From: Emil Chynn

July 4, 2015 at 2:22 AM

dear keranet pals

i have recently been graciously invited (by dick and billy) to submit a talk to speak at hawaiin
eye and the ASA congress in utah in 2016, and wanted to ask if some of you out there have
good experience treating extreme myopes (eg -10 to -20) with ASA or PRK
i believe some of you have said yes, several in south america where one would think the risk
of scarring (the major complication of extreme ablations besides KC) would be higher bc of
high UV exposure
i am taking billy's sage advice that pooled results are always more convincing that that of 1
surgeon, as it shows reproducibility at different centers by different surgeons
please reply to me directly, or if you prefer, through knet, if you have similar good results on
extreme ablations, and whether or not you would be interested in pooling data for presentation
and/or submission as a paper
attached are 2 presentations that 2 of my fellows did recently about this topic
thanks!
yours
----------------------------------------------------------------------------------------------*Emil William Chynn, MD, FACS, MBA*

From: Ronal

July 4, 2015 at 3:38 PM

Emil
How much is the lowest final pachimetry you go. On my case with Lasek I choose myself
would not go below 400 micras
Ronal Perino
Brazil
From: Emil Chynn

July 4, 2015 at 4:41 PM

Ronal
I used to have a lower limit of 350
Then studies showed a LASIK flap contributes 0 to the structural integrity of the cornea bc it's
cut 300 degrees and is only stuck on loosely by proteoglycans or whatever. Like a hat sitting
on your head

In LASIK almost everyone uses 250 right?

So wouldn't it be OK to go down to 250 on an ASA??
The logic seems reasonable. And I know of some doctors who now follow this logic
However I've not been so brave yet. But about 4 years ago I went down from 350 to 300 with 0
cases of ectasia yet??
I also have an upper minimum of 475 because the 1 pt I gave KC to 15 yrs ago would up w
350 after LASIK (was still cutting flaps back then) but in retrospect had an initial patchy of 470.
We really didn't identify initial pachy as an independent risk factor parameter back then
Of course this assumes all orbscan and/or Pentacam patterns and other indices are normal,
including Stulting/Randleman and the patient manifests to 20/20, etc
Interested to see if others find this logic also reasonable
Contact me privately w your extreme cases. Another MD already has. We would each be
authors, and each contribute cases and help write up the paper??
Thanks and too bad the U.S. men's soccer team isn't as good as our women's (or the Brazilian
women's team isn't as good as your men's, right?);)
--From: William Trattler

July 4, 2015 at 4:51 PM

Emil,
One of the challenges on your 470 microkeratome case - is that microkeratomes often went
deeper than what they were labelled - and most doctors did not measure the stromal bed prior
to the initiation of the excimer laser on the bed. So - with a preop thin cornea and a metal
microkeratome - the risk may be more likely to be related to a deeper than expected flap
rather than the cornea itself being thin. I am aware of some cases where two patients
underwent LASIK on the same day by the same surgeon with the same microkeratome - and
despite both have a preop corneal thickness above 500 microns - both patients developed
ectasia. Do you still have the topos of your patient who experienced ectasia? Did you measure
the stromal bed prior to performing the excimer ablation? Which microkeratome were you
using back then?
best regards
Bill
From: William Trattler <wtrattler@gmail.com>
Emil
Corneal thickness and corneal strength are not directly related
When you perform corneal crosslinking on a patient - the cornea becomes stronger. Does it
become thicker or thinner?

When a patient ages - the cornea becomes stronger. Does the cornea become thicker or
thinner with age
If you can answer these questions - it becomes obvious that looking at a patients corneal
thickness as a pseudo-measurement of an eyes corneal strength does not hold water.
What matters is the strength of the cornea preop
The only method we have to accurately determine a patient's preop strength is corneal
mapping (topography and tomography). Preop corneal thickness is not an independent factor
if the corneal shape is normal in both eyes
So yes - my answer is: a patient with a 440 corneal thickness and bilateral normal topography
is not at increased risk for ectasia with PRK.
Bill
PS: In your case of ectasia in a thin cornea - would you be able to share the preop
topography. Most of the time, in retrospect, there are some risk factors visible on the
topography. As well, you are speaking of averages. Dan Reinstein has two papers showing
that the standard deviation of flap thickness with various microkeratomes is quite wide,
regardless of which eye. So yes - one of the eyes could have had a deeper than expected
flap.
From: Emil Chynn
July 4, 2015 at 7:32 PM
Billy
I did consider those factors
I doubt it was a deeper accidental cut as initial pachy was lower in the affected eye. Plus the
affected eye was the second left eye not the first right eye
As you're probably aware many studies including the pioneering one by Kerry Solomon
demonstrated thicker flaps in first right eyes bc the blade is new and sharper than in second
eyes (brief article appended below)
So it's unlikely that the ectasia was caused by a thicker flap being cut
Are you actually suggesting that you don't agree patients with an abnormally thin cornea have
an abnormal cornea?
For example:
A patient has initial pachys of 440. Topos look normal in every way and all other indices are
normal. Rx is -3 so you calculate you'd be left with 400 microns of RSB after ablation
You'd actually PRK this person??
Abstract PURPOSE: To determine the flap thickness accuracy of 6 microkeratome models and
determine factors that might affect flap thickness.SETTING: Magill Research Center for Vision
Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South
Carolina, USA.METHODS: This multicenter prospective study involved 18 surgeons. Six
microkeratomes were evaluated: AMO Amadeus, Bausch & Lomb Hansatome, Moria
Carriazo-Barraquer, Moria M2, Nidek MK2000, and Alcon Summit Krumeich-Barraquer. Eyes
of 1061 consecutive patients who had laser in situ keratomileusis were included. Age, sex,
surgical order (first or second cut), keratometry (flattest, steepest, and mean), white-to-white
measurement, laser used, plate thickness, head serial number, blade lot number, and
occurrence of epithelial defects were recorded. Intraoperative pachymetry was obtained just

