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Digital Supplement | Sponsored By ZEISS

Don’t Forget About the Flap

The VisuMax femtosecond laser is much more than a tool for SMILE.

Right now in refractive surgery, there is much excitement surrounding new surgical procedures, and for good reason. The addition of novel techniques like small incision lenticule extraction (SMILE) to our armamentarium not only create excitement about refractive surgery in general, but give us a better opportunity to treat a wider range of patients more effectively.

Truth told, one reason that Vold Vision decided to purchase the VisuMax femtosecond laser (ZEISS) in August 2016 was so that we could perform SMILE. But what I quickly realized is that the VisuMax is much more than a tool for that procedure. It is the most gentle, kind, and precise laser that I have ever used, and herein I explain why it has been so valuable to my practice.


There are several things that set the VisuMax femtosecond laser apart from other platforms.

No. 1: It is a great flap maker. For starters, of all the other femtosecond laser platforms I have used to make LASIK flaps, nothing compares to the VisuMax. On average, I can create a flap in about 18 seconds, and the design of these flaps has been instrumental in achieving superb postoperative outcomes. I cannot think of a single patient in who we did not have a superb LASIK outcome with the VisuMax.

Generally speaking, I use a flap diameter between 8.2 to 8.5 mm, but the VisuMax is also capable of creating much larger flaps, such as those required in treatments for hyperopia and astigmatism. In my experience, the accuracy of the VisuMax as a flap creator has been unbelievable.

No. 2: It is gentle. The patient interface of the VisuMax applanates on the cornea, not on the sclera like other laser platforms. For the patient, this creates a much gentler experience. For the surgeon, this means that IOP is not elevated nearly as much as it can be with other lasers.

No. 3: It has given us the confidence to perform more LASIK procedures. I am grateful to have the VisuMax femtosecond laser, as it has helped us to change our standard of care. Prior to owning this platform, we probably only performed LASIK in 50% of cases and PRK in the other 50%. But now, with the VisuMax, we perform LASIK in well over 90% of cases simply because we have so much confidence in the laser.

No. 4: Our refractive surgical volume is growing. For the first time in our practice's history, we are now performing more than 100 refractive surgeries per month. In comparison, in years past, it was typical for us to perform between 30 and 50 refractive surgeries per month. When you think about it, as a glaucoma and anterior segment surgeon, 100-plus refractive surgeries per month is a pretty crazy number. Honestly, it will not shock me if we end up eventually doing more than 150 to 200 eyes per month with the VisuMax.

No. 5: There is greater potential to perform other procedures. I have also used the VisuMax in conjunction with corneal inlay implantation (Figure 1), specifically the Raindrop (ReVision Optics). We just started performing this procedure in Spring 2017, and we have been rolling it out carefully. Our numbers are not huge at this time, but eventually I see our inlay volume growing. I don’t think I would be as confident with this procedure had it not been for the VisuMax.

Figure 1. Dr. Vold creates a corneal pocket with the VisuMax femtosecond laser and implants the Raindrop inlay.

No. 6: SMILE is an attractive procedure. At Vold Vision, we have also been performing SMILE since Spring 2017 (Figure 2), and it has been a powerful experience. What initially attracted me to the procedure was its safety, especially in that it causes potentially less symptoms of dry eye than LASIK. Second, I like that it achieves LASIK-like results.

Figure 2. Dr. Vold performs SMILE with the VisuMax.


At this time, we are cautiously rolling SMILE out to our patients; however, we expect our use of the procedure to increase once indications for astigmatism and hyperopia are approved in the United States. In our experience, patients love that SMILE is performed with only one laser instead of two like with LASIK. Further, we like that it is a very efficient and accurate procedure and is intuitive to perform.

In very active patients—those who play sports or who have physicially demanding jobs, like police officers for instance—it often makes more sense to perform SMILE because there is no risk of flap-related complications and because there is a reduced risk for dry eye disease postoperatively. These are the patients we have targeted in our early experience with SMILE, but as I mentioned previously we do envision performing the procedure more often once there are wider indications for its use. In short, we have found an added layer of safety and comfort with SMILE compared to LASIK, and we envisionn our use of the procedure growing.


The VisuMax femtosecond laser is the finest laser that I have used in my career, hands down. In our clinical practice, having the VisuMax has helped us to go from performing LASIK in 50% of cases to more than 90% of cases, and the vast majority of our patients—70% or more—are 20/20 uncorrected on postoperative day 1.

I am convinced that the reason for our recent successes is that the VisuMax is an excellent tool for flap creation. It has given us the confidence that we need to perform more LASIK procedures and the tool that we need to grow our overall refractive surgery volume. The VisuMax is much more than a tool for SMILE, it is a tool for success with refractive surgery procedures of all types.

Steven D. Vold, MD
Steven D. Vold, MD
  • Vold Vision, Fayetteville, Arkansas
  • svold@voldvision.com
  • Financial disclosure: Consultant (Carl Zeiss Meditec)