap and prevent any tear.
Complication #3: Black Peripheral Vertical

Gas Breakthrough
The initial surgery on the right eye resulted in black VGB in the periph-
ery (video 4; time: 2 minutes 55 seconds; Figures 4-7, 4-8, 4-9, and 4-10).
• Assess the position of air bubbles within the flap.
44 Chapter 4
Figure 4-7. Initial surgery resulted in black VGB in the periphery

(red arrow).
Figure 4-8. Photograph showing black VGB in the periphery (red

arrow).
Figure 4-9. Photograph showing black VGB in the periphery (red

arrow).
Figure 4-10. Flap lift resulted in small buttonhole in the periphery (red arrow). Excimer
laser treatment was uneventful. Surgery was uneventful in the fellow eye.
• A flap with peripheral black VGB not involving the visual axis may be
lifted carefully if the surgeon determines that a buttonhole in this area
is acceptable.
• Consider using flap forceps to gently lift the flap to prevent any tear.
Complication #4: White Peripheral Vertical

Gas Breakthrough
The initial surgery resulted in white VGB in the periphery (video 4; time:
4 minutes 32 seconds; Figures 4-11, 4-12, 4-13, and 4-14).
• Assess the position of air bubbles within the flap; white VGB is at lower
risk of tearing during a flap lift.
• Consider using flap forceps to lift the flap and prevent any tear.
The initial surgery on the left eye resulted in white VGB in the periphery
(see Figures 4-6 and 4-7). A flap lift and excimer laser treatment in the right
eye and left eye (see Figures 4-8 and 4-9) were uneventful. At the patient’s
46 Chapter 4
Figure 4-11. Initial surgery resulted in white VGB in the periphery

(red arrow).
Figure 4-12. Photograph showing white VGB in the periphery (red

arrow).
Figure 4-13. Flap lift and excimer laser treatment were uneventful.

Surgery was uneventful in the fellow eye.
Figure 4-14. Corneal appearance at the end of the procedure.
2-month follow-up visit, the uncorrected distance visual acuity was 20/15 in
each eye and topography pattern was within normal limits in the left eye.

LASIK Surgery
Once VGB is detected, the following should occur:
• Continue the femtosecond laser treatment to avoid a partial flap.
• Assess the position of air bubbles within the flap.
• Do not lift flaps with VGB (black and/or white) to avoid affecting the
visual axis.
• Full central breaks (buttonhole) should not be lifted.
• Full peripheral breaks (buttonhole) may be lifted and excimer laser
treatment attempted.
• Partial bubble breaks in the periphery could be carefully lifted.

Complication #5: Buttonhole

48 Chapter 4
Figure 4-15. Initial surgery using the Hansatome platform.
Figure 4-16. Irregular corneal reflex noted after the keratome pass.

The initial surgery on the right eye resulted in a central buttonhole (video
4; time: 6 minutes 10 seconds; Figures 4-15, 4-16, and 4-17).
Figure 4-17. Photograph showing the buttonhole during flap lifting. Surgery was
aborted, and a surface refractive procedure was planned several weeks later (as dis-
cussed in Chapter 15).

• Plan for a future surface refractive procedure.
Complication #6: Buttonhole Associated

With Pterygium
Platform: Hansatome
The initial surgery on the right eye resulted in a central buttonhole (video
2; time: 8 minutes 5 seconds; Figure 4-18).
50 Chapter 4
Figure 4-18. Initial surgery resulted in a buttonhole (red arrow). Pterygium is seen in

the nasal area.

LASIK Surgery
Once a buttonhole is detected, the following should occur:
• Follow the algorithm to determine the best course of action (Figure
4-19).6
PREVENTION OF BUTTONHOLED FLAPS

AND VERTICAL GAS BREAKTHROUGH
Femtosecond LASIK
A careful slit lamp examination prior to surgery should reveal areas of
scarring that are typically the precursors to vertical bubble breaks. Eyes that
have had previous radial keratotomy surgery are also at higher risk of verti-
cal gas dissection. The incidence of splaying the radial keratotomy incision
can be high and may be due to gas breakthrough or from the mechanical
lifting. Surface ablation may be a safer approach in these situations.
LASIK Flap
Buttonhole
Epithelial
ingrowth?
No: Stage 1 Yes
Observe Stromal melt/

3 months irregular
astigmatism?
Smooth
epithelium?
No: Stage 2 Yes: Stage 3
Treatment
Yes No Ingrowth Ingrowth pro- individual-
small and gressive and/ ized
non-progressive or threatening
1. PTK 50 μm 1. 20% alcohol stromal melting
2. PRK for 60 seconds
3. MMC 0.02% 2. PRK PTK until
x 60 seconds 3. MMC 0.02% x Proceed as in ablation of
60 seconds Stage 1 epithelial
ingrowth
If PTK < 50 μm, If PTK > 50 μm,

proceed to delay further
1. PRK treatment
2. MMC 0.02% x till refraction
60 seconds stabilizes.
Figure 4-19. Algorithm.
Microkeratome LASIK
Avoid cutting the flap if the intraocular pressure is low due to low suc-
tion. Set the microkeratome to a deeper cutting depth if keratometry read-
ings show evidence of a steep cornea, assuming that the amount of intended
myopic correction to be treated allows such modification. Most refractive
surgeons follow such an approach, setting the cut-off point at 46 to 48
diopters (D), although no definitive supportive study exists in the literature.
52 Chapter 4
REFERENCES
1. Melki S, Azar DT. LASIK complications: etiology, management, and prevention. Surv
Ophthalmol. 2001;46(2):95-116.
2. Srinivasan S, Herzig S. Sub-epithelial gas breakthrough during femtosecond laser flap
creation for LASIK. Br J Ophthalmol. 2007;91(10):1373.
3. Shah DN, Melki S. Complications of femtosecond-assisted laser in-situ keratomileusis
4. Prakash G, Agarwal A, Kumar DA, et al. Femtosecond sub-bowman keratomileusis:
a prospective, long-term, intereye comparison of safety and outcomes of 90- versus
100-µm flaps. Am J Ophthalmol. 2011;152(4):582-590.
5. Pietilä J, Huhtala A, Jääskeläinen M, Jylli J, Mäkinen P, Uusitalo H. LASIK flap
creation with the Ziemer femtosecond laser in 787 consecutive eyes. J Refract Surg.
2010;26(1):7-16.
6. Harissi-Dagher M, Todani A, Melki S. Laser in situ keratomileusis buttonhole: clas-
sification and management algorithm. J Cataract Refract Surg. 2008;34(11):1892-1899.
SUGGESTED READING
Muñoz G, Albarrán-Diego C, Sakla HF, Pérez-Santonja JJ, Alió JL. Femtosecond laser in situ
keratomileusis after radial keratotomy. J Cataract Refract Surg. 2006;32(8):1270-1275.
Muñoz G, Albarrán-Diego C, Sakla HF, Javaloy J. Femtosecond laser in situ keratomileusis
for consecutive hyperopia after radial keratotomy. J Cataract Refract Surg.
2007;33(7):1183-1189.
5
Opaque Bubble Layer

OPAQUE BUBBLE LAYER
Opaque bubble layer (OBL) varies in incidence depending on the par tic-
ular femtosecond laser that is used. Some femtosecond laser systems have
programs that create a decompression pocket or channel that facilitates gas
escape during the raster pass.1-3 In some cases, gas can still collect in the
stroma and lead to an OBL.1-3
Cavitation bubbles formed during flap creation can expand into a cleav-
age plane at the stromal interlamellar space, which connects to the surface
via the side cut. It is hypothesized that when the laser energy is too high
(causing excessive bubbles) or too low (resulting in an inadequate pocket to
vent the bubbles), microplasma bubbles can travel in errant directions, push
apart collagen fibrils around them, and expand into the created space.4 This
is especially true in cases where the pocket/channel is turned off and no
meniscus is present.4 It is also thought that older patients have denser col-
lagen in the peripheral cornea and sclera compared with younger patients,
which may not allow bubbles to exit the periphery.4 Steeper, thicker corneas,
small flap, and hard-docking technique have been associated with more
OBLs.4
Reported OBL incidence varies between 3.69% on WaveLight FS200
(Alcon Labs) and 52.5% on IntraLase FS60 kilohertz (kHz) (Abbott Medical

54 Chapter 5
Optics).5 Studies using the IntraLase 60 kHz femtosecond laser found that
52.5% developed an OBL of various severities.5 Forty percent were with a
hard pattern, and 12.5% were with a soft pattern (under pocket-on mode).5-
8 Studies on eyes undergoing WaveLight FS200 femtosecond LASIK found
an average of 3.69% OBL in the flap area in the group with 1.7 mm channel
length and 6.06% OBL in the group with 1.3 mm channel length.6 Studies
on the VisuMax 500 kHz femtosecond laser (Carl Zeiss Meditec Inc) shows
that the incidence of OBL was 5%. Studies on FEMTO LDV Z6 (Ziemer
Ophthalmic Systems) shows that the incidence of OBL was 2%.9

Complication #1: Opaque Bubble Layer

in Visual Axis
The initial surgery resulted in OBL reaching the visual axis (video 5;
time: 1 minute 5 seconds; Figures 5-1, 5-2, and 5-3).
• Downward pressure with a spatula over the involved area after flap lift-
ing may facilitate tracker registration and pachymetry measurement.
Opaque Bubble Layer 55
Figure 5-1. Initial surgery resulted in OBL in the pupillary

area (red arrow).
Figure 5-2. Downward pressure with a spatula over the

involved stromal area was exerted to express the air out
and to facilitate tracker registration and pachymetry
measurement.
Figure 5-3. Excimer laser treatment (VISX STAR S4 [Abbott

Medical Optics]) was then uneventful.
56 Chapter 5
Figure 5-4. Initial surgery resulted in OBL in the superior

area reaching the pupillary zone (red arrow).
Figure 5-5. Downward pressure with a spatula over the

involved area was exerted to spread the bubbles into adja-
cent corneal layers and to facilitate tracker registration and
pachymetry measurement.

Superiorly Extending to Visual Axis
Platform: WaveLight FS200
The initial surgery resulted in OBL reaching the visual axis (video 5;
time: 2 minutes 7 seconds; Figures 5-4, 5-5, and 5-6).
Figure 5-6. Excimer laser treatment (WaveLight EX500 [Alcon Labs]) was then
uneventful.

