Refractive lenticule extraction (ReLEx), performed with the Visumax femtosecond laser (Carl Zeiss Meditec, Jena, Germany), is a new procedure that involves the creation and removal of a lenticule within the corneal stroma resulting in a refractive correction. Both the flap and the refractive lenticule are created in a one-step procedure using the Visumax femtosecond laser. Sekundo et al.1
and Shah et al.2
reported results of femtosecond lenticule extraction to treat myopia using a femtosecond laser without the need for excimer laser ablation.
An 18-year-old girl presented to our clinic for refractive surgery in both eyes. She had been using contact lenses for the past 5 years. Refractive error was −10.00 −1.75 × 10° in the right eye and −4.50 in the left eye. Corrected distance visual acuity was 20/20 in both eyes. Corneal topography was normal and the rest of the ocular examination was within normal limits. She was advised to undergo femtosecond LASIK in the right eye (because the refractive error was out of current range for ReLEx) and ReLEx surgery in the left eye. Lenticule extraction was planned for both eyes because recent publications have shown ReLEx to be safe, predictable, and effective in treating myopia and myopic astigmatism.2,3
LASIK was done for the right eye because the refractive error was high.
During the ReLEx procedure, the patient squeezed against the eyelid speculum and suction was lost after creation of the lenticule and 90% of the lamellar flap cut. The side cut was not started. Although the eye was redocked and a repeat procedure initiated, suction was lost again after the flap cut and surgery was abandoned.
On the first day after attempted surgery, corrected distance visual acuity was 20/25 in the left eye with lamellar corneal haze. Anterior segment optical coherence tomography revealed two levels of lamellar haze, which became less distinct with time (Figure 1
). The patient was treated with low-dose steroids and antibiotics in the left eye. The patient underwent an uneventful femtosecond LASIK procedure in the right eye 1 week later and was doing well postoperatively with an uncorrected distance visual acuity of 20/20.
Figure 1. Anterior segment optical coherence tomography of the left eye after the first surgery was abandoned. (A) The red arrows show the lamellar cut. (B) The image 1 month after the second surgery.
The left eye was scheduled for repeat surgery 2 months later. Interestingly, repeat corneal topography and aberrometry done on the day of surgery did not show any significant difference from the preoperative measurements (Figure 2
). The patient underwent uneventful LASIK surgery, with the flap created with the Visumax femtosecond laser at the same depth and diameter (7.90 mm) as the previous attempted flap (treatment pack size S) at the level of the anterior lamellar cut. The uncorrected distance visual acuity on the first postoperative day was 20/25, which improved 3 months later to 20/20.
Figure 2. Aberrometry results (A) before and (B) after the first surgery. The red box indicates that the values of higher-order aberrations were similar.
All-in-one refractive correction using a small incision technique has been reported to be safe, predictable, and effective in treating myopia and myopic astigmatism.2,3
This case describes a patient who underwent attempted ReLEx surgery that, despite two lamellar incisions made in the cornea, did not seem to have any bearing on the aberrations in the eye and eventually resulted in a good visual outcome. It also demonstrates the possibility of performing femtosecond LASIK after failed ReLEx, with good visual outcomes. Additional studies will be necessary to determine biomechanical concerns.
- Sekundo W, Kunert KS, Blum M. Small incision corneal refractive surgery using the small incision lenticule extraction (SMILE) procedure for the correction of myopia and myopic astigmatism: results of a 6 month prospective study. Br J Ophthalmol. 2011;95:335–339 doi:10.1136/bjo.2009.174284 [CrossRef] .
- Shah R, Shah S, Sengupta S. Results of small incision lenticule extraction: all-in-one femtosecond laser refractive surgery. J Cataract Refract Surg. 2011;37:127–137 doi:10.1016/j.jcrs.2010.07.033 [CrossRef] .
- Vestergaard A, Ivarsen AR, Asp S, Hjortdal JO. Small-incision lenticule extraction for moderate to high myopia: predictability, safety, and patient satisfaction. J Cataract Refract Surg. 2012;38:2003–2010 doi:10.1016/j.jcrs.2012.07.021 [CrossRef] .