ARTICLE

Laser in situ keratomileusis flap complications

using mechanical microkeratome versus
femtosecond laser: Retrospective comparison
Majid Moshirfar, MD, Jeffrey P. Gardiner, Joshua A. Schliesser, Ladan Espandar, MD, Vahid Feiz, MD,
Mark D. Mifflin, MD, Joann C. Chang, MD

PURPOSE: To compare the incidence of flap complications after creation of laser in situ keratomi-
leusis (LASIK) flaps using a zero-compression microkeratome or a femtosecond laser.
SETTING: John A. Moran Eye Center, Department of Ophthalmology, University of Utah, Salt Lake
City, Utah, USA.
DESIGN: Evidence-based manuscript.
METHODS: The flap complication rate was evaluated during the initial 18 months of experience
using a zero-compression microkeratome (Hansatome) or a femtosecond laser (IntraLase FS60)
for flap creation.
RESULTS: The flap complication rate was 14.2% in the microkeratome group and 15.2% in the fem-
tosecond laser group (P Z .5437). The intraoperative flap complication rate was 5.3% and 2.9%,
respectively (P Z .0111), and the postoperative flap complication rate, 8.9% and 12.3%, respec-
tively (P Z .0201). The most common intraoperative complication in the microkeratome group was
major epithelial defect/sloughing; the rate (2.6%) was statistically significantly higher than in the
femtosecond laser group (P Z .0006). The most common postoperative complication in both
groups was diffuse lamellar keratitis (DLK) (6.0%, microkeratome; 10.6%, femtosecond laser)
(P Z .0002).
CONCLUSION: Although the total complication rates between the 2 groups were similar, the micro-
keratome group had significantly more epithelial defects intraoperatively and the femtosecond laser
group had significantly more DLK cases postoperatively.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2010; 36:1925–1933 Q 2010 ASCRS and ESCRS

A critical step in laser in situ keratomileusis (LASIK) is
creation of the corneal flap. The 2 most common ways
to create the flap are with a femtosecond laser or a me-
chanical microkeratome. In recent years, the femtosec-
ond laser has gained popularity and is replacing
mechanical microkeratomes for LASIK flap creation.1
The mechanical microkeratome uses shear force trav-
eling across the corneal stroma with an oscillating
blade to create a flap. The femtosecond laser emits
a 1053 nm wavelength (infrared) light that produces
microcavitation bubbles at a preset depth in the
corneal stroma.2,3 Because of its precision and more
predictable flap depth,3–7 this technology may offer
several advantages over mechanical microkeratomes.
These include better predictability of postoperative re-
fraction, better uncorrected distance visual acuity
(UDVA),8 and possible reduction in overall induced
astigmatism.3,8,9
Even though femtosecond lasers may offer more ad-
vantages than mechanical microkeratomes, complica-
tions have been reported after laser flap creation.
Several studies2,10,11 found the incidence of diffuse la-
mellar keratitis (DLK) to be higher in eyes in which the
LASIK flap was created with a femtosecond laser than
in those in which the flap was created with a mechan-
ical microkeratome. Gas breakthrough,12 an opaque
bubble layer,10 transient light-sensitivity syndrome
(TLSS),13 and suction loss leading to incomplete