• As stated previously, downward pressure with a spatula over the involved
area may facilitate tracker registration and pachymetry measurement.

Superiorly With Vertical Gas Breakthrough
The initial surgery resulted in OBL reaching the visual axis. A vertical
gas breakthrough can also be seen in the superior area. Flap adhesion was
noted superiorly (video 5; time: 3 minutes 9 seconds; Figures 5-7, 5-8, 5-9,
5-10, 5-11, and 5-12).
• Downward pressure with a spatula over the involved area may facilitate
tracker registration.
• Firm dissection and using flap forceps may be helpful to release the
adhesion.
• Measuring the optical zone with a caliber may be necessary to ensure
an adequate stromal bed exposure for excimer laser treatment.
• Reducing the optical zone to 6 mm may facilitate laser treatment.
58 Chapter 5
Figure 5-7. Initial surgery resulted in OBL in the superior

area reaching the pupillary zone. A vertical gas break-
through can also be seen in the superior area.
Figure 5-8. Photograph showing flap adhesion superiorly.
Figure 5-9. Flap adhesion was separated by firm dissec-

tion using the flap lifter. Downward pressure over the
involved area was exerted to spread the bubbles into
adjacent corneal layers and to facilitate tracker registra-
tion and pachymetry measurement.
Figure 5-10. Flap adhesion was separated by firm dissection

using flap forceps.
Figure 5-11. Optical zone was then evaluated from the adher-
ent area to the center of the pupil to guarantee at least a 6-mm
treatment zone.
Figure 5-12. Excimer laser treatment (WaveLight EX500) was

then uneventful.
60 Chapter 5
LASIK Surgery
Once OBL is detected, the following should occur:
• Continue laser treatment.
• OBL may interfere with the tracker or the iris registration of the
excimer.
• After lifting the flap, press firmly with a spatula to dissipate some of the
trapped gas from the stroma to help pupillary tracking and pachymetry
measurement.
• OBL usually dissipates within minutes to hours.
• OBL may lead to a tighter flap adhesion, which can result in flap tears
if not dissected carefully.
• Consider using the flap-lifting forceps to release the adherence between
the flap and the underlying stoma.
• Always ensure adequate pupil recognition by the tracker to avoid
decentered ablations.
PREVENTION OF OPAQUE BUBBLE LAYER

OBL has not been shown to affect refractive outcomes with the excimer
laser. OBL may be avoided by performing a soft dock, which pertains to
docking the patient interface enough on the suction ring to leave a ring of
tear meniscus through which the cavitation bubbles can escape. It also pre-
vents mechanical pressure that may seal the vertical pocket where bubbles
are usually collected.
REFERENCES
1. Mrochen M, Wullner C, Krause J, Klafke M, Donitzky C, Seiler T. Technical aspects
of the WaveLight FS200 femtosecond laser. J Refract Surg. 2010;26(10):S833-S840.
2. Kanellopoulos AJ, Asimellis G. Three-dimensional LASIK flap thickness variability:
topographic central, paracentral and peripheral assessment, in flaps created by a
mechanical microkeratome (M2) and two dif ferent femtosecond lasers (FS60 and
FS200). Clin Ophthalmol. 2013;7:675-683.
3. Faktorovich E. Femtodynamics. Thorofare, NJ: SLACK Inc; 2009.
4. Jung HG, Kim J, Lim TH. Possible risk factors and clinical effects of an opaque bubble
layer created with femtosecond laser–assisted laser in situ keratomileusis. J Cataract
Refract Surg. 2015;41(7):1393-1399.
5. Liu CH Sun CC, Hui-Kang Ma D, et al. Opaque bubble layer: incidence, risk factors,
and clinical relevance. J Cataract Refract Surg. 2014;40(3):435-440.
6. Kanellopoulos JA, Asimellis G. Essential opaque bubble layer elimination with novel
LASIK flap settings in the FS200 femtosecond laser. Clin Ophthalmol. 2013;7:765-770.
7. Shah SA, Stark WJ. Mechanical penetration of a femtosecond laser-created laser-
assisted in situ keratomileusis flap. Cornea. 2010;29(3):336-338.
8. Salomão MQ, Wilson SE. Femtosecond laser in laser in situ keratomileusis. J Cataract
Refract Surg. 2010;36(6):1024-1032.
9. Pietilä J, Huhtala A, Mäkinen P, Salmenhaara K, Uusitalo H. Laser-assisted
in situ keratomileusis flap creation with the three-dimensional, transportable
Ziemer FEMTO LDV model Z6 I femtosecond laser. Acta Ophthalmol. 2014
Nov;92(7):650-655.
SUGGESTED READING
6
Free Flaps
ETIOLOGY AND INCIDENCE OF FREE FLAPS

Femtosecond LASIK
A free flap or a cap is a rare but significant complication that can occur
with femtosecond LASIK. This can happen during flap manipulation rather
than during flap creation. Following its creation, the corneal flap can be
inadvertently severed from the hinge in the process of lifting, positioning,
and refloating. On occasion, a tear may happen at the hinge leading to a free
flap. Risk factors include the following:
• Tight adherence of the flap to the closed lid speculum due to flap dehy-
dration resulting from a longer than typical procedure.
• A thin corneal flap.
Some of the potential complications of free flap include irregular astig-
matism, recurrent flap dislodgement, and complete flap loss. Studies show a
rate of less than 0.5% of true free flap during femtosecond LASIK.1,2
Microkeratome LASIK
A free flap results from unintended complete dissection of the corneal
flap. Flat corneas (K < 42 diopters [D]) are more prone to this complication.
Often, a free flap is thinner than intended. Intraoperative factors leading to
a free flap include the following:
64 Chapter 6
• Inadequate suction ring placement.
• Lack of synchronization between translational keratome movement
and oscillatory blade movement.
• Malposition and misadjustment of the thickness foot-plate or the “stop”
mechanism during assembly of microkeratomes (early models of cer-
tain horizontal microkeratomes eg, Bausch + Lomb’s ACS keratome).
• Microkeratome jam, preventing microkeratome head reversal to free
the cap. This might prompt the surgeon to release the suction, thus
lifting the instrument with an incarcerated flap, resulting in a free flap.
The reported incidence of true free flap during micokeratome LASIK
ranges from 0.01% to 1% in large sample studies.3

Complication #1: Free Flap

The initial surgery on the right eye resulted in air bubbles in the anterior
chamber. Radial gentian violet marks were applied using an optical zone
marker at the intersection of the flap edge and corneal bed. The flap was
carefully lifted, and excimer laser ablation was applied. In the process of
repositioning the flap back onto the ablated corneal bed, its tight adherence
to the lid speculum resulted in a full-thickness detachment of the flap from
its superior hinge (video 6; time: 0 minutes 26 seconds; Figures 6-1, 6-2, 6-3,
6-4, 6-5, 6-6, and 6-7).
• Reposition the free flap using the fiduciary marks.
• Place a 10-0 nylon suture at the 9 o’clock position with an air knot to
minimize any torque, irregular astigmatism, or decentration tension.
• Place a contact lens.
Free Flaps 65
Figure 6-1. Initial surgery resulted in air bubbles in the ante-

rior chamber (red arrow).
Figure 6-2. Flap positioned on lid speculum. Air bubbles led

to a longer procedure and flap dehydration.
Figure 6-3. Air bubbles made tracking difficult and led to a

longer procedure and flap dehydration.
66 Chapter 6
Figure 6-4. While the flap was being pushed down with the irri-
gation cannula, its tight adherence to the lid speculum resulted
in a full detachment of the superiorly located hinge.
Figure 6-5. Flap was realigned using the previously placed

fiduciary marks.
Figure 6-6. Single 10-0 nylon suture was placed at the 9 o’clock

position with an air knot to keep the suture loose with minimal
vector force on the flap and the corneal bed.
Free Flaps 67
Figure 6-7. On the first postoperative day, the free flap was
clear and well-centered. The suture was removed under direct
visualization at the slit lamp without complications. At 3 months
postoperatively, the free flap was clear and well-centered. The
corrected distance visual acuity was 20/20 with a refraction of
-2.50 sphere (preoperative monovision target).

LASIK Surgery
Once a free flap is detected, the following should occur:
• If the exposed stroma is of the appropriate size and quality, laser abla-
tion treatment can proceed as planned. If the exposed stroma is smaller
than treatment optical zone, abort the procedure to allow proper flap
alignment. Surface excimer treatment can be planned after 1 week.
• If the free flap is intact, the placement of fiduciary marks at the inter-
face edge between the corneal flap and the peripheral cornea usually
allows the surgeon to replace the free flap in its original position.
• The flap is then removed and placed epithelial side down between 2
moist methylcellulose sponges.
• When the markings are not placed or are effaced during irrigation,
improper orientation may result in irregular astigmatism.
• The placement of a 10-0 nylon suture is the best method to secure the
flap. Proposed alternatives include the placement of a contact lens and
pressure patching. These are not as secure as a suture and may lead to
flap loss.
68 Chapter 6
Figure 6-8. Initial surgery resulted in a free flap. The flap was retrieved inside
the microkeratome head.

Complication #2: Free Flap

Platform: M2 Microkeratome (Moria)
The initial surgery on the right eye resulted in a free flap (video 6; time:
2 minutes 10 seconds; Figures 6-8, 6-9, 6-10, and 6-11).
• Try to locate the flap inside the microkeratome and assess whether it
is intact.
• When the markings are not placed or are effaced during irrigation, the
technique described by Todani et al can be used to adequately reposi-
tion the free flap by marking the free flap with gentian violet and then
using it to adequately orient the flap (Figure 6-12).
• For the subsequent steps, refer to Complication #1 with femtosecond
LASIK.
Free Flaps 69
Figure 6-9. Flap was repositioned on the stromal bed.
Figure 6-10. Proper flap alignment using fiduciary marks.
Figure 6-11. Flap alignment at the end of the surgery.

70 Chapter 6
Figure 6-12. Creation of a free LASIK flap with an automated microkeratome. (A) Following
placement of a longitudinal corneal incision at the proposed hinge site, the vacuum shaft is
aligned so the arrow on the suction ring points superiorly (12 o’clock position). (B) The free
flap is inspected on the superior surface of the microkeratome head. (C) A dot of gentian
violet is applied to the most peripheral epithelial edge of the flap on the side facing the
surgeon. (D) After the flap is retrieved, it is placed on the corneal bed, epithelial side up. A
Mendez Degree Gauge is placed on the cornea with the 0 degree reference mark aligned
at the 12 o’clock position (corresponding to the position of the arrow on the suction ring).

