FEMTO-LASIK and BEYOND - Carl Zeiss, Inc.

SUPPLEMENT June 2012
EDUCATIONAL SUPPLEMENT
JUNE 2012
Supported by an Educational
Grant from Carl Zeiss
2012 Refractive Compendium
Panelists from the International Refractive User Symposium, in Kuala Lumpur, and
the ESCRS ReLEx ® smile Satellite Symposium, in Vienna, share their latest clinical
experiences in the use of VisuMax ® femtosecond system, ReLEx and Keratoplasty.
FEMTO-LASIK and BEYOND
A compendium of the latest global perspectives on the
VisuMax femtosecond system and the promise it holds
for the future of refractive surgery.

Introduction
Table Of Contents
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A Winning Combination:
Femtosecond Lasers and Flapless Laser
Vision Correction
VisuMax in Conventional
Femto-LASIK Surgery
VisuMax: The Femto-only
Option of Laser Correction
LASIK in High Myopia
ReLEx smile: The New Application
ReLEx smile: All-in-one Correction
ReLEx Versus Femtosecond LASIK:
A Comparison
ReLEx smile: An Outstanding
Treatment for Low, Moderate
and High Myopia
ReLEx smile: My New
Clinical Standard
VisuMax in Keratoplasties
The Importance of ReLEx in Our
Current Laser Vision Correction
Business
At the International Refractive User
Symposium, in Kuala Lumpur,
and the ESCRS ReLEx smile
Satellite Symposium, in Vienna,
Carl Zeiss gathered key opinion leaders from
around the world to share their experiences in
advanced techniques of refractive surgery. The
subspecialty continues to evolve dramatically,
not only in terms of advancements in
LASIK techniques but also in lenticular
options available to give a patient the best
possible visual result. Twenty years after
its advent, LASIK is today the most widely
done refractive procedure. However, as was
evident in the discussions in Kuala Lumpur
and Vienna, refractive surgery steps beyond
traditional LASIK.
Three key advancements were discussed
in detail at the conferences—the VisuMax
Femtosecond System, ReLEx and the
femtosecond laser’s role in keratoplasties.
VisuMax was appreciated for its precision,
performance and infallible patient satisfaction.
Many surgeons shared how the laser pulse rate
of 500 kHz has helped the VisuMax to set new
standards of efficiency, and hence scores over
the frequency of 200 kHz.
ReLEx, meanwhile, marks a strong
step forward in laser vision correction by
combining precise refractive femtosecond
laser technology with lenticule extraction. The
predictable results which the technique offers
are a boon to surgeons and patients alike.
Apart from the role of VisuMax in
procedural LASIK, speakers acknowledged
that the femtosecond system presents a
comprehensive option for keratoplasty and
enables superior corneal grafting with minimal
complications. Indeed, one can certainly think
beyond LASIK with the VisuMax.

The Panelists
Ekktet Chansue, MD
Medical Director
TRSC International LASIK Eye Center
Bangkok, Thailand.
Dr Bertram Meyer
Consultant, Laser Eyecare and Research Centre
Dubai Healthcare City
Dubai, UAE
Prof Osama Ibrahim
Professor of Ophthalmology, Alexandria University
Chairman, Roayah Vision Correction Centers
Egypt
Dr Burjor P Banaji
Medical Dirctor, Banaji Eyecare
Mumbai, India
Dr Donald Tan
Medical Director, SNEC
Chairman, SERI
Singapore
Dr Iain Dunlop
Director, Canberra Eye Hospital
Canberra, Australia
Dr Lennard Thean
Clinical Director, Ophthalmology
National University Hospital and
NUH Eye and LASIK Centre
Quezon City, Philippines
Dr Ruben Lim Bon Siong
Clinical Associate Professor
University of Philippines
Manila, Philippines
Prof Dan Z. Reinstein
Medical Director,
London Vision Clinic
London, UK
Walter Sekundo, MD
Chairman, Department of Ophthalmology
Philipps University of Marburg
Germany
Dr Khairidzan Mohd Kamal
Associate Professor
International Islamic University
Kuala Lumpur, Malaysia
Rupal Shah, MD
Director, New Vision Laser Centers
Vadodara, India
Prof Muhaya Mohammad HJ
Director, PCMC Eye and Lasik Center
Prince Court Medical Center
Kuala Lumpur, Malaysia
Prof Zhou Xingtao
Director, Eye and ENT Hospital
Fudan University
Shanghai, China
Dr Patrick Versace
Medical Director
Vision Eye Institute
Bondi, Australia
Jesper Hjortdal, MD, PhD
Director of Corneal and Refractive Surgery
Aarhus University Hospital
Denmark.
Dr Cordelia Chan
Senior Consultant
Singapore National Eye Center
Singapore
Dr Khaled Ben Amor
Tunisia

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Ophthalmology WORLD REPORT
A Winning Combination:
Femtosecond Lasers and Flapless
Laser Vision Correction
ESCRS ReLEx smile Satellite Symposium Vienna, Austria
Cataract & Refractive Surgery Today Europe
With the right candidate, ReLEx provides many advantages over PRK or LASIK.
Reviewed by Walter Sekundo, MD
Refractive surgery is still a
relatively new frontier in
ophthalmology. It began as
a radical idea in the late 1980s and
early 1990s but it quickly transformed
into a trend that is acceptable
worldwide and boasts impressive
postoperative results.
Today, millions of people undergo elective laser vision
correction to fix refractive errors in the hopes of achieving
spectacle independence. LASIK and PRK are exceptional
procedures with outstanding safety and efficacy, but there
are now other laser vision correction options for our patients.
One newer choice in refractive surgery is ReLEx, a less
invasive, highly precise form of laser vision correction
that is performed completely inside the intact cornea with
the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena,
Germany). This innovation allows the surgeon to create a 3-D
cut within the cornea, intrinsically increasing predictability
of refractive surgery due to less tissue destruction and better
ambient conditions.
Overview: Marcus Blum, MD, of Erfurt, Germany, and I
belong to a small group of principal investigators for the VisuMax
femtosecond laser and have been using this platform
for refractive surgery since 2007. We also helped develop
the company’s original lenticule extraction technique, femtosecond
lenticule extraction (ReLEx flex). Now,
Carl Zeiss Meditec has a successive lenticule extraction
technique, ReLEx smile, using small incision extraction. This
method has eliminated the need for flap creation. Instead of a
corneal flap, the surgeon creates a small incision and manually
extracts the intrastromal lenticule. For a video demonstration
of ReLEx smile, visit http://eyetube.net/?v=ginuh.
The company has branded both techniques under the general
name of ReLEx. This technique is unique to other laser procedures
because it uses precise laser cutting patterns instead
of ablation patterns typical of LASIK and PRK procedures.
One advantage of ReLEx is that the same laser can be used
throughout the entire procedure, saving time in the operating
room and eliminating the need to move the patient between
two laser platforms.
Laser Quality: By today’s increasing standards of patient
care, I feel that the VisuMax is the only machine that can be
used for full refractive purposes. My initial experience is with
ReLEx flex. In the beginning, I used the 200-kHz VisuMax
femtosecond laser for this procedure, which includes creation
of two cuts, one at the bottom and one at the top of the
refractive lenticule. Once the lenticule is removed, the flap is
repositioned and the procedure concludes.
ReLEx flex treatments with the 200-kHz laser were efficient
and lasted between 50 and 60 seconds, depending on the
lenticule and flap diameter. My surgical results were quite
impressive. Of the more than 100 commercial patients I
treated with the 200-kHz machine, all achieved a visual acuity
of 20/40 or better at 1 month and roughly 80% were 20/20 or
better by the last follow-up at 3 months.
In March 2011, I upgraded to the 500-kHz VisuMax, which
has allowed me to achieve even more impressive results for
my patients. Most notably, virtually all patients treated are
20/25 at 1 week and 20/20 unaided at the second follow-up
at 1 month. Surgically, what I am most impressed with is the
improved quality of the cut within the cornea and the speed of
the treatment. With the 500-kHz engine, the treatment is done
within 40 seconds. Thus, I have been able to reduce laser
energy, leading to faster visual recovery. Now, I can also treat
patients who I would have previously found unsuitable for
this procedure with the 200-kHz laser, such as those who I did
not feel could lay still for 60 seconds.
The more important issue, however, is that the 500-kHz
laser also handles the corneal tissue more delicately, which
combined with the quality of the corneal cut makes it easier to
extract the lenticule. I performed ReLEx smile as a study pro-

June 2012 Supplement
5
Figure 1. At 3-month follow-up after ReLEx smile, only a faint
superior incision site is detectable at the slit lamp.
“ReLEx currently has the most advantages for
moderate and high myopia when compared
with excimer-based procedures.”
cedure with the 200-kHz laser, but today it is my procedure of
choice with the 500-kHz laser, in particular for moderate and
high myopia.
Patient comfort: I have found that
patients are more comfortable during
and after ReLEx versus femtosecond
LASIK and surface ablation procedures,
and I believe this is because
the cuts made during ReLEx flex, and
especially ReLEx smile, are smaller
than the surface manipulation with
LASIK and PRK. Smaller cuts shorten
the time it takes for the epithelium
to heal (Figure 1). While the eye is
healing, patients typically experience
foreign body sensations; with ReLEx
smile procedures, this lasts for no more
than 2 to 3 hours as a minor discomfort
in comparison to approximately 4 to
5 hours with LASIK and 2 to 3 days
PRK.
During the entire procedure, the patient
feels a little pressure. As shown in a
study by Vetter et al, 1 treatment with the
VisuMax femtosecond laser leads to the
lowest increase in intraocular pressure
as compared with other femtosecond
lasers. Additionally, there is neither any central artery occlusion
(ie, blackout of vision) nor the smell of the fumes typically
created during excimer-based surgery.
Because of the increased stability of the achieved refractive
correction, I can also perform ReLEx in patients with up to
-10.00D of myopia, which otherwise would have received a
phakic IOL. In fact, this week I saw a patient 3 months after
ReLEx smile for -9.50D of myopia. He had an impressive
distance UCVA of 20/12.5 and no night driving problems
despite a 6.8-mm scotopic pupil.
Incision size: The nice thing about ReLEx smile is that there is
no longer a need for the corneal flap. Therefore, this all-in-one
laser procedure reduces the complications associated with the
flap cut, including incomplete or irregular corneal flaps, thin
or small corneal flaps, buttonholes, and free caps.
ReLEx smile can be performed using either one or two
incisions. I prefer making two small incisions (3–5 mm) at
the 12- and 6-o’clock positions. The use of two incisions
enhances the flow of fluid within the eye when I flush the
interface. These incisions can alternatively be created at the
3- and 9-o’clock positions, as is Professor Blum’s technique,
with the same result. Because the opening incisions are only
100 to 120 μm deep, they do not induce astigmatism. When
only one incision is placed, a technique that Rupal Shah, MD,
of India uses, a small pocket is created to extract the lenticule.
ReLEx currently has the most advantages for moderate and
high myopia when compared with excimer-based procedures.
However, I am participating in a second ongoing study to test
its efficacy for hyperopia. What we do know is that visual
recovery, higher-order aberrations, and stability are excellent
for moderate and high myopia, as shown in the comparative
studies by Gertnere and Hjortdal at a recent Carl Zeiss users’
meeting held in Dubai. Hyperopia treatment has always been
a more challenging terrain than myopia. However, our first
results on hyperopic ReLEx are encouraging, and once we
perfect a cut profile we hope to achieve results similar to
the current excimer standards.
Conclusion: ReLEx is an exciting new realm in refractive surgery,
and any reasonably skilled surgeon can achieve successful
outcomes with this procedure. What I enjoy about ReLEx
is being able to use the same femtosecond laser workplace
for the nonrefractive cut and the surgical manipulation itself,
and my patients enjoy the faster surgery and improved patient
comfort.
1. Vetter JM, Schirra A, Garcia-Bardon D, Lorenz K, Weingärtner WE, Sekundo W.
Comparison of Intraocular Pressure During Corneal Flap Preparation Between a
Femtosecond Laser and a Mechanical Microkeratome in Porcine Eyes. Cornea. 2011
Jul 26. [Epub ahead of print.]

