Femtosmile Complications: How to avoidAhmed Yousry Fekry, MD. 3/16/2018 25 Equation = Famous names...
Transcript of Femtosmile Complications: How to avoidAhmed Yousry Fekry, MD. 3/16/2018 25 Equation = Famous names...
3/16/2018
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Femto SMILE
Abdelmonem HamedFellow of Baylor college, TX, USA
Professor of ophthalmology,
Benha University, Egypt
I have no any financial interest from Zeiss co. or
from its agents and distributors
Femto SMILE
Abdelmonem HamedFellow of Baylor college, TX, USA
Professor of ophthalmology,
Benha University, Egypt
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Excimer laser Photoablation
The excimer Lasers produce UV light, that hits tissue , then
the Collagen molecules become excited and absorb photons & heat up, that lead to:
breaking of hydrogen bonds of tissue water, so water expand and undergoes a phase
transition into hot gas & burst out that burst out includes the tissue protein.
Femtolaser laser Photodisruption
Ionization of the electrons of the tissue by Femtolaser produce plasma
This plasma expands which lead to
pressure as high as 10 kilobars
that lead to creation of cavitation bubbles
that bubbles exert a cutting effect upon the tissues.
1 2 3
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Meaning of Femtosecond
• A femtosecond is the unit of time equal to • 10−15 (10 power negative 15) or• 1/1,000,000,000,000,000 of a second;
• Which means, one millionth of one billionth, of a second.
• A nanometer= 10−9
Femtosecond laser VS excimer laser7 advantages of femtolaser over Excimer laser
Femtolaser: Wave length = 1053fmExcimer laser: Wave length = 193nm
Results of these advantages Ultra-high precisionUltra-low collateral damageThe femtolaser has:
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SMILE
Advantages
AccuracyOf SMILE
SMILE
Advantages
AccuracyOf SMILE
Complete one machine
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SMILE
Advantages Accuracy
Complete one machine
It doesn’t get affected by humidity
Of SMILE
SMILE
Advantages Accuracy
Complete one machine
Better corneal biomechanics
It doesn’t get affected by humidity
Of SMILE
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SMILE
Advantages Accuracy
Complete one machine
Better corneal biomechanics
Complete femtolaser surgery
It doesn’t get affected by humidity
Of SMILE
SMILE
Advantages Accuracy
Complete one machine
Better corneal biomechanics
Complete femtolaser
Minimally invasive: 2-3 mm incision
It doesn’t get affected by humidity
Of SMILE
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SMILE
Advantages Accuracy
Complete one machine
Better corneal biomechanics
Complete femtolaser
It doesn’t get affected by humidity
Of SMILE
Better visual quality @ larger pupil diameter.
Minimally invasive: 2-3 mm incision
SMILE
Advantages Accuracy
Complete one machine
Better corneal biomechanics Complete femtolaser
It doesn’t get affected by humidity
Of SMILE
Better visual quality @ larger pupil diameter.
Minimally invasive: 2-3 mm incision
No dryness
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SMILE
Advantages Accuracy
Complete one machine
Better corneal biomechanics Complete femtolaser
It doesn’t get affected by humidity
Of SMILE
Better visual quality @ larger pupil diameter.
Minimally invasive: 2-3 mm incision
No dryness
No postop. Restriction.
SMILE
Advantages Accuracy
Complete one machine
Better corneal biomechanics Complete femtolaser
It doesn’t get affected by humidity
Of SMILE
Better visual quality @ larger pupil diameter.
Minimally invasive: 2-3 mm incision
No dryness
No postop. Restriction.
FDA approved
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Advantages Accuracy
Complete one machine
Better corneal biomechanics
Complete femtolaser
It doesn’t get affected by humidity
Of SMILE
Better visual quality @ larger pupil diameter.
Minimally invasive: 2-3 mm incision
No dryness No postop. Restriction. FDA approved
No lasik flap complications
SMILE
SMILE
Advantages Accuracy
Complete one machine
Better corneal biomechanics
Complete femtolaser
It doesn’t get affected by humidity
Of SMILE
Better visual quality @ larger pupil diameter.
Minimally invasive: 2-3 mm incision
No dryness No postop. Restriction. FDA approved
No lasik flap complications
No PRK complications
Haze
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Hyperopia correction is under research
Professor Dr. Osama Ibraheem
(Latest results of ReLEx for Hyperopia are quite encouraging)
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November 9, 2017
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It looks that, SMILE is better thanlasik, femto-lasik, and PRK
So, where the problem,what prevents SMILE from progress
?
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The major problems with ReLEX SMILE are
3. Difficult start up in the beginning of learning curve
1. Enhancement
2. Epith. ingrowth 4. Cost
1. Enhancement
A. Surface ablation (SMILE + PRK)B. Secondary SMILE (SMILE + SMILE)
I. Anterior to the 1ry. Procedure (Cap).II. Posterior to the 1ry. Procedure (Bed)
C. Covert the cap to flap, then followed by excimer ablation (SMILE + Femto-LASIK)
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• (SMILE +PRK)• induced corneal edema and haze (23±6 cells).
• It needs mitomycin-C in order to reduce inflammation.
• (SMILE + SMILE) offers advantages:• minimal inflammation (7±1 cells).
• maintaining a ‘flap-less’ surgery.
• 2ry lenticule is very thin.