LASIK Surgery
Once a free flap is detected, the following should occur:
• Try to locate the flap inside the microkeratome and assess whether it
is intact.
• When the markings are not placed or are effaced during irrigation, the
Todani et al technique can be used to adequately reposition free flap by
applying a dot of gentian violet on the free flap (peripheral epithelial
edge; see Figure 6-12).
• For the remaining steps, refer to Complication #1 with femtosecond
LASIK.
Free Flaps 71
• If the free flap cannot be retrieved, the corneal epithelium is allowed to
heal. The excimer laser treatment should be aborted and retreatment
should be deferred until refractive stability is achieved.
PREVENTION OF FREE FLAP

Femtosecond LASIK
Because a free flap is commonly due to difficulty with lifting the flap,
flap lifting technique modification may help to decrease the incidence
of free flap. For a difficult flap lift, dissection should be conducted by
lifting smaller flap portions one at a time. The tip of the lifting spatula
should be parallel to the stroma rather than pointed upwards to avoid a
tear. Additionally, being cognizant of the instrument for dissection and its
tilt, speed, and rotation can also be impor tant to avoid inadvertent hinge
detachment. Minimizing patient factors such as eye movement or squeezing
can also be key to preventing this complication.
Microkeratome LASIK
The incidence of free flaps may be reduced if the surgeon ensures ade-
quate suction, inspects the blades, adjusts the plate thickness according to
corneal curvature, and pays attention to the following guidelines:
LASIK Enhancement
Identify the hinge prior to lifting the flap. Surgeons who routinely use
superior hinges may not recognize that an old flap has a nasal hinge and
may therefore tear it inadvertently. Areas of old epithelial ingrowth may
result in scarring and lead to a thin or melted flap that could easily tear
upon lifting.
72 Chapter 6
REFERENCES
1. Pietilä J, Huhtala A, Jääskeläinen M, Jylli J, Mäkinen P, Uusitalo H. LASIK flap
creation with the Ziemer femtosecond laser in 787 consecutive eyes. J Refract Surg.
2010;26(1):7-16.
2. Todani A, Al-Arfaj K, Melki SA. Repositioning free laser in situ keratomileusis flaps.
J Cataract Refract Surg. 2010;36(2):200-202.
3. Melki SA, Azar DT. LASIK complications: etiology, management, and prevention.
Surv Ophthalmol. 2001;46(2):95-116.
SUGGESTED READING
Choi CJ, Melki S. Loose anchoring suture to secure a free flap after laser in situ
keratomileusis. J Cataract Refract Surg. 2012;38(7):1127-1129.
7
Flap Tears
ETIOLOGY AND INCIDENCE OF FLAP TEARS

Femtosecond LASIK
Flap tears occur with the femtosecond laser mostly during flap dissection
rather than during flap creation. Femtosecond-created flaps are more resis-
tant to lifting compared with the microkeratome-created flaps. The risk of
tear is even higher with thinner flaps. On occasion, a tear may occur at the
hinge, leading to a free flap. Flap tears can also occur during the dissection
of flaps with a vertical gas breakthrough (VGB). The incidence of torn flaps
is approximately between 0.1% and 0.4% in eyes with femtosecond-assisted
flaps; similar percentages are found in eyes treated with microkeratome
LASIK.1,2
Microkeratome LASIK
Flap tears can also occur with microkeratome LASIK, and are mainly
associated with concomitant complications, such as thin and irregular flaps.

74 Chapter 7
Figure 7-1. Initial surgery resulted in an irregular flap cut

pattern.

Complication #1: Flap Tear During

Flap Dissection
The initial surgery resulted in a flap tear in the periphery during flap dis-
section (video 6; time: 0 minutes 15 seconds; Figures 7-1, 7-2, 7-3, and 7-4).
• Assess the position of the flap tear within the flap.
• A small peripheral flap tear may be lifted. Dissect the flap toward the
tear followed by the rest of the flap until it is entirely free.
• In cases of severe adherence, surgery should be aborted and a plan for a
future surface refractive procedure should be established.
Flap Tears 75
Figure 7-2. Dissection resulted in a flap tear at 9 o’clock on

an unusual thin flap.
Figure 7-3. Further dissection resulted in extension of the

tear. The flap was repositioned, and the surgery was aborted.
Figure 7-4. Flap was repositioned, and the surgery was

aborted. A surface refractive procedure was performed 1
week later. At 3 months postoperatively, the flap was clear
and well-centered with no signs of epithelial ingrowth. The
uncorrected visual acuity was 20/20.
76 Chapter 7
Figure 7-5. Initial surgery resulted in a black VGB in the periphery.
Figure 7-6. Photograph showing a black VGB in the periphery.
Complication #2: Flap Tear on Vertical

Gas Breakthrough
The initial surgery resulted in a black VGB in the periphery and a flap
tear during dissection (video 7; time: 2 minutes 20 seconds; Figures 7-5, 7-6,
and 7-7).
Flap Tears 77
Figure 7-7. Flap lift resulted in a tear in the periphery in the area of

VGB. Excimer laser treatment was uneventful.

• Apply excimer laser treatment.
Complication #3: Iatrogenic Flap Tear

During Dissection
The initial surgery resulted in a flap tear during dissection (video 7; time:
4 minutes 16 seconds; and Figures 7-8, 7-9, and 7-10).
78 Chapter 7
Figure 7-8. Initial surgery resulted in a flap tear during dissection.
Figure 7-9. Flap tear during dissection.
Figure 7-10. Excimer laser treatment was uneventful.

Flap Tears 79
LASIK Surgery
Once a free tear is detected, the following should occur:
• Large flap tears affecting the visual axis should be repositioned. If the
procedure is aborted, surface ablation is the safest approach to complete
the treatment.
• Small peripheral flap tears may be lifted. One can dissect the flap
toward the tear followed by the rest of the flap until it is entirely free.
• In cases of a free flap, put a loose anchoring suture to secure the flap
after completion of the stromal ablation.

Complication #4: Irregular Thin Torn Flap

The initial surgery resulted in an irregular torn flap construction due to
poor suction occurring at two-thirds the distance across the planned cut
(Figures 7-11 and 7-12).
• Assess the available space for the excimer laser treatment.
bed created is not adequate to apply the excimer treatment.
80 Chapter 7
Figure 7-11. Irregular flap construction due to poor suction. Stromal bed is inadequate
for the excimer laser treatment.
Figure 7-12. Surgery was aborted, and future refractive surgery was planned.

LASIK Surgery
Once a flap tear is detected, the following should occur:
Flap Tears 81
PREVENTION OF FLAP TEARS

Femtosecond LASIK
Because a flap tear is commonly due to difficulty with lifting the flap,
optimizing energy settings and technique may help to decrease its inci-
dence. As discussed in Chapter 6, for a difficult flap lift, dissection should
be limited to smaller flap portions at a time. The tip of the lifting spatula
should be parallel to the stroma rather than pointed upwards. Peripheral
tags can be prevented by increasing the side cut energy, by decreasing the
raster energy, or by refining flap lift techniques. Additionally, being cog-
nizant of the instrument for dissection and its tilt, speed, and rotation can
also be impor tant to avoid tag creation. Ensuring adequate suction and
minimizing patient factors such as eye movement or squeezing can be key
to preventing this complication.
Microkeratome LASIK
As with free flaps, the incidence of flap tears may be reduced if the sur-
geon ensures adequate suction, inspects the blades, adjusts the plate thick-
ness according to corneal curvature, and pays attention to the following
guidelines:
82 Chapter 7
REFERENCES
2013;39(11):1647-1652.
SUGGESTED READING
8
Incomplete Flaps

INCOMPLETE FLAPS
Femtosecond LASIK
An incomplete flap may happen with femtosecond LASIK if suction
proves to be unsuccessful, despite repeated attempts after an initial aborted
pass. It may also occur if the tear meniscus, debris, ink marks, or epithelial
defect shields an area of the flap from the laser ablation. The incidence of
incomplete flaps with femtosecond LASIK is approximately 0.03%.1,2
Microkeratome LASIK
Incomplete flaps may occur with microkeratome LASIK after loss of suc-
tion. Microkeratome jamming due to either electrical failure or mechanical
obstacles may also result in incomplete flaps. Lashes, drape, loose epithe-
lium, and precipitated salt from the irrigating solution have been recognized
as possible impediments to smooth keratome head progression. Incomplete
flaps also occur when the gear advancement mechanism jams or is inad-
equate. The incidence of incomplete flaps with microkeratome LASIK varies
between 0.23% and 1.2%.3

84 Chapter 8
Figure 8-1. Initial surgery resulted in a suction loss during the raster cut. The raster and
side cuts were not repeated in this case.

Complication #1: Incomplete Flap

(Unable to Lift)
The initial surgery resulted in a partial suction loss. Laser treatment was
continued. Adherence was found during dissection at the place where suc-
tion was lost (video 8; time: 0 minutes 6 seconds; Figures 8-1 and 8-2).
• Discontinue the laser treatment immediately and repeat the raster cut.
• Start the mechanical flap dissection in front of and behind the suspect-
ed uncut zone (place where suction was lost during the first raster cut).
• Blunt dissection and the use of flap forceps may release adherence.
• Extensive adherence may result in a flap tear with blunt dissection.
Incomplete Flaps 85
Figure 8-2. Flap lifting revealed adherence at the same place where suction was lost.
Surgery was aborted, and the patient underwent a surface refractive procedure 9
days later.
• Abort the procedure.


(Unable to Lift)
Platform: WaveLight FS200 (Alcon Labs)
The initial surgery resulted in an irregular flap cut pattern. Laser treat-
ment was continued. The flap was unable to be lifted (video 2; time: 1 min-
ute 53 seconds; Figures 8-3 and 8-4).
• An irregular raster cut pattern may be due to a deeper stromal cut.
86 Chapter 8
Figure 8-3. Initial surgery resulted in an irregular raster and site cut

configuration.
Figure 8-4. Flap lifting was not possible. Surgery was aborted, and
the patient underwent a surface refractive procedure 14 days later.

(Debris at Interface; Unable to Lift)
The initial surgery resulted in an incomplete flap due to debris at the
patient interface. Adherence was found during dissection at the place where
the debris was found (video 8; time: 5 minutes 18 seconds; Figures 8-5, 8-6,
and 8-7).
Incomplete Flaps 87
Figure 8-5. Initial surgery showed debris at patient interface

(red arrow).
Figure 8-6. Uncut area at flap-stroma interface (red arrow).
Figure 8-7. Flap lifting was not possible (red arrow). Surgery

was aborted, and the patient underwent a surface refractive
procedure 7 days later.
88 Chapter 8
• Start the mechanical flap dissection in front of and behind the sus-
pected uncut zone.

(Iatrogenic Epithelial Defect; Unable to Lift)
The initial surgery resulted in an incomplete flap due to an iatrogenic
epithelial defect. Adherence was found during dissection at the place of the
epithelial defect (video 8; time: 7 minutes 10 seconds; and Figures 8-8, 8-9,
and 8-10).
pected uncut zone.
Incomplete Flaps 89
Figure 8-8. Initial surgery showed an epithelial defect (red

arrow).
Figure 8-9. Uncut area at the epithelial defect zone (red arrow).
Figure 8-10. Flap lifting was not possible. Surgery was aborted,

and the patient underwent a surface refractive procedure 11
days later.
90 Chapter 8
Figure 8-11. Uncut area at the epithelial defect zone.
Figure 8-12. Flap lifting showed adherence at the epithelial defect

zone.

(Iatrogenic Epithelial Defect; Able to Lift)
epithelial defect (video 8; time: 8 minutes 45 seconds; Figures 8-11, 8-12,
and 8-13).
Incomplete Flaps 91
Figure 8-13. Optical zone was reduced to 6 mm, and the excimer laser treatment was
applied.

pected uncut zone.
• Assess the available stromal bed for the excimer laser treatment.
• Reduce the optical zone to 6 mm.
• Apply the excimer laser treatment.

(Able to Lift With Forceps)
The initial surgery resulted in a partial suction loss. Laser treatment
was not discontinued. A second raster cut was successfully attempted.
Adherence was found during dissection at the place where suction was lost
(video 8; time: 10 minutes 10 seconds; Figures 8-14, 8-15, 8-16, and 8-17).
92 Chapter 8
Figure 8-14. Initial surgery resulted in a suction loss during

the raster cut.
Figure 8-15. Raster and side cuts were repeated.
Figure 8-16. Flap lifting revealed adherence at the same

place where suction was lost first. Use of forceps to release
adherence is recommended.
Incomplete Flaps 93
Figure 8-17. Adherence was released, and the excimer laser

treatment was applied successfully.

• Blunt dissection may result in a flap tear in the area of the incomplete
flap.
• Use flap forceps to release adherence.

(Able to Lift With Dissection)
The initial surgery resulted in a partial suction loss. Laser treatment was
discontinued. A second raster cut was successfully attempted. Adherence
was found during dissection at the place where suction was lost (video 8;
time: 11 minutes 31 seconds; Figures 8-18, 8-19, 8-20, and 8-21).
• Blunt dissection may release adherence.
94 Chapter 8
Figure 8-18. Initial surgery resulted in a suction loss during the

raster cut.
Figure 8-19. Raster and side cuts were repeated.
Figure 8-20. Flap lifting revealed adherence at the same place

where suction was initially lost.
Incomplete Flaps 95
Figure 8-21. Adherence was released by simple dissection, and

the excimer laser treatment was applied successfully.
Complication #8: Incomplete Flap (Able to Lift

With Use of Vannas Scissors at Edge)
The initial surgery on the left eye resulted in an incomplete inferior side
construction due to a tear meniscus shields at 6 o’clock after partial suction
loss (video 8; time: 12 minutes 37 seconds; Figures 8-22, 8-23, 8-24, and
8-25).
• Start the mechanical flap dissection gently in the cut area toward the
uncut zone.
• Try to assess the extent of the uncut area.
flap.
• Use Vannas scissors to cut the adherent side cut zone.
96 Chapter 8
Figure 8-22. Initial surgery resulted in an incomplete inferior

side construction due to a torn meniscus shield at 6 o’clock after
partial suction loss (red arrow).
Figure 8-23. Incomplete inferior side construction resistant to

dissection.
Figure 8-24. Vannas scissors were used to release the adherent

side cut.
Incomplete Flaps 97
Figure 8-25. Ablation was subsequently performed, and the flap

was repositioned.
Complication #9: Incomplete Flap (Ink Mark)

The initial surgery resulted in an incomplete flap due to an ink mark used
to pinpoint the pupillary center. Adherence was found during dissection at
the place of the ink (video 8; time: 15 minutes 27 seconds; Figures 8-26, 8-27,
8-28, and 8-29).
pected uncut zone.
• Assess the available stromal bed for laser treatment, and apply the
excimer laser treatment.
98 Chapter 8
Figure 8-26. Uncut area at the ink zone.
Figure 8-27. Flap lifting showed adherence at the uncut zone.
Figure 8-28. Use forceps to release adherence.

Incomplete Flaps 99
Figure 8-29. Successful flap release and excimer laser treatment.

LASIK Surgery
Once incomplete flap is detected, the following should occur:
pected uncut zone.
flap.
• Use flap forceps to release adherence.
• Use Vannas scissors to cut the adherent side cut zone.
• Abort procedure when extensive adherence and/or irregular raster cut
bed are found.
• Plan for a future surface refractive procedure if the excimer laser treat-
ment was not applied.
100 Chapter 8

loss occurring at one-third the distance across the planned cut. Surgery was aborted,
and surface refractive procedure was planned 1 week later.

Complication #10: Loss of Suction During

Microkeratome Pass
suction loss occurring at one-third the distance across the planned cut
(video 8; time: 17 minutes 32 seconds; Figure 8-30).
• Pause the surgery.
Incomplete Flaps 101
Figure 8-31. Microkeratome jamming due to a mechanical obstacle, resulting in

incomplete flap (microkeratome hitting the speculum; red arrow).
Figure 8-32. Incomplete flap construction due to microkeratome jamming at two-

thirds the distance across the planned cut.
Complication #11: Incomplete Flap Due to

Mechanical Obstruction
Platform: Automated Corneal Shaper (Bausch + Lomb)
keratome being blocked by the lid speculum occurring at two-thirds the
distance across the planned cut (video 8; time: 17 minutes 52 seconds;
Figures 8-31, 8-32, and 8-33).
102 Chapter 8
Figure 8-33. Risky maneuver showing blade #15 used to extend the dissection plan.
Ablation was subsequently performed.

• Avoid manually extending the dissection with a blade, as this can result
in a buttonhole during dissection.
• If the laser ablation is performed, the flap should be protected from
laser exposure.

LASIK Surgery
Once an incomplete flap is detected, the following should occur:
• Avoid manually extending the dissection with a blade.
• If the laser ablation is performed, the flap should be protected from
laser exposure.
• Abort the procedure in cases involving an irregular bed and/or flap.
Incomplete Flaps 103
PREVENTION OF INCOMPLETE FLAPS

Femtosecond LASIK
The main preventable cause of an incomplete flap is suction loss. Careful
observation during docking of the patient interface and reposition if neces-
sary can be helpful. Additionally, recognizing preoperative risk factors, such
as a deep set orbit, and planning accordingly can also be useful in prevent-
ing suction loss. Patients who forcefully squeeze their lids may benefit from
additional sedation or the placement of a wire lid speculum. The following
interventions may be also helpful in preventing an incomplete flap in fem-
tosecond LASIK:
• Eliminate all patient interface debris using pressurized air dust remover.
• Postpone a flap cut in case of an epithelial defect in the pupillary area.
• Avoid using ink to mark the center of the flap cut.
Microkeratome LASIK
The incidence of incomplete flaps may be reduced if the surgeon ensures
adequate suction, inspects the blades, adjusts the plate thickness according
to corneal curvature, and pays attention to the following guidelines:
104 Chapter 8
REFERENCES
1. Davison JA, Johnson SC. Intraoperative complications of LASIK flaps using the
IntraLase femtosecond laser in 3009 cases. J Refract Surg. 2010;26(11):851-857.
2. Shah DN, Melki SA. Complications of femtosecond-assisted laser in-situ
keratomileusis flaps. Semin Ophthalmol. 2014;29(5-6):363-375.
3. Nakano K, Nakano E, Oliveira M, Portellinha W, Alvarenga L. Intraoperative
microkeratome complications in 47,094 laser in situ keratomileusis surgeries.
J Refract Surg. 2004;20(5 Suppl):S723-S726.
SUGGESTED READING
Ang M, Mehta JS, Rosman M, et al. Visual outcomes comparison of 2 femtosec-
ond laser platforms for laser in situ keratomileusis. J Cataract Refract Surg.
2013;39(11):1647-1652.
Melki SA, Azar DT. Lasik complications: etiology, management, and prevention. Surv
Ophthalmol. 2001;46(2):95-116.
Muñoz G, Albarrán-Diego C, Ferrer-Blasco T, Javaloy J, García-Lázaro S. Single ver-
sus double femtosecond laser pass for incomplete laser in situ keratomileusis
flap in contralateral eyes: visual and optical outcomes. J Cataract Refract Surg.
2012;38(1):8-15.
Rosman M, Hall RC, Chan C, et al. Comparison of efficacy and safety of laser in situ
Refract Surg. 2013;39(7):1066-1073.
9
Irregular Flaps

OF IRREGULAR FLAPS
Femtosecond LASIK
An irregular flap may happen after suction loss and a repeated flap cut
attempt. Another risk factor for an irregular second pass is the disappear-
ance of the transient opaque bubble layer before performing the second
femtosecond pass. Irregular flap incidence with femtosecond LASIK is
unknown.
Microkeratome LASIK
Irregular flaps (bileveled, bisected, or with a notch) may result from
poor suction, damaged microkeratome blades, or irregular oscillation.
Irregular flap incidence with microkeratome LASIK varies between 0.09%
and 0.2%.1,2

106 Chapter 9
Figure 9-1. Initial surgery resulted in an incomplete flap con-

struction due to suction loss occurring at two-thirds the distance
across the planned cut.