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Ophthalmology WORLD REPORT
VisuMax
In Conventional
Femto-LASIK
Surgery Kuala Lumpur, Malaysia
International Refractive User Symposium
Dr Iain Dunlop on the “Australian
Experience with the ZEISS Femtosecond
Laser”
“I am very happy with this
machine. It is very forgiving, safe
and accurate.”
The Australian experience: Discussing the Australian
experience with VisuMax, Dr Dunlop rightly called it a
“platform for growth, both refractive and therapeutic”.
It holds a promise for service excellence and is costeffective.
“Well you get what you pay for and ideally
it is worth it,” he added. It is exceptionally stable and
self-calibrating; “it has an integrated uninterrupted
power supply and excellent audiovisual capabilities. It
does not require a stand-by mode and can be installed
‘out-of-the box’”.
Configuration: Dr Dunlop spoke about the configuration
of the VisuMax for the hinge location, flap
diameter and thickness and the side-cut angle. “You
can configure your VisuMax however you like. You
can change the hinge location. Before it is all in the
software. The flap diameter can be chosen to fit the
cone you use,” he explained. He shared details of how
the energy, spot and track distance settings can be chosen
for standard mode, standard mode enhanced, fast
mode and fast mode enhanced, which appear on the
screen of the VisuMax. He then compared the ablation
patterns in the initial and advanced models.
LASIK with VisuMax and MEL 80 ® : Dr Dunlop described
the flap lift using the MEL 80. According to him, there
is no need to wait till the bubble layer regresses into
transparency. He then shared the results of 400 cases
he had done. For the choice of cones, he said “Medium
cones (n=289) are used about 3 times more than the
small ones (n=108) and we rarely use the large cones
(n=3).With the cone comes a license, so you use one
cone for one eye. This means ZEISS maintains quality
control and it is, I guess, a reasonable step though it is
a bit confronting when you first meet it.” He finds the
machine to be successful as complications are rare. “The
machine is so pleasant and successful to use that one has
to look for irregularities or surprises that arise,” said
Dr Dunlop. He described suction loss as being
“something that can be dealt with” and shared that the
VisuMax was very forgiving. He showed videos of cases
of suction loss and how it can be avoided by using the
right cone, correct positioning of the head, and reassuring
the patient. Lastly, he described his experience with
patients in range of -8.5D to +4.5D. He said, “We have
had a 100 μm flap thickness with a 110 degrees side cut
and it is very satisfying and predictable. The patients are
very comfortable and happy as well. Importantly, there
has been no machine downtime.”
Dr Cordelia Chan on “Femto-LASIK with
VisuMax: The SNEC Experience”
“Since its inception in November
2008, SNEC has developed a
successful Femto-LASIK with
VisuMax program. Good clinical
outcomes for myopic LASIK have
been achieved with excellent safety,
predictability and efficacy profiles.”
The VisuMax fits into the Singapore National Eye
Center practice as it is a part of the major Translational
Clinical Research (TCR) program, Translational
Research in Ocular Surgery (TRIOS) conducted by
the Singapore Eye Research Institute (SERI) and funded
by the Singapore government. “We started refractive
surgery in 1993 with PRK and LASIK in 1996. Today, we
have done over 50,000 procedures and do a 100% clinical
audit for all our procedures. This year we published our
10 year audit results of 37,932 cases performed between
1998 and 2007—the largest published series on LASIK,”
Dr Chan briefed.
Sharing the results of the 200 kHz device, she said that
there was excellent safety, predictability and efficacy
of VisuMax femtosecond platform for LASIK. She also
discussed the results of the study done to evaluate the
impact of the suction breaks upon tissue separation with
VisuMax 200 kHz done on eye bank corneas (n=10) and
said that suction loss was much less of concern with
VisuMax. “In SNEC, we do predominantly aging eyes,

June 2012 Supplement
7
we normally use an S cone if it is a 12-2 or 12-3 mm
cornea. With an M cone, it is a little easier to get suction
breaks,” she said.
VisuMax vs IntraLase LASIK: She discussed the retrospective,
multi-surgeon study of LASIK performed for myopia
with or without astigmatism from September 2009 to
April 2010 at SNEC. According to her, the efficacy index,
predictability and safety were similar for VisuMax (n=882)
and IntraLase (n=654). The VisuMax seemed to be much
better in high myopes (-10D or more) with an efficacy index
of 0.97 (n=8) as against the IntraLase with an efficacy
index of 0.84 (n=9). “But the numbers are small and we
may have confounded the results,” she cautioned.
VisuMax vs IntraLase, Contralateral Eye Study: The
prospective randomized study consisted of a bilateral
simultaneous LASIK with VisuMax 500 kHz femtosecond
laser for LASIK flap creation in one eye and IntraLase
femtosecond system in the fellow eye. Excimer laser
ablation was done with Wavelight® Allegretto 400 kHz
in both eyes. The patients and surgeons were interviewed
perioperatively with a standardized questionnaire
about their operative experiences and preferences. Dr
Chan shared the results of 24 patients of the 40 target
population. Despite of the VisuMax being a low pressure
system, 17% had a loss of light perception during suction
and during the femtosecond pass. The same was seen
in around 45% with IntraLase. When questioned about
the fear factor, 46% of the VisuMax patients and 67% of
IntraLase patients were frightened during vacuum suction
or applanation. “Most patients said that the vacuum
suction for both the systems was the most painful part.
The pain score for VisuMax was 1.7 and for IntraLase
was much higher (4.3),” she said. Seventy-five percent
and 2% of patients preferred the VisuMax and IntraLase,
respectively. The patients disliked the discomfort and pain
in IntraLase and the constant stare at green light in the
VisuMax. According to Dr Chan, she finds the VisuMax
to be “an easier platform” with lesser subconjunctival
hemorrhage and suction loss. “About 45% of us felt that
the IntraLase was easier to lift, 17% found VisuMax was
easier to lift and 37% are had no preference,” she said.
Conclusions: Dr Chan concluded that a nice and assuring
upward trend in predictability has been obtained with the
VisuMax. She feels that the VisuMax is also a preferred
choice by patients. Loss of light perception occurred more
frequently with the IntraLase during flap creation. “Since
its inception in November 2008, SNEC has developed
successful Femto-LASIK with VisuMax program. Good
clinical outcomes for myopic LASIK have been achieved
with excellent safety, predictability and efficacy profiles,”
she summarized.
Dr Patrick Versace on “Registration,
Alignment and Tracking”
“ZEISS provides us with a platform
that effectively has three elements of
a laser delivery system. It has good
diagnostic, so we can measure corneal
shape, we can measure the wavefront
of the cornea and total eye, and these
things are integrated into the
CRS-Master. We can plan treatments
integrating all the data that we collect.”
Ablation, rotational alignment and tracking: “Zeiss
system tracks both the pupil and the limbus. It has
a sampling speed and a response time,” Dr Versace
said. He showed the impact of change in tracking speed on
various parameters.
Dr Versace specified how it was important to “put the ablation
where it is meant to be on the cornea and to maintain
that position throughout the treatment.” He agreed that
success was in “having the device placed on the visual axis
not on the pupil center.”
Talking about an acceptable misalignment he said that a
translational error of 300 μm to 400 μm and a rotational
error of 8-10 degrees would still give a 50% reduction in
higher order aberrations. He said that a workable registration
would be an XY shift of less than 200 μm and a
rotational alignment within 5 degrees. He then spoke about
the wavefront alignment with the Zernicke reference and
how the pupil was used for wavefront capture. According
to him, the ZEISS system does compensate for the shift in
center of the pupil as the pupil dilates or gets smaller. “The
ZEISS platform has a resolution of 100 μm with pupil
center shift. That is well within what we need.”
Angle kappa: Describing how a large angle kappa leads
to a significant induction of coma, he shared the results
for angle kappa from a recent study done in Iraq which
unleashed that the angle kappa was common and the values
were pretty much the same for all refractive errors, myopia
and hyperopia.
Cyclorotation: Referring to rotational alignment and astigmatism,
Dr Versace spoke about “how much cyclorotation
occurs when the patient goes from sitting to lying down.”
“Most patients have less than 5 degrees cyclorotation,” he
said. Dr Versace showed the WASCA/CRS-Master/MEL 80

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Ophthalmology WORLD REPORT
tion he said that “the topography treatment automatically
compensates for angle kappa and has 2 separate points of
centration.”
Summary: According to Dr Versace, the ZEISS platform
compensates for cyclorotation and change in pupil center.
In the event of visual axis overriding the laser, there is
ATLAS registration and automatic angle kappa compensation.
In astigmatism with iris registration, he “overrides the
laser and sets the pupil center or visual axis”. For WASCA
ablation, he said that one should consider the higher order
on center of pupil present at aberrometer, the sphere and
cylinder on pupil center or visual axis and incorporation of
second order into Zernike set. What he does is “over ride
and place cursor on the pupil center”.
MEL 80 eye tracker (Dr Patrick Versace, Australia)
He also described the topoguided ablation using ATLAS.
In presbyopic LASIK ablation he said, “We shift to visual
axis and compensate the angle kappa and set ablation on
visual axis prior to flap lift.” He said that the pre-existing
and induced spherical aberrations should be considered.
For enhancement, he uses the toporefractive treatment
when possible. Lastly, he said that the ZEISS system
integrates topography, refraction, wavefront, patient data,
flap creation, eye motion, pachymetry, corneal curvature
and refraction. “We still have to work towards automated
centration and registration of ablations to avoid all errors
that we make,” he concluded.
Zeiss dynamic registration (Dr Patrick Versace, Australia)
eye registration data for clinical test done on 37 eyes (OD/
OS) where the torsion between sitting and supine position
was less than +15 degrees. He showed graphical
results for cyclorotation tolerances. “The system is quite
forgiving and what is great is that the manufacturers have
the cyclorotation compensations in the platform. This is
though not as critical as is the XY registration and centering
on the right point,” he said. “The resolution for the
ZEISS platform for cyclorotation is only 0.1 degrees. It is
voluntarily able to compensate within the sensible cut off
of 5 degrees,” he added.
OcuLight eye registration: Talking about the compensation
for cyclotorsion and pupil size, Dr Versace elaborated
on the advantages offered by the OcuLign like the wavefront
measurements, use of limbus margin rather than
pupil for centration, limbus position being independent of
pupil size and utilization of iris and scleral vessels as reference.
He next spoke about the ZEISS topography-based
ablation and described how the two treatments were integrated
and superimposed. Regarding topographic registra-
Dr Lennard Thean on “Why I Switched to
ZEISS Refractive Laser Platform?”
“Personally for me, it is a real
workhorse excimer laser system.
We have treated over 500 soldiers,
fighter pilots, commandoes and
naval divers.”
MEL 80: Dr Thean discussed the benefits with
MEL 80, i.e. accuracy, faster recovery due to
shorter exposure time, and excellent eye tracker
response time. It has a tracking system: pupil tracking,
limbus tracking and iris registration. He discussed the
special application of this technique for people engaged
in military and other armed services where spectacles and
contact lenses are not appropriate, where refractive surgery
has helped to increase the talent pool. Discussing the
results in candidates chosen for the Republic of Singapore
Air Force (RSAF) PRK Programme, he said that the
MEL 80 was a benchmark in refractive surgery success.