before the microkeratome was placed on the eye. Residual bed pachymetry was measured
after the microkeratome cut had been created and the flap lifted. The estimated flap thickness
was determined by subtraction (ie, mean preoperative pachymetry measurement minus mean
residual bed pachymetry).RESULTS: A total of 1634 eyes were reviewed. Sex distribution was
54.3% women and 45.7% men, and the mean age was 39.4 years +/- 10.6 (SD). In addition,
54.5% of the procedures were in first eyes and 45.5%, in second eyes. The mean
preoperative pachymetry measurement was 547 +/- 34 microm. The mean keratometry was
43.6 +/- 1.6 diopters (D) in the flattest axis and 44.6 +/-1.5 D in the steepest axis. The mean
white-to-white measurement was 11.7 +/- 0.4 mm. The mean flap thickness created by the
devices varied between head designs, and microkeratome heads had significant differences
(P<.05). Factors that explained 78.4% of the variability included microkeratome model, plate
thickness, mean preoperative pachymetry, Kmin, surgery order, head serial number, blade lot
number, and surgeon. Factors such as age, sex, Kmax, Kaverage, white to white, and laser
had no significant correlation to flap thickness.CONCLUSIONS: The results demonstrated
variability between the 6 microkeratome models. Device labeling did not necessarily represent
the mean flap thickness obtained, nor was it uniform or consistent. Thinner corneas were
associated with thinner flaps and thicker corneas with thicker flaps. In addition, first cuts were
generally associated with thicker flaps when compared to second cuts in bilateral procedures.
From: David Glasser <dbg@comcast.net>
Good points, Bill. I agree that corneal thickness alone is not a reliable proxy for cornea
strength, even though thin corneas raise red flags for increased risk of ectasia.
Can you elaborate on your comment that topography and tomography are accurate indicators
of corneal strength? They may produce more reliable red flags than thickness alone. But
other than revealing abnormalities that occur as a result of corneal weakness, how do they
actually determine corneal strength? Is this something that hysteresis is supposed to tell us?
David Glasser
From: Emil Chynn <safesightsurgeon@gmail.com> wrote:
Billy
It's illogical as David says for you to first state that thickness is not related to strength. And
then in the next sentence to say pachy is a measure of strength
It's also illogical in the first place for you to say that thickness isn't related to strength
More logical and accurate would be to say something like:
"Obviously, within any individual, corneal thickness and strength are strongly related. If you
remove x tissue, you are by definition reducing strength by y. This is intuitively obvious from a
mechanical/structural engineering/materials science POV
Unfortunately surgeons now don't have a good direct measure of corneal strength or rigidity
that's available to them in clinical practice. So we have to rely on indirect measures, such as
pachymetry and other pachymetric indices to assess risk of postop ectasia preoperatively"
But to state as you do that "Corneal thickness and corneal strength are not directly related" is
both misleading and incorrect

Certainly if you compact most materials to make them denser, without interfering with their
internal organization if any, that material as a rule usually gets stronger. This should also be
intuitive from a mechanical/structural engineering/materials science POV, and is the main
basis of why high strength concrete for skyscrapers can bear loads 10x higher than a package
of Sakrete found in Home Depot (it contains less water, so the sand and silica particles wind
up more dense; there is an interesting article in this month's Popular Science for those who
are interested). CXL is analogous to providing more rebar in concrete, which then compacts
and thus strengthens the cornea
Simply put, ectasia after laser probably occurs for one of the following factors:
1. Person was going to get KC anyway in time because of predisposing factors (failure to
properly Dx FFKC)
2. Too much normal cornea was violated
3. A normal amount of cornea was violated in an eye with abnormal cornea to begin with (my
contention in my KC case involving thin initial and thick final pachy)
Of course, some cases can involve more than one of these factors (eg too much tissue
removed in a cornea that was also initially abnormal)
I think this is a more accurate way to summarize current understanding, no? (verbal tic
acquired from my European girlfriend;))
Yours
Emil
From: William Trattler <wtrattler@gmail.com>
Emil - my comments were regarding preop corneal thickness as a measure of corneal
strength. That was the topic of the conversation.
I agree that thinning any cornea with PRK/Lasik will weaken the cornea
Bill
William Trattler, MD
From: Emil Chynn July 4, 2015 at 3:23 PM
Here then is a question for you Billy, and a poll for everyone else:
Would you agree with the following statement:
All things being equal (ie in a given patient) a surface ablation (PRK or ASA) is always safer
than a LASIK in terms of remaining corneal structural integrity/strength and thus risk of postop
iatrogenic ectasia?
If so, I don't think we've done a very good job of properly conveying this to the general public. .
From: David Glasser <dbg@comcast.net>Jul 4, 2015, at 3:42 PM
The problem with phrasing the question this way is that it asks us to apply population-based
data (risk of ectasia associated with RSB) to an individual patient (in a given patient").

