FEATURE EWAP MARCH 2023 13 LASIK. “I think the nomograms, accuracy, and consistency have improved in general,” he said. There are potential complications that can occur during the SMILE procedure that surgeons should be on the lookout for. These include issues with the lenticule. Dr. Kugler said he has experienced a thin lenticule in a low myope that has torn, and he’s had to take it out in a few pieces. This is not a big deal, he said, but the important thing is to recognize when it happens and realize you didn’t get the whole lenticule. When you do remove the lenticule, it’s important to lay it out flat and make sure you’ve gotten it all. “It seems like a waste of time when you don’t find a problem, but occasionally you might find that it’s not a perfect circle, and there’s still a partial fragment that needs to be removed.” As far as other potential complications, “If you’re going in and out of the SMILE pocket/ interface several times in the procedure, either to retrieve part of the lenticule or for some other reason, there is an increased chance of epithelial ingrowth,” Dr. Kugler said. “I’ve seen a few cases of this happen.” He added that this problem is fairly easy to manage if it does occur, and its incidence seems to decrease with experience. “I think the more experienced surgeons become, the less time they’re spending in the pocket. The less in and out there is, the less chance for epithelial ingrowth.” Dr. Kugler offered some advice for surgeons just starting out with SMILE. “I think it’s a little less forgiving than LASIK,” he said. “The lenticule is removed with manual dissection, so there’s definitely more technique involved.” There are more surgeon technique and manual steps compared to LASIK, and LASIK has had a 30-year head start over SMILE, so it is more refined. “If you look at where SMILE is on the timeline, it’s quite remarkable how far along it is,” Dr. Kugler said. “But someone who is used to having a lot of things automated in the LASIK process is going to need to realize that SMILE is more surgeon dependent.” Dr. Kugler said there is currently a gap in what is available overseas for the VisuMax femtosecond laser and what is available in the U.S. “We see a lot of great features that are coming but not here yet,” he said. “I think that’s going to be an important step forward in the technology for U.S. surgeons.” There are also several femtosecond laser companies working on lenticular creation and extraction technologies and software. “We’re going to see a real step forward in innovation and options on other platforms as well,” he said. “I don’t think there’s any question that the lenticular extraction techniques are going to evolve and improve, and a lot of the advantages of that technique that have been theoretical will continue to be refined and become a reality.” Dr. Kugler said that his practice made a conscious decision a couple of years ago to make sure that they were maximizing the SMILE technique because they think it’s going to become more relevant as more options enter the marketplace. “Carl Zeiss Meditec deserves tremendous credit for bringing this to market,” he said. “What’s also great is that we have other companies innovating in the same space, and the innovation will propel everyone forward.” When choosing which procedure to use, it’s a matter of matching the technology to the patient. “One thing I think surgeons should be mindful of is that patients are looking to them to make a recommendation as to the best procedure,” he said. “It’s impossible for patients to understand nuances among SMILE, LASIK, and other options.” Because of this, Dr. Kugler said it’s important for the surgeon to outline the differences and to recommend the most appropriate option for each patient. ‘There are some fallacies with SMILE’ In Dr. Rostov’s refractive practice, anyone who is a candidate for SMILE gets SMILE. She estimated that it’s upward of 80% of patients who come in for a refractive surgical procedure. She said that over the years, outcomes with SMILE, LASIK, and PRK have been shown to be very similar. “There isn’t a significant difference among laser vision correction procedures, and that’s exactly what I tell patients,” she said. “I tell them that when we look at laser vision correction, any of the three procedures will give you a great outcome.” Dr. Rostov said there are a few factors that she particularly likes about SMILE. First, she said it’s less invasive, and she thinks there is less dry eye than with LASIK. There is no flap with SMILE, so you don’t have to worry about late flap dislocation. You also don’t have the concern about haze that you get with PRK or the delay in healing, she added. “I think there’s some fallacies with SMILE, mostly from people who haven’t done it and think you’re not going to get the same results as LASIK and PRK, and that’s just not true,” Dr. Rostov said. “I think that as you refine your technique with SMILE, you can get those nice first-day 20/20 results.”
RkJQdWJsaXNoZXIy Njk2NTg0