Complication #1: Double Flap Due to Recut at

Different Plane
struction due to suction loss occurring at one-third the distance across the
planned cut. The second pass resulted in complete flap creation. Flap lifting
revealed the presence of 2 dif ferent flaps that disrupted during dissection
(video 9; time: 0 minutes 7 seconds; Figures 9-1, 9-2, 9-3, 9-4, 9-5, 9-6, and
9-7).
• Try to reconstruct the irregular flap before repositioning.
Irregular Flaps 107
Figure 9-2. Second pass resulted in complete flap creation.
Figure 9-3. Flap lifting revealed the presence of 2 dif ferent flap

planes.
Figure 9-4. Several attempts were undertaken to reconstruct

the irregular flap.
108 Chapter 9
Figure 9-5. Flap was repositioned, and surgery was aborted. On the
first day after surgery, the patient had a corrected distance visual acu-
ity of 20/40 with a clear LASIK flap on slit lamp examination. At his
4-month follow-up visit, his corrected distance visual acuity was 20/25
with −2.50 −0.50 × 90 (see Figure 9-14). He underwent a surface refrac-
tive procedure with 40 seconds of mitomycin-C 0.02% 1 week later.
Figure 9-6. Topography 1 week after the aborted procedure.

Irregular Flaps 109
Figure 9-7. Topography 3 months after the surface refractive procedure.
Complication #2: Irregular Flap Secondary to

Uneven Cut
The initial surgery resulted in an irregular partial epithelial flap (video 9;
time: 2 minutes 2 seconds; Figures 9-8 and 9-9).
110 Chapter 9
Figure 9-8. Initial surgery resulted in an irregular partial epithelial flap.
Figure 9-9. Flap was repositioned, and the surgery was aborted. On the first day after
surgery, the patient had an uncorrected distance visual acuity of 20/50 with LASIK
flaps clear and well-centered on slit lamp examination. At his 1-month follow-up
visit, uncorrected distance visual acuity was 20/20. He underwent a surface refractive
procedure with 40 seconds mitomycin-C 0.02%. His uncorrected visual acuity 1 month
later was 20/20.
Complication #3: Irregular Flap Secondary to

Flap Dryness
Irregular Flaps 111
Figure 9-10. Initial surgery showed a dry flap (red arrow).
Figure 9-11. Flap lift showed an irregular stromal bed in the paracentral pupillary area
(red arrow). The excimer laser treatment was uneventful. At his 2-month follow-up
visit, uncorrected distance visual acuity was 20/20.

The initial surgery resulted in an irregular partial epithelial flap (video 9;
time: 2 minutes 44 seconds; Figures 9-10 and 9-11).
• Assess the position of the irregular stromal bed to papillary area.
• Apply the excimer laser treatment if the irregular bed is away from the
visual axis.
• Plan for a future surface refractive procedure elsewhere.
112 Chapter 9
LASIK Surgery
Once an irregular flap is detected, the following should occur:
• Plan for a future surface refractive procedure over the incomplete flap
as early as 1 week after the aborted procedure with the application of
mitomycin-C to avoid scarring.

Complication #4: Poor Microkeratome Suction

and Irregular Incomplete Flap
The initial surgery resulted in an irregular flap construction due to
(Figures 9-12, 9-13, and 9-14).
Irregular Flaps 113
Figure 9-12. Irregular flap construction due to poor suction.
Figure 9-13. Stromal bed was inadequate for the excimer laser
treatment.
Figure 9-14. Surgery was aborted, and a future refractive surgery was

planned.
114 Chapter 9
LASIK Surgery
Once irregular flap is detected, the following should occur:
• Plan for a future surface refractive procedure over the incomplete flap
as early as 1 week after the aborted procedure with the application of
mitomycin-C to avoid scarring.
PREVENTION OF IRREGULAR FLAPS

Femtosecond LASIK
Careful observation during docking of the patient interface and reposi-
tioning, if necessary, can be helpful to avoid suction loss and the risk of an
irregular flap after recuts.
Microkeratome LASIK
The incidence of free flaps may be reduced if the surgeon ensures ade-
Irregular Flaps 115
REFERENCES
1. Stulting RD, Carr JD, Thompson KP, et al. Complications of laser in situ keratomileusis
for the correction of myopia. Ophthalmology. 1999;106(1):13-20.
2. Lin RT, Maloney RK. Flap complications associated with lamellar refractive surgery.
Am J Ophthalmol. 1999;127(2):129-136.
SUGGESTED READING
Melki SA, Azar DT. LASIK complications: etiology, management, and prevention. Surv
Ophthalmol. 2001;46(2):95-116.
10
Epithelial Defect

EPITHELIAL DEFECT
Femtosecond and Microkeratome LASIK
An epithelial defect is defined as an area of epithelium with a break or
loose cells greater than 2 mm. Trauma to the epithelium seems significantly
less likely with the femtosecond laser compared with the microkeratome
laser. It can still occur during several docking attempts, or especially when
inexperienced surgeons have difficulty inserting the dissecting spatula
under the flap edge. Epithelial defects tend to occur in patients with pre-
disposing risk factors such as epithelial basement membrane dystrophy or
a history of recurrent corneal erosion syndrome. They are also more com-
monly seen in older patients, in patients with large flap diameters, and with
excessive topical anesthetic use. Epithelial defects also tend to occur when
lifting the flap for LASIK refractive enhancement. The main advantage of
the femtosecond laser is the absence of the keratome rotational movement
that can lead to tearing or shearing of the epithelium. The incidence of epi-
thelial defect with femtosecond LASIK is approximately 0.6%,1-3 while the
incidence with microkeratome is between 1% and 8.65%, depending on the
type of microkeratome used.1-3

118 Chapter 10
Figure 10-1. Iatrogenic epithelial defect induced during a flap

lift.
Figure 10-2. Excimer laser treatment was uneventful.

Complication #1: Epithelial Defect During

Flap Lift
The initial surgery on the left eye resulted in an epithelial defect from
an inadvertent epithelial flap lift (video 10; time: 0 minutes 5 seconds;
Figures 10-1, 10-2, and 10-3).
Epithelial Defect 119
Figure 10-3. Epithelial defect was repositioned, and a contact

lens was placed at the end.

• Try to reposition the epithelial defect.
• Place a contact lens at the end of the procedure.

Flap Repositioning
flap repositioning (video 10; time: 3 minutes 9 seconds; Figures 10-4 and
10-5).
120 Chapter 10
Figure 10-4. Iatrogenic epithelial defect induced during flap repositioning (red arrow).
Figure 10-5. Epithelial defect was repositioned, and a contact lens was placed at the
end (red arrow).
Complication #3: Epithelial Defect During Flap

Lifting for LASIK Enhancement Surgery
Figure 10-6. Iatrogenic epithelial defect induced during flap lifting (red arrow).
Figure 10-7. Epithelial defect was repositioned, and a contact lens was placed at the
end.
flap repositioning (video 10; time: 0 minutes 30 seconds; Figures 10-6 and
10-7).
122 Chapter 10
Figure 10-8. Initial surgery showed an epithelial defect (red arrow).
Figure 10-9. Uncut area at the epithelial defect zone (red arrow).
Complication #4: Iatrogenic Epithelial Defect

During Docking (Flap Unable to Lift)
epithelial defect (video 10; time: 8 minutes 39 seconds; Figures 10-8, 10-9,
and 10-10).
Figure 10-10. Flap lifting was not possible. Surgery was aborted, and the patient
underwent a surface refractive procedure 11 days later.

pected uncut zone.

LASIK Surgery
Once an epithelial defect is detected, the following should occur:
• If the epithelial defect happens after femtosecond treatment, one should
do as follows:
º Continue the laser treatment.
º Lift the flap gently in case an incomplete flap is suspected.
º Try to reposition the epithelial defect at the end of the procedure.
º Treat with topical antibiotics and a bandage contact.
• If the epithelial defect happens before femtosecond treatment, refer to
Chapter 8.
124 Chapter 10
Figure 10-11. Initial surgery was uneventful but resulted in an

epithelial defect in the visual axis.
Figure 10-12. Flap lift and excimer laser treatment were

uneventful. Epithelial defect was repositioned, and a contact
lens was placed.


Flap Cut
The initial surgery on the right eye resulted in a complete flap cut with
an epithelial defect (video 10; time: 10 minutes 14 seconds; Figures 10-11
and 10-12).

LASIK Surgery
Once an epithelial defect is detected, the following should occur:
• If the epithelial defect happens without any buttonhole or irregular
flap, one should do as follows:
º Apply excimer laser treatment.
º Try to reposition the epithelial defect at the end of the procedure.
º Treat with topical antibiotics and a bandage contact.
• If the epithelial defect happens with a buttonhole, refer to Chapter 4.
PREVENTION OF EPITHELIAL DEFECT

Because the majority of epithelial defects occur in patients with predis-
posing risk factors, it is impor tant to identify them preoperatively. Patients
with asymptomatic epithelial basement membrane dystrophy may still
undergo femtosecond LASIK at a much lower risk than with keratome
LASIK; however, they should be counseled accordingly. A consideration for
surface ablation should be given for patients with a history of symptomatic
recurrent corneal erosion syndrome.
126 Chapter 10
REFERENCES
1. Kezirian GM, Stonecipher KG. Comparison of the IntraLase femtosecond laser
and mechanical keratomes for laser in situ keratomileusis. J Cataract Refract Surg.
2004;30(4):804-811.
2. Feder R, Rapuano C. The LASIK Handbook: A Case-Based Approach. Second edition.
Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
3. Moshirfar M, Gardiner JP, Schliesser JA, et al. Laser in situ keratomileusis flap com-
SUGGESTED READING
11
Thin and Thick Flaps

THIN AND THICK FLAPS
A flap is considered thin when the keratome or laser cuts are within or
above the 12-microns (μm)-thick Bowman’s layer. This is recognized by a
shiny reflex on the stromal surface. The use of corneal pachymeter before
and after lifting the flap may be helpful in recognizing this occurrence. A
measurement below 60 μm is suspicious, as the thickness of the corneal
epithelium is approximately 50 μm. The definition of thick flap is not clear
in the literature, but usually involves flaps with a thickness resulting in a
lesser-than-intended residual stromal bed (ie, residual stromal bed < 300 μm
after excimer laser treatment). The incidence of thin flaps after LASIK
has been reported to vary between 0.3% and 0.75%.1-3 With femtosecond
LASIK, the rate is approximately 0.08%.1,2 Thick flap incidence is not
reported in the literature.
Femtosecond LASIK
Cavitation bubbles from the femtosecond laser can dissect upwards
toward the epithelium and may stay below the Bowman’s membrane to
create a focal or diffuse thinning in the flap. Also, air bubbles may diffuse
accidently deeper, creating a thick flap.