Q 2010 ASCRS and ESCRS 0886-3350/$dsee front matter 1925

Published by Elsevier Inc. doi:10.1016/j.jcrs.2010.05.027
1926 MICROKERATOME VERSUS FEMTOSECOND LASER FLAP COMPLICATIONS
flap14 have also been reported with femtosecond
lasers.
In this study, we analyzed our initial surgical expe-
rience using a zero-compression microkeratome and
a femtosecond laser. We compared the incidence of
intraoperative and postoperative complications using
these 2 methods of LASIK flap creation.
PATIENTS AND METHODS
All patients who had LASIK flap creation with a Hansatome
zero-compression microkeratome (Bausch & Lomb) between
February 2001 and July 2002 or with an IntraLase FS60 laser
(Abbott Medical Optics, Inc.) between August 2006 and
January 2008 were included in this retrospective study. The
LASIK procedures were performed by 1 of 2 surgeons
(M.M., M.D.M.) at John A. Moran Eye Center. An institu-
tional review board at the University of Utah approved the
study.
Patients were screened for surgery with at least 1 cyclople-
gic evaluation and 2 manifest refraction evaluations; in all
cases, LASIK was deemed safe according to the U.S. Food
and Drug Administration guidelines.A The patients had
a full ophthalmic examination including slitlamp micros-
copy, dilated fundoscopy, ultrasound pachymetry, and
topography.
Surgical Technique
Microkeratome Flap Creation The microkeratome used for
LASIK flap creation had a 160 mm zero-compression head
and an 8.5 to 9.0 mm ring. All flaps had a superior hinge. Im-
mediately after flap creation, stromal ablation was started
using the Visx Star excimer laser (Abbott Medical Optics,
Inc.).
Laser Flap Creation The femtosecond laser procedures
were performed at 60 kHz in a raster pattern with a bed en-
ergy of 1.15 mJ, pulse separation of 8  8, and side-cut energy
of 2.00 mJ, with the pocket enabled. The flaps were created
with a diameter between 8.7 mm and 9.0 mm, a thickness
Submitted: November 3, 2009.
Final revision submitted: April 7, 2010.
Accepted: May 13, 2010.
From the Department of Ophthalmology and Visual Sciences
(Moshirfar, Chang, Mifflin), John A. Moran Eye Center, and the
School of Medicine (Schliesser), University of Utah, Salt Lake
City, Utah; Arizona College of Osteopathic Medicine (Gardiner),
Glendale, Arizona; Ophthalmology Department (Espandar), Tulane
Health Science Center, New Orleans, Louisiana; Department of
Ophthalmology (Feiz), School of Medicine, University of California
Davis, Sacramento, California, USA.
Supported in part by an unrestricted educational grant from Aller-
gan, Inc., Irvine, California, to the Department of Ophthalmology
and Visual Sciences, John A. Moran Eye Center, University of Utah.
Corresponding author: Majid Moshirfar, MD, John A. Moran Eye
Center, 65 Mario Capecchi Drive, Salt Lake City, Utah 84132,
USA. E-mail: majid.moshirfar@hsc.utah.edu.
J CATARACT REFRACT SURG - VOL 36, NOVEMBER 2010
of 110 mm, a superior hinge angle of 50 degrees, and a side-
cut angle of 70 degrees. Patients were instructed to keep their
eyes closed for 5 to 15 minutes after flap creation to ensure
resolution of the opaque bubble layer. Stromal ablation
was then performed using the Visx Star excimer laser.
Postoperative Treatment
At the completion of the LASIK procedures, gatifloxacin
0.3% was used 4 times a day for 7 days. In the microkeratome
group, prednisolone acetate 1.0% was given 4 times a day for
6 days. In the femtosecond laser group, prednisolone acetate
1.0% was given every hour on the day of surgery and then
4 times a day for 6 days. The prednisolone acetate 1.0%
dose in the femtosecond laser group was higher because of
the known increased risk for DLK with this method.
Postoperative Follow-up
All patients were examined at the slitlamp immediately
after surgery and 1 day postoperatively. The frequency of
subsequent visits was determined by the nature of the flap
complication and any treatment required. At a minimum,
patients had follow-up visits at 1 week and 1, 3, and 6
months. The final corrected distance visual acuity (CDVA)
at 6 months was compared between the microkeratome
group and the femtosecond laser group.
Definitions of Complications
Definitions for intraoperative flap complications included
the following:
1. Major epithelial defect/sloughing. A break or a loose area of
epithelium larger than 2.0 mm  2.0 mm.
2. Incomplete flap suction. Suction is lost during passage of the
mechanical microkeratome or during the lamellar cut or
side cut using the femtosecond laser.
3. Buttonhole. Inability of the microkeratome or femtosecond
laser to complete the lamellar cut, resulting in a hole or
thinning of the flap upon lifting. Because vertical gas
breakthrough with the femtosecond laser has a similar
outcome, the complication was included in the buttonhole
group.
4. Torn flap. Any tear in the flap occurring before or during
the lifting process.
5. Severely decentered flap. A 6.0 mm stromal ablation zone is
not attainable under the flap.
6. Gas bubbles. Bubbles of gas that accumulate and seep into
the anterior chamber of the eye during femtosecond laser
flap creation.
Definitions for postoperative flap complications included
the following:
1. Dislocated flap. The flap is displaced from its original
position after LASIK.
2. Epithelial ingrowth. The presence of epithelial cells under
the flap.
3. Diffuse lamellar keratitis. Sterile inflammation with an
accumulation of inflammatory cells in the flap interface.
5. Central toxic keratopathy. Central stromal opacification
occurring within 1 week of surgery.
6. Transient light-sensitivity syndrome. Light sensitivity out of
proportion to that in normal eyes that typically occurs 2 to
6 weeks after uneventful LASIK.
 MICROKERATOME VERSUS FEMTOSECOND LASER FLAP COMPLICATIONS 1927

