Re-Treatments after ReLEx - SMILE

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1 Re-Treatments after ReLEx - SMILE - own Experiences - Bertram Meyer - AOC Laser Center/LERC - Cologne/Dubai ESC Meeting Cairo Re-Treatments after ReLEx - SMILE Retreatments are rare (< 2%) - n = 18 of 1242 SMILE (since 7/2011), - incl.learning curve - incl.adjustments of nomogram - incl. 2x re-retreatments bcos of intolerance of monovision very high stability of the refractive outcomes high tolerance of small refractive errors postoperatively (+- 0,5) principally: no second SMILE after previous SMILE (thin lenticule) 1

2 Re-Treatments after ReLEx - SMILE Options: surface ablation (= PRK), preserving corneal stability (n = 6) standard femto-flap with same parameters + excimer laser (n = 8) single sidecut with clearance zone (= circle) + excimer laser ( n = 2) F-LASIK with thin flap (90µ or 100µ) (n = 1) SMILE above original interface (-> thick cap >140µ) ( n = 1) SMILE below the original interface (-> cave: RST) SMILE Enhancement: Thin Flap LASIK Pro: thin flap creates more superficial sidecut than circle procedure less biomechanical side effect less dry eyes 2

3 SMILE Enhancement: Thin Flap LASIK Pro: thin flap creates more superficial sidecut than circle procedure less biomechanical side effect less dry eyes Con: correct flap thickness to avoid crossing interfaces Bowman's layer (cryptic buttonhole / gas breakthrough) SMILE lamellar interface SMILE Enhancement: Thin Flap LASIK Pro: thin flap creates more superficial sidecut than circle procedure less biomechanical side effect less dry eyes Con: correct flap thickness to avoid crossing interfaces Bowman's layer (cryptic buttonhole / gas breakthrough) SMILE lamellar interface Conclusion: thick cap ( >140µ) + thin flap (= 100µ) 3

4 SMILE Enhancement: SMILE above interface Pros: second SMILE preserving biomechanical stability of cornea SMILE Enhancement: SMILE above interface Pros: Cons: second SMILE preserving biomechanical stability of cornea normally not enough space between Bowman`s layer and the cap interface only for small refractive errors difficulty in handling the very thin lenticule disturbing the corneal nerve plexus removing the strong anterior lamellae more likely to have complications (OBL, hard dissection) 4

5 SMILE Enhancement: SMILE above interface Pros: Cons: second SMILE preserving biomechanical stability of cornea normally not enough space between Bowman`s layer and the cap interface only for small refractive errors difficulty in handling the very thin lenticule disturbing the corneal nerve plexus removing the strong anterior lamellae more likely to have complications (OBL, hard dissection) Conclusion: not without risk SMILE Enhancement: SMILE below interface Pros: second SMILE below the cap interface (RST?) preserving biomechanical stability of cornea conservation of corneal nerve plexus retaining strongest anterior lamellae 5

6 SMILE Enhancement: SMILE below interface Pros: Cons: second SMILE below the cap interface (RST?) preserving biomechanical stability of cornea conservation of corneal nerve plexus retaining strongest anterior lamellae preparation of a thin lenticule in the deep part of the cornea (>200µ; weak lamella) -> regularity? potential difficulty in handling the very thin lenticule SMILE Enhancement: SMILE below interface Pros: Cons: second SMILE below the cap interface (RST?) preserving biomechanical stability of cornea conservation of corneal nerve plexus retaining strongest anterior lamellae lenticule too thin (regularity?) potential difficulty in handling the very thin lenticule Conclusion: high risk 6

7 Re-Treatments after ReLEx - SMILE Options: surface ablation (= PRK), preserving corneal stability standard femto-flap with same parameters + excimer laser ablation single sidecut with clearance zone (= circle) + excimer laser ablation F-LASIK with thin flap (80µ or 90µ ) SMILE above original interface (-> thick cap >140µ) SMILE below the original interface (-> cave: RST) Surface-Ablation (= PRK) - n = 6 ( -0,5 to -1,25 D ) - 4x without MMC -> Haze 2, no DLK - 2x with MMC -> no Haze, no DLK - prolonged healing > 1 week - visual recovery 2-4 weeks - patients not amused 7

8 Surface-Ablation (= PRK) - n = 6 ( -0,5 to -1,25 D ) - 4x without MMC -> Haze 2, no DLK - 2x with MMC -> no Haze, no DLK - prolonged healing > 1 week - visual recovery 2-4 weeks - patients not amused thin cap ( µ) + high correction (n = 5) -> mud cracks at Bowman s membrane thick cap (150µ) + low correction (n = 1) -> smooth Bowman s surface Surface-Ablation (= PRK) 8

9 Surface-Ablation (= PRK) Surface-Ablation (= PRK) Courtesy Dan Reinstein 9

10 Surface-Ablation (= PRK) - n = 6 ( -0,5 to -1,25 D ) - 4x without MMC -> Haze 2, no DLK - 2x with MMC -> no Haze, no DLK - prolonged healing > 1 week - visual recovery 2-4 weeks - patients not amused thin cap ( µ) + high correction (n = 5) -> mud cracks in Bowman s layer thick cap (150µ) + low correction (n = 1) -> smooth Bowman s surface Standard Femto-flap with same parameters n = 8 same contact glas (e.g. S ) same thickness of cap / flap flap diameter larger than cap diameter nasal hinge (not in incision area) no double contour or double lamella excimerlaser ablation very short recovery time but: weakening of the corneal stability by sidecut 10

11 Single Sidecut with Clearance Zone (= Circle) n = 2 intrastromal sidecut transition zone flap sidecut nasal hinge excimer laser ablation very short recovery time but: weakening of the corneal stability by sidecut Single Sidecut with Clearance Zone (= Circle) n = 2 intrastromal sidecut transition zone flap sidecut nasal hinge excimer laser ablation very short recovery time but: weakening of the corneal stability by sidecut 11

12 Thank you very much for your kind attention! Bertram Meyer, MD AOC Laser Center / Cologne Laser Eye Care & Research Center / Dubai 12

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