128 Chapter 11
Microkeratome LASIK
Higher keratometric values offer increased resistance to cutting when
applanated, leading to upward or downward movement of the blade, and
may result in thin and thick flaps. Also, a lack of synchronization between
translational flat keratome movement and oscillatory blade movement
results in forward displacement of corneal tissue, leading to thin or thick
flaps. Flat corneas may also result in a thin flap, as they could be below
the adequate cutting plane in certain locations. Blade positioning in the
microkeratome and the preset space for the blade in the microkeratome may
affect flap thickness in the absence of an irregular flap shape.

Complication #1: Thin Regular Flap

The initial surgery resulted in a thin regular flap that disrupted during
flap dissection (video 11; time: 0 minutes 5 seconds; Figures 11-1, 11-2, and
11-3).
• Assess the flap regularity.
• Apply excimer laser treatment with regular flap and an adequate-sized
stromal bed.
• Try to reposition the flap and epithelial defect in the best anatomical
configuration.
Thin and Thick Flaps 129
Figure 11-1. Initial surgery resulted in a thin flap with a tear dur-

ing dissection.
Figure 11-2. Successful excimer laser treatment.
Figure 11-3. Flap was repositioned. At 3 months postoperatively,

the flap was clear and well-centered with no signs of epithelial
ingrowth.
130 Chapter 11
Figure 11-4. Initial surgery resulted in an irregular flap cut pattern.
Figure 11-5. Dissection resulted in a flap tear at 9 o’clock on an unusual thin

flap.
Complication #2: Localized Thin Regular Flap

The initial surgery resulted in a thin flap in the periphery with a tear
during dissection (video 11; time: 1 minute 53 seconds; Figures 11-4, 11-5,
11-6, and 11-7).
Figure 11-6. Further dissection resulted in an extension of the tear. Flap was

repositioned, and the surgery was aborted.
Figure 11-7. Flap was repositioned, and the surgery was aborted. A surface
refractive procedure was performed 1 week later.

• In case of severe adherence, surgery should be aborted and one should
plan for a future surface refractive procedure.
132 Chapter 11
Figure 11-8. Initial surgery resulted in a thin flap. The red arrow shows the intersection
between a full-thickness and an epithelial flap. Flap was repositioned, and the surgery
was aborted. A surface refractive procedure was performed 1 week later.
Complication #3: Thin Irregular Flap

Platform: IntraLase FS60 kHz (Abbott Medical Optics)
The initial surgery resulted in a thin irregular flap (partial epithelial flap;
video 11; time: 3 minutes 52 seconds; Figure 11-8).
• Abort the procedure when dealing with an irregular flap.
• Plan for a future refractive procedure.
Complication #4: Thick Regular Flap

The initial surgery resulted in a thick regular flap (video 11; time: 6 min-
utes 19 seconds; Figures 11-9, 11-10, 11-11, and 11-12).
Figure 11-9. Initial surgery resulted in an irregular flap cut

pattern.
Figure 11-10. Flap lifting showed an irregular stromal bed cut

pattern resulting in a thick regular flap.
Figure 11-11. Ultrasound revealed a flap thickness of 200 μm

and a residual stromal bed of 260 μm in case treatment is
undertaken.
134 Chapter 11
Figure 11-12. Flap was repositioned, and the surgery was

aborted. A surface refractive procedure was performed 1 week
later.

• Assess the flap and stromal bed regularity.
• Perform corneal pachymetry.
• Abort the procedure if the residual stromal bed will be < 300 μm after
the excimer laser treatment.
Complication #5: Thick Irregular Flap

The initial surgery resulted in a thick irregular flap pattern that was
unable to be lifted (video 11; time: 7 minutes 12 seconds; Figures 11-13 and
11-14).
Figure 11-13. Initial surgery resulted in an irregular flap cut pattern.
Figure 11-14. Flap was unable to be lifted, and the surgery was aborted. A
surface refractive procedure was performed 2 weeks later.

LASIK Surgery
Once thin or thick flaps are detected, the following should occur:
• Assess the available space for excimer laser treatment.
136 Chapter 11
• Apply excimer laser treatment with thin regular flaps performed under
Bowman’s layer and with an adequate-sized stromal bed.
configuration.
• Abort the procedure if the extent of the stromal bed created is not
adequate to apply the excimer laser treatment.
the excimer laser treatment.

Complication #5: Thin Regular Flap

Video section: 8 minutes 1 second
Platform: Amadeus II (Ziemer Ophthalmic Systems)
The initial surgery resulted in a thin regular flap (video 11; time: 8 min-
utes 1 second; Figures 11-15, 11-16, and 11-17).
• Apply excimer laser treatment with regular flap and an adequate-sized
stromal bed.
• Try to reposition the flap in the best anatomical configuration.
Figure 11-15. Initial surgery was uneventful.
Figure 11-16. Surgery resulted in a thin regular flap. Excimer laser treat-

ment was applied.
Figure 11-17. Flap was repositioned.

138 Chapter 11
Figure 11-18. Thin irregular flap construction due to poor suction.

The stromal bed is inadequate for excimer laser treatment.
Figure 11-19. Surgery was aborted, and a future refractive surgery

was planned.
Complication #6: Thin Irregular Flap

The initial surgery resulted in an irregular torn flap construction due to
(Figures 11-18 and 11-19).
• Abort the procedure and plan for a future surface refractive procedure
if the extent of the stromal bed created is not adequate to apply the
excimer laser treatment.

LASIK Surgery
Once thin or thick flaps are detected, the following should occur:
• Apply excimer laser treatment with thin regular flaps and an adequate-
sized stromal bed.
configuration.
• Abort the procedure if the extent of the stromal bed created is not
adequate to apply the excimer laser treatment.
the excimer treatment.
PREVENTION OF THIN AND THICK FLAPS

Femtosecond LASIK
Thin flaps are usually due to technical issues within the femtosecond
laser, and are beyond a surgeon’s control. However, ensuring adequate suc-
tion and minimizing patient factors such as eye movement or squeezing can
help to prevent this complication.
Microkeratome LASIK
The incidence of thin flaps may be reduced if the surgeon ensures ade-
140 Chapter 11
REFERENCES
2013;39(11):1647-1652.
SUGGESTED READING
12
Decentered Flaps

OF DECENTERED FLAPS
Appropriate flap centration is crucial for the success of LASIK. Creating
a flap with an adequate diameter is necessary to create a bed that is suf-
ficient for excimer laser treatment. A decentered flap is a complication that
occurs during the LASIK procedure that can affect the visual and refractive
outcome, causing the loss of best-corrected visual acuity if not managed
properly. It is impor tant to be prepared to abort the procedure if the exposed
stroma cannot accommodate the planned ablation zone.
Patient and surgeon factors can influence flap creation. Head posi-
tion, ring position, and applanation can all influence the procedure.
Decentered flaps have been reported as a complication with mechanical
microkeratomes. They mainly occur when the vacuum ring slowly shifts
between the application of suction and the initiation of the keratome pass.
This is a phenomenon referred to as oozing; it can be missed if the surgeon
is not attentive to it. Decentered flaps have been reported with less frequency
with the femtosecond laser. The femtosecond laser allows small adjustments
in flap centration prior to ablation to permit the realignment of the flap.
This is not possible with a microkeratome laser. The incidence of decentered
flaps after microkeratome LASIK has been reported to be approximately

142 Chapter 12
0.6%.1-3 Only one study in the literature reports the rate of decentration
with femtosecond LASIK at approximately 0.1%.2-4

Complication #1: Difficult Docking Resulting

in Decentered Flap
The initial surgery resulted in a decentered flap (video 12; time: 0 min-
utes 10 seconds; Figures 12-1, 12-2, and 12-3).
• Assess the available stroma for excimer laser treatment.
• Abort the procedure in cases of severely decentered flaps (ie, situation
where a 6.0-mm stromal ablation zone is not attainable under the flap).
Decentered Flaps 143
Figure 12-1. Initial surgery showed a difficult docking

attempt.
Figure 12-2. Docking was repeated, and the laser cut

resulted in an inferiorly decentered flap.
Figure 12-3. Flap was not lifted. A surface refractive

procedure was performed 1 week later.
144 Chapter 12
Figure 12-4. Initial surgery resulted in a decentered flap. The flap was repositioned,
and the surgery was aborted. A surface refractive procedure was performed 1 week
later. At 2 months postoperatively, the flap was clear and well-centered with no signs
of epithelial ingrowth. The uncorrected visual acuity was 20/20.
Complication #2: Decentered Thin Irregular Flap

The initial surgery resulted in a decentered flap (video 12; time: 1 minute
30 seconds; Figure 12-4).
• Assess the flap regularity and available stroma for excimer laser
treatment.
• Abort the procedure when dealing with an irregular flap.
Decentered Flaps 145
LASIK Surgery
Once decentered flap is detected, the following should occur:
• Assess the flap regularity and available stroma for excimer laser treat-
ment. It is preferable to make that assessment prior to flap lifting.
• Consider shrinking the optical zone if needed. This may be difficult to
do if the patient has a large pupil.
• Abort the procedure in cases of severely decentered flaps (ie, situations
where the stromal ablation zone is not adequate).
• Abort the procedure if the flap is too irregular to be lifted.
• On occasion, the blend zone may extend beyond the exposed stroma
and ablate the surrounding epithelium. This may increase the risk of
epithelial ingrowth. A microsponge can be placed on the epithelium to
protect it from the overlying excimer ablation.
• Place a contact lens if needed.
PREVENTION OF DECENTERED FLAPS

Femtosecond LASIK
Decentered flaps are usually due to difficult docking. Ensuring adequate
suction and minimizing patient factors such as eye movement or squeezing
can help to prevent this complication when using femtosecond lasers.
Microkeratome LASIK
The incidence of decentered flaps may be reduced when using
microkeratome if the surgeon ensures adequate suction, inspects the blades,
adjusts the plate thickness according to corneal curvature, and avoids cut-
ting the flap if the intraocular pressure is low.
146 Chapter 12
REFERENCES
2013;39(11):1647-1652.
13
Subconjunctival
Hemorrhage and Bleeding

OF SUBCONJUNCTIVAL HEMORRHAGE
AND BLEEDING
Femtosecond LASIK
Subconjunctival hemorrhage can occur with IntraLase platforms (Abbott
Medical Optics) when the syringe is applied too quickly or released too
quickly during the suction application. It can also occur when multiple
suction applications are needed due to suction loss. Bleeding from limbal
vessels may also occur at the edge of the flap. It is seen most commonly
in patients with limbal neovascularization and prior contact lens use.
Limbal neovascularization as a result of rosacea, atopy, and meibomian
gland dysfunction may also contribute to subconjunctival hemorrhage.
Subconjunctival hemorrhage incidence is noted in 68.9% of eyes with the
IntraLase (Abbott Medical Optics) platform but none with the VisuMax
Femtosecond Laser (Zeiss).1 This is thought to be secondary to the variation
in the docking mechanisms. For instance, suction is applied to the sclera
with the IntraLase laser as compared to cornea with the VisuMax laser.1
Bleeding incidence is less than 1% with the femtosecond laser.