Minor epithelial defects, subconjunctival hemorrhages, Complications

difficulty lifting the flap, and thin or thick flaps were not
included in the analysis.
Statistical Analysis
The data were exported to Excel (Microsoft Corp.). The
Student t test was used to detect statistically significant
differences in flap complication rates between the 2 groups.
Differences with a P value of 0.05 or less were considered
statistically significant.
RESULTS
The microkeratome group comprised 896 eyes (493 pa-
tients) and the femtosecond laser group, 902 eyes (500
patients). The mean age of the patients was 37.20 years
and 36.42 years, respectively (P Z .0840). There were
no statistically significant differences in preoperative
data between the 2 groups. The mean manifest refrac-
tion spherical equivalent (MRSE) was 3.74 diopters
(D) in the microkeratome group and 3.57 D in the
femtosecond laser group (P Z .0994) and the mean
keratometry (K) value, 44.18 D and 44.07 D, respec-
tively (P Z .2058). There was no statistically significant
difference in preoperative MRSE, K values, or age be-
tween eyes that had complications and those that did
not have complications (Table 1).
One hundred twenty-seven eyes (14.2%) in the
microkeratome group and 137 eyes (15.2%) in the
femtosecond laser group developed a flap-related
complication (Figure 1); the difference between the 2
groups was not statistically significant (P Z .5437).
Table 2 shows the incidence of minor flap complica-
tions and final visual acuity in eyes with complica-
tions. Figure 2 shows the incidence of major flap
complications. Six months postoperatively, 95 eyes
(74.8%) in the microkeratome complication group
and 125 eyes (91.2%) in the femtosecond laser compli-
cation group had a CDVA of 20/20 or better
(P Z .2085) and 118 eyes (92.9%) and 137 eyes
(100%), respectively, had a CDVA of 20/40 or better
(P Z .6285) (Figure 3).
Intraoperative Major epithelial defect/sloughing
occurred in 23 eyes (2.6%) in the microkeratome group
and 5 eyes (0.6%) in the femtosecond laser group; the
difference between groups was statistically significant
(P Z .0006). Of eyes with this complication, 19 (82.6%)
in the microkeratome group and 3 (60.0%) in the femto-
second laser group achieved a CDVA of 20/20 or better
(P Z .0598) (Figure 3). The loss of CDVA was likely
a result of irregular astigmatism and corneal haze.

Table 1. Patient demographic and preoperative data.

