Femtosecond-assisted LASIK:

Complications and Management

Claudia Perez-Straziota, MD
J. Bradley Randleman, MD

Introduction

Laser in situ keratomileusis (LASIK) is one of the most successful

elective surgical procedures performed in the world for treatment of
refractive error. The first critical step, the creation of the corneal flap,
can be performed using either a mechanical microkeratome (MK) blade
or a femtosecond (FS) laser. The MK creates a flap using an oscillating
blade that traverses through the corneal stroma in a controlled manner, 1
whereas the FS laser uses infrared light (1053 nm) to produce micro-
plasma and microcavitation bubbles within the corneal stroma to
functionally create a corneal dissection plane interface that can be
manually opened with minimal effort. 2 Since the introduction of the FS
laser in 2001, its technology has continued to evolve, making it the
preferred method for LASIK flap creation for most cases.3
Studies comparing outcomes between FS LASIK and MK LASIK have
been inconclusive, with similar visual outcomes for both groups. 2,4 FS flaps may
be more accurate, reproducible, and uniform than most but not all MK flaps, 2,58
and may produce thinner, smoother flaps with a more planar or uniform
architecture and minimal thickness variation within each flap. 9 These
characteristics may reduce post-LASIK ectasia risk by providing more
biomechanical stability, and may also provide faster visual recovery. 1012
FS-assisted LASIK (femtoLASIK) shares many similar
complications with MK LASIK; however, there are unique complications
associated only with FS laser use, including optical issues, flap-related
complica-tions, and interface-related complications.

Optical Issues

Rainbow glare phenomena is a poorly understood optical side effect

that occurs exclusively after FS-assisted LASIK flap creation. Patients
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60 Perez-Straziota and Randleman

describe rainbow-colored light radiating from white light sources. First

described by Krueger et al 13 in 2008, rainbow glare is thought to be due
to diffraction of light caused by the grating pattern created on the back
surface of the LASIK flap that does get smoothed with excimer
ablation.11
Gatinel et al14 demonstrated this pattern with confocal microscopy
at the level of the flap interface. Rainbow glare may be associated with
the quality of the FS laser beam profile. 11 In most instances it is self-
limited and requires no intervention. In persistent cases, symptom
resolution has been reported after flap undersurface ablation. 15

Ocular Surface Issues

Dry eye symptoms are common in the early postoperative period

after LASIK with MK or FS flaps. These symptoms appear to occur as a
result of severing afferent corneal nerves during flap creation. This
results in sensory nerve damage and relative reduction in corneal
innervation, impacts tear film stability, goblet cell number, blink rate, and
basal tear secretion.1618 Thinner, planar flaps created with the FS laser
sever less anterior stromal nerves and lead to a lower incidence of post-
LASIK dry eye.19
Effective treatment strategies for dry eye after LASIK include
aggressive lubrication with tears drops and ointments, cyclosporine
0.05%, punctual plugs, and even serum tears and in most situations. 20

FS Flap-related Complications

Vertical gas breakthrough occurs when small gas bubbles break

through the stroma and epithelium (Fig. 1). This results in a flap defect
similar to a buttonhole flap caused by the MK. When vertical gas
breakthrough occurs the flap should not be lifted, as the buttonholed area
can lead to irregular ablation, scarring, and epithelial ingrowth. Preoperative
corneal scarring, microscopic breaks in Bowman membrane, and thin flaps
may contribute to the occurrence of vertical gas breakthrough. 1,21
Opaque bubble layer (OBL)22 occurs when gas bubbles accumulate
within the interface and stroma, creating a focal or diffuse opacity
depending on the extent of the OBL (Fig. 2).23 This opacity usually
resolves with flap lifting and rarely has an effect on postoperative visual
acuity.24 However, OBL may interfere with laser tracking and intra-
operative measurement of the residual stromal bed. As thicker corneas
have been associated with increased risk of development of an OBL, 24
a higher pulse rate and less line spacing can be adjusted in these cases
to ensure an adequate cleavage plane and minimize the retention of
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 Femtosecond Laser Complications 61

Figure 1. Vertical gas breakthrough as shown during the femtosecond laser pass with the
IntraLase laser. Images courtesy of Samir Melki, MD.

Figure 2. Opaque bubble layer after femtosecond laser flap creation. Images courtesy of
Samir Melki, MD.
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62 Perez-Straziota and Randleman

Figure 3. Anterior chamber bubbles after femtosecond flap formation. Image courtesy of
Samir Melki, MD.

stromal bridges and gas buildup. Many cases require a delay to allow
the OBL to resolve before performing excimer laser ablation.
Gas bubbles can also exit through the trabecular meshwork and
enter the anterior chamber, creating anterior chamber bubbles (Fig. 3).
These often have minimal impact on visual outcome but may interfere
with pupil tracking during the ablation. 1 When anterior chamber bubbles
appear, they will dissipate oftentimes on the same day; therefore
ablation should be postponed until pupil tracking is not impacted.
In ultrathin flaps, and especially in young myopic individuals with
flaps <90 mm, interface haze can occur. The relationship with ultrathin
flaps is thought to be from trauma to the epithelium and Bowman
membrane, initiating an inflammatory response that results in interface
haze.25 Therefore, a minimal threshold of flap thickness of 100 mm has
been proposed to prevent interface haze formation, especially in
younger patients.11

