EyeWorld India September 2016 Issue

September 2016 EWAP FEATURE 25 lit lamp image taken 1 day after SMILE. It is hardly visible that the cornea underwent lenticule removal the day before. Source: Jesper Hjortdal, MD SMILE compared to LASIK and other procedures by Ellen Stodola EyeWorld Contributing Writer The procedure is catching on in many countries around the world T he SMILE (small incision lenticule extraction) procedure (Carl Zeiss Meditec, Jena, Germany) is increasing in popularity, with many studies on its results and how it compares to LASIK. Though it does not have as long of a track record as LASIK, which has been used for around 2 decades, SMILE is gaining ground, with particular application Advantages and disadvantages There are a lot of benefits to SMILE for patients, Dr. Ganesh said. It’s a virtually painless procedure and is quick. There is no long-term dryness, he said. After doing a comparative study between SMILE and femto LASIK several years ago, Dr. Ganesh said the refractive predictability of SMILE was found to be similar to femto LASIK. At 3 months postop, quality of vision and aberrations were better than wavefront LASIK. It was found that the optical zones were larger with SMILE, which translates to better night vision. There were not as many complaints of night vision problems as with LASIK. The accuracy of correction and safety were almost the same between the procedures, Dr. Ganesh added. The biggest advantage many see with SMILE compared to LASIK is the lack of a flap. “By decreasing the incision almost down to 2 mm, we eradicate several problems associated with the flap,” Dr. Sekundo said. SMILE has no pain, or only for a short period of time, and there are no problems with flap dislocation. On the other hand, SMILE is a much more demanding procedure, Dr. Sekundo said, and it is largely dependent on the laser and the surgical skill of the surgeon. The learning curve becomes evident in presentations at meetings, he added. In comparative studies, SMILE performs better in terms of stability, especially in high myopia, Dr. Sekundo said. Additionally, the regression rate with SMILE is smaller compared to excimer laser- based procedures. “The main advantages of for patients with myopia. Jesper Hjortdal, MD , clinical professor, Department of Ophthalmology, Aarhus University, Aarhus, Denmark; Walter Sekundo, MD , chairman, Department of Ophthalmology, Philipps University of Marburg, Marburg, Germany; and Sri Ganesh, MD , chairman and managing director, Nethradhama Hospital, Bangalore, India, commented on their experience with SMILE, advantages and disadvantages compared to LASIK, and potential applications in the future. Predictability and safety of SMILE and LASIK In both short-term and long- term results, Dr. Hjortdal said that predictability and safety results seem similar between SMILE and LASIK. A recent meta-analysis 1 found SMILE and femtosecond LASIK were comparable in terms of safety and efficacy but that SMILE may create fewer dry eye symptoms than femtosecond LASIK, and corneal sensitivity was restored faster after SMILE compared with femtosecond LASIK, he said. Because LASIK has been in use for about 20 years, Dr. Sekundo doesn’t see the introduction of SMILE as controversial. LASIK is a well-proven and highly developed procedure, he said, but it’s at the end of its development, and Dr. Sekundo doesn’t think anything can be done to make LASIK better because “we’ve gotten to the stage where lasers and results are getting close to the variation in refraction.” Refraction is dynamic, and from this point of view, LASIK/femto LASIK is a great procedure. SMILE is gaining popularity because patients desire this approach with a small incision and no flap, he said. Dr. Ganesh started doing SMILE about 3.5 years ago. Before that, he did a lot of femto wavefront LASIK. He thinks that SMILE is a better procedure, mentioning the risk of ectasia and the common problem of postop dryness with LASIK, as well as concerns with the LASIK flap. After first hearing about SMILE, Dr. Ganesh said he researched reports that indicated visual recovery was not as good as with LASIK. Now, he has performed close to 4,000 procedures and said that he rarely chooses LASIK anymore because he thinks SMILE is the better procedure. “As I refine my nomograms and techniques, I’m getting very good results,” Dr. Ganesh said. “I personally think that this is the future of refractive surgery.” AT A GLANCE • One benefit of using SMILE over LASIK is the lack of a flap, which can cause complications. SMILE is also thought to be a virtually painless procedure. • SMILE is currently only indicated for myopia. There may be other applications in the future. • SMILE may have slower visual recovery than LASIK, but some studies indicate that long-term results of SMILE are better. continued on page 26