Device/Parameter Eyes with No Complications Eyes with Complications P Value

Microkeratome
Male:female ratio 0.7:10 1.2:10
Age (y)
Mean G SD 39.42 G 10.16 39.93 G 8.59 .7666
Range 21 to 71 24 to 60
MRSE (D)
Mean G SD 3.74 G 2.34 4.31 G 1.96 .2318
Range 11.00 to 7.25 7.63 to 2.00
K value (D)
Mean G SD 44.18 G 1.37 44.19 G 1.02 .9712
Range 40.00 to 48.05 42.00 to 46.31
Femtosecond laser
Male:female ratio 1:1 1:1
Age (y)
Mean G SD 36.42 G 9.72 34.82 G 8.27 .3053
Range 21 to 68 21 to 56
MRSE (D)
Mean G SD 3.57 G 2.10 4.04 G 1.69 .2270
Range 10.25 to 4.62 8.50 to 1.13
K value (D)
Mean G SD 44.07 G 1.50 43.83 G 0.83 .4477
Range 40.06 to 49.15 41.69 to 45.00

K Z keratometry; MRSE Z manifest refraction spherical equivalent

J CATARACT REFRACT SURG - VOL 36, NOVEMBER 2010

1928 MICROKERATOME VERSUS FEMTOSECOND LASER FLAP COMPLICATIONS

the microkeratome laser group and 9 (90.0%) in the

Figure 1. Total, intraoperative, and postoperative complication rates
(* Z statistically significant).
Flap suction was lost in 8 eyes (0.9%) in the micro-
keratome group, resulting in an incomplete flap. At
a later date, the flap was successfully recut in 5 eyes
and photorefractive keratectomy (PRK) was per-
formed in 1 eye. Two eyes had no further surgery. In
the femtosecond laser group, suction was lost in 10
eyes (1.1%), leading to an incomplete flap (P Z
.6461); 6 cases occurred during the lamellar cut and 4
during the side cut. Of the 6 incomplete lamellar
cuts, 3 were recut at the same depth on the same
day, 2 were recut at the same depth 6 weeks later,
and 1 was recut 1 month later and measured 20 mm
deeper than the original cut. In 3 of 4 cases with an in-
complete side cut, the small tags were separated
bluntly with a sharp 15-degree blade, allowing the sur-
geon to proceed with the procedure. In the other eye,
a second side cut with a smaller diameter was made
because the initial cut was relatively small (270 de-
grees). Of eyes with an incomplete flap, 7 (87.5%) in
femtosecond laser group achieved a CDVA of 20/20
or better (P Z .9117). Irregular astigmatism was the
most likely cause of decreased CDVA.
Of the eyes that developed a buttonhole in the mi-
crokeratome group, 1 had a recut at a greater depth
6 months later, 1 was recut at the same depth 1 year
later, and 5 had PRK at a later date. In the femtosecond
laser group, 1 eye was recut at a later date due to
a small paracentral vertical gas breakthrough closer
to the visual axis. The eyes had a second incision on
the same day for a partial buttonhole in the first eye
and a small partial vertical gas breakthrough peripher-
ally in the second eye. The final CDVA in these eyes is
shown in Table 2. Although it was speculated that eyes
with steeper corneas would be predisposed to button-
hole, there was no statistically significant difference in
the mean preoperative K values between eyes with
buttonhole and eyes without buttonhole (P Z .2272,
microkeratome group; P Z .5405, femtosecond laser
group) (Table 3).
Torn flaps occurred in both groups. All tears in the
femtosecond laser group were at the hinge and re-
sulted from significant resistance as the flap was being
lifted. In 3 cases, the surgeon was able to proceed with
stromal ablation on the same day. In 1 case, PRK was
performed at a later date. All torn flaps in the micro-
keratome group were significant, causing the LASIK
procedure to be aborted. In 1 eye, the cause was a de-
fective blade; no identifiable cause could be deter-
mined in the other cases. Of eyes with a torn flap in
the microkeratome group, 1 had PRK at a later date;
no further surgery was performed in the other eyes.
The final CDVA in these eyes is shown in Table 2.
Severely decentered flaps occurred in both groups.
Of the decentered flaps in the microkeratome group,

Table 2. Incidence of minor flap complications and final visual acuity.