• (SMILE + FEMTO-LASIK)• induces more inflammation (10±2 cells)
compared to (SMILE + SMILE).
(Rabbits)
• (SMILE +PRK)• induced corneal edema and haze (23±6 cells).
• It needs mitomycin-C in order to reduce inflammation.
• (SMILE + SMILE) offers advantages:• minimal inflammation (7±1 cells).
• maintaining a ‘flap-less’ surgery.
• 2ry lenticule is very thin.
• (SMILE + FEMTO-LASIK)• induces more inflammation (10±2 cells)
compared to (SMILE + SMILE).
(Rabbits)
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• (SMILE +PRK)• induced corneal edema and haze (23±6 cells).
• It needs mitomycin-C in order to reduce inflammation.
• (SMILE + SMILE) offers advantages:• minimal inflammation (7±1 cells).
• maintaining a ‘flap-less’ surgery.
• 2ry lenticule is very thin.
• (SMILE + FEMTO-LASIK)• induces more inflammation (10±2 cells)
compared to (SMILE + SMILE).
(Rabbits)
• (SMILE +PRK)• induced corneal edema and haze (23±6 cells).
• It needs mitomycin-C in order to reduce inflammation.
• (SMILE + SMILE) offers advantages:• minimal inflammation (7±1 cells).
• maintaining a ‘flap-less’ surgery.
• 2ry lenticule is very thin.
• (SMILE + FEMTO-LASIK)• induces more inflammation (10±2 cells)
compared to (SMILE + SMILE).
(Rabbits)
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• (SMILE +PRK)• induced corneal edema and haze (23±6 cells).
• It needs mitomycin-C in order to reduce inflammation.
• (SMILE + SMILE) offers advantages:• minimal inflammation (7±1 cells).
• maintaining a ‘flap-less’ surgery.
• 2ry lenticule is very thin.
• (SMILE + FEMTO-LASIK)• induces more inflammation (10±2 cells)
compared to (SMILE + SMILE).
(Rabbits)
• (SMILE +PRK)• induced corneal edema and haze (23±6 cells).
• It needs mitomycin-C in order to reduce inflammation.
• (SMILE + SMILE) offers advantages:• minimal inflammation (7±1 cells).
• maintaining a ‘flap-less’ surgery.
• 2ry lenticule is very thin.
• (SMILE + FEMTO-LASIK)• induces more inflammation (10±2 cells)
compared to (SMILE + SMILE).
(Rabbits)
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Secondary SMILE (SMILE + SMILE) enhancement
Anterior to the 1ry. Procedure o SMILE retreatment in cap.o 1st SMILE cap thickness must be > 160 µo It is a 2ry complete SMILE procedureo 2nd cap thickness must be not less than 100 µ
Cap 100 µ
2ry SMILE
1ST SMILE
Bed 250 µ
Cornea
Cap
Bed
Secondary SMILE (SMILE + SMILE) enhancement
Posterior to the 1ry. Procedure (case report, Donate and Thäeron, 2015 JRS)o SMILE retreatment in
stromal bedo Minimum residual stromal
bed after 2ry SMILE must
be not less than 250 µ
o Good centration with Dr.
Sedky marker
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Secondary SMILE (SMILE + SMILE) enhancement
Posterior to the 1ry. ProcedureAfter docking and
starting the laser get
your foot off the laser
pedal after doing the
side cut of the
lenticule.
We don’t need the
cap creation step.
2. Epithelial ingrowth?
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Epithelial ingrowth?
SMILE with 2incisions?
Panel discussion
Epithelial ingrowth?
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Epithelial ingrowth?
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Pt. OLD SMILE pass
Circle pass
Junction
Circle pass
Diameter of circle 3 mm bigger than cap
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Circle has the same thickness like the cap
SMILE incision position @ 120
Circle hinge position @ 70
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This was my 1St Case
3. To facilitate the start up in the beginning of
the learning curve
We created a new technique called:
(ReSMILE): Push-up and push-down techniques,
Abdelmonem Hamed, MD
Ahmed Yousry Fekry, MD
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Equation =
Famous names of femto-smile:
1. (ReLEx)
2. (SMILE)
Refractive + SMall-Incision + Lenticule Extraction
= Refractive SMall Incision Lenticule Extraction
(ReSMILE)
3. Difficult start up in the beginning of learning curve
Refractive
SMall-IncisionLenticule Extraction
Lenticule Extraction
(ReSMILE): Push-up and push-down techniques
ReSMILE: Push-up technique
Benha University
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ReSMILE: Push-up technique
Benha University
ReSMILE: push-down technique
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Restrictions & Complications
Myopia up to -10.0 D
Astigmatism up to -5.0 D.
Cap or lenticule rupture
Cap lamellar keratitis
Limited to the cap, not the bed
Less responsive to corticosteroid therapy
What about double SMILE?
Rainbow glare
Due to micro-irregularities of the interface.
Transient Light Sensitivity Syndrome (TLSS)
Good visual acuity + Photophobia
Usually resolves with days to weeks
Restrictions & Complications
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VisionMy vision for the future is:
The SMILE is going to replace all the old refractive procedures , however it needs A hard research work for
optimization.
The refractive surgeons should be convinced by the SMILE, to be able to overcome the resistance of the change.
Resistance to change
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Thank you very much