If one believed that thicker corneas have a lower risk of ectasia, independent of any other
factors and in the absence of any other data, then one would likely conclude that over a large
number of patients, there would be fewer cases of ectasia in the surface ablation group than in
the LASIK group.
But that's a lot of "ifs" that we don't have to live with, and it doesn't predict what would happen
in a single "given" patient.
David Glasser
From: Emil Chynn <safesightsurgeon@gmail.com> Jul 4, 2015, at 4:36 PM
David
But we always have to apply population-level analyzes to individuals when assessing risk:
1. Isn't it almost always safer for an individual to wear a seatbelt than not?
2. Wouldn't your risk of cardiovascular disease almost always be somewhat lower if you were
a vegan than if you ate red meat?
3. Wouldn't your risk of skin cancer be lower if you never went outside on sunny days between
the hours of 11 AM - 3 PM?
4. Isn't the risk of iatrogenic Ectasia always slightly less in a given patient if we perform a
surface ablation rather than cutting a flap??
Awaiting your vote??
Emil William Chynn, MD, FACS, MBA
From: Steven Safran July 4, 2015 at 4:42 PM
It's not just ectasia.......there are many other risks you avoid when you do surface ablation
instead of cutting a flap. I got tired of dealing with flap issues personally.
Steve

From: David Glasser <dbg@comcast.net> Jul 4, 2015, at 10:53 PM

I agree, Steve. Surface ablation is safer for a number of reasons, including lower risk of
ectasia.
I still think Emil phrased his question incorrectly.
David Glasser

From: William Trattler <wtrattler@gmail.com> Jul 4, 2015, at 6:55 PM

David - I am a huge fan of surface ablation. But comparing LASIK with a femto flap to surface
ablation leads to a similar risk for loss of BCVA. For example - there is a much higher rate of
infection with surface ablation (5-10 times higher). As well, patients can experience severe
delays in epithelial healing. We have also seen many patients lose vision from haze and
delays in healing due to meds - including nevanac a number of years ago - to other thicker
drops that accumulate under the contact lens.
In regard to ectasia - the risk is less than 1 in 3000 eith LASIK when carefully screening for
normal topography (data presented by steve Schallhorn). As well, most patients who develop
ectasia can be treated successfully with CXL.
So while I am a big fan of surface ablation, the risks for vision threatening complications are
relatively similar.
Bill
William Trattler, MD
Center For Excellence In Eye Care

From: Emil Chynn July 04, 2015 9:22 PM

Billy
Your numbers don't add up that LASIK is as safe as ASA
Every complication is lower or vastly lower in ASA vs LASIK except haze, which can almost
always be prevented with MMC, oral steroids, Vit C, and UV protection
Delayed epithelialization in itself isn't a complication unless it leads to haze or infection
What's your basis for saying ASA has a 5-10x higher risk of infection vs LASIK? While I'm
willing to concede that risk is higher, I'd say it's only about 2x higher, based on my own series
(infection every 4,000 LASIKs vs every 2,000 ASAs). Plus a surface infection is much easier to
culture and diagnose and eradicate than an interface infection. That should also be factored in
Here's another thought experiment (which I know some of you love so much):
If we worked on promoting faster epithelialization, so you could replace the epi after ASA and
it'd be perfectly viable and totally grown back normally after only 2 days each and every time
Wouldn't all of us abandon LASIK?

If that's true, doesn't that prove that ASA is indeed safer?

From: Nancy A. Tanchel <ntanchel1@verizon.net> Jul 4, 2015, at 9:55 PM

Emil,
I know you've committed your entire strategy to PRK, or ASA - the term you prefer; so you do
not want to concede that current LASIK techniques are wonderful for patients.
Thin flap femto-LASIK is equally safe for patients, with flaps of 90 - 110 on all patients.
Although we don't currently have population data to prove it, I suspect that the risk of ectasia
with our current techniques is equal for both modern procedures. Most ectasia is probably
associated with pre-existing corneal weakness, which would be exacerbated by either
procedure. Billy has already listed the higher risks associated with PRK - which I agree is an
excellent procedure, but infection is significantly more likely with PRK than LASIK. In my
experience of performing over 25,000 LASIK procedures, none has developed infection.
However, out of 3000+ PRK procedures, I have seen two cases of infection.
However, for the patient, modern LASIK is infinitely easier with exceedingly rapid recovery,
minimal discomfort, as well as ease of enhancement, if needed. However, for those who are
at higher risk for eye trauma, PRK is a better alternative.
Delayed epithelialization IS a complication for the patient who can't return to work and enjoy
life for an extended period of time.
In this case, your conclusion is flawed. Both procedures are great and each has pros and
cons - neither is better, it just depends upon the needs of the individual patient.
Happy 4th to our USA colleagues!
Nancy
Nancy A. Tanchel, M.D.