June 2012 Supplement
9
There was a 95% of UCVA of 6/6 or better (6/12 was not
used as it would not have been compatible with a flying
vocation), and 95% within + 1D of intended correction
and 95% preservation of BSCVA (

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Ophthalmology WORLD REPORT
VisuMax:
The Femto-only
Option of Laser
Correction
International Refractive User Symposium
Kuala Lumpur, Malaysia
Prof Dan Z. Reinstein on “Laser Blended
Vision”
Flap centration on corneal vertex. (Prof Dan Z. Reinstein, the United
Kingdom)
we have a very new ablation profile algorithm via this
topographic mode,” he added. He further explained that the
ablation depth is minimal and there are considerations of
biomechanical effects of the cornea. “It is safe in tissues.
There is 25-30% less tissue waste when using this profile,”
he added.
Clinical experiences: He shared the results of 84 eyes with
hyperopia or mixed astigmatism where the mean sphere
was +2.67D and the mean cylinder was -2.51D. “The
astigmatic corrections are very reliable. Even in higher
astigmatic cylinders we have good results,” he said.
Further he showed the results of VisuMax femtosecond
flap cut of 514 myopic eyes where the mean sphere was
-4.48D and the mean cylinder was -1.14D. According to
him, there were “marvelous outcomes” with no technical
complications intraoperatively and no significant side effects.
He showed the case reports for topographic findings
in myopic (-4.25D and -2D cylinder) and hyperopic (+4D
and -0.25D cylinder) eyes. These had a well centered very
large and homogenous optical zone postoperatively. He
then shared an exceptional case with +6.5D sph combined
with a -7D cylinder,which according to him “nobody will
do”. Even in this case he said, “We had a very nice refractive
outcome.”
Conclusions: He concluded that the VisuMax and MEL 80
is an “all-laser procedure,” which allowed an easy and safe
handling of VisuMax, MEL 80 and CRS-Master. According
to him the refractive outcomes were excellent: safe,
predictable and effective with long-term stability. Minimal
induction of high order aberrations (HOA), large optical
zones and a reduced ablation depth were other positive
attributes.
“We are able to make a 80 µm flap
now and we hardly ever do a PRK
now as we have the limits set by the
corneal thickness and not by the
resultant stroma.”
Prof Reinstein spoke on the accuracy of the femtosecond
laser and how it could replace the much-used
microkeratome. According to him, the short procedure
time, easy flap lift and excellent cut quality together
helped to produce the best results. “Now we are at 0.1 μJ
with VisuMax. We are dealing with 1/10th of the power of
the IntraLase. Spot size is much smaller and pulse repetition
rate was much higher. Optimization was much better
with the VisuMax as it wasn’t intended to be a flap cutter.
It was intended to be a refractive surgery machine,” he
added.
Accuracy in VisuMax: The VisuMax makes possible an
ultra-thin flap and the flap can be made-to-measure. There
is high flap thickness reproducibility and flap scan be done
even in difficult eyes. Besides these, there is low corneal
suction and centration on corneal vertex. According to
him, there is great future potential in the VisuMax and it is
an all-in-one option. He explained repeatability, reproducibility
and how validation of the measurement instrument
influences the accuracy measurements.
Flap Thickness Study: He discussed the results of a study
published in the Journal of Refractive Surgery for 24 eyes,
which included an intended flap thickness of 110 μm and
average flap thickness of 112.3 μm with an accuracy of
2.31. Precision was just under 8 μm. Artemis very high
frequency digital ultrasound arc-scanner was used to
measure the flap thickness. The central flap thickness was
essentially the thickness of the stromal component of the
flap measured 3 months after surgery. Reiterating how the
VisuMax is so accurate he said that it was because “the

June 2012 Supplement
11
cornea is not being applanated but is effectively being accurvated”.
In other words, there is minimal distortion of the
lamellae.
Comparing the intraocular pressures, he said that it was 300
mm Hg with the IntraLase and that with the VisuMax was
much less, being lower than even 100 mm Hg. Elaborating
on the flap centration on corneal vertex he said, “The centration
is very important for accuracy as the flaps automatically
center during refractive surgical procedures on the vertex of
the cornea. VisuMax gives the best approximation.”
VisuMax in diverse eyes: Prof Reinstein said the VisuMax
was a preferred option where the Hansatome was not possible.
He then went on to discuss the VisuMax in a RK patient
in whom they measured the epithelial thickness, added
three standard deviations and produced a femtosecond flap.
Next, he shared an example of a VisuMax flap deep lamellar
keratoplasty. Finally, he showed the visual outcomes in the
series of 232 eyes in 131 patients with a median age of 38
years and a mean spherical equivalent of -4D and a mean
cylinder of -0.72D. All had BCVA of 20/20 and 59% had
a BCVA of 20/16. “Stability was reached at 3 months,” he
added. Lastly, he shared his experiences with the ReLEx
flex cut in a patient with coloboma.“I argued with her that
eye tracking is very tricky in a coloboma, so I did a ReLEx
and worked through a small incision,” he said.
LASIK in High Myopia
Prof Dan Z. Reinstein
Very High Myopic LASIK Using New
Aspheric Hybrid Profiles
Spherical aberration: Prof Reinstein explained the spherical
aberrations being due to the excimer laser beam landing
on the cornea at an angle which lead to a projection error
causing the lower fluence and hence less ablation as one went up
towards the periphery. He explained the biomechanics of how on
the pachymetric topography of LASIK, the stroma was actually
thickening and showed examples for the same. He discussed the
option for precompensation of spherical aberration and shared
more examples.
New hybrid profile: Prof Reinstein then discussed the new
profile for high myopes. According to him, the non-linear
aspheric ablation profile increased peripheral ablation (not more
than z(4,0)) and reduced induction of spherical aberration. In
the process, some myopia can be corrected due to the central
flattening. “In the new ‘free lunch’ profile, the patients were
overcorrected by half a diopter. This is because we were
Laser Blended Vision: Prof Reinstein elaborated on the components
for Laser Blended Vision relating to surgical planning,
the patients themselves and most importantly residual
accommodation. He described how the eye has an inherent
spherical aberration that increases as the accommodation
decreases with aging. This, however, is not accompanied
by a loss of miosis, hence increasing the depth of field. He
then discussed the reduction of anisometropia in monovision
because of increased depth of field. He then shared an
elegant study to explain the blur adaptation that happens in
the brain. He explained how visual anisometopia decreases
as the day goes on. Finally, he spoke of the neural suppression
and the problems with multifocality. “The brain is not
wired for a monocular diplopia,” he said when referring to
the problem of obtaining two images. He specified that the
eye should have the “right amount of spherical aberration”
as too much of it would give disturbances in nightvision and
contrast and too little of it would leave no depth of field.
Night vision disturbances and centration: Elaborating on
the causes and treatment of night vision disturbances, Prof
Reinstein shared the results of a study titled “A new night
vision disturbance parameter and contrast sensitivity as indicators
of success in wavefront-guided enhancement”, which
has been published in the Journal of Refractive Surgery in
2005. Prof Reinstein said that unlike the IOLs it was easier
to center with the excimer laser. He shared an example of
MEL 80 in high myopia: Accuracy
Continued on P13 >>

12
Ophthalmology WORLD REPORT
a patient where the measured wavefronts revealed an angle
kappa and showed the calculated point spread function from
the vertex of centered wavefront. “Subjective point spread
function correlates with the vertex point spread function and
not pupil point spread function,” he said. “In clinical practice,
patients see aberration relative to the vertex which is in approximation
to the visual axis,” he added. He showed the
published myopic, hyperopic, and emmetropic results where
a Hansatome was used for treatment and the results were not
as good as with the femtosecond laser.
Safety and efficacy: “On the safety front, shockingly we
found that patients who started with very high stereo, only 1
in 20 lost one patch,” he said, to show that there was a statistically
significant change in stereo acuity by this procedure.
For efficacy he said, “About two-thirds of the patients had
100 seconds of stereo and 90% of them had 200 seconds of
stereo uncorrected.” The post-op uncorrected stereo acuity
was thus lower than the pre-op near-corrected.
Summary: He summarized the non-linear aspheric micromonovision.
“We have a procedure which is based on
LASIK, which corrects pure presbyopia, wide range of
refractive errors (+5D to -9D), does a simultaneous accurate
correction of cylinder, is centered perfectly by an eye tracker,
allows a minimal compromise to contrast sensitivity and
night vision disturbances, is well tolerated by more than
95% patients, maintains a functional stereo acuity and is
performed as a 10 minute bilateral procedure that heals in
3 hours,” he said. This according to him was actually the
solution.
Future of VisuMax: Prof Reinstein spoke about the unsurpassed
future potential of VisuMax which he referred to as
“the new horizon of femtosecond technology in ophthalmology”.
According to him, the VisuMax is designed to become
the corneal surgery workstation for a large spectrum of
procedures. ReLEx flex and ReLEx smile have undoubtedly
added unprecedented accuracy in corneal incision.
Prof Zhou Xingtau on “Clinical and Research
Experience of Femto-LASIK and ReLEx using
VisuMax in China”
“ReLEx appears to be a safe and
promising corneal refractive
procedure for correcting high myopia.”
Experience with ReLEx: Prof Zhou has been doing
Femto-LASIK procedures since 2008. He presented
the preliminary 5-month results of a recent prospective
study for femtosecond lenticule extraction in correction
of high myopia. He then discussed his clinical experiences
with patients ranging from 32 to more than 45 years of age.
“ReLEx recovery may be slower than the excimer laser
LASIK but the outcome in general is very good,” he said.
VisuMax Femto-LASIK: Prof Zhou showed the results of the
first 60 cases of high myopia (SE of -8.05D) who underwent
Femto-LASIK with VisuMax femtosecond laser. He then
showed comparative results of the femtosecond flap to the
microkeratome, where the predictability of femtosecond was
much better. According to him, the patients were satisfied
with -0.34D and the cylinder was -0.3D. He also showed the
good topography outcomes in cases of hyperopic patients.
He shared that recently he has been choosing to do flaps of
only 85-90 μm and discussed the results of the post-corneal
aberration of Femto-LASIK for high myopia.
CXL Research with VisuMax: “With VisuMax, we not
only do Femto-LASIK, not only do ReLEx, but we can
also do some research,” he said, and shared the procedure
of intrastromal pocket creation in animal eyes. The
stromal pocket was apparently visible shortly after the
operation and disappeared within 2 weeks normally.
In 8 of 10 cases, a demarcation line-like change in the
stroma, indicating the cross linking was visible as early
as 2 weeks after crosslinking treatment. The reflection
density of the crosslinking stroma slightly decreased at 1
month postoperatively.“Crosslinking with femtosecond
laser appears to be a safe approach. The demarcation line
may be a potential tool to monitor the depth of effective
crosslinking with the femtosecond laser in the early phase
postoperatively,” he concluded.
Prof Muhaya Mohammad on “LASIK and
Character Building”
“The VisuMax femto energy is regular
and smooth. Every step is smooth.
Post-LASIK discomfort is less.”
LASIK and Character Building: Prof Mohammad shared
her observations about the use of VisuMax. According
to her the VisuMax femtosecond energy is very
regular and smooth and the post-LASIK discomfort is less.
Every step is gorgeous. She believes in deep breathing and
meditation and reassures her patients through talking. She
specified that intention, attention and no tension were the
secrets of attaining the desired results. She then supported a
positive mental attitude as a prerequisite to success. She has
even done VisuMax Femto-LASIK on her daughter.

