Back to Journals » Clinical Ophthalmology » Volume 15

Femtosecond-Assisted Laser in situ Keratomileusis with De Novo Flap Creation Following Previous Microkeratome Laser in situ Keratomileusis [Letter]

Authors Srirampur A

Received 16 June 2021

Accepted for publication 24 June 2021

Published 7 July 2021 Volume 2021:15 Pages 2933—2934


Checked for plagiarism Yes

Editor who approved publication: Dr Scott Fraser

Arjun Srirampur

Department of Cornea, Cataract and Refractive Surgery, Anand Eye Institute, Hyderabad, 500007, India

Correspondence: Arjun Srirampur
Department of Cornea, Cataract and Refractive Surgery, Anand Eye Institute, Hyderabad, 500007, India
Tel +91-9989229832
Fax +91 040-27151999
Email [email protected]

View the original paper by Dr Rush and colleagues

A Response to Letter has been published for this article.

Dear editor

I have read with great interest the article by Rush et al. on ‘Femtosecond-Assisted Laser in situ Keratomileusis with de novo Flap Creation Following Previous Microkeratome Laser in situ Keratomileusis’.1 I would like to compliment the authors for describing an effective technique for creating a new flap with the femtosecond laser in patients undergoing repeat LASIK after previous microkeratome LASIK. However, I would like to raise a few queries.

Firstly, vertical side cut configuration of the flap reduces the chances of epithelial ingrowth when compared with an angulated cut.2,3 The authors in this article mention a 30 degree cut and fortunately none of the eyes had an epithelial ingrowth in the post-operative period.

Secondly, the maximum flap diameter by default mentioned in the article is 9 mm. Some of the eyes underwent hyperopic and high astigmatic corrections where the ablation zone is usually larger than myopic ablations and predominant ablations happen in the near periphery of the cornea. It is not clearly mentioned about any modifications done for such corrections.

Thirdly, all the eyes had a flap diameter (9 mm) so that it could fit outside the prior microkeratome flap. The mean intended flap depth for the study population was 158.8 ± 23.2 microns with range of 130–190 microns with 9 of the flaps (52.9%) posterior to the original flap. That means that 8 out of 17 eyes had the new flap anterior to the existing flap. If the new flap diameter was larger and anterior to the prior microkeratome flap, the new flap while lifting could lead to a 360 degree peripheral ring-like tear due to the cuts between the old and new flaps. Hence, careful and slow dissection of the new flap has to be done so as not to cause any amputation or loss of peripheral part of the flap (corneal tissue).

Also, performing another interface with a femto energy in an eye with an existing flap can lead to other complications such as vertical gas breakthrough.4 The original interface might act as a low-resistance pathway for the gas bubbles to expand, resulting in formation of a buttonhole. This phenomenon has to be kept in mind when performing a femto flap in such operated corneas.

It has been hypothesized that performing the ablation at a different plane than the original ablation might have an adverse effect on the visual outcomes.5 It would have been better if the authors had mentioned the higher order aberrations in the post-operative results.


The author reports no conflict of interest in this communication.


1. Rush SW, Rush RB. Femtosecond-Assisted laser in situ keratomileusis with de novo flap creation following previous microkeratome laser in situ keratomileusis. Clin Ophthalmol. 2021;15:1813–1818. doi:10.2147/OPTH.S301450

2. Güell JL, Elies D, Gris O, Manero F, Morral M. Femtosecond laser-assisted enhancements after laser in situ keratomileusis. J Cataract Refract Surg. 2011;37(11):1928–1931. doi:10.1016/j.jcrs.2011.09.016

3. Vaddavalli PK, Diakonis VF, Canto AP, et al. Complications of femtosecond laser-assisted re-treatment for residual refractive errors after LASIK. J Refractive Surg. 2013;29(8):577–580. doi:10.3928/1081597X-20130620-03

4. Moshirfar M, Gardiner JP, Schliesser JA, et al. Laser in situ keratomileusis fl ap complications using mechanical micro-keratome versus femtosecond laser: retrospective comparison. J Cataract Refract Surg. 2010;36:1925–1933. doi:10.1016/j.jcrs.2010.05.027

5. Davis EA, Hardten DR, Lindstrom M, Samuelson TW, Lind-strom RL. LASIK enhancements: a comparison of lifting to recutting the flap. Ophthalmology. 2002;109:2308–2313. doi:10.1016/S0161-6420(02)01245-9

Creative Commons License © 2021 The Author(s). This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.