No Flap, No Fuss: Pure Lenticule Precision at AAO 2025

Laser-focused and flap-free. KLEx sets the tone for refractive’s next act.

Move over, flaps…lenticules are having their moment.

If refractive surgery had a trend forecast, “flapless” would be the word of the year. A Day 1 subspecialty symposium at the American Academy of Ophthalmology Annual Meeting 2025 (AAO 2025) proved just that, as experts gathered to talk lasers, lenticules and everything in between.

The vibe? Electric. The focus? Keratorefractive lenticule extraction (KLEx), the shiny new umbrella term taking over from SMILE (small incision lenticule extraction). With multiple platforms now available (and more in the pipeline), KLEx isn’t the future anymore. It’s the “right now.”

The case for going flap-free

Dr. John Doane (USA) kicked off the session by tackling the big question: why make room for KLEx in your practice?

“The ‘why’ of KLEx is fairly straightforward,” he said. “There’s no flap, so you don’t have to deal with that as a surgeon. But, from a patient standpoint, there’s no physical limitation as far as activity restrictions.” Translation: less hassle for surgeons, fewer post-op restrictions for patients and smoother sailing for everyone involved.

Dr. Doane highlighted KLEx’s biomechanical perks and impressively low enhancement rates. “We’ve seen this in Kansas City—and some others across the globe—about one-third the number of enhancements with SMILE compared to laser vision correction with an external laser,” he noted.

For surgeons eyeing a KLEx start, Dr. Doane recommended hands-on training. Think didactic sessions, pig-eye labs and supervised procedures, plus smart patient selection.

“This is probably the key point in your initial cases,” he advised. “For patients that are greater than -3 [D] for your starting cases, it’s easier to dissect. Then, advance to lower corrections.”

Europe’s KLEx factor

Across the pond, Prof. Dr. Thomas Kohnen (Germany) brought the European perspective, where KLEx has been strutting its stuff for years.

“We had the pleasure to go this route with the development of PRK [photorefractive keratectomy] and LASIK [laser-assisted in situ keratomileusis] in Europe, but also in 2006, the first SMILE procedure in the world,” he said.

Prof. Kohnen shared data showing KLEx performing on par with LASIK and PRK, while Europe’s platform portfolio has expanded to include CLEAR (Ziemer; Bern, Switzerland), SmartSight (SCHWIND; Kleinostheim, Germany), and SILK (Johnson & Johnson Vision; Florida, USA).

“We did a meta-analysis in Europe comparing PRK, LASIK and KLEx over time,” he explained. “In summary, these showed PRK and LASIK at high safety. Late complications are rare. Effectiveness increased over time with high corrections. But with KLEx, at least equivalent to these procedures and no superiority on any single procedure.”

His takeaway? KLEx is a great match for patients with thin corneas, dry eyes or a low tolerance for halos.

Battle of the platforms

Dr. Ronald Krueger (USA) took the stage next, comparing KLEx platforms. “KLEx has replaced SMILE as the categorical name for lenticular extraction,” he clarified, before launching into a rapid-fire rundown.

“The platforms are the VisuMax 500 and 800 [ZEISS; Oberkochen, Germany], the SCHWIND ATOS, Ziemer Z8, and the J&J Elita,” he said, noting that new-generation designs are all about lower energy, faster frequency and higher precision.

He also gave a sneak peek into the future with “plasma KLEx,” a technique by ZEISS and SCHWIND that uses asymmetric pulse spacing.

“Because of that, you can get a little bit better, finer overlap and, therefore, you can have less energy in order to get a successful KLEx removal,” he explained. “It also has less induction of aberrations because of that smoother surface.”

While the ZEISS VisuMax is currently the only U.S. Food and Drug Administration (FDA)-approved system stateside, global competition is heating up…and fast.

Managing complications like a pro

Even in flap-free territory, things can occasionally go sideways. Dr. Soosan Jacob (India) shared practical pearls for navigating complications, dividing them neatly into intraoperative and postoperative challenges.

For suction loss, she offered a simple rule. “If it’s gone more than 10% of lenticular cut, that is the posterior plane cut. Then you have to convert to a LASIK procedure or a femtosecond flap,” Dr. Jacob advised.

She also introduced her signature “WiFi sign,” a nifty dissection landmark. “If your instrument lies above the lenticular side cut, it obviously means you’re doing the anterior plane dissection,” she noted. “And if your instrument is lying below the lenticular side cut or the white rim, it means you’re in the posterior plane.”

Her advice? Always start with the anterior cap, then move to the central posterior plane, and save the side cut for last. Post-op issues are largely LASIK-like, though she flagged epithelial implantation as a unique watch-out for KLEx.

The enhancement game

When enhancements do crop up (rarely, thankfully), Dr. Nandini Venkateswaran (USA) has the playbook ready. “Enhancement rates are actually very low, under 4%, depending upon the study,” she said.

Her go-to move? PRK. “I think that it preserves the flap-free approach of your initial SMILE surgery and it’s straightforward as many refractive surgeons already perform PRK,” she said. “And it’s likely the most tissue-sparing of your enhancement options.”

Her enhancement tips: map epithelial thickness for consistency, and don’t skip mitomycin C to prevent haze. For surgeons feeling experimental, she noted that cap-to-flap techniques and the CIRCLE method are also effective.

“Studies have shown that the cap-to-flap technique has performed very well in contrast to thin flap, thick flap or even surface ablations,” she added.

Thinking beyond refractive

To wrap up, Dr. Rahul Tonk (USA) took things deeper (literally) with a look at intrastromal keratoplasty.

“The basic idea here is to use corneal inlays to reshape the cornea,” he explained. “As compared to the intracorneal ring segments, we’re working with biological tissue, so improved biocompatibility, less risk of extrusion, vascularization and other complications.”

He outlined options ranging from fresh donor tissue to processed grafts such as KeraNatural (VisionGift; Oregon, USA), Optigraft CAIRS (Lions World Vision Institute; Florida, USA) and CTAK (CorneaGen; Florida, USA).

The takeaway

KLEx isn’t just the “next” thing in refractive surgery. It’s already reshaping the landscape. With new platforms, smarter lasers and growing global data, lenticule-based procedures are showing they’ve got serious staying power.

With lower enhancement rates, smoother surfaces and flap-free freedom, the lenticule revolution isn’t coming. It’s here, and it’s laser-focused on the future.

Editor’s Note: The American Academy of Ophthalmology Annual Meeting 2025 (AAO 2025) is being held on 17-20 October 2025, in Orlando, Florida. Reporting for this story took place during the event. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.