Interface-related Complications

Most LASIK interface complications can occur with either MK or FS

flaps, with similar incidence for most conditions except diffuse lamellar
keratitis and epithelial ingrowth.
Transient light sensitivity syndrome presents as increased photosensitivity
after uncomplicated FS-assisted LASIK procedure with good visual acuity
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 Femtosecond Laser Complications 63

and no obvious inflammation. As a direct correlation with higher FS energy

settings has been described, preventive strategies include using the lowest
possible laser energy settings when creating the flap. Patients with
transient light sensitivity syndrome generally improve with a course of
topical steroids and have no long-term visual consequences. 1,6,26
Infectious keratitis is the most vision-threatening interface complica-
tion after LASIK, which can occur early within the first 2 postoperative
weeks (usually caused by Staphylococcus and Streptococcus bacterial
species) or many weeks after surgery (usually caused by mycobacterial
and fungal species). Once infectious keratitis has been diagnosed, the
best course of treatment is usually immediate flap lift with cultures and
irrigation, and the implementation of fortified antibiotics. 27 In some
instances flap amputation may be needed to limit the infection, improve
antibiotic penetration, and improve visual outcomes. 28,29
Epithelial ingrowth is the most common interface complication after
LASIK, with an incidence between 1% and 20%.30 It can occur in flaps
created with both MK and FS lasers but has been shown to occur at a
lower rate with FS LASIK,31,32 perhaps due to a more vertical cut of the
flap edges, which serves as a barrier to epithelial cell migration.
Epithelial ingrowth usually presents weeks to months after LASIK
surgery as epithelial pearls within the flap interface, fluorescein pooling
at the edge of the flap, and potential melting at the flap edge. 30
Treatment typically involves observation in early stages. Progressive
cases may require flap lifting and scraping if the ingrowth invades the
visual axis; and recalcitrant cases may require eventually flap
amputation after all therapeutic measures have failed. 33
Diffuse lamellar keratitis (DLK) is an inflammatory reaction in the
stroma and interface which can also occur with both MK and FS-assisted
LASIK; however, a higher incidence has been reported in cases with FS
flap creation,1,34,35 likely due to a local inflammatory response to the
formation of gas bubbles and the FS energy at the flap interface. 1 It is
characterized by a noninfectious, diffuse, white, and granular inflam-matory
material within the flap interface during the first postoperative week. DLK
has also been linked to bacterial endotoxins, debris or blood within the
interface, and povidone-iodine solutions.27,3436
DLK should be managed aggressively to avoid flap scarring and
melting. Topical steroids are often sufficient for stage 1, whereas stage
3 often requires flap lift, interface irrigation, and oral steroids for
resolution.37 Stage 4, with flap necrosis and scarring, is rare and has
been estimated to occur in 1 of 5000 patients with DLK. 27,37
Symptoms of DLK include foreign body sensation with or without
decreased visual acuity. It is critical to differentiate DLK from other less
common disorders, including pressure-induced stromal keratopathy (PISK) and
central toxic keratopathy (CTK). PISK occurs from steroid response with
elevated intraocular pressure, resulting in interface fluid accumulation. 27
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64 Perez-Straziota and Randleman

PISK mimics stage 2 DLK but occurs much later, usually several weeks
after LASIK. As opposed to DLK, which requires aggressive topical
steroid use, PISK worsens with continued steroids and requires steroid
cessation. CTK is a rare, noninflammatory central opacification that
presents abruptly within 3 to 5 days after an uncomplicated LASIK. The
etiology is still unclear, but CTK may result from enzymatic degradation
of keratocytes leading to a paucity of stromal matrix and thinning. 38,39
CTK mimics stage 4 DLK buts presents acutely as opposed to DLK,
which progresses to stage 4 over time. CTK generally resolves
spontaneously, but no treatments have proven effective. 40
Interface heme can present after either MK or FS flaps creation but
has an additional unique mechanism with some FS laser treatments. In
an attempt to minimize interface gas bubble build up, the Wavelight
FS200 FS laser (Alcon Laboratories Inc., Fort Worth, TX) can create a
gas evacuation canal during flap. If limbal vessels bleed, this heme can
travel through the canal into the interface. 41 It is recommended to
observe the canal during flap creation, and if a large amount of heme is
present, special attention should be given during the flap dissection to
avoid creating a connection between the canal and the interface.

Summary
FS-assisted LASIK has become the preferred method for LASIK
flap creation due to the precision, accuracy, and reproducibility of the
flap creation. Thinner, planar flaps may help prevent cases of post-
LASIK ectasia and may have a superior refractive outcome. However,
FS flap creation has several unique complications that require early
recognition and optimal timely management for the best visual
outcomes.

Supported in part by an unrestricted departmental grant to Emory University Depart-ment

of Ophthalmology from Research to Prevent Blindness Inc. The authors declare that they
have no conflicts of interest to disclose.

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 Femtosecond Laser Complications 65

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