June 2012 Supplement
Ophthalmology WORLD REPORT
13
Continued from P11 >>
Dr Donald Tan on “Preliminary Results of
ReLEx in SNEC: As good as LASIK, or better?”
“The future of this technology lies
in ReLEx smile, which is a major
advance over LASIK with no flap,
minimal ocular surface disturbance,
or dry eye. It is a quantum leap.
Another advantage is the potential
reversibility of ReLEx, which is a
new concept of long-term lenticule
storage for patients. Lenticules
may be re-implanted back at a later
stage, in the event of keratectasia,
refractive shift or even to restore
myopia for presbyopic correction.”
taking more of peripheral tissue out and creating a mechanical
flattening at the center of the cornea in these highly myopic
eyes.” Explaining the ablation depth for the new profile, he
said that “we are taking it much more efficiently from where it
has to go.” And where it has to go from is actually measured
at the stromal level with ultrasound. Sharing an example of
RST planning, he spoke of how in a -11D, with 509 μm in
pachymetry, treating with VisuMax with flap thickness of 80 μm
and an ablation depth of 135 μm, one can still leave around
300 μm residual stromal thickness.
Outcomes: “I am sure femtosecond lasers will take over in
high myopic treatments,” said Prof Reinstein. He discussed the
results in 220 eyes with a 1-year follow-up and myopic spherical
equivalent of up to -14.5D. The myopia maximum meridian
was -10.18 ± 1.48D -8D, up to -16D and the cylinder went up to
-6.25D. Around 45% eyes were treated with staged procedures.
The enhancement rate for the non two-stage was 35%. According
to him, the advantages of the two-stage procedure were an
increased safety, more accurate results, and lower patient expectations.
“If after the first stage, someone had a main issue of
night vision disturbances, we had the option of using the remaining
tissue for topography-guided expansion instead of further
myopic corrections.”
Femtosecond lasers: Dr Tan enlisted the
femtosecond lasers currently available. He then
discussed the results of femtosecond laser-assisted
sutureless ALK in 12 eyes with anterior corneal scarring
using the IntraLase.“Only 58% improved visual acuity
and about 33% had 20/50 or better,” he said. Further, he
shared results of a study published in 2009 for DALK
with femtosecond laser (IntraLase ALK with zigzag
incisions) where a poor stromal bed quality was reported
and good lenticules were not obtained.
Dr Tan presented the results of their 2008 study comparing
the ALTK microkeratome (R2=0.24, with a wide
scatter) with the femtosecond laser (R2=0.93, more statistically
significant). “So we know that the femtosecond
laser is much more predictable than the microkeratome
for depth,” he confirmed. Showing pictures of the rim
cuts, he said, “There is not much collateral damage.”
He also specified the minimal morphological damage to
endothelium.
VisuMax: Dr Tan discussed the “very precise vertical
ablations” with “minimal collateral endothelial damage”
and “reasonably smooth lamellar bed” with VisuMax
200 kHz and showed how the atomic force microscopy
pictures with deep stromal lamellar dissection (400 μm)
improved with the 500 kHz VisuMax than with the 200
kHz VisuMax and the 40 kHz FEMTEC. He shared pic-
Monocular efficacy (Excluding eyes not intended plano)
MEL 80 High myopia: Safety - BSCVA
Continued on P15 >>

14
Ophthalmology WORLD REPORT
tures of Femto-DALK and Femto-DSEK procedures and
showed results for the VisuMax-ALK done for a post-
PRK scarring. Post-op a 20/40 was obtained.
He then showed a second patient with granular dystrophy
and previous PRK with 20/60. The patient attained 20/40
unaided on postop day 1. In the view of Dr Tan, stromal bed
quality, rim cut quality and accuracy of depth with femtosecond
can exceed microkeratome quality but further optimization
is needed. The endothelial morphology appears
unaffected in the presence of laser ablation 150 microns
from Descemet’s membrane. “Femtosecond laser ablation
of the deep corneal stroma is close to being a viable alternative
to microkeratome for donor preparation for DSEK and
DALK. The next major advance we would like to see is to
have a topographic link-up using anterior segment optical
coherence tomography (AS-OCT) for accurate ablation
profiles in reference to the posterior corneal surface. I think
the femtosecond laser for DSEK and DALK are currently
on horizon now,” he said.
Singapore ReLEx Study: Dr Tan discussed the results of
30 ReLEx flex and 10 ReLEx smile cases of which 17 were
analyzed. There was no algorithm adjustment. All cases
were followed up for at least 1 month and 33 for 3 months.
Speaking about the wide range of myopia, he said, “We
went up to -10D and the average mean spherical equivalent
was about -5.5D. The range was up to -9.75D and cylinder
went up to -2.75D.”
At 1 month postoperative, the mean spherical equivalent
was 0.33. This hyperopic mean was good as most patients
were young. And at 3 months postoperatively (33 eyes), the
mean spherical equivalent was 0.22 (1.75 to -0.63). There
was a case of hyperopic surprise and there wasn’t much
myopic regression. Speaking about safety, he said that there
does occur loss of lines. The results though are far better at
3 months. He shared his learning experience about suction
loss in a 30 year old female, -8.75D/-1.25D. According to
him, the ReLEx was stable and predictable without nomogram
adjustments unlike the excimer laser nomograms.
Talking about the reasonable efficacy he said that the results
at 3 months were appreciable with 95% at 1D visual acuity.
ReLEx smile results (6 eyes): These had a full ReLEx
ablation profile, but the flap was only partially opened
(about 1/3) and the lenticule extracted. According to him,
“Enhancement could be done and it was easier.” The
encouraging results seemed better than ReLEx. He further
explained that the advantage of ReLEx smile was the
easier enhancement.“I shifted the hinge to 160 degrees, as
I am a right-handed surgeon,” he said. Comparing these
with ReLEx, he said that ReLEx smile is a bit more challenging.
He feels that ReLEx smile is good in the hands
of surgeons who are experienced. For an average surgeon,
who has not done many cases, there is a learning curve. He
showed the various dissectors they have used in lamellar
surgery and his favored DSAEK forceps. He shared a video
of the ReLEx smile procedure and showed how centration
is the key to visual acuity.
ReLEx experiences and research at SERI: According to
Dr Tan, ReLEx seems to be a promising new modality
which may well challenge the superiority of LASIK, further
clinical studies including direct comparison with LASIK
are underway. Early clinical results with no nomogram
adjustment appear to confirm good refractive efficacy,
predictability, stability and safety though more cases need
to be done. Preliminary results of ReLEx smile are also
highly promising, with major advantages of better tectonic
strength and possibly less dry eye and ocular surface
disturbance. Lastly, the potential reversibility of ReLEx
procedures may be a reality. “We have a cornea wound
healing laboratory at the Singapore Eye Research Institute
and the main role is to explore new surgical and therapeutic
modalities for selective lamellar keratoplasty and corneal
lamellar laser refractive surgery. We do have facilities for
small and large animal primates with dedicated ophthalmic
theatres, surgical microscopes, confocal microscopy, AS-
OCT, immunohistochemistry, range of methodologies like
EM, microkeratome, femtosecond laser and excimer laser
platforms. He also said that the VisuMax platform is a part
of the Translational Clinical Research (TCR) Flagship
Program (TRIOS) funded by Government National
Research Foundation Grant in collaboration with Carl Zeiss
Meditec and discussed the changing trends of selective
lamellar keratoplasty at SNEC.
Storage of lenticules: He discussed the potential of
reversibility of ReLEx and shared that SERI has filed
a patent (#61/382,037) for the technique of storage of
lenticules following femtosecond refractive lenticule
procedures.
SERI studies in rabbit eyes: SERI is experimenting in
rabbit eyes for Femto-LASIK and ReLEx. Dr Tan showed
the comparable results of in-vivo confocal microscopy
for lamellar interface and anterior stroma in LASIK
and ReLEx. He then discussed the ongoing studies to
investigate the various markers for inflammation (CD
11b), cell proliferation (Ki-67), wound healing response
(Fibronectin) and cell death. He showed the ReLExlenticule
re-implantation technique wherein the lenticule
placed on RGP CL and stored at -80 degree centigrade was
replaced in correct anatomical orientation at 1 month after
a flap relift. “We have tested the proof of concept that we
can re-implant at least in rabbits,” he affirmed. He showed
the topographies before ReLEx, 3 days after ReLEx and
3 days and 7 days after re-implantation of lenticule. He
showed the AS-OCT imaging obtained after reimplantation

June 2012 Supplement
15
Continued from P13 >>
and the results of in-vivo confocal at the anterior flap
interface, lenticule lamellae and the posterior flap interface,
3 days and 7 days after re-implantation of the lenticule.
Non-human primate model: Dr Tan said that ReLEx
study had been initiated in monkeys at SERI and these
should now prove the proof of concept of reversibility of
ReLEx. He then showed the averaged topographies from 3
non-human primates (-6D treatment) before ReLEx and 3
days and 7 days after ReLEx.
International Refractive User Symposium
Kuala Lumpur, Malaysia
In 2009, Prof Reinstein published the results for the combined
corneal topography and corneal wavefront in treatment of corneal
irregularity and refractive error in LASIK or PRK using MEL 80
and CRS-Master. Here, he reported a 41% decrease in spherical
aberration and a 21% reduction in HORMS. Sharing the graphical
record of attempted vs achieved spherical equivalent, he elaborated
on the accuracy of the MEL 80 in high myopia. Seventy-one
percent of the eyes were within +/- 0.5D and 94% within +/-1D.
He shared the results of monocular efficacy in 127 eyes (excluding
eyes not intending plano). Pre-op only 83% had 20/20 and postop
uncorrected 90% had 20/20. “That is excellent,” he said. Then
talking about safety (BSCVA) in 220 eyes, he said, “No loss of two
lines. Very little loss of one line.” There was no change in 40% and
52% gained one line. According to him, the contrast sensitivity
increased statistically significantly for only the higher frequencies.
The stability was also maintained at 24 months.
ReLEx smile:
The New Application
Prof Osama Ibrahim on “ReLEx: Clinical
Update (ReLEx flex and ReLEx smile). My
Experience with VisuMax”
“ReLEx smile is a real innovation
and a real challenge. It maintains
the biomechanical integrity of the
cornea in the anterior surface which
actually is most important.”
High myopia: Contrast Sensitivity
Experience with VisuMax: Prof Ibrahim shared
videos of the ReLEx flex and ReLEx smile procedures
and said that “the VisuMax procedure was
simply tissue removal rather than tissue ablation”. He
specified the direction of scanning and how it is best
to remain above the lenticule when making the flap.
Sharing a video for ReLEx smile and explaining the
correction of higher errors, he said that the technique
is very simple and he ensures that he “remains anterior
all the time”. “I go to one part and leave the other part
as a counterpart. I use a very thin flap and can go up to
90µm,” he added.
Study results: He shared the results of analysis of 189
eligible eyes (120 female and 69 males) that were mostly
cases with high errors, higher even than -10D. The mean
High myopia: Stability
Summary: According to Prof Reinstein, one should know the
spherical aberration induction per diopter, measure pre-op spherical
aberration and know if the spherical aberration may cross the
threshold. If crossing the threshold, one can do a spherical aberration
pre-compensation or use a two-stage procedure, i.e. the
wavefront-topograph-guided repair if necessary as second treatment.
He cautioned with predicting the RST. “Pachymetry is best
done with a high repeatability instrument. It is best to use a high
reproducibility flap creation technique and always include the flap
thickness bias,” Prof Reinstein concluded.