148 Chapter 13
Figure 13-1. Photograph showing a large peripheral flap and

peripheral vessels transected.
Microkeratome LASIK
Subconjunctival hemorrhage can occur with microkeratome LASIK from
the suction ring. Micropannus formation is commonly seen with soft contact
lens wear, and hemorrhage may occur if the microkeratome pass transects
these vessels. This complication may be frequently encountered with larger
flaps (9 to 9.5 mm) and larger treatment zones needed for hyperopia. With
the microkeratome, subconjunctival hemorrhage incidence is between 50%
and 70%.3 Bleeding incidence is less than 1% with the microkeratome.1,3

Complication #1: Large Peripheral Flap

The initial surgery resulted in subconjunctival hemorrhage and bleed-
ing in the interface (video 13; time: 0 minutes 5 seconds; Figures 13-1, 13-2,
13-3, and 13-4).
Subconjunctival Hemorrhage and Bleeding 149
Figure 13-2. Photograph showing blood reaching the stromal bed.
Figure 13-3. Dry the stromal interface before applying the excimer

laser.
Figure 13-4. Irrigate the interface after treatment to avoid any

residual blood.
150 Chapter 13
Figure 13-5. Photograph showing difficult docking.
Figure 13-6. Photograph showing scleral show and peripheral

blood vessels transected.
• Dry the blood from the interface before applying excimer laser
treatment.
• Keep drying the periphery during laser treatment.
• Irrigate the interface to avoid any residual blood.
Complication #2: Several Docking Attempts

The initial surgery on the left eye resulted in subconjunctival hemorrhage
and bleeding from the hinge zone after several difficult docking attempts
(video 13; time: 2 minutes 0 seconds; Figures 13-5, 13-6, 13-7, and 13-8).
Figure 13-7. Photograph showing the bleeding of vessels near the

hinge area.
Figure 13-8. Dry the stromal interface before applying the treat-
ment. Excimer laser treatment (WaveLight EX500 [Alcon Labs]) was
then uneventful. Irrigating the interface after treatment was also
performed to avoid any blood in the interface.

• Dry the interface before applying excimer laser treatment.
152 Chapter 13
LASIK Surgery
Once subconjunctival hemorrhage is detected, the following should
occur:
• Continue the laser treatment.
• Exert downward pressure with a sponge to stop any active conjunctival
bleeding.
• Dry well before and during the laser treatment to avoid irregular
astigmatism.
• Irrigate any blood from the interface after the laser treatment to
decrease the risk of diffuse lamellar keratitis.
Even though a subconjunctival hemorrhage is generally of no conse-
quence, it is impor tant to inform patients of the risk so that they are not
alarmed.

Complication #3: Large Peripheral Flap

The initial surgery resulted in bleeding (video 13; time: 4 minutes 24
seconds; Figure 13-9).
• Dry the interface before applying excimer laser treatment.
Figure 13-9. Dry the stromal interface before applying the treatment.

LASIK Surgery
Once subconjunctival hemorrhage is detected, the following should
occur:
• Exert downward pressure with a sponge to stop any active conjunctival
bleeding.
• Dry well before and during the laser treatment to avoid irregular
astigmatism.
• Irrigate any blood from the interface after the laser treatment to
decrease the risk of diffuse lamellar keratitis.
• If associated with an irregular flap, the surgery should be aborted.
Even though a subconjunctival hemorrhage is generally of no conse-
quence, it is impor tant to inform patients of the risk so that they are not
alarmed.
PREVENTION OF SUBCONJUNCTIVAL
HEMORRHAGE AND BLEEDING
The slow and controlled application of suction and release is impor tant in
preventing bleeding. Large peripheral flaps are more commonly associated
with an increased risk of transecting peripheral blood vessels. Flaps that
154 Chapter 13
are decentered and closer to the limbus on one side are also at greater risk.
Avoiding superior flap decentration and making a smaller flap can prevent
bleeding in patients with neovascularization. Although brimonidine has
been used in the past to minimize the risk of bleeding, it has been reported
to increase the risk of flap dislocation.2
REFERENCES
1. Rosman M, Hall RC, Chan C, et al. Comparison of efficacy and safety of laser in situ
Refract Surg. 2013;39(7):1066-1073.
2. Aslanides IM, Tsiklis NS, Ozkilic E, Coskunseven E, Pallikaris lG, Jankov MR. The
effect of topical apraclonidine on subconjunctival hemorrhage and flap adherence in
LASIK patients. J Refract Surg. 2006;22(6):585-588.
3. Yildirim R, Devranoglu K, Ozdamar A, Aras C, Ozkiris A, Ozkan S. Flap compli-
cations in our learning curve of laser in situ keratomileusis using the Hansatome
microkeratome. Eur J Ophthalmol. 2001;11(4):328-332.
SUGGESTED READING
Feder R, Rapuano C. The LASIK Handbook: A Case-Based Approach. Second edition.
Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
14
Special Considerations
DIFFICULT DOCKING
The following are 5 main factors that may coexist and result in difficult
docking: small palpebral fissure (Figure 14-1), lid squeezing, conjunctival
chalasis (Figure 14-2), deep orbit, and par ticular nose shape.
Small Palpebral Fissure

In patients with narrow palpebral fissures, space is limited. Turning an
individual’s head away from the eye that is having surgery causes the eyeball
to rotate away from the nose, and creates extra space to place the suction
ring. A lid speculum may be used to give better exposure to get the vacuum
ring onto the globe.
Lid Squeezing
This may exert pressure on the suction ring, and lead to loss of suction.
Prompting the patient to relax and adding an anesthetic drop may help.
Furthermore, putting an anesthetic in the fellow eye and asking the patient
to keep that eye open can assist in keeping the surgical eye open. Using a lid
speculum may improve exposure to get the vacuum ring into the eye and
counteract lid squeezing.

156 Chapter 14
Figure 14-1. Docking with a small palpebral fissure.
Figure 14-2. Photograph showing conjunctival chalasis and lid squeezing during a
docking attempt.
Conjunctival Chalasis
Sometimes, patients have loose redundant conjunctiva. In these cases,
the conjunctiva closes the suction port rather than the eyeball itself, giving
pseudosuction. Pushing the lid speculum down (if used during docking) or
pushing the conjunctiva away with a suction ring (prior to suction initia-
tion) may help to initiate suction.
Special Considerations 157
Figure 14-3. Relationship between the tracking system and the headrest.
Deep Orbit
In patients with deep orbit, docking is more difficult due to difficult
access to the surface of the eye. Pushing down slightly on the lid speculum
(if used during docking) can help to get more clearance. Using a lid specu-
lum may improve exposure to get the vacuum ring onto the globe.
Particular Nose Shape

A large nose can make docking more difficult. With femtosecond LASIK,
the applanation cone can become hindered by the nose during docking.
With microkeratome LASIK, the microkeratome head may become hin-
dered by the nose during rotation or a translation movement. Turning the
patient’s head away from the eye that is having surgery causes the eyeball to
rotate away from the nose and therefore improves exposure.
CHEST CONFIGURATION INTERFERING

WITH TRACKER
Some excimer platforms (eg WaveLight EX500 [Alcon Labs]) use an
eye tracker system that moves downward toward the eye upon activation
(Figure 14-3). This requires a free space between the tracking system and the
158 Chapter 14
upper part of the chest. In some cases (eg, obesity, macromastia, kyphotic
neck or spine), this space is reduced and the tracker hits the chest and
deactivates.
• Move the headrest upward: This allows the bed to move downward to
focus the laser on the surface of the eye. Moving the bed down increases
the space between the tracking system and the upper part of the chest.
• Ask the assistant to press on the upper part of the patient’s chest down
and toward the feet: This may create some space between the tracking
system and the upper part of the chest.
ANXIOUS PATIENT
One of the most common fears about LASIK surgery is pain. Many
prospective LASIK patients are afraid that they will experience discomfort
since the procedure is performed while they are fully conscious. A mild
sedative (eg, diazepam 10 mg) is given to patients to ensure that they remain
comfortable during the procedure, and numbing drops are applied to the
eyes before the surgery begins.
Relaxation techniques can also work.1 The following types of relaxation
techniques exist: autogenic relaxation, progressive muscle relaxation, and
visualization. With autogenic relaxation, visual imagery and body aware-
ness are used to reduce stress. A person repeats words or suggestions in his
or her mind to relax, both mentally and physically. With progressive muscle
relaxation, a patient focuses on the difference between muscle tension and
relaxation to become more aware of physical sensation. This is done by tens-
ing muscles for 5 seconds and relaxing them for 30 seconds. A good place
to start would be the toes. Visualization involves forming mental images
of calming places or situations. The object is, not just to visualize, but also
to use as many senses as possible, including smell, sight, sound, and touch.
On rare occasions, one will encounter patients who have extreme
anxiety—if not an outright phobia—about an eye examination. Not only
will they refuse all drops, but there is also absolute defiance toward any
tonometry or touching of the eyelids. If feasible, these cases can be done
under general anesthesia in a surgery center.
Special Considerations 159
REFERENCE
1. Kamath PS. A novel distraction technique for pain management during local anesthe-
sia administration in pediatric patients. J Clin Pediatr Dent. 2013;38(1):45-47.
SUGGESTED READING
15
Management of
Postoperative Complications
VISION REHABILITATION FOR CORNEAS

WITH BUTTONHOLE
A buttonholed flap occurs when the microkeratome blade travels more
superficially than intended and enters the epithelium/Bowman’s complex.
Buttonholes may be partial thickness if they transect the Bowman’s layer or
full thickness if they exit through the epithelium. The incidence of button-
holes ranges between 0.2% and 0.56%.1 This is the most common complica-
tion in microkeratome LASIK, resulting in the loss of best-corrected visual
acuity (BCVA). Risk factors include the following:
• High keratometric values.
• Previous incisional keratotomy.
• Pre-existing surface lesion (eg, pterygiums, corneal scars).
Management
While some recommend proceeding with scraping the epithelium and
performing a photorefractive keratectomy (PRK)/LASIK laser ablation
(Figures 15-1 and 15-2), this approach may not be feasible in high myopic
patients due to the appearance of subepithelial haze.