Microkeratome (n Z 896) Femtosecond Laser (n Z 902)

Final CDVA (n) Final CDVA (n)

Complication n (%) %20/20 %20/40 n (%) %20/20 %20/40

Intraoperative
Buttonhole or gas breakthrough 7 (0.8) 4 7 3 (0.3) 1 3
Torn flap 4 (0.4) 3 4 4 (0.4) 4 4
Decentered flap 5 (0.6) 4 5 1 (0.1) 1 1
Gas bubble in AC 3 (0.3) 3 3
Postoperative
Epithelial ingrowth 2 (0.2) 0 2 1 (0.1) 1 1
Central toxic keratopathy 2 (0.2) 0 2 0 d d
Transient light-sensitivity syndrome 0 d d 4 (0.4) 4 4

AC Z anterior chamber; CDVA Z corrected distance visual acuity

J CATARACT REFRACT SURG - VOL 36, NOVEMBER 2010

 MICROKERATOME VERSUS FEMTOSECOND LASER FLAP COMPLICATIONS
Figure 2. Incidence of major epithelial defect/sloughing, incomplete
flap, dislocated flap, and DLK (* Z statistically significant; DLK Z
diffuse lamellar keratitis).
3 were recut at a later date and 2 were left alone. The
decentered flap in the femtosecond laser group had
PRK 3 months after the original surgery. The final
CDVA in these eyes is shown in Table 2.
Figure 3. Corrected distance Snellen visual acuity of total, intraoper-
ative, and postoperative complicated eyes with major epithelial
defect/sloughing, incomplete flap, dislocated flap, and DLK
(DLK Z diffuse lamellar keratitis).
J CATARACT REFRACT SURG - VOL 36, NOVEMBER 2010
1929
In cases with gas bubbles in the femtosecond laser
group, the bubbles interfered with pupil tracking in
2 eyes; the bubbles were allowed to absorb and sur-
gery was completed later the same day. There was
no interference in tracking in 1 case, and surgery was
completed without further complication. The final
CDVA in these eyes is shown in Table 2.
Postoperative One day postoperatively, the flap dislo-
cated in 22 eyes (2.5%) in the microkeratome group
and 10 eyes (1.1%) in the femtosecond laser group
(P Z .0308). The dislocated flaps were refloated the
same day with subsequent placement of a bandage
contact lens. The final CDVA was 20/20 or better in
20 eyes (90.9%) with a dislocated flap in the microker-
atome group and 9 eyes (90.0%) with dislocated flap in
the femtosecond laser group (P Z .9753). All eyes with
a dislocated flap had CDVA of 20/40 or better.
Although it was speculated that eyes with high
myopia or a steeper cornea would be at an increased
risk for a dislocated flap, there was no statistically
significant difference in preoperative relative corneal
curvature or MRSE between eyes without a dislocated
flap and eyes with a dislocated flap (Table 3).
All cases of epithelial ingrowth were identified
within 6 weeks after surgery and were treated by relift-
ing the flap and scraping. The final CDVA in these
eyes is shown in Table 2.
Diffuse lamellar keratitis of stage I or II developed in
54 eyes (6.0%) in the microkeratome group and 96 eyes
(10.6%) in the femtosecond laser group (P Z .0002).
Two cases in the microkeratome group progressed to
DLK stage III; no eye in the femtosecond laser group
progressed to this stage. Of eyes with stage I or II
DLK in the microkeratome group, 44 (81.5%) achieved
a CDVA of 20/40 or better and 38 (70.4%) achieved
20/20 or better. In the femtosecond laser group, all
eyes with DLK achieved a CDVA of 20/40 or better
and 90 (93.7%) achieved 20/20 or better (Figure 3).
In the 2 eyes with stage III DLK, the final CDVA was
20/50 in 1 eye and 20/40 in the other eye. The cause
of loss of CDVA in DLK cases was likely haze or scar-
ring. Although the rate of DLK was significantly high-
er in the femtosecond laser group, the DLK appeared
to be self-limiting with a good visual prognosis.
Both cases of central toxic keratopathy were in the
microkeratome group and in the same patient. The
final CDVA was 20/40 in 1 eye and 20/30 in the other
eye.
All cases of TLSS were in the femtosecond laser
group and affected both eyes of 2 patients. Both
patients presented with photophobia 3 to 4 weeks
postoperatively despite good visual acuity and no
signs of inflammation. All cases responded well to
1930 MICROKERATOME VERSUS FEMTOSECOND LASER FLAP COMPLICATIONS