16
Ophthalmology WORLD REPORT
age was 27 years and the mean spherical equivalent was
-5.65D ± 2.91D. Next he showed the collective results
for both ReLEx flex and ReLEx smile at 1 week for 175
eyes. “The mean spherical equivalent is less than a quarter
(-0.27D± 0.57D), though some cases called the outliers
were not corrected fully. Ammetropia was not our aim in
all cases both for sphere and cylinder. The range for sphere
went from +1.75D to -2D,” he said. The results were better
still for 136 eyes followed at 1 month postoperatively with
the mean spherical equivalent being -0.25D ± 0.63D. “The
sphere is perfect, as good as the excimer laser except for
the few outliers,” he said. The correction remained better
at 3 months postoperatively for 93 eyes that were followed.
Explaining the results further at 1 year after procedure, he
said, “This is a very stable procedure as we do not see a regression
that we see in high myopes. The stability was very
good at 1 year.” He then explained the challenges, saying
that in the initial series there were patients who lost lines.
“These were cases where we had used a very high energy,
the section was very clumpsy, or had taken us a longer
time,” he elaborated. But these cases where someone lost
one or two lines decreased over a period of time as the
learning curve improved. According to him the visual recovery
was excellent. “At 1 day or at 1 week, almost 95%
of cases were able to achieve the legal driving vision. As
time goes by, the number of patients who are 20/20 or better
improves. For high myopes, the results are very good,
very comparable and even better than excimer laser.”
200 kHz vs 500 kHz: He discussed a comparison of 200 kHz
(97 eyes) and 500 kHz (78 eyes). “The refractive outcome
was not much of a difference,” he said. However at 3
months, the results were better with the 500 kHz. Similarly,
better results were seen with the 500 kHz for the
spherical equivalent percentage. According to him, the real
difference was in the visual recovery.
Conclusion: He concluded that ReLEx was effective,
predictable, safe and stable. He thinks ReLEx is definitely
“as effective as the excimer laser”. He said that improvement
in customization can certainly make it better. “It
is definitely as predictable. Safety is very good and it
has improved. Stability is beyond doubt and even better
than the excimer laser ablation,” he added. He shared
the results for some clinical cases like -8.00D and also
cases with high astigmatism. He said that future may hold
promise of going down to use smaller lenticules of even
5 mm. “This opens a new horizon for the correction of
higher errors even if you use smaller lenticules.”
International Refractive User Symposium
Kuala Lumpur, Malaysia
ReLEx smile:
All-In-One Correction
Dr Ekktet Chansue on “ReLEx smile in Low and
Moderate Myopia”
“The procedure is highly accurate
and very neutral in terms of spherical
aberration and independent of the
amount of correction.”
ReLEx: Dr Chansue described ReLEx as “a procedure
where the femtosecond laser is used to create an intrastromal
lenticule” which is then removed manually
in a single piece. He then showed how the side and anterior
cuts are made in steps. He also shared his opinion about and
showed videos for ReLEx smile along with the instruments
used for the procedure and added that “there is nothing that
can inhibit the surgeon from doing a small incision surgery”.
Speaking about his experiences with the ReLEx smile technique
in the last 100 cases, he said, “We did a range of -1.13D
to -9.75D, with spherical mean of about 5D and cylinder
anything between zero and 4D.”
ReLEx smile: Dr Chansue said that the efficacy was mostly
20/25 or better at 1 week. “At 3 months, we had only 12
eyes. All the eyes are seeing 20/20 or better,” he added. He
then spoke of accuracy being very high (R2 being 98%). “It
does not lose any accuracy at the higher end (up to -10). It
takes the same amount of time to do a -1D or -10D. It cuts
the two planes following a basic geometry and without being
influenced by other elements around the field.” He explained
ReLEx Technique (Dr Ekktet Chansue, Thailand)

June 2012 Supplement
17
The TRSC experience (Dr Ekktet Chansue, Thailand) with this figure we can add the section in pink above
a) ReLEx smile at TRSC: Efficacy
b) ReLEx smile at TRSC: Accuracy c) ReLEx smile at TRSC: Safety
d) Topographical changes: -2.75D correction e) Topographical changes: -7D correction f) ReLEx smile at TRSC: Spherical aberration
how ReLEx smile attained
a “wide optical
zone”. “We don’t
have any correlation
between the amount
of correction and the
spherical aberration,”
he said. The same
large optical zone
was maintained even
at -7D correction.
Talking about safety,
he said, “We did lose
lines at some times
and at 3 months no
one lost more than
ReLEx smile: Instrumentation
one line.” Complications
in the procedure were minimal. There was a failure
to dock in one case which had a very small cornea, a case of
suction loss during anterior cut in the lenticule, some epithelial
problems and a lenticular tear which according to him “occurred
in a thin lenticule in a low myope with 1D”.
Conclusion: He concluded that the procedure gives potentially
better corneal strength than LASIK. The peripheral cornea
needs minimal dissection. “If you look at the eye, you appreciate
that there is incision only on the top, actually completely
covered by the lid, so there is no wound actually. Then you
dissect the cornea only enough to get the lenticule out,” he
explained. According to him, ReLEx is a procedural breakthrough.
“Technology has enabled us to do what we have been
wanting to do,” he added.
The path ahead: He shared valuable suggestions for further
improvement. The illuminator according to him is too bright
and should not be coaxial. Another concern is the lack of a
real fixation target in the microscope. He wished there was an
assistant’s joystick. He then spoke about the need for optimal
enhancement strategies. “In any refractive procedure success
depends on enhancement strategies,” he said. According to
him adjustments are a little difficult with ReLEx as compared
to LASIK and will need to be improved upon. “This is important
because the patient needs change with time as the refractive
status is likely to change. For someone who has been
doing refractive surgeries for 20 years, patients do come back
and say after 10 years that they are willing to get corrected
for whatever progression they have had,” he said. Lastly, he
questioned if “ReLEx is the beginning of the end of LASIK.”
Dr Rupal Shah on “ReLEx: An Update of the
Results”
“ReLEx is an interesting procedure
and an exciting paradigm shift in
refractive surgery that we are very
proud to be able to be a part of.”
Dr Shah shared a video for ReLEx smile and emphasized
how she checks centration. She currently is using a 3
mm incision in the ReLEx smile procedure and said
that perhaps even smaller incisions would be possible in future.

18
Ophthalmology WORLD REPORT
VisuMax Femtosecond Laser System (Dr Rupal Shah)
a) Change in CDVA: Safety
b) Achieved correction (MR SEQ) over time
c) Refractive outcome (MR SEQ percent within attempted @ 1m and @ 3m)
d) pre-op CDVA vs. post-op UDVA – 500 kHz (Only full-correction cases)
She then said that “the tissue separation is very simple and you do
not need any fancy instruments”.
Experience with ReLEx: Dr Shah described ReLEx smile as
a preferred procedure to Femto-LASIK for the treatment of
myopia and myopic astigmatism. They are also looking at
ReLEx flex for investigating the possibility for hyperopia treatment.
She shared the results of 860 eligible myopic eyes (427 OD, 433
OS) in 518 female patients and 342 males with a mean age of 25
years. Preoperatively, the mean spherical equivalent was -4.53D
with a range of up to -10D and the mean cylinder was -0.67D and
ranged up to -4.5D. 1 month postoperatively, the procedure showed
impressive predictability. The mean spherical equivalent (827
eyes) was very close to zero and the range was 1.63D to -1.25D.
The trend continued at 3, 6 and 12 months. The refractive outcome
was particularly encouraging because there were no nomogram
adjustments. The treatment of myopic astigmatism was equally
impressive.
Taking about complications, she said that there was a suction
loss in 13 eyes. In 12 of the eyes, the procedure was immediately
repeated with excellent post-operative outcome. The only
case which was aborted was the 1st eye which suffered from a
suction loss. 5 eyes suffered from deep lamellar keratisis postoperatively.
These were either related to the use of high energy
settings or due to the use of a new type of instrument. There
were few cases of lenticule being stuck on the undersurface
of the flap and these could be removed without any incident.
Besides these, there were 14 cases of visually non-significant
haze that responded to stepping up of steroids and a case of stationary
epithelial ingrowth at the flap edge. Two of the ReLEx
procedures needed a retreatment and in these an excimer laser
ablation was done. She showed topography of a patient with
- 4.5D and -1.75D cylinder. “The cylinder gets treated very
satisfactorily and there is a nice big zone of flattening,” she said.
Hyperopic cases: Dr Shah shared the results of the first 38
hyperopic eyes they have done. “We have treated up to 7.5D
of spherical equivalent with some amount of cylinder,” she
said in introduction. Explaining the outcome at 1 month,
she said, “At 1 month, we have results from 30 eyes, again
a mean very close to zero (spherical equivalent of 0.15D ±
0.75D), so the predictability of the instrument is not an issue.
The visual recovery is still something to be refined on.” She
wasn’t really positive for the CDVA. “We are getting some
losses in best corrected visual acuity. Of course, this is getting
offset by some gains also in best corrected visual acuity. But,
today, Hyperopic ReLEx is a work in progress. ” she said. The
stability was also not as encouraging as in myopia.
Conclusion: Dr Shah concluded that ReLEx is a promising new
modality for laser vision correction. Treatment for
myopia and myopic astigmatism has been revolutionized
and hyperopic trials have already begun. “This is a work in
progress and the results are much better than the initial results
that we saw with excimer laser,” she said.

