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Dr. Chynn on SMILE procedure

A college of Dr. Chynn inquired about the new SMILE ReLEX procedure

Q:

I have a friend in London with myopia (-1.75 & -2.75, Aet ~ 40 & female) considering refractive surgery.
Is it time for SMILE (1,2) or if it were your family member would you do LASIK … or PRK?
Any recommendations re surgeon – please contact me directly.
Is there really less dry eye (3)?
A by Emil Chynn, MD:
My humble yet informed opinion as the 1st eye MD in NYC to get LASIK and having switched from incisional to non incisional surgery years ago:
at such a low rx, she should have LASEK, as there is 0 risk of making her see worse in well-trained hands, and there is no need to cut a flap for such a low Rx, and her chance of haze at such a low Rx is also 0, and she will heal quickly if it is a true LASEK not a PRK (defined as en bloc removal of epithelium, not whether you put it back or not, i suggest not after 20,000 surface ablations), and he chance of dry eyes or night glare will be lower than after any incisional surgery, and i don’t know why smile is all the rage except for marketing, having seen many and done 1 while in europe last year, and you cannot treat HOA or even cyl very well with smile, so isn’t it really a glorified ALK?

A doctor had post-LASIK complications here is Dr. Chynn’s answer

Q:

I would be most thankful if you could give me your precious input in this case. The 35 yo patient had a LASIK in both eyes 8 months ago, in her 1st post op day, she had both eyes dislocated flaps and epithelial ingrowth after that.

However, the bilateral weird lesions were found in addition to the epithelial ingrowth. There is no eye inflamation, no complaints at all, no soreness and even the V/A is 6/5 with prescription. Is this an infections crystalline keratopathy (ICK)?
There is an indolent course and in stereoscopic view, looks like a cyst under the flaps with some cristal like shape material inside.
Please, find the picture from both eyes attached. I look forward to receiving your opinion!
Thank you.
A by Emil Chynn, MD:
i would do this myself:

1. lift up flap very atraumatically
2. scrape very aggressively, both the bed and undersurface of the flap, need a lot of pressure or won’t remove the tissue
3. when you scrape the underside of the flap it helps to put something underneath or the flap will slide around and you will unintentionally debride all the epithelium which would again predispose to epi ingrowth
4. apply alcohol afterwards to kill off the many epi cells you aren’t going to be able to scrape off
5. may need to apply hypotonic saline to swell up the flap as a good scraping takes several minutes, during which time the flap dehydrates, and if that happens too much you’ll get a mismatch between flap and bed, which would again predispose to epi ingrowth. an additional benefit is the hypotonic saline will remove any striae that might be present (which is common)
6. stretch flap out so you don’t have flap/bed size mismatch
7. put in sutures where the epi ingrowth was, don’t tie too tight or will induce a lot of astigmatism, but tight enough that it secures the edge to prevent recurrance, what i like to do is tie them a bit tight to induce a tiny bit of cyl, which then mostly goes away when you later cut the sutures, i usually use interrrupted bc that is a LOT easier than running, but i have seen excellent and possibly more astimatically-neutral running sutures by surgeons who might be more dextrous than myself;)
and, my final plug for my sub-sub-specialty:
EPITHELIAL INGROWTH IS IMPOSSIBLE AFTER LASEK!:)
hope this helps and good luck

Dr. Elghobaier, former fellow

Working with Dr. Chynn as a refractive fellow at PAL is a great experience I will never forget. It’s very hard to summarise all what I gained in such few words. At PAL all staff are multifunction, well trained and continuously educated. Any mistake is analysed in front of all so nothing there is kept for chance.

As a doctor I learned a lot of paramedical and nonmedical stuff such as marketing, administration, dealing with hightech software and hardware and doing simple maintainance of medical machines. One will never find all of this at any other private practice. So I think PAL is the best center to learn any fellow how to manage a private practice in USA particularly Dr. Chynn has no work secrets in front of his fellows and every thing is a subject of extended discussion.
Away from working hours, Dr. Chynn is not that kind of stiff managers but he is a very nice guy. He is a real New Yorker ? He told me about many things in the big city. I still remember our walking from his home to the practice with his nice dog Rhett :) we made ice balls and used high trees as targets :) He won by the way ?

Dr. Mohamed Gamal Elghobaier, medical director of  Oyoun Masr Center for Refractive and ophthalmic surgeries, Sohag, Egypt

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