EyeWorld Asia-Pacific June 2016 Issue

June 2016 26 EWAP SECONDARY FEATURE to be best performed with surface excimer ablation,” Dr. Dell added. One obvious barrier for SMILE is that LASIK has come to be a very popular, very safe, and very stable procedure, Dr. Kanellopoulos said. “SMILE promises to offer the same, therefore, there will be a very small incentive to convert from a successful LASIK practice into a SMILE practice,” he said. “We, nevertheless, are currently experiencing the large wave of SMILE adopters along with the larger number of reports from clinicians who are the next generation of adopters who will establish potential advantages that SMILE has compared to LASIK.” Dr. Kanellopoulos said that patients seem motivated to have laser vision correction so they do not have to wear contact lenses and glasses. Hesitation comes from fear of a procedure on their eyes and the cost. “Once they have made that decision, I see very little differentiation between them having SMILE, LASIK, or PRK,” he said. “LASIK, compared to PRK, has had a higher adaptation due to its facility and quick recovery and very minimal postoperative pain for the patients in contrast to PRK, but no one can deny that at 1 month’s time, it is quite difficult to note the significant differences [of the procedures].” SMILE appears to be a procedure that resembles LASIK in regard to the very little postoperative pain involved and the quick recovery, Dr. Kanellopoulos said. Having had a little less than a year of experience with the SMILE procedure, Dr. Kanellopoulos’ learning curve has taught him that SMILE is a bit more of a “surgeon- dependent” procedure in regard to the surgical manipulation needed to remove the “carved” lenticule from inside the cornea without causing significant injury to the SMILE opening and/or the potential pocket that is created. “Our initial data are excellent for low and moderate myopia, but we did encounter some under corrections in higher myopes in the range of –8 to –10,” he said. Although an easy enhancement for LASIK, to retreat SMILE cases, PRK or converting the procedure to a LASIK with an extra side cut with SMILE must be used. Dr. Kanellopoulos still finds SMILE a bit more challenging than a LASIK procedure. As far as cyclorotation adjustment and dynamic visual axis centration, LASIK technologies are currently better. With the femtosecond laser, both procedures would require a similar surgical skill for the creation, for the femtosecond laser portion, with docking, reassuring the patient, designing the ablation, and delivering the femtosecond laser flap creation in LASIK and lenticule carving in SMILE. “The second part of the procedure, though, is far more surgically challenging in SMILE compared to LASIK,” Dr. Kanellopoulos said. This is why it is not recommended yet for myopes under 3 D. Targeting new patients? LASIK carries with it the baggage from public perception of technology used 2 decades ago, Dr. Dell said. “Certainly some patients treated with what is now archaic technology suffered from night vision complaints and other issues,” he said. “The supreme irony is that today, with the best results ever achieved with LASIK, the market is depressed.” However, he said it’s hard to know if a newly branded procedure change would matter significantly. “Because the laser vision correction market in the aggregate only accounts for a single-digit share of the overall vision correction market, a small change in the percentage of people willing to consider laser vision correction would have a profound impact on the industry,” he said. Dr. Kanellopoulos thinks that SMILE will initially be pulling from the traditional pool of LASIK candidates. These would be myopic LASIK candidates, as it is not yet available for hyperopia within the European Union. He said we will have to wait and see if the data, efficacy, and safety will prove it to be a better procedure in the future. “Of course, it is unfair to compare SMILE to LASIK currently, as SMILE is in its infancy in clinical application and technology design, whereas LASIK has gone through a multitude of generations of excimer lasers, keratomes, mechanical initial femtosecond lasers, and millions of eyes treated,” Dr. Kanellopoulos said. Dr. Kanellopoulos thinks that a “SMILE-like procedure” will eventually replace LASIK, “purely based on the fact that SMILE is the least invasive procedure for the corneal surface.” SMILE may have an advantage over LASIK in biomechanics and may have an advantage over both LASIK and PRK as far as the disturbance to the corneal surface, epithelial remodeling, cornea nerve damage, and regeneration, he said. Dr. Kanellopoulos and his team are currently investigating, on a clinical level, the epithelial remodeling properties of SMILE vs. LASIK vs. PRK, the centration achieved with SMILE compared to LASIK, the amount of tissue removed, and its correlation to the whole ablation zone involved, and cornea biomechanics evaluation ex-vivo of LASIK vs. SMILE. EWAP Editors’ note: Dr. Dell has financial interests with Abbott Medical Optics (Abbott Park, Ill.), Bausch + Lomb (Bridgewater, NJ), and Optical Express (Glasgow, Scotland). Dr. Kanellopoulos has financial interests with Alcon (Fort Worth, Texas), ARC Laser (Nuremberg, Germany), Avedro (Waltham, Mass.), KeraMed (Orange, Calif.), Optovue (Fremont, Calif.), and Carl Zeiss Meditec. Contact information Dell: steven@dellmd.com Kanellopoulos: ajkmd@mac.com Update on small - from page 25