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Thank You for your opinion, It was 130 mkm flap, we use Ziemer from early 2009 and have great clinical experience with this laser, as well as with AMO IFS, Visumax and new FS200 . I strongly believe that it is was much better to postpone surgery in this case and not to repeat it at the same day mostly due to second side cut and all flap probable irregularity. We performed surgery with AMO IFS after 30 days, all regular, with no complications. Sincerely Mikhail

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Professor Pozharitskiy I assume you were attempting a 90um flap? There are serveral mechanisms that can lead to a femto gas breakthrough. The Ziemer, as you know, does not use gas as a mechanism of dissection. This is what allows for creation of very thin flaps that are not recomended with large bubble devices like the Intralase and the Alcon Wavelight platforms. As I was a consultant to to the Intralase in the early days we made the recomendation that the device be limited to 100um as the risk of breakthrough was too great below this. And though you can watch this occur you really have no recourse during the procedure to do anything about it. You simply complete the procedure and assess the implications. With Ziemer, unlike the large bubble devices you really did no need to wait to retreat. As the bubble are not in the tissue but in the interface, you simple give them a few minute to disapate and then retreat. I normally recommend retreating at 140 above your 110 or 110 above your 90um attempt. Mark your intial edge so you can begin your second dissection in the right plane. You will find you have a smooth and perfect surface below. Of course this is why small bubble femto's like Ziemer and Ziess are likely the future of this work as they allow for multiple planes to be cut as there is minimal tissue expansion. As you know the Smile procedure has achieved amazing early results. These bubbles are actually larger then you Ziemer. It is possible to have a false vacuum green light by the Ziemer even though it uses a microprocessor controlled feedback (unlike the Leur lock system still employed amazingly by Intralase). Always lift a bit after vacuum is attained to prove you have suction. The pressure is normally high enough to cause graying out of vision so asking the patient is another feedback. A corneal scar from a contact lens or other infection is a passage for gas through bowmans. I will not make a 90um flap in such an eye. I generally do not to go below 100um in most of my patients but my friend Scott MacRae has done hundreds and has great results. Be careful to use Oasis tears or LaserVisc to achieve a perfect interface thickness between the plate and the epithelium. All the best and I hope your patient has done well!

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