Table 3. Comparison of preoperative visual characteristics in cases of buttonhole flap and dislocated flap.
Device/Parameter No-Complication Group
Microkeratome
MRSE (D)
Mean G SD 3.74 G 2.34
Range 11.00 to 7.25
K value (D)
Mean G SD 44.18 G 1.37
Range 40.00 to 48.05
Femtosecond laser
MRSE (D)
Mean G SD 3.57 G 2.10
Range 10.25 to 4.62
K value (D)
Mean G SD 44.07 G 1.50
Range 40.06 to 49.15
K Z keratometry; MRSE Z manifest refraction spherical equivalent
a short course of topical corticosteroidal agents with
no loss of CDVA.
DISCUSSION
The femtosecond laser is slowly replacing some
mechanical microkeratome models in use today. A
survey foundB that in 2008, more than 50% of all
LASIK flaps were created with a femtosecond laser.
In this retrospective case series, we compared intra-
operative and postoperative complications during our
initial 18 months of experience with flap creation using
a Hansatome zero-compression microkeratome and
an IntraLase FS60 femtosecond laser. The total compli-
cation rate was 14.2% in the microkeratome group and
15.2% in the femtosecond laser group, with no
statistically significant difference between the groups
(P Z .5437). To our knowledge, this is the first pub-
lished study to compare complications between the 2
devices. Jacobs and Taravella15 report a total intra-
operative complication rate of 0.16% with the
Hansatome microkeratome, lower than the 6.38 rate
with the Automated Corneal Shaper (Bausch &
Lomb). In a more recent larger study of the 2 devices,16
the intraoperative complication rate was 0.63% and
1.26%, respectively. In our study, the most common
intraoperative complication in the microkeratome
group was major epithelial defect/sloughing (2.6%),
a rate that was significantly higher than in the femto-
second laser group (P Z .0006). Polk et al.17 found
a 2.7% incidence of epithelial defects with the same mi-
crokeratome, which is comparable to the rate in our
study. This complication is likely caused by the pivotal
movement and shearing force of the microkeratome,
which has a tendency to disrupt the epithelium from
J CATARACT REFRACT SURG - VOL 36, NOVEMBER 2010
Buttonhole Group P Value Dislocated Flap Group P Value
4.23 G 2.34 .5813 3.79 G 2.66 .9306
7.63 to 2.00 6.87 to 1.25
44.86 G 0.73 .2272 44.42 G 1.18 .4673
44.00 to 45.88 41.69 to 45.88
2.75 G 2.10 .5017 3.03 G 2.33 .4445
4.13 to 1.13 6.00 to 2.00
43.54 G 1.67 .5405 44.50 G 1.34 .4249
41.69 to 44.94 42.69 to 45.88
the basement membrane.17 Theoretically, this compli-
cation would not occur with a femtosecond laser
because no direct shearing force is applied to the
corneal surface. Our study supports this, with signifi-
cantly fewer cases of major epithelial defects (0.6%) in
the femtosecond laser group.
The other intraoperative complication was incom-
plete flap, and the incidence in the 2 groups was
similar. However, with the femtosecond laser, the sur-
geon has the option of creating a smaller flap within
the original area on the same day or creating a flap
with the original parameters within the next few
days. In the case of microkeratomes, most surgeons
choose to postpone stromal ablation for several weeks
to several months, as was the case with the incomplete
flaps in our microkeratome group.
In our study, vertical gas breakthrough was
grouped with buttonhole because of the similar results
in eyes with these 2 complications. With a femtosecond
laser, coalescing of microcavitation bubbles in the
stroma causes vertical gas breakthrough.18 The gas
breakthrough can mislead the surgeon into leaving
a piece of stroma intact when creating the flap. As
the flap is lifted, the intact stroma will tear, causing
a hole. The buttonholes in the microkeratome group
were typically central, round, and approximately
3.0 to 4.0 mm in diameter. The subepithelial gas break-
through in the femtosecond laser group was often pe-
ripheral and 1.0 to 2.0 mm in diameter. Although gas
breakthrough is not typically classified as a buttonhole,