June 2012 Supplement
19
ESCRS ReLEx smile Satellite Symposium Vienna, Austria
Cataract & Refractive Surgery Today Europe
ReLEx Versus
Femtosecond LASIK:
A Comparison
As a new technique for laser vision correction,
ReLEx is a single-step, single instrument
operation.
By Osama Ibrahim, MD
ReLEx smile is a minimally invasive approach to laser
vision correction. Instead of a corneal flap, which is
mandatory for the execution of LASIK, an intrastromal
lenticule is created with the femtosecond laser. The size
and shape of the lenticule corresponds to the desired refractive
correction in the intact cornea, and the incision is subsequently
prolonged to the anterior corneal surface with a very
small opening incision. ReLEx uses tissue removal instead
of tissue ablation (Figure 1); it achieves a high precision of
cutting that contributes to the predictability of the procedure.
Comparing results: I have been using femtosecond LASIK
for 5 years and ReLEx for 2 years now. In this time, we have
performed ReLEx flex and ReLEx smile in approximately
200 eyes and 400 eyes, respectively. Similar to LASIK,
ReLEx flex is performed with a corneal flap-like access cut;
however, the flap created for ReLEx flex is smaller than
the LASIK flap (Figure 2). Another difference is that, for
ReLEx flex, after the flap is lifted, the lenticule is peeled
off of the corneal bed rather than ablated. ReLEx smile is
entirely different from LASIK, as there is no longer need to
create a corneal flap. Instead, a small incision is made in the
cornea and the lenticule is dissected and extracted through
the incision.
As our experience with ReLEx grew over the course of the
clinical study, we were able to titrate the energy levels of
the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena,
Germany) as well as its spot distance and size to make the
system more case specific. These adjustments have provided
us with more repeatable and reproducible study results.
Since then, we have also fine-tuned the lenticule geometry,
resulting in more accurate astigmatic correction.
Comparing ReLEx smile to femtosecond LASIK,
ReLEx smile has a slightly steeper learning curve, yet
after mastering it, ReLEx smile became a much easier and
shorter procedure. It is a single-step, single instrument
operation, and therefore there is no need to move the
patient between two lasers as there is during femtosecond
LASIK. Additionally, laser treatment time (ie, time to create
the lenticule) is nearly the same for all levels of myopic
correction. For instance, I can treat -10.00D of myopia
in the same amount of time it takes me to treat -1.00D of
myopia, provided the eyes have the same cap diameter and
optical zone.
The long-term results after ReLEx smile and LASIK are
similar, but visual recovery can take a bit longer after
ReLEx smile in some eyes. However, there is less incidence
of dry eye after ReLEx smile compared with LASIK. One
more important advantage for the use of ReLEx smile is that
the incidence of straie and other flap complications have
vanished.
Surgical advantages: The major advantage of ReLEx
smile is that there is no flap cutting involved, which we
believe minimizes the induction of spherical aberration.
Without the thread of spherical aberration, ReLEx smile
patients are more likely to achieve better quality of vision
than patients treated with an excimer laser, which is
especially true for those with high myopia. We also believe
that ReLEx smile offers better biomechanical stability than
procedures employing flap creation, going along with less
postoperative discomfort and less cases of dry eye. With
no flap displacement, even after trauma, ReLEx smile is
the best procedure for those who are involved in contact
sports.
Figure 1. ReLEx uses tissue removal instead of tissue ablation.
Unlike excimer-laser-based procedures, ReLEx smile
uses a solid-state laser, and therefore there is no need for
consumable gases or tight environmental humidity control.
The VisuMax is a silent, soft, and gentle laser. It does not
produce any smell, there is no vision blackout during the
procedure, and the cornea is not forced into a nonphysiological
planar shape. Thus, deformation and artifacts can
be avoided in the cutting results, as well as unnecessarily
high intraocular pressure (IOP).
The procedure: The first step for ReLEx smile is to attach
a disposable curved contact glass onto the laser aperture

20
Ophthalmology WORLD REPORT
Figure 2. (A,B) The flap-like cut for ReLEx flex is smaller than the flap
created for LASIK.
cone of the VisuMax femtosecond laser. The curved surface
of the contact glass is designed to couple with the cornea
after the VisuMax system self calibrates the contact glass.
Keratometry data can then be entered into the VisuMax
software to account for the difference between the relaxed
cornea and the contact glass curvature. This calculation allows
the system to determine the ratio between the intended
clinical treatment and the cap diameter on the relaxed eye as
well as the incision diameter when cutting the eye coupled
to the contact glass.
With the patient fixating on a flashing green light, the
patient bed is repositioned so that the cornea comes into
contact with the contact glass. At this time, the patient will
notice a flashing fixation target in clear focus. This target
uses the manifest refraction of each individual eye to align
the target visibility. The bed is raised vertically while the
surgeon observes the alignment of the contact glass application
through the operating microscope and the side screen.
The cornea slightly applanates and centers, aiming for
the corneal vertex, and suction is applied. The eye is then
immobilized with low corneal suction. The increase in
IOP with the VisuMax is low enough for the patient to see
throughout the procedure. The laser is activated when the
surgeon presses on the foot pedal. After the lenticule and
a small incision are created with the laser, the patient is
moved to the observation microscope, where manual dissection
is performed. This process starts with dissection of
the upper surface (ie, cap) from the intrastromal lenticule.
The lenticule is then dissected from the stromal bed and
removed with a forceps through a 3- or 4-mm incision.
Conclusion: The evolution of refractive surgery is heading
closer to preservation of corneal biomechanics. Increased
safety was first achieved by creating thinner flaps; now, it
goes one step further by using small incisions. ReLEx smile
is the latest technique to follow this pattern of preserving
corneal biomechanics. The most important point that refractive
surgeons are aiming to achieve is aberration-free treatments.
ReLEx smile is one step closer to this quest.
ReLEx smile:
An Outstanding
Treatment for Low,
Moderate and High
Myopia
I have treated more than 600 eyes with this
minimally invasive technique.
By Rupal Shah, MD
ESCRS ReLEx smile Satellite Symposium Vienna, Austria
Cataract & Refractive Surgery Today Europe
Of all the surgeons currently using ReLEx smile
(Figure 1), I have completed the most cases to
date. The reason that I choose this procedure time
and time again is threefold. First, I feel it offers the most
advantages to my patients in terms of the accuracy of
refractive outcomes and safety. In fact, 99% of all eyes
treated for myopia at our center are within ±0.50D of intended
correction. While 30% of patients gain visual acuity
after the procedure, less than 3% lose 1 or more lines of
visual acuity. The advantages are particularly stark for high
myopia. Second, ReLEx is a very time-efficient procedure,
meaning that I am able to perform more procedures each
day with the reassurance that I am selecting the best possible
solution for my patients’ refractive errors. Third, it is
a unique procedure that is easily distinguishable from other
laser vision techniques (no flap), which allows me to use a
unique marketing strategy.
My experience with ReLEx totals more than 2,000
procedures for the treatment of low, moderate, and high
myopia (up to -10.00D). There are two ReLEx techniques,
femtosecond lamellar extraction (ReLEx flex) and small
incision lamellar extraction (ReLEx smile), which are both
minimally invasive and are performed with the VisuMax
femtosecond laser (Carl Zeiss Meditec, Jena, Germany).
The major difference between ReLEx flex and
ReLEx smile is that a corneal flap is created prior to
lenticule extraction in ReLEx flex only. I prefer ReLEx
smile, because I no longer have to create and lift a flap in
the cornea but rather just make a small corneal incision to
excise the refractive lenticule.
Advantages : ReLEx smile offers many advantages:
• Postoperative discomfort for the patient is significantly less.
• The lack of a corneal flap eliminates the risk of a flap
displacement, and so the amount of care that patients need
to exercise is significantly less.

June 2012 Supplement
21
• Use of a small incision means that fewer corneal nerves
are severed. This also leads to fewer issues after surgery,
including dry eye.
in the ablation rate. This causes the commonly observed increased
scatter in the results of excimer laser LASIK once you
start treating high myopia. Such increase in scatter is much
less in ReLEx.
Within each of the three groups—low myopia, moderate
myopia, and high myopia—at 3 months, 97%, 97%, and
90%, respectively, were within ±0.50 D of intended correction
(Figure 2). At 1 year, approximately 2% of eyes in the
low myopia group and approximately 4% of eyes in the other
two groups lost 1 or more lines of BCVA, but 25%, 29%,
and 49%, respectively, gained 1 or more lines of visual acuity
(Figure 3).
Figure 1. Schematic representation of the ReLEx smile procedure.
Patient selection: I am happy that ReLEx smile is
available for commercial purposes since I can now use this
technique for all suitable patients independent from study
participation. Before it was commercially available, I only
performed ReLEx smile if patients agreed to participate in
our current study, which precluded them to be available for
at least 1 year of follow-up visits.
There are certain cases for which special attention must be
given to patient selection for ReLEx, including if patients
are too anxious; if they have astigmatism higher than the
spherical component of myopia; or if they have more than
-10.00D of myopia, as this is still under investigation.
In these patients, I typically perform LASIK, creating a
flap with the femtosecond laser and ablating the corneal
tissue with the excimer laser. However, the disadvantage
with this treatment is that it takes more time, because I am
moving the patients between two lasers.
Treatment results: As I said previously, I have extensive
experience performing ReLEx treatments. Of the nearly 1,200
eyes for which I have at least 3-month follow-up, 29% have
been for the treatment of low myopia, 50% for moderate
myopia, and 21% for high myopia.
If I had to provide a quick snapshot of my results to date,
I would say that visual outcomes after ReLEx have been
equivalent to visual outcomes after LASIK in eyes with low
myopia. Therefore, even if I have a -1.00D treatment, I am
not hesitant to perform a ReLEx procedure.
For eyes with moderate or high myopia, ReLEx has an edge
over excimer laser treatments. Because the technique involves
cutting a lenticule instead of ablating it, the results are
less dependent on environmental factors including humidity
and organic vapors. During ablation for high myopia, there is
considerable drying of the corneal bed, with resultant scatter
Added benefits: As I see it, there are three distinct benefits
that I have achieved by incorporating ReLEx into my surgical
armamentarium: patient benefits, surgeon benefits, and
marketing benefits.
Patient benefits. The beauty of ReLEx smile is that it builds
on existing—and successful—laser vision techniques, and
our results reflect that. In all three groups, more than 90%
of eyes had a UCVA of 20/30 or better. Additionally, patient
discomfort was minimized, and, in the majority of cases, pain
was gone within the first few hours after surgery. Another
benefit to ReLEx smile is that there is no risk of possible flap
displacement from eye trauma or surgery at a later date. This
is especially important for those patients who are involved in
contact sports or jobs in which eye trauma is more likely.
Surgeon benefits. For me, two important surgical benefits of
performing ReLEx smile are as follows. First, I can better
maintain biomechanical stability. Second, this procedure
causes fewer cases of dry eye. I make only a small incision in
the cornea, and even the cap separation extends only up to 7
mm from the center of the cornea.
Both of these reasons should ensure that biomechanical
stability is better maintained and that there are fewer cases of
dry eye. Additionally, I save significant amount of time when
performing ReLEx smile compared with Femto-LASIK—approximately
10 minutes per patient. I treat more than 1,000
patients a year, which means that I can conceivably save about
45 minutes on every working day.
Another aspect that I find beneficial is that I only have to
purchase and maintain one laser instead of the two lasers that
are needed for PRK or LASIK. Economically, this is the better
set-up, because here in India we cannot up-charge the patient
as much as what can be done in other countries, and it is hard
for us to afford the maintenance and capital costs on two different
laser systems.
Marketing benefits. We are in a very unique position, because we
are one of the only centers that can offer blade-free, flap-free laser