From: Emil Chynn July 05, 2015 12:05 AM

Nancy
I never said lasik isn't "wonderful." Didn't I mention I was one of the first eye MDs in the USA
to get lasik myself?;)
I said ASA is safer than lasik on a statistical basis

A complication is something that has a reasonably high probability to cause permanent visual
disability. Delayed epithelialization doesn't meet that criterion. Neither do over and
undercorrections for that matter, which is why many surgeons don't think of them as true
complications
Please don't confuse ASA with PRK. ASA is associated with significantly less pain and risk of
scarring. An alcohol-assisted PRK is a LASEK which with epiLASEK comprise ASA. Not using
alcohol and manually scraping off epithelium is an old-fashioned PRK which I feel has no
place in 2015
From: Nancy A. Tanchel <ntanchel1@verizon.net> Jul 5, 2015, at 1:25 PM
Emil,
SBK, the current form of LASIK is just as safe as ASA, statistically speaking - why do you think
it's not? The difference is that patients are happier with the fast recovery and return to
normalcy after SBK.
A complication is not just a problem causing permanent visual disability for an elective
procedure, so you can't just define the term yourself. Delayed epi healing is a serious issue
for the particular patient, when it happens. Any haze that forms will disappear over time, but
anything that delays recovery for an elective procedure is a serious problem.
The higher risk of infection is the biggest risk for ASA; it is much less likely with SBK, and
infection is a major complication, which is very difficult to handle.
Also, ingestion of systemic meds for ASA pain relief and extended use of drops are issues
which make ASA less attractive for most patients.
So, the bottom line is that ASA is not safer than SBK. There is a place for both procedures but given the choice, most patients prefer SBK, if that option is available to them.
Nancy
Nancy A. Tanchel, M.D.

From Emil Chynn Sunday, July 05, 2015 3:39 PM

Nancy
SBK still has many possible complications you can't get w ASA. It's also weakening the cornea
more than ASA which increases the risk of Ectasia more

Ergo ASA is still (slightly) safer than SBK. Especially if you do all the things Steve suggested
to prevent delayed healing/haze/infection

From: Nancy A. Tanchel <ntanchel1@verizon.net> Jul 5, 2015, at 3:56 PM

Disagree - what are the possible complications?
Also, what is your proof that the cornea is weakened more than ASA? With only a difference
of 40 - 50um of stroma, is there an appreciable difference in weakening?
What about the infection risk?
No "ergo" here ...
Nancy A. Tanchel, M.D.

From: Emil Chynn Sunday, July 05, 2015 8:53 PM

Pls read my earlier longer post on why the cornea must necessarily be stronger after ASA than
after LASIK
It was yesterday around 1pm in response to something Billy said
From: Nancy A. Tanchel <ntanchel1@verizon.net> Jul 5, 2015, at 9:12 PM
Your post did not address why SBK would lead to a weaker cornea than ASA; so again, I state
that the safety profile is equal, with NO evidence to the contrary.
Again, I must insist that you are wrong in your conclusion that ASA is safer than SBK.
Perhaps that is true in your experience, however, many of us have come to a different,
reasoned conclusion. As Bill stated, you create fodder for lawsuits with your opinions stated
as fact. PRK, ASA, LASIK, SBK etc. produce safe results for patients in the hands of careful
surgeons. You have chosen, and promote what you think is best for your patients. Many of us
have as much or more experience than you, and get great, safe results with other procedures,
as well as ASA. In fact, one type of procedure is not the best choice for every patient.
Nancy
Nancy A. Tanchel, M.D.
Steven Safran <safran12@comcast.net> Jul 5, 2015, at 9:22 PM

Nancy:
In my comments earlier I discussed the presence of a permanent potential space in the cornea
after Lasik as being a potential problem down the road when the patient has other issues such
as glaucoma, endothelial problems, uveitis etc.
I think corners that have had PRK do not have this problem which is an advantage.
Anyone who has removed the epithelium on a lasik flap knows how much irregularity is being
masked by the epithelium. Those flaps have a lot of wrinkles and striae that Im pretty sure
would cause aberrations and visual problems were it not for epithelial masking and Im not
sure that they dont cause some issues anyway.
I feel that PRK is a safer procedure that avoids many potential flap complications even with
using laser to cut the flaps. I believe it is a safer procedure and if it were my own eyes Id
certainly entertain the notion of PRK but Id not have Lasik. Ive chosen to perform surface
ablation on my staff, family members and now do the bulk of my LVC with it because I do
believe its the better and safer option.
I used to do almost all Lasik but over time got tired of flap related problems which invariably
occur. I also do believe that the risk of ectasia is lower with ASA than Lasik no matter how thin
you slice it. No epi ingrowth, no striae, no DLK no flap dislocations with trauma , no fluid in the
interface with high IOP, etc. Ive had a very smooth and easy go of it with PRK.no real
complications in years so Im quite comfortable with it but I dont have a large refractive
practice and if I did I might find myself doing more Lasik.
I dont think Lasik is a bad procedure.I just believe ASA is a safer and better one. Not by
much but by enough to be preferable. Thats my personal belief so its what I do.
Steve
From Jeffrey <jgold2@comcast.net> Jul 5, 2015, at 9:27 PM:
Just the facts that the flap NEVER completely heals and that I have had to deal with 4
traumatic flap dislocations over the past 20 years is enough for me to have completely
abandoned LASIK about 5 yrs ago after over 10000 cases
Jeffrey D. Gold, MD

