EyeWorld India March 2019 Issue

56 March 2019 EWAP REFRACTIVE A symposium at the 2018 APACRS Annual Meeting, sponsored by Carl Zeiss Med- itec (Jena, Germany), covered the “Full Spectrum of Laser Vision Correction.” The session was moderated by Khairidzan Mohd Kamal, MD , Selangor, Malaysia. Johan Hutauruk, MