Want the rapid visual rehabilitation and wound healing results of LASIK but wary of its flap related complications? 

Logically, an ideal scenario would be a no flap LASIK procedure that provides all the benefits of LASIK without the complications brought on by needing to cut a corneal flap.

What if I were to tell you that there are eye laser surgeries out there that produces similar results as LASIK, without the need to cut flaps?

Benefits and Risks of LASIK

According to Market Scope, an industry market analysis company, LASIK is the most commonly performed vision correction procedure in the United States, with over one million procedures done annually.

No flap LASIK

LASIK is popular because patients tend to experience improved vision within 24 hours of the procedure, and most people report being able to go back to work and their daily activities the very next day.

In addition, as compared to other earlier forms of laser eye surgery, LASIK patients generally report faster wound healing and comparatively less discomfort and pain.

A 2008 review paper explored patients’ satisfaction after primary LASIK procedures performed between the year 1995 to 2003 found an overall satisfaction rate of 95.4%.

However, a high overall satisfaction rate does not mean that patients do not experience intra and post operative related complications.

The application of laser to reshape the cornea to improve focusing power of the eye can also bring about a whole boatload of complications.

There are risks and possible complications involved in all refractive surgery procedures.

Most refractive surgery procedures share a common list of possible complications such as irritation and discomfort.

What sets LASIK apart from many other refractive surgery techniques is the creation of a corneal flap to act as a natural bandage after the cornea have been reshaped.

As a result of having to cut the cornea to form a flap in LASIK, LASIK patients are exposed to the risks of intraoperative and postoperative flap related complications.

Why LASIK Flap Complication Are Troublesome

According to Schallhorn and colleagues (2005), intraoperative complications include free flaps, thin flaps, incomplete faps, flap buttonholes, flap decentration and epithelial defects.

I don’t plan to go into detail with the specifics of each flap complication because it is beyond the scope of this post. What matters is that all these flap related complications can delay the healing process as well as  decrease the effectiveness of visual correction.

The American Academy of Ophthalmology listed flap folds and dislocations, as well as affected corneal sensation and dry eyes as part of postoperative flap related complications.

Nettune and Pflugfelder (2010) reported that dry eyes and irritation are the common early and postoperative complaints.

Dry eyes syndrome has been linked to the thickness of flap, location and length of hinge.

A hinge is the part of the flap that is left uncut and remains connected to the rest of the cornea surface. Just like the hinge that holds our doors to the walls.

Flap related complications usually results in increased post operative discomfort as well as the need for retreatment.

This can be time and financially consuming, not to mention emotionally disturbing.

Afterall, your confidence level in the procedure, as well as skill of surgeon, will inevitably be dampened by the flap complication.

Alternatives to LASIK

There are other safe and viable alternatives to LASIK, also known as surface ablations (vaporization).

In simple terms, it just means that the surface of the cornea is removed before laser is applied to reshape the cornea. 


According to the Flaum Eye Institute, PRK (Photorefractive Keratectomy) is one such procedure that requires no flap of tissue to be created prior to the reshaping of the cornea to correct vision.

PRK was the first laser refractive surgery approved by FDA to be used in the United States.

In fact, it was based on the theory behind PRK that many other forms of laser refractive surgeries such as LASIK, LASEK, Epi-LASIK, etc. were developed.

PRK utilizes the fact that the surface of the cornea (epithelium) is able to regenerate, and thus employ the technique of removing the epithelium instead of cutting a flap, to get to the eye tissue below for reshaping.

However, one of the drawbacks of PRK is that because the epithelial cells take time to heal and regenerate (about seven to ten days), you may experience more pain and discomfort associated with the healing process, as compared to a LASIK patient.

A PRK patient typically also needs a longer recovery period as compared to if you received LASIK treatment.

These issues of downtime and discomfort may be important consideration factors for a person exploring laser refractive surgery options.

You can find out more about the differences between LASIK and PRK here.

So what about other types of laser refractive surgery procedures?


LASEK (Laser-assisted in situ epithelial keratomileusis)  is a modified variation of PRK.

Kellogg Eye Centre explains that LASEK involves the detachment of a very thin layer of the corneal epithelium to create a flap that is moistened with a diluted alcohol solution and folded back. 

A research paper that compared LASEK with LASIK for correction of low myopia stated one of the benefits of LASEK is the absence of flap-related complications associated with LASIK. 

However, it also noted that LASEK has slower visual recovery and higher postoperative discomfort than LASIK.


The Department of Ophthalmology & Visual Sciences of Washington University stated that similar to PRK, the surface of the cornea is prepared by using a blunt separator (epikeratome) to make a superficial flap in Epi-LASIK.

The flap is then either removed or moved aside to be repositioned later after the laser is used to reshape the cornea.

It was noted that like PRK, Epi-LASIK can be painful and require more postoperative pain medication. The recovery period may also take longer than LASIK. 

No Flap LASIK?

It would seem that none of the no flap laser refractive surgery procedures mentioned thus far have managed to resolve the issue of increased discomfort experienced postoperatively, as compared to LASIK.

Is there really no No Flap LASIK procedure out that that can be more comfortable postoperatively than LASIK?

Well, the beauty of time is that with time, companies that design and manufacture laser vision correction technology are able to improve on their technology that can support potential breakthroughs in procedures. 

ReLEX SMILE or Refractive Lenticule Extraction

One of the breakthrough in laser vision correction technology in the past ten years is the development of a new procedure called ReLEX SMILE or Refractive Lenticule Extraction. 

Professor Dan Reinstein, a pioneer in vision correction surgery, says “Ever since femtosecond (infrared) lasers were first introduced into refractive surgery, the ultimate goal has been to do flapless laser eye surgery - keyhole surgery.”

The ReLEX SMILE procedure utilizes a keyhole incision on the surface of the cornea to remove tissue to reshape the cornea to correct vision with a femtosecond laser.

Dr. Farooq Ashraf of The Atlanta Vision Institute has this to say about the procedure.

“SMILE… is PRK without the pain and LASIK without cutting of a flap… It has the potential of being a safer procedure than LASIK and offers less discomfort than PRK or LASIK.”

In terms of logistics, the procedure should take about ten minutes with minimal recovery time, and most people are able to resume daily activities the day after the surgery.

The company that designed the technology to support SMILE, VisuMax Femtosecond Laser, received approval from the US FDA in early September 2016 to use the procedure for myopia treatment.

SMILE is suitable for people with moderate or high myopia.

According to Singapore National Eye Centre Laser Vision Centre, the procedure is relatively painless and fast. In addition, it is also laser odorless and silent.

As the technology is fairly new and not as widely available, ReLEX SMILE is generally more expensive than LASIK. However, it is gaining in popularity as more clinical data supports the efficacy of the procedure.

As always, check with your surgeon regarding your suitability for any form of laser refractive surgery to find the procedure that best suit your condition and needs.

Have you tried ReLEX SMILE yet? If you have, what was your experience like?

Related Readings:

› No Flax LASIK

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