From: Emil Chynn July 06, 2015 10:49 AM

Yes we've all seen flaps dislocated by minor trauma after years

I had a patient who had LASIK 5 years prior get poked in the eye with a friend's finger while
rebounding in a pickup basketball game. He came in without a flap. It had gotten torn
completely off
I carefully cut off the tiny irregular fringe of cornea that was left, like a 1 mm wide arc that was
where his flap should have been. Let him heal up. He wound up with 20/60 vision
He actually asked me "if I had had a PRK, could this have happened?"
What am I going to do? Lie to him?
I told him the story of my secretary, Missy, whom I did a LASEK on years earlier. 5 years after
her procedure, she got mugged
Missy lives in the Bronx. This was 10 years ago. In the Bronx, they don't "ask" you for $ when
they mug you. They attack you first, then take your money
Missy got savaged with brass knuckles to her eye. Never lost any vision. Only had subconj
heme. Surely it was safer for her that she had a surface ablation
Anyway I told him he was right, it'd be impossible to have any flap-related complication if he
had a surface ablation
I'm not going to spend more hours here defending my math. Here's the facts: If you do a
LASIK approximately 90% of all possible complications are in some way flap-associated.
Therefore impossible w ASA
With proper use of MMC you can reduce the risk of haze in an ASA down to nearly zero, and
with proper pre and post regime, the incidence of delayed epi n subsequent infection also
down to almost zero
Therefore ASA must be safer than LASIK. As Steve correctly says, only slightly. But still safer.
This is why most Special Forces military groups throughout the world only allow for surface
ablations, not LASIK
I never said that LASIK is a bad or unsafe procedure. It's obviously a great procedure. But we
are not even decreasing the new candidate pool with all our efforts. With financing refractive
surgery is the same cost as contacts in the short term, and cheaper in the long term.
Therefore it's safety not cost that's holding patients back
By not admitting that surface ablations are marginally safer than incisional surgery, we as a
group are being disingenuous with the patients, who are smart and do perceive this, either on
a conscious or unconscious level, and this in the long run does a disservice to the growth of
refractive surgery

I tell my patients "to be honest, ASA takes longer to recover and is slightly more uncomfortable
than LASIK, but is slightly safer, both intraop as well as days, weeks, months, and even years
later"
This is a true statement
It'd be nice if LASIK surgeons said something like "LASIK is extraordinarily safe, so safe it's
actually safer than long term contact lens wear. Surface ablation is slightly safer, but recovery
is substantially longer, and you might have some pain. Therefore it's perfectly reasonable for
you to choose LASIK for its quicker recovery--as most of my patients do, and most patients
around the world do, where 90% are having LASIK, and only 10% are getting a PRK or ASA."
By saying a true statement like that you'd actually decrease the risk of getting sued, and by
having a paragraph like that in your consent it'd be easier defending any suit, as it would then
be more legally sound that you properly told them about their alternatives, and so then if they
had a bad flap cut, for example, it'd be much more difficult for them to claim they weren't
properly consented, and if they had been, they'd have made a better different choice
So, in my humble opinion, more admission by the LASIK camp would actually be a triple win
for the patients, LASIK surgeons, and ASA surgeons
Full disclosure: I've done expert review on 100 cases over the past 20 years, for both sides, so
I do know what I'm talking about

From: Nancy A. Tanchel <ntanchel1@verizon.net> Jul 6, 2015, at 8:08 PM

OMG - Emil, you do us all a disservice with your "safety" comments.
These are your opinions and not based on facts - these opinions are what you use to market
your practice and to differentiate your practice in a crowded NYC marketplace.
Actually, refractive surgery only became very popular after the availability of LASIK. PRK was
unpleasant for patients and the long recovery time was not an option for many people, who
could not take time-out from work and life.
It is comments like yours regarding LASIK that scare people and continue to raise the safety
issue in the mind of the public.
Furthermore, you have a poor understanding of the legal system - recommending some
nonsense be added to the consent stating that surface treatment is safer than LASIK is not a
way to decrease the chance of a lawsuit. If that were the case, you should add language to
your consent form stating that the risk of infection is at least double for ASA, vs LASIK, "so
patients can make an informed and better choice!"

You should measure your words more carefully, so as not to provide fodder for ambulance
chasers, when those words are only based on your opinion.
Both procedures are EQUALLY safe, with different types of risk - those are the facts.

From: Emil Chynn <safesightsurgeon@gmail.com> Jul 6, 2015, at 8:53 PM

Nancy
We all know the reason lasik is more popular is faster painless recovery. All surface surgeons
freely admit that
Why cant lasik surgeons admit it's slightly more risky?
And you have zero understanding how malpractice cases develop. Certainly not by comments
posted on a restricted usergroup
I said I've reviewed nearly 100 medical malpractice cases as expert review for both sides
Do you have similar expertise and if so what is it?