22
Ophthalmology WORLD REPORT
ReLEx smile:
My New Clinical
Standard
ESCRS ReLEx smile Satellite Symposium Vienna, Austria
Cataract & Refractive Surgery Today Europe
Using this procedure in a high-volume clinic
saves us from having to create a corneal flap.
By Jesper Hjortdal, MD, PHD
Figure 2. Refractive outcome after ReLEx for treatment of myopia and
myopic astigmatism up to -10.00 D.
Figure 3. Safety of the ReLEx procedure, as expressed in the change in
the numbers of lines of BCVA.
vision correction. This has provided patients with incentive to
come into our center and find out more about ReLEx flex and
ReLEx smile. Of course we still offer LASIK and PRK, as it is
very important that the patient selects the treatment that is right
for him or her specifically, but I have noticed that more often
patients prefer one of the two ReLEx techniques.
Conclusion: In the future, ReLEx procedures will be able
to be performed through even smaller incisions than we use
today. I have already attempted the use of 3-mm incisions in
a number of ReLEx smile cases, and the results have been
promising. The limiting factor at this point is the instruments
we have to separate the lenticule in situ, which at this time are
too large for smaller incision sizes. One solution may be the
use of hydrodissection to separate the lenticule.
I feel very lucky to be among the first surgeons to use ReLEx
in a large patient population. To date, I have noticed a surge
in the number of patients who ask for ReLEx by name, and I
look forward to growing my number of treated patients even
more. It is truly an exciting time to be a refractive surgeon.
Iwork in an extremely high-volume, hospital-based clinic.
In a typical day, I see up to 40 patients, treat a multitude of
conditions, and correct various forms of refractive errors. My
work is extremely rewarding—I find great joy in helping patients
achieve better visual quality and in most cases spectacle
independence—but it is also time-consuming, and anything I
can do to safely reduce procedural times is helpful.
Approximately 16 months ago, we switched from using LASIK
to lenticule extraction with ReLEx in the majority of my
patients. We have performed approximately 900 procedures in
this period. I have noticed a significant time-saving benefit. Of
the two available ReLEx procedures, femtosecond lamellar
extraction (ReLEx flex) and small incision lamellar extraction
(ReLEx smile), I prefer the latter because I no longer need to
create a corneal flap to perform the refractive correction. For
the past 4 months, I have been using ReLEx smile whenever
possible, promoting it as my new clinical standard for refractive
surgery. We have thus far performed approximately 400
ReLEx smile procedures.
Differences: ReLEx is a simplistic but effective procedure that
can today only be performed with the VisuMax femtosecond
laser (Carl Zeiss Meditec, Jena, Germany); it is the only laser
vision correction technique that uses a femtosecond laser to
create a cut in the cornea and perform the refractive correction.
With this technique, I am able to create the lenticule
without ever having to break through the corneal surface. I
typically use ReLEx for the treatment of high myopia, as this
is the majority of patients who elect treatment due to reimbursement
by the public health service. I treat patients with as
much as -10.00D. Below I describe the differences between
both ReLEx procedures.
ReLEx flex. In the initial steps of the procedure, ReLEx flex is
similar to LASIK in that a corneal flap is created and lifted;
however, instead of ablating the tissue underneath the flap, the
surgeon peels off a small refractive lenticule to provide the
refractive correction. This is extremely easy to do, and after
about 10 procedures I was comfortable with this technique.

June 2012 Supplement
23
I have seen less cases of patient discomfort, including dry
eyes and foreign body sensation, and so far in my clinical
experience with ReLEx smile I expect even less risk of
corneal ectasia compared with LASIK. Regarding procedure
time, I no longer have to move the patient from the
femtosecond laser to the excimer laser, but rather I simply
perform the cut and the refractive correction on the same
patient bed at the VisuMax laser. There was a slight learning
curve in which the procedure time was longer than it
is for LASIK, but after I understood the ins and outs of the
technique the surgical time decreased.
Figure 1. View through the operating microscope immediately before
completion of a ReLEx smile laser treatment using the VisuMax femtosecond
laser.
ReLEx smile. The main difference between ReLEx flex and
ReLEx smile is that there is no longer a need for a corneal
flap. Instead, a small tunnel incision is created and the
refractive lenticule is extracted through the incision using
a spatula. The learning curve is slightly longer with ReLEx
smile, but by 20 cases I had the technique perfected.
Procedural advantages: My typical ReLEx smile procedure,
which lasts approximately 10 minutes, is outlined
below:
• The patient is prepped for surgery by two drops of topical
anesthesia and a lid speculum is inserted;
• Using the VisuMax femtosecond laser, an intrastromal
lenticule is cut and a 3-mm incision is created at the
12-o’clock position. With a length of 500 μm, this small
channel-like incision produces an entryway to the refractive
lenticule (Figure 1); and
• The lenticule is loosened with a spatula and is manually
extracted through the tunnel using a small forceps (Figure
2).
Surgically speaking, the ReLEx smile procedure has
several advantages over excimer ablation techniques such
as LASIK and PRK. Perhaps the largest is that I no longer
have to create a preflap on the surface of the eye, meaning
that I no longer have to worry about the complications
associated with a corneal flap, such as buttonholes and
later flap dislocation. Additionally, there is minimal risk of
epithelial growth under the flap, as only one small incision
replaces the need for a flap, and there is more intact
cornea compared with surface ablation procedures, which
increases corneal stability.
Clinically speaking, the main advantages are that the
procedure is shorter and follow-up shows less variations.
Higher-order aberrations: We have begun to analyze
higher-order aberrations before and after ReLEx and
LASIK. Thus far, we have studied 3-month results for 100
patients, 50 of whom underwent femtosecond LASIK and
50 of whom underwent ReLEx flex. Patients in the ReLEx
flex group had fewer higher-order aberrations after surgery
compared with femtosecond LASIK patients. Once we have
longer-term results, we will repeat the same study using
ReLEx smile patients. Since the process is similar to ReLEx
flex, whereby the refractive lenticule is removed, we expect
that the higher-order aberrations after ReLEx smile will be
similar or even better than those after ReLEx flex.
Figure 2. Lenticule removal is completed through a small
incision in the ReLEx smile procedure.
How can this difference in higher-order aberrations after
ReLEx flex and femtosecond LASIK be explained? We
postulate that, with LASIK, once the flap is cut and following
the excimer laser ablation, there tend to be small
decentrations that can lead to coma. However, with the
ReLEx procedures this is avoided because any and all cutting
is done within the cornea. More research is needed to
confirm this hypothesis.
Conclusion: ReLEx, and most specifically ReLEx smile,
has become the new standard of care at our clinic for
patients with high myopia. This treatment has many advantages
over excimer ablation techniques, the most important
two being a decreased number of higher-order aberrations
after surgery compared with LASIK and the time it saves
me in the operating room.

24
Ophthalmology WORLD REPORT
International Refractive User Symposium
Kuala Lumpur, Malaysia
VisuMax
in Keratoplasties
Dr Khaled Ben Amor on “Keratoplasties
with VisuMax”
“Even in DLK, the results of
femtosecond laser are very nice
optically and we have much more
success rate with the technique.”
Keratoplasties with VisuMax: : Dr Ben Amor shared his
experiences about the keratoplasty with VisuMax which
according to him is “the obligation of the VisuMax,
much beyond refractive surgery”. Discussing the advantages
of the VisuMax he said that it offered a curved corneal interface
and a planar cut. He then showed the high performance
optics in ZEISS that was the key to optimum cut. He shared
videos showing how it was easy to lift a donor graft and those
for keratoconus hydrops, corneal scarring, bullous keratopathy
and adherent leucoma. Dr Ben Amor also discussed the
advantages of the femto penetrating keratoplasty due to the
regular side cut. “Better centration and better donor recipient
fit give a nice optical result better than that with a manual
keratoplasty,” he said.
Deep lamellar keratoplasty (DLK): He explained the principle
approach in a DLK which required the separation of
the endothelium from the stroma by injecting a bubble. In
manual DLK, the bubble layer is seen in around 52% cases
which necessitate desiccation of the rest of the stroma. According
to him, Femto DLK ensures precision during surgery.
Dpt
Dense central corneal scarring (Dr. Burjor P. Banaji, India)
“The cut can easily be lifted and then a big bubble is injected
which works in 75% of cases. It is much easier to take off the
remaining stroma. So, you have a complete Descemet barring
which is very important. This happens in 90% of the
Femto DLK cases versus 60% in manual DLK,” Dr Ben
Amor added.
Dr Burjor P. Banaji on “Challenging Cases
Corrected with Topography-Linked LASIK”
Clinical experiences: Dr Banaji shared his experiences
with topography-guided LASIK in some “weird”
cases he has done over the past few years, which
otherwise would be very difficult if not impossible to treat
with the standard modalities of LASIK. He showed the
topographical picture of a corneal central island. He shared
another case of multiple prior corneal surgeries. He then
shared interesting results in a patient who had dense corneal
scarring after a lacerating full thickness injury to the cornea
many years ago and was complaining of haloes, scatter and
distortion of images. The refraction was -8D spherical with
-5D cylindrical and BCVA was approximately 6/36. The scar
was right in the center of the pupil and the corneal thickness
was almost 600μm. “We smoothened the bed and about 4-5
months later lifted the flap and corrected the residual error
again with a topography guided treatment,” he specified. He
showed the large 10D shift in the center of the pupil that was
causing debilitating symptoms and how just smoothing it
with topography brought down the dioptric shift by 6D, thus
abating the symptoms. LASIK was planned as the patient was
still severely myopic. The pre-op refraction was -8D/-5D and
post-op it miraculously was -0.75D. “I could not have done
it with anything other than a topography-guided treatment,”
added Dr Banaji.
Further, he discussed a post-op cataract case, which was
referred to him in not very distant past. A well-centered
multifocal IOL was given and there was a residual
astigmatism.“Confirm that your central rim
and the lights are like a bull’s eye, one within
the other when the patient is asked to look into
the microscope after the procedure. Then you
see that your lens is centered properly. You
will often need to decenter your lens nasally
for that to happen. When you look at your eye
postoperatively, that ring should, if you have
done your job properly, never be in the center
of our pupil,” he explained. He attributed the
astigmatism to an LRI that “had done something
very naughty to the cornea”. The patient
was not only having an asymmetrical astigmatism,
it was non-orthogonal. “Post-op the
patient was very happy and the topography has
worked very well,” he said in delight.