the final results were the same. The occurrence of
buttonholes with a femtosecond laser is rare,12 and
the lower incidence in our femtosecond group could
be because the laser creates a planar flap rather than the
meniscus-shaped flap created by microkeratomes.4,9
 MICROKERATOME VERSUS FEMTOSECOND LASER FLAP COMPLICATIONS
The incidence of torn flaps was similar in the 2
groups. However, all tears in the femtosecond laser
group occurred at the flap hinge, as opposed to the
more central flap tears in the microkeratome group.
When the tear is at the hinge, it avoids the central
axis and the surgeon has the option of proceeding
with stromal ablation on the same day.
One eye in the femtosecond laser group had a decen-
tered flap. Decentered flaps have been reported as
a complication with mechanical microkeratomes;
however, a literature search found no reports of decen-
tered flaps with the femtosecond laser. When a flap is
created with a microkeratome, complete separation of
tissue has taken place by the time the flap is made.
However, with a femtosecond laser, the surgeon can
chose not to disrupt the flap and to create a different
flap at a later date.
A significant finding in our study was the greater oc-
currence of flap dislocation in the microkeratome
group. The lower incidence of flap dislocations in the
femtosecond laser group is likely a result of the laser’s
steeper side-cut angle and deeper gutter and the
increased adhesion strength of the femtosecond
flap.19–21
The incidence of DLK was significantly higher in the
femtosecond laser group than in the microkeratome
group (P Z .0002). Diffuse lamellar keratitis is charac-
terized by diffuse white granular lamellar keratitis.22 It
has been hypothesized that an accumulation of gas
bubbles and femtosecond laser energy could increase
the inflammatory response in patiens who might be
more susceptible to DLK.2 Earlier models of the laser
we used, especially the 15 kHz and earlier models,
not only used higher energy levels but also had a pulse
geometry that produced a larger width cut through the
epithelium around the perimeter of the flap. This cre-
ated a flap edge that was easier for the surgeon to
visualize at the operating microscope but that resulted
in more epithelial damage, a greater release of
epithelial-derived cytokines, greater production of
keratocyte-derived chemokines, and more inflamma-
tory cell infiltration.23,24 One explanation for the high-
er incidence of DLK in our study might be the use of
2 mJ energy for the side cut because higher energies,
even in the side cut, produce more cell damage,
a greater release of cytokines, and more inflammatory
cell infiltration. A study by de Medeiros et al.23 com-
pared the wound-healing response in rabbit corneas
using different energy ranges. At the low end of
the femtosecond laser energy range (from 0.7 mJ to
1.6 mJ), cell death and inflammatory cell infiltration
were small. The authors mentioned that in their prac-
tice, with refinement in energy selection, postoperative
corticosteroid treatment had become identical to what
they use in LASIK performed with a microkeratome,
J CATARACT REFRACT SURG - VOL 36, NOVEMBER 2010
1931
without an increase in the incidence of DLK. In our
experience, even though the femtosecond laser group
had a higher incidence of DLK, the DLK did not prog-
ress to stage III. This could be attributed to differences
in increased dosing of prednisolone acetate 1.0% in the
acute postoperative period in the femtosecond laser
group.
Central toxic keratopathy results in stromal thin-
ning and a hyperopic shift in most eyes.25 The 2 cases
of central toxic keratopathy in our study were in the
microkeratome group. Although there were cases of
central toxic keratopathy in the femtosecond laser
group, this condition has been known to occur with
the laser.25 Central toxic keratopathy has also been
observed with PRK,25 suggesting that it may not be
appropriate to classify it solely as a flap complication.
Bubbles in the anterior chamber, TLSS, and rainbow
