Should we be cutting a flap at all? NO

December 1, 2008

Whether the stromal flap is thin or thick is irrelevant; it will never heal fully.

Key Points

The debate for me is not microkeratome vs. femtosecond laser; it is whether or not we should be creating a LASIK flap at all. I believe flap creation disfigures the cornea, and is unnecessary.

Although my experience with LASIK is minimal, the flap-related complications that I witnessed in my patients and those that I have seen amongst my colleagues have completely deterred me from performing this procedure.

I support surface ablations. I was performing alcohol disepithelialization in 1998 when I invented the LASEK procedure. Because the first operations that I had performed yielded excellent results when compared with PRK, I have continued to practice LASEK to this day. I have also now invented a modification to this technique: Epi-LASEK, which is LASEK performed with an epi-keratome.

The cost of safety

Although I admit that my patients do not experience the same "wow factor" that they would experience with LASIK surgery, I think this is a small price to pay. The risk of complications with surface ablations is far lower; in fact I very rarely experience any complications at all, early or late. My patients can usually go back to work within 10 days of the procedure, with 80% visual recovery. Pain is usually only slight and, only in rare cases, must this be managed with an ice compress for the first postoperative days. Again, this is a small price to pay for a safe procedure.

The key to minimizing intraoperative complications is good surgical practice. With LASEK, around 80% of flaps can be very easily managed and one can obtain excellent flaps in 100% of cases when alcohol is used with an epi-keratome. Re-treatment rates are exceptionally low (less than 3%) and mainly relate to hyperopic astigmatism. Low-degree haze (2°) affects just 1% of cases.

Microkeratome vs. femtosecond: it's irrelevant!

I personally think that if you don't want to have stromal flap complications, techniques that involve the creation of a flap must be avoided. Whether the stromal flap is thin or thick is irrelevant; it will never heal fully.

I would therefore like to ask: why should the cornea be cut and weakened if the same overall results can be obtained by operating on the surface?

I do not believe that we should be questioning whether a femtosecond laser is better than a microkeratome, or vice-versa. Today's microkeratomes work well; however, the real complications that emerge from LASIK relate to the flap, whether it's cut with a femtosecond laser or a microkeratome.

I do appreciate femtosecond laser technology; I truly believe that it will transform the way that we perform corneal transplantations, but as for laser refractive surgery, I think that cutting the cornea should be avoided altogether.

The harsh reality

Convincing refractive surgeons to convert to surface procedures and accept early postoperative patient complaints is difficult, even though the risk of rare, serious late complications is far lower with surface ablations than with LASIK. This is the harsh reality. In spite of this, LASEK is growing in popularity every year.

I personally believe that more and more surgeons will continue to move back to surface ablation, not only because of the excellent safety record, but also because of the high quality of the surgery and the smoothness of new laser ablations. I believe that both surface techniques and LASIK will continue to coexist for many years to come.

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To read Dr Omid Kermani's counter-argument, please go to http://www.oteurope.com/2008debates/cutflap/yes