EyeWorld Asia-Pacific June 2016 Issue

June 2016 28 EWAP SECONDARY FEATURE important to use a lenticule dissector instrument specifically designed for SMILE to minimize the trauma to the stroma from the lenticule extraction. We now consider this part of the routine procedure, not a complication.” Retreatments As with any corneal refractive surgery procedure, some refractive error can remain because of the “natural variation between individuals in the corneal response with respect to healing and biomechanics,” Dr. Reinstein said. His preference for retreatment is to perform a thin-flap LASIK, which he said will always be possible by using a cap thickness of 135 µm. “Doing a LASIK over a SMILE has the benefit of reducing the risk of epithelial ingrowth compared to doing a flap-lift LASIK retreatment,” he said. But if the cap used was thinner, surgeons could use a “circle” method where a femtosecond laser converts the cap into a LASIK flap and retreats from there, Dr. Reinstein said. PRK is also a retreatment option. David Donate, MD , Lyon, France, developed a new retreatment method called sub-cap- lenticule-extraction (Sub-Cap-LE), which he described as a modified SMILE procedure at the same depth as the first without the upper cut. “Then the inferior face of the previous interface becomes the superior face of the new lenticule,” he said. “The point is to avoid a millefeuille—or layered effect—by performing another regular SMILE, which is difficult to place above or below the first SMILE.” This technique, which Dr. Donate presented at the 2015 International Society of Refractive Surgery annual meeting in Las Vegas, maintains the benefits of the original SMILE procedure, but he said it is the trickiest retreatment option, especially if the lenticule is thin. The case report describing Sub-Cap-LE published in the Journal of Refractive Surgery in October 2015 noted that “more cases are needed to develop a consistent surgical protocol.” Dr. Donate said another complication of SMILE is a tear of the incision to the cornea. He advised surgeons to be focused during the procedure to avoid this situation altogether. Overall, Dr. Donate said if the surgeon is comfortable with docking the patient and the laser, SMILE is not difficult, provided “all the steps of the procedure are well respected.” EWAP References 1. El-Naggar MT. Bilateral ectasia after femtosecond laser- assisted small-incision lenticule extraction. J Cataract Refract Surg. 2015;41(4):884–888. 2. Donate D, et al. Preliminary evidence of successful enhancement after a primary SMILE procedure with the sub-cap-lenticule-extraction technique. J Refract Surg. 2015;31(10):708–10. Editors’ note: Dr. Reinstein has financial interests with Carl Zeiss Meditec. Dr. Donate has no financial interests related to his comments Contact information Donate: david.donate@yahoo.fr Reinstein: dzr@londonvisionclinic.com Skills - from page 27