June 2012 Supplement
25
Conclusion: Dr Banaji supported that ZEISS had the best
refractive outcome among all topography-guided systems.
He referred to the topography-guided treatment as
“ZEISS’ hidden jewel” and called it an “Optical success
for Carl Zeiss”.
Topography assisted ablation with Carl Zeiss Meditec MEL 80 and
CRS-Master (Dr Ruben Lim-Bon-Siong, Philippines)
Dr Ruben Lim Bon Siong on “Topography-
Guided Refractive Surgery: For the Sins of
Our Past and Present”
“It is not the end of the road when a
flap complication occurs. There are
topography-guided procedures that
can help these kinds of problems.”
a) Change in Snellen lines of BCVA (N=48)
Topography-guided refractive surgery: Dr Lim Bon
Siong spoke of the topographically customized systems
that aim to correct an irregular corneal surface.
He shared the published results of topography-guided
ablation with MEL 80 and CRS-Master by Dan Reinstein.
The results were of 48 eyes in 32 patients who underwent
the procedure for small optic zones, decentered ablations,
decentration after radial keratotomy, high myopia after
deep lamellar keratoplasty, irregular astigmatism due
to wound gape following cataract surgery and irregular
astigmatism due to scars. The median follow-up was 7.7
months (1 month to more than 1 year) and the mean preop
spherical equivalent was -1.12D ± 1.97D with a mean
preoperative cylinder of -1.34D ± 1.65D. “All patients
had good topographies. LASIK, LASIK-enhancements,
or PRK were done and treatments were centered on the
corneal vertex. “It is a very safe procedure. None of
the patients lost more than 2 lines after the procedure.”
Speaking about the accuracy, he said, “79% of patients
were within +/- 1D and 63% within +/- 0.5D. All these
patients had an improvement of least 2 lines or more.
This was very significant compared to the pre-op. It is
very stable. All patients had improved contrast sensitivity.”
Clinical cases: Dr Lim Bon Siong discussed clinical experiences
including cases of a central island, post-LASEK
corneal scar, lost cap and incomplete flap. Additionally,
he discussed a case of a 22-year-old male Filipino who
underwent LASIK with XP microkeratome and ended in
an incomplete flap with subsequent haze in the left eye.
The preoperative refraction of OS was -3.25-0.50 x 170
(20/20). Three months after the the flap complication, the
UCVA was 20/200 with refraction of +6.50 -2.00 x 170
and BCVA 20/30. In this patient a transepithelial PTK was
done with ablation depth of 50µm and a diameter of 8mm
b) Accuracy
c) UCVA improvement
d) Stability

26
Ophthalmology WORLD REPORT
The Importance
of ReLEx in Our
Current Laser
Vision Correction
Business
ESCRS ReLEx smile Satellite Symposium Vienna, Austria
Cataract & Refractive Surgery Today Europe
e) Contrast Sensitivity
followed by topographic smoothing to a depth of 58µm.
At 7 months after the topo smoothing, UCVA was 20/100,
refraction +4.25-4.25x180 (20/30). Corneal topographyguided
PRK was done and at one and a half months post
PRK, UCVA was 20/25, refraction +0.75D sphere (20/20).
Summary: Dr Lim Bon Siong summarized that
topography-guided ablations with the MEL 80 and
CRS-Master allowed regularization of corneas with
irregular astigmatism resulting in the improvement of
quality of vision.
Dr Donald Tan, Medical Director, SNEC,
Singapore, Chairman, Singapore Eye
Research Institute
Femtosecond laser assisted penetrating
keratoplasty: Dr Tan shared the outcomes in a small
series of 8 eyes (bullous keratopathy, Fuchs herpetic
keratopathy, regraft) done at their center. The donor and
recipient trephined with femtolaser had a mean follow-up
of 9.5 months and mean post-graft astigmatism of 2.56D.
The mean endothelial cell count was 1.753 mm 2 and there
weren’t any complications. “The potential of femtosecond
lasers to perform deep stromal ablation will allow us to
perform Femto-DSEK and Femto-DALK. Advantages,
there is ease of surgery, improved bed quality and better
accuracy in terms of depth of ablation. There should be
better donor edge quality with no restriction to shape and
edge profiles and better lenticule profiles,” he said. Talking
further he said that the disadvantages were “cost and
poor laser penetration of corneal scars. Arcus senilis is an
issue. Many femtosecond lasers do not reach the good bed
quality that we need. There are limitations because we are
relying on the anterior corneal surface”. This in his view
could be solved by linking with AS-OCT technology.
Gradual Incorporation of This Technique
Has Led to Steady Growth.
By Ekktet Chansue, MD
ReLEx combines the latest femtosecond laser technology
with an exact method for lenticule extraction within the
intact cornea to achieve precise, accurate, and gentle
vision correction. This procedure not only provides an easier
approach to refractive correction, but it does so using just one
device, the VisuMax femtosecond laser (Carl Zeiss Meditec,
Jena, Germany). I transitioned to using ReLEx in July 2010
and have since performed approximately 600 procedures.
This article reviews my personal motivation behind the
switch to ReLEx, demonstrates the benefits of transitioning to
ReLEx flex and subsequently ReLEx smile, and lastly offers
my unique perspective of marketing the procedure.
Personal motivation: I am continually striving to achieve
better refractive results for my patients. Part of this equation
is the willingness to consider incorporating new procedures
into daily practice. Throughout my career as a refractive
surgeon, I have made a habit of objectively analyzing any
new procedure that I am curious about, and if it makes sense,
I consider adopting it. For instance, in 1994, I was the first
surgeon in Thailand to perform LASIK. Looking back to that
period, the procedure was being performed by only a handful
of surgeons around the world—it was even considered an
aggressive approach by a lot of ophthalmologists. But my
objective analysis of LASIK told me that it would help me to
achieve better postoperative outcomes compared with radial
keratotomy, PRK (with first-generation excimer lasers), and
automated lamellar keratoplasty.
LASIK is commonplace today, but I believe that laser vision
correction is evolving from excimer laser-based ablation
procedures to microincision surgery procedures like ReLEx
smile. Like any other procedure I have considered for routine
use, I performed an objective analysis of ReLEx and determined
it may perhaps be the most ideal way to perform laser
vision correction.

June 2012 Supplement
27
The basis for the ReLEx procedure is the Law of Thickness,
which was introduced by the late Jose Ignacio Barraquer, of
Bogotá, Colombia, in 1949. 1 This is also the same principle
for which numerous methods of laser vision correction—
LASIK included—are based. However, ReLEx is unique to
these other laser vision correction procedures because of the
elegance with which the Law of Thickness is implemented.
The beauty of ReLEx is its minimalistic approach to surgical
correction. My incision size is now routinely between 2.0 and
2.5 mm long (Figure 1). You can say it is the cutting edge of
refractive surgery because there is almost no cut edge.
Benefits: I gradually incorporated ReLEx into my practice
over the past year, with a steady growth in the number of
procedures I was performing. Currently, approximately half
of my procedures are ReLEx surgeries. My initial experience
(six eyes) was with ReLEx flex. I then transitioned to performing
ReLEx with a continuously smaller incision size, still
using the flex program on the VisuMax femtosecond laser.
This is a helpful transition procedure based on ReLEx flex.
In July 2011, the ReLEx smile program was installed on
our laser, and since then almost all of my cases have been
done with this program. I have always been a firm believer
in Dr. Barraquer’s Law of Thickness, but only when I saw
Rupal Shah, MD, of India, perform ReLEx smile did I
realize that this is what LASIK wants to be when it grows
up. ReLEx smile does what LASIK does—only better. There
are minimal disturbances to the cornea, both structurally and
physiologically. I see this procedure as the ultimate homage to
Dr. Barraquer.
ReLEx flex and ReLEx smile procedures both have advantages.
I prefer ReLEx smile, because I have found that, after
surgery, these eyes tend to be more comfortable during the
first night postoperative. Additionally, ReLEx smile eyes have
the potential to be structurally stronger than ReLEx flex eyes,
as there is no flap-edge cut by the laser. The benefit of such
cut, however, is the ease with which you can go back and do
enhancement surgery much in the same way as after LASIK.
Stepping stone: I use ReLEx smile whenever I can. When
I do use ReLEx flex, I perform this technique with a small
incision size while still using the flex program. ReLEx flex
is a steppingstone, albeit an important one, to ReLEx smile.
This procedure is a helpful step to optimize laser settings and
to gain valuable experience learning the techniques required
for this type of surgery. The ReLEx flex software also allows
the surgeon to start performing a small-incision technique
as described above by only making a small access cut even
when the laser has created LASIK flap-like cuts. This serves
as a training step for the surgeon to gain the confidence for
progressing to ReLEx smile.
I can use the same preoperative process with ReLEx smile
Figure 1. (A) During ReLEx smile, the lenticule is removed through a
2-mm incision. (B) ReLEx smile: Postoperative day 1.
as we did for ReLEx flex and also for LASIK. We carefully
explain the risks and benefits of each surgical option, and the
patient has the freedom to make an informed decision. ReLEx
has expanded the range of myopic treatment we can offer to
patients. Historically, we have limited our myopic treatment
to -10.00D with LASIK, more from an optical quality standpoint.
Now, with the superior optics that we see with ReLEx,
we are treating cases above -10.00D in the course of our clinical
study, if pachymetry allows, with great results. Therefore,
having ReLEx as a surgical option may increase the number
of potential candidates for the future.
Marketing services: As with any service I offer my patients,
I truly believe in the ReLEx procedure. This is the first
message that I tell patients. After that, it is mostly about
providing clinical data and describing the procedure to the
patient. I offer ReLEx to all patients who are candidates
for the procedure, but it is important to let them choose the
procedure that they feel is best suited. I do not like to think of
it as marketing, but rather information gathering. I am able
to offer a wider range of procedures to my patients. In the
beginning, when there was not a lot of data on ReLEx, I made
sure to point that fact out to the patient. Today, I feel very
comfortable offering ReLEx to my patients.
It is not always easy to explain the procedure and make the
patient understand completely, but one of the things patients
like about ReLEx smile is that it uses a microincision and the
vision correction cut is performed inside the intact cornea.
Most people can identify with the benefits of minimally
invasive procedures, as the whole of medical practice seems
to be progressing. An analogy such as endoscopic surgery as
opposed to laparotomy (in cholecystectomy, for example) is
helpful.
Conclusion: Using ReLEx flex and ReLEx smile, I have been
able to provide patients with a minimally invasive approach
to laser vision correction that affords short treatment times
and inherent accuracy, even in cases of high myopia. I have
been able to expand my treatment range within the scope of
the study well past the -10.00D of myopia I could treat with
LASIK, and I have done so safely and accurately using these
techniques.
1. Barraquer JI. Queratoplastia refractiva. Estudios Inform Oftalmol Inst
Barraquer.1949;10:2-21.

This is the moment we work for.
The moment flapless surgery
becomes clearly visible: in a smile.
This is the moment we work for.
// ReLEx
MadE By CaRL ZEiss
// ReLEx
MadE By CaRL ZEiss
Flapless. All-femto. Single-step. For the first time ever, advanced femtosecond technology and highly
precise lenticule extraction are combined to perform minimally invasive corrections – with a single system:
the VisuMax ® from Carl Zeiss. Thereby, a refractive lenticule is created within the intact cornea and extracted
through a small incision. The new flapless procedure offers clear advantages: minimal surgical impact on the
corneal stability and excellent predictability of the refractive outcomes.
Flapless. All-femto. Single-step. For the first time ever, advanced femtosecond technology and highly
www.meditec.zeiss.com/ReLEx
precise lenticule extraction are combined to perform minimally invasive corrections – with a single system:
the VisuMax ® from Carl Zeiss. Thereby, a refractive lenticule is created within the intact cornea and extracted
through a small incision. The new flapless procedure offers clear advantages: minimal surgical impact on the
000000-1839-885
corneal stability and excellent predictability of the refractive outcomes.