162 Chapter 15
Figure 15-1. Epithelial flap lifting after alcohol application for 40s.
Figure 15-2. Successful excimer laser treatment. At the patient’s 2-month follow-up

visit, his uncorrected distance visual acuity was 20/20. No epithelial ingrowth was
observed.
Using a no-touch transepithelial PRK within 2 weeks may prevent irreg-

ular astigmatism formation from the uneven ablation profile resulting from
any late scar formation.
Video: 0 minutes 5 seconds; LASIK 3 months over buttonhole.
Management of Postoperative Complications 163
Figure 15-3. Identifying and lifting the flap edge carefully to avoid flap tear due to
underlying scarring or melting.
EPITHELIAL INGROWTH
Implantation of epithelial cells in the interface may be due to seeding
during surgery or migration under the flap. Most of these cells will dis-
appear without consequences. More concerning is epithelial ingrowth that
is contiguous with the flap edge. This can progress to involve the visual axis
with irregular astigmatism and possible flap melting. Epithelial growth at
the interface may be more common after enhancement procedures due to
adjacent epithelial abrasions with increased cell proliferation.
Management
Nonprogressive epithelial ingrowth should be monitored. Hyperopic
shift is an early indicator of possible underlying stromal melt. This may
result in loss of BCVA. Epithelial cells under the LASIK flap should be
managed aggressively if they progress toward the visual axis or if they
induce stromal melting. The flap is lifted, the stromal bed and the flap
undersurface are thoroughly irrigated and scraped, and the flap is reposi-
tioned (Figures 15-3, 15-4, 15-5, and 15-6). Epithelial cell debridement can
be achieved mechanically with a #15 blade or with dedicated instruments
(eg, Yaghouti LASIK Polisher [ASICO]), or by using excimer laser bursts in
phototherapeutic keratectomy mode.
Video: 0 minutes 58 seconds
164 Chapter 15
Figure 15-4. Scrape the bed with a blade and/or a LASIK flap lifter.
Figure 15-5. Scrape the flap. A closed speculum can be used as a

working platform by asking the patient to look superiorly.
Figure 15-6. Flap suturing at the area of epithelial ingrowth to

decrease the risk of cell migration under the flap.
FLAP FOLDS AND STRIAE

Striae and folds are both seen commonly after LASIK and can be visually
symptomatic. Causes have been hypothesized to include mechanical disrup-
tion; dryness of the flap leading to shrinkage; misalignment; and changes in
the corneal contour, specifically in high myopic correction. If they involve
the visual axis, folds can induce irregular astigmatism and the loss of BCVA.
Striae are rare, with an incidence that varies between 1% and 2.4%.2
Management
Management can range from light stroking with a moist microsponge
or instrument at the slit lamp to lifting the flap and stretching radially fol-
lowed by repositioning (Figures 15-7, 15-8, and 15-9). Recalcitrant folds may
require the removal of the central epithelium as it may prevent the flatten-
ing of the folds due to epithelial hyperplasia in the crevices formed by the
folds. Suturing the flap can also be considered if the striae do not resolve
(Figure 15-10). Flap folds are managed more successfully if the intervention
is initiated as soon as they are recognized to be visually significant.
166 Chapter 15
Figure 15-7. Flap folds are more apparent after epithelium removal.
Figure 15-8. Lift the flap gently to avoid flap tears.
Figure 15-9. Stretch the flap radially, and massage the underside of the flap.
Figure 15-10. Flap suturing at 2 opposite positions allows the stretching of the

flap and results in striae resolution.
FLAP TRAUMA AND DISLOCATION

Dislocated flaps can occur any time after surgery and most com-
monly present with acute pain and a decrease in vision. Etiology often
includes mechanical trauma to the flap. In the early postoperative period
(first 24 hours), they can be secondary to minor manipulations such as
rubbing the eye or squeezing following the procedure. More significant
trauma is needed to dislocate the flap afterwards. Flap dislocations 1 day
following LASIK vary between 1.1% in femtosecond LASIK and 2.5% in
microkeratome LASIK.1,2
Management
A dislodged flap should be repositioned immediately (Figures 15-11 and
15-12). Generally, the longer it has been since the displacement, the more
extensive the treatment, as epithelial hyperplasia may fill the crevices of the
folded flap. The underside of the flap and the stromal bed may need to be
scraped to remove any epithelial ingrowth. Any folds should be stretched
out, and epithelial debridement may be needed to flatten any recalcitrant
flap folds.
168 Chapter 15
Figure 15-11. Localized flap trauma. Clean the bed, irrigate the interface, and then
reposition the flap.
Figure 15-12. Photograph showing post-traumatic flap dislocation, bed irrigation, and

flap repositioning.
PERSISTENT EPITHELIAL DEFECT

Concern involves large epithelial defects, especially those with a connec-
tion to the flap edge. The incidence of epithelial defects with LASIK was
reported to be approximately 5%.1,2 The proliferating epithelial cells might
migrate under the flap edge. Associated inflammation can also lead to the
Figure 15-13. Persistent epithelial defect on a LASIK flap.
Figure 15-14. Lift flap gently to avoid flap tears.
melting of the surrounding flap tissue. Increased risk of diffuse lamellar

keratitis in patients with epithelial defects has also been observed.
Management
If an epithelial defect is noted intraoperatively, a higher index of suspi-
cion for epithelial ingrowth should be maintained (Figures 15-13, 15-14,
15-15, and 15-16). An attempt at repositioning the loose epithelium should
be performed. Alternatively, the epithelium can be gently debrided and a
contact lens can be applied. These measures help with pain control and with
170 Chapter 15
Figure 15-15. Scrape flap. A Melki LASIK flap stabilizer (Rhein Medical, Inc) can be used
for this step.
Figure 15-16. Flap suturing at 2 opposite positions may help to keep the flap edge
flattened, allowing an easier path for epithelial cells to repopulate the flap surface.
improving flap adherence and preventing epithelial cell ingrowth. Topical

nonsteroidal anti-inflammatory drugs may also be useful to ease the asso-
ciated discomfort, but they may be associated with the induction of sterile
infiltrates.
REFERENCES

LASIK Emergencies

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What are some potential complications of LASIK surgery?

What are some potential complications of LASIK surgery?

How should a dislodged LASIK flap be managed?

How should a dislodged LASIK flap be managed?

Samir A.

Melki, MD, PhD

Ali Fadlallah, MD, MSc, MPH

Copyright © 2018 by SLACK Incorporated

To all my mentors who guided me day-by-day through all my

Chapter 1 The Normal LASIK Procedure: A Step-By-Step Surgical

To all of us who operate on a regular basis, encountering com-

—Samir A. Melki, MD, PhD

—Dimitri Azar, MD, MBA

Melki SA, Fadlallah A.

We advise hanging a photo of the LASIK and photorefractive keratec-

Figure 1-2. Patient should be asked to maintain

Figure 1-3. Patient in a chin-up position with

Figure 1-5. WaveLight FS200 (Alcon Labs) platform.

Figure 1-6. IntraLase cone.

Figure 1-7. WaveLight FS200 cone.

Figure 1-8. IntraLase FS60 suction ring.

• Ensure proper head positioning: Depends mainly on eye and nose

■ Liquid interface is seen in the periphery (between the glass and

■ Using a small dial pad (see Figure 1-4) may facilitate communi-

• Dry the bed in case of excessive fluid at the stroma interface.

Please see videos on the accompanying website at

ETIOLOGY AND INCIDENCE OF

Melki SA, Fadlallah A.

FEMTOSECOND LASIK COMPLICATIONS

Complication #1: Loss of Suction

Figure 2-1. Initial surgery resulted in an incomplete flap construction due to

Figure 2-3. Initial surgery resulted in an incomplete flap construction due to suction

Complication #2: Loss of Suction

• The subsequent side cut should be created within the already-created

General Practical Measures in Femtosecond

Figure 2-5. Initial surgery resulted in an incomplete flap construction due to suction

MICROKERATOME LASIK COMPLICATIONS

Complication #3: Loss of Suction During

PREVENTION OF LOSS OF SUCTION

Please see videos on the accompanying website at

Melki SA, Fadlallah A.

Figure 3-1. Initial surgery resulted in air bubbles in the AC (red arrow).

FEMTOSECOND LASIK COMPLICATIONS

Complication #1: Air Bubbles in

Complication #2: Air Bubbles in Anterior

Figure 3-5. Initial surgery resulted in air bubbles in the AC.

• Decrease flap diameter on the fellow eye by 0.5 mm.

• In some cases, the above maneuvers are not successful.

General Practical Measures in Femtosecond

PREVENTION OF AIR BUBBLES

Please see videos on the accompanying website at

ETIOLOGY AND INCIDENCE

Melki SA, Fadlallah A.

FEMTOSECOND LASIK COMPLICATIONS

Complication #1: Black Vertical Gas

Figure 4-1. Initial surgery resulted in black VGB in the visual axis

Figure 4-2. Photograph showing black VGB in the visual axis

Figure 4-3. Photograph showing black VGB in the visual axis

Figure 4-4. Initial surgery resulted in white/gray VGB in the paracentral

Figure 4-5. Photograph showing white/gray VGB in the paracentral