From: Rowsey, MD, John <jrowsey@verizon.net> Jul 7, 2015 at 6:43 AM

Dear Kera A team,
I thought that ectasia was related to the Stress/Strain relationships of thin walled spheres (550
micron cornea is under 10% of 8 mm radius sphere, if the cornea is a sphere, the definition of
thin walled):
Stress = Pressure x Radius
2 x thickness
So if the pressure remains the same in an eye and the thickness of the wall decreases, the
stress on the wall of the globe increases, the radius decreases further to accommodate the
stress/strain relationship. That is why a descemetocele, although thinner than the remainder
of the cornea bulges out until the stress of the smaller radius of curvature of the
descemetocele is equal to the rest of the globe, or it perforates. Share with me your insights.
Jim Rowsey, MD
From: Daniel Dawson 09 July 2015 19:52
John and Emil,

Here is my work on this topic (see attached). According to my calculations, before accounting
for the ablation depth (and its associated additional loss of cohensive strength of cornea), SBK
(~110 um flap) results in an average loss of 21% of the cohesive tensile strength of the cornea
and conventional LASIK (~160 um flap) results in an average loss of 33% of the cohesive
tensile strength of the cornea; ASA result in none since it does not disturb the corneal stroma
or Bowman's layer until the actual ablation.
-Dan Dawson
From: Clive Novis <clivenovis@mweb.co.za> Jul 9, 2015 at 6:02 PM
Wow! You can rest your case now Emil!!! J :)
Clive Novis, Ophthalmologist, South Africa
From: Emil Chynn <safesightsurgeon@gmail.com> 10/07/2015, at 00:54
ha ha clive
yes, i can rest my case now, but can no longer email the group since m n m unilaterally and
unfairly banned me fr knet
apparently, they think that it's ok for jim abrahms to attack me, and goran to say i'm unethical
and not ok for me to defend myself
now that's fair, right?!?:(

From: Ronal <ronal.perino@gmail.com> July 9, 2015 at 5:18:23 PM PDT

Emil
Please continue, we need your insights a lot
There are many silent fellows that like you
Ronal Perino MD
BRAZIL

From: Mark Mannis <mjmannis@ucdavis.edu> Jul 10, 2015, at 12:18 AM

Emil:
You astound me. No one has unilaterally and unfairly banned [you] from knet as you publicly
stated. How could you possibly post such a preposterous statement to our membership? It is
only out of respect for you that I am not calling you on this to the list serve membership. I only
asked that you tone down the rhetoric not that you not express your opinion. This type of
blatant hyperbole is exactly why I wrote you before. Honestly, this issue is taking more of my

time than it is worth. I only ask that you be a good citizen on the list serve. And, if you dont
think you can do that, then perhaps you should step away.
MJM

_________________________________
Mark J. Mannis, MD, FACS
From: Emil Chynn <safesightsurgeon@gmail.com> Jul 9, 2015, at 11:33 PM
Dear Mark
If it's true that I was not "banned" from knet
Then why right after you sent me that (actually polite and reasonable) request to "tone things
down" are my emails to knet suddenly bouncing? I have two bounce email notifications to
forward to you to prove it. You're claiming that's a coincidence?!? That'd be weird, as not once
in the past 2+ years has a single one of my posts bounced
It's really unfair that you play favorites on knet. Why is it ok for Matt Goren to post that I'm an
unethical surgeon? Bet you don't have an email to show me to him asking him to "tone that one
down"
Why is it ok for Jim Abrams to attack me openly with ad hominem attacks about my sig file, and
it's not ok for me to ask him why on his website he claims to be "the best cornea surgeon in
Santa Clara County" or whatever. Do you have an email to him asking him to be "more civil" to
me?
Why do you and Marion the moderators insist that it's better to silence people privately, rather
than post on the forum and openly explain you rationale for ending threads (eg redundant,
uncivil) so members have some guidance of what your standards are. Isn't it better, in general,
to be open and clear and transparent? Is this the Information Age and the internet of 2015, or
do we want to go back to opaque "experts" deciding what does and does not deserve to be
released to the public?
What's wrong with my asking you to ask the forum if anyone else feels "bullied" on your forum?
What's wrong with my pointing out that over 80% of all posts are by the same dozen experts
(myself included)? Why did you write back that you feel "insulted" by this line of questioning?
Would you feel similarly "insulted" (threatened?) or feel I was being "inappropriate" if I were to
post the following analysis on keranet:
Since 2000, women have finally achieved parity with men in terms of the number of graduating
eye surgeons from US residence programs, with female surgeons comprising 50% of the total

graduating pool. Similarly, minorities have made enormous strides being accepted by
prestigious surgical training programs, with something like 25% of graduating eye surgeons
coming from a minority group
Yet, in 2015, based on my analysis, here is the approximate breakdown of posts on this
ListServe, which is closed to the public, closed to even most general ophthalmologists, closely
moderated, and open mostly to "the top corneal transplant and laser vision correction surgeons
in the world" (with some unusually qualified optometrists with specialized expertise thrown in):
80% White men
5% Asian men (mostly me)
5% Hispanic men
5% White women
5% Black men, black women, Asian women, and Hispanic women combined
You call this diversity??
This would make a Confederate Flag rally in South Carolina look like a Benneton Ad!
I wrote to you privately last month, basically pleading with you to open your eyes, and see that
this vaunted forum isn't actually that diverse, and asking you (not me, as I didn't want to usurp
your role as moderator) to poll the group and ask them if they thought having more diverse
opinions would be helpful
You wrote back saying my question was "offensive" or something like that
How is it "offensive" to want to ask how our group of influential "thought leaders" can become
more diverse?
We all know (the public doesn't) that in the U.S. and most of the world ophthalmology is one of
the hardest specialities to get into, harder than cardiology, harder than cardiac surgery, and on
a par with neurosurgery. Therefore, every ophthalmologist by definition graduated towards the
top of his or her medical class. Thus, by definition, the pool of graduating eye surgery residents
isn't exactly representative of middle America
If we can't even replicate the already not-very-balanced composition of graduating
ophthalmologists, aren't we doing something wrong?
What about the aggressive attacks on me, just because I have the temerity to post that there
might be a safer alternative to LASIK?
Have you ever seen any surgeon attack another surgeon on Knet like Matt Goren did to me,
where he misrepresented that I was saying I'd laser pregnant women, and called me unethical,
when all I ever said was that the science saying that pregnancy commonly causes significant