glare are complications unique to the femtosecond
laser. The gas bubbles formed by the laser can accumu-
late in the flap interface and seep through the trabecu-
lar meshwork into the anterior chamber of the eye.19
Two case reports by Srinivasan and Rootman26 and
Lifshitz et al.27 found that anterior chamber bubbles
can interfere with pupil tracking but are self-limiting
and resolve over a short period. Our experience agrees
with these reports; all cases of anterior chamber bub-
bles in our series resolved and were successfully
treated without significant delay. Unlike anterior
chamber bubbles, TLSS and rainbow glare occur
postoperatively. Their exact cause is not known. It is
theorized that in TLSS, the increased energy from the
femtosecond laser stimulates local keratocytes, corneal
nerve endings, or both.13 Stonecipher et al.13 evaluated
different groups with a TLSS incidence rate of 1.0% to
1.4%; they noted that when the raster and side-cut en-
ergy settings were lowered (by an average of 24% and
33%, respectively), there was a significant reduction in
the incidence of TLSS. Our raster and side-cut energy
settings were well below the lowest settings that Stone-
cipher et al.13 recommend; as a result, we had a lower
incidence of TLSS. Similar to TLSS, rainbow glare
appears to occur more often with higher raster energy
settings.28 Although there were no cases of rainbow
glare in our study, it is important to recognize this com-
plication and its relationship to the femtosecond laser.
There are several limitations to our study. First, we
compared only 1 one type of microkeratome and 1
type of femtosecond laser. Thus, our results may not
be applicable to all types of microkeratomes or femto-
second lasers. In addition, this was a retrospective
analysis. A prospective study could have addressed
the question better; however, we wanted to evaluate
the first patients to be treated with these 2 methods
because theoretically, there would be more complica-
tions early in the use of these methods. This
1932 MICROKERATOME VERSUS FEMTOSECOND LASER FLAP COMPLICATIONS
comparison would not be possible in a prospective
study because we are no longer using the microkera-
tome for LASIK flap creation at our institution.
Another limitation is the different postoperative pred-
nisolone acetate 1.0% dosing in the microkeratome
group and the femtosecond laser group. Because this
was a retrospective study, we could not control for
this limitation. Although the study evaluated a signifi-
cant number of eyes (nearly 1800), flap complications
are uncommon; therefore, a larger number of patients
would have added more statistical power to the study.
This study also did not assess the rate of enhancement,
dry eye, or long-term complications, all of which are
important parameters when evaluating the pros and
cons of LASIK flap creation.
We did not find a significant difference in the total
complication rate between the microkeratome group
and the femtosecond laser group. The final CDVA in
complicated cases appeared to be clinically better in
the femtosecond laser group; however, the difference
between groups was not statistically significant. The
microkeratome group had a statistically greater
number of intraoperative complications than the fem-
tosecond laser group, with most attributed to major
epithelial defects/sloughing. The femtosecond laser
group had a statistically greater number of postopera-
tive complications, primarily as a result of the greater
incidence of stage I and stage II DLK, which was self-
limiting with good visual outcomes in all cases. Even
though there were fewer postoperative complications
in the microkeratome group, there were significantly
more dislocated flaps, none of which was visually sig-
nificant. As improvements are made to both the micro-
keratome and femtosecond laser, it will be interesting
to see which will become the preferred instrument for
flap creation in LASIK procedures.
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