changes in a person's eyeglass or contact lens prescription was weak? I've read all of the
thousands of posts for the past 2 years, and not once have I seen ANYTHING like that
It reminds me nothing more than the people who attack Obama, because they actually hate
him. Sure, it's fine to disagree or even hate his policies. But hate him as a person? You don't
even know him as a person. It's not like he's your next door neighbor who got drunk and ran
over your dog with his car. I love my dog. I'd hate a guy who did that
People who scream "You Lie!" at a State of the Union address are doing so because of a
visceral hate of Obama, because he's black. They'd never slander any President that way if he
were white. They'd have too much respect for the Office of the President to do so
Please be clear. I'm not suggesting I've been attacked for the past year on Knet because I'm
Asian. While I did get beaten up a few times as a kid for being Asian, that was in the 1970s.
I'm suggesting that some other surgeons on Knet have a visceral dislike of me, because like
Obama to some people, I'm a threat--a threat to the status quo
Only in this case, the status quo is "that LASIK is the best, most modern, safest laser vision
correction procedure out there, and this is why it's the most popular"
Untrue. LASIK is NOT the safest procedure. I proved in half a dozen ways that ASA is (slightly)
safer for everyone (they conceded it's much safer for some people)
LASIK is the most popular procedure for one reason, and one reason alone--it's got the fastest,
easiest recovery which not only benefits patients, but makes things a whole lot easier (and
more profitable) for doctors
You asked me to "tone things down"? Can you even BEGIN TO IMAGINE what would happen if
I were to even imply that one reason some doctors prefer LASIK over the safer ASA is they
don't want to deal with 1-3 more postop visits that are unfortunately UNREIMBURSED?
That would be (pardon my French) a TOTAL SHIT SHOW. You'd probably have to pry Matt
Goren and Jim Adams off of me with a 2x4 and some pepper spray
I'm sure you and the other knet users are clear that I have zero financial incentive for spending
hundreds of hours on Knet to post why I feel ASA is objectively safer than LASIK. No patient
will ever come to me for that because knet is a CLOSED forum. I've never had any doctor from
Knet refer a patient to me (because they're mostly LASIK surgeons and many are not even in
the U.S.).
Like you and Marion, I've DONATED HUNDREDS OF HOURS (thousands for you two
collectively) posting on Knet because we have a burning desire to SHARE OUR EXPERTISE

with other prominent surgeons around the world so that our advances can ADVANCE THE
STATE OF MEDICINE to benefit patients AROUND THE WORLD
Because you two collectively seem to read every post (don't know how you can manage to do
that) I know you've read a few kind posts by other prominent surgeons on different continents
thanking me for "helping them convert from PRK to ASA and so helping their patients avoid all
pain". That's incredibly rewarding to me, and what makes devoting my entire life (I'm still single)
to becoming the most recognized LASEK surgeon in the world (admittedly, there's
unfortunately not that much competition) so rewarding
In summary, Mark and Marian, if either of you would like to "ban" me from your closed user
group Knet, that's totally your decision. I wouldn't exactly "respect" that decision. Because I'm a
huge proponent of freedom of expression, telling truth to power, that knowledge desires to be
free, and very much against suppressing the truth in favor of "political correctness". After all,
both my parents literally fled Communism. My father was actually on the proverbial "Last boat
from China" before the Communists invaded Shanghai, and my mom had to be smuggled out
of Communist China by "secret railway" even after that!
However, I have always had, and will always have, enormous respect for you both, as founders
and moderators of KeraNet, which is now 1,000 members strong (10 of whom I did recruit for
you), the #1 resource in the world for advice from leading voices in cornea cataract and
refractive surgery, and has for the last 20 years been a force to help tens of thousands of
patients around the world receive the best eye care
Hopefully, one day the general public will learn that there's another, safer alternative to LASIK.
Until then, I view it as my duty to help that day come sooner--even if it's just my voice and that
of a handful of other pure LASEK surgeons trying to be heard over the voices of 1,000 LASIK
surgeons
Appreciatively
Emil

From: Mark Mannis <mjmannis@ucdavis.edu> Jul 10, 2015 at 8:28 AM

No idea why your emails are bouncing. I checked and your status with the server has not
changed
MMannis

From: Emil Chynn <safesightsurgeon@gmail.com> Jul 10, 2015, at 7:24 PM

LOOK AT THIS

MAYBE MARIAN DID IT?:)

Jul 9 (1 day ago)
SYMPA <sympa@ucdavis.edu>

to me

Your message for list 'kera-net' (attached below) was rejected.

You are not allowed to send this message for the following reason:
Message distribution in the list is restricted to list subscribers.
If you are subscribed to the list with a different email address, you should
either use that other email address or update your list membership with the
new email address.

For further information, please contact kera-net-request@ucdavis.edu

From: Mark Mannis <mjmannis@ucdavis.edu> July 11, 2015 at 6:07:35 PM EDT

No, I am the only one who can do this. Not sure what this message is all about, but you are not
deleted from the list serve. Have a nice weekend.
MJM
_________________________________
Mark J. Mannis, MD, FACS

From: Emil Chynn <safesightsurgeon@gmail.com> Sun, Jul 12, 2015 at 2:46 AM

See bounce notice below
I'm banned whether they'll admit it or not
Also I only got your email bc you cc'd
Had you not I wouldn't have gotten anything
I'm no longer on their ListServe
Ie unreasonably banned
But thanks for your kind support Nathan
--Emil William Chynn, MD, FACS, MBA
From: Mark Mannis <mjmannis@ucdavis.edu>

to:
Chynn Emil <safesightsurgeon@gmail.com>
cc:
Marian Macsai <MMacsai@northshore.org>
Date: Fri, Jul 10, 2015 at 6:18 AM
Emil:
You astound me. No one has unilaterally and unfairly banned [you] from knet as you publicly
stated. How could you possibly post such a preposterous statement to our membership? It is
only out of respect for you that I am not calling you on this to the list serve membership. I only
asked that you tone down the rhetoric not that you not express your opinion. This type of
blatant hyperbole is exactly why I wrote you before. Honestly, this issue is taking more of my
time than it is worth. I only ask that you be a good citizen on the list serve. And, if you dont
think you can do that, then perhaps you should step away.
MJM
_________________________________
Mark J. Mannis, MD, FACS
From: Joseph Williams <jmwilliams00777@gmail.com>
To:
Emil Chynn <safesightsurgeon@gmail.com>
Date: Fri, Jul 10, 2015 at 9:00 PM
Subject:
Kera-net ban
Emil
I was disappointed to see you were "banned" from keranet. Altough I no longer do LASIK, PRK
or ASA I think there were many valid points in your discussions. Improving methods to facilitate
rapid re-epithelialization of the cornea is useful for much of our work as corneal specialists and
not just for the ASA surgeon. Obviously you have become very comfortable with dealing with reepithelialization. If I were to have refractive surgery I would opt for ASA for that little bit of extra
safety.
I hope your ban is only temporary and we'll see you back in the future.
Joe
Joe Williams, MD, PhD

_______________________________
From: Dan Goodman <dgoodmaneyemd@gmail.com> Jul 6, 2015, at 9:17 PM
Emil.

LASIK surgeons won't "admit" that it is "slightly more risky" because it isn't. The risks of slow-healing
epithelium and of haze (which is visually significant whether or not you can adequately measure it in your
lane) and infections is equal to (if not greater than) the flap-related risk. My guess is that in a practice
doing PRK (even if you call it ASA) for -12.00 to -24.00 myopes, the risk is much greater than a
LASIK/SBK practice treating patients with a residual stromal bed of greater than 300 microns and careful
topographic and tomographic screening.
By the way, it wasn't too long ago that you were bemoaning Keranet "bullies", but it seems to me that
you've become a bit of a bully yourself -- chiding others who don't agree with you and refusing to accept
others' opinions (when their opinions are also based on their honest work and valid observations). Just
my two cents.
Sent from my eyePhone
Daniel Goodman, M.D.

from: Emil Chynn <safesightsurgeon@gmail.com>

to:
Dan Goodman <dgoodmaneyemd@gmail.com>
cc:
"Nancy A. Tanchel" <ntanchel1@verizon.net>,
Jeffrey <jgold2@comcast.net>,
Steven Safran <safran12@comcast.net>,
William Trattler <wtrattler@gmail.com>,
David Glasser <dbg@comcast.net>,
Ronal <ronal.perino@gmail.com>,
kera-net <kera-net@ucdavis.edu>
date: Tue, Jul 7, 2015 at 3:51 AM
subject: More proof that ASA is slightly safer than LASIK

More proof that ASA is slightly safer than LASIK

Dan
As requested, I'll now further prove my point that surface ablations are slightly safer than
incisional surgery:
Every lasik surgeon has to sometimes convert to a surface ablation if they're careful and
prudent
Let's review the indications for this:
Most lasik surgeons will go to surface for:
Irregular borderline topographies

Thin initial corneas

FF KC in the fellow eye
Calculated low RSB
Patient who plays contact and extreme sports like martial arts, boxing, etc
Military special forces
Patient who might freak out during the cut
Patient with very narrow fissures
Patient with very steep K's
(The last ones might not apply to fempto)
In addition many lasik surgeons will convert to surface if:
It's a family member
It's a diamond cutter
It's a jet pilot
It's their own eyes
The patient states "I just want the absolute safest procedure and don't care about recovery time
or having a little pain"
Let's assume you and Nancy and nearly every lasik surgeon would agree with at least this first
list. Aren't you converting for SAFETY REASONS? Doesn't this mean GOING TO THE
SURFACE IS SAFER? I mean, you wouldn't convert to a more risky technique would you? And
you're certainly not converting for speed of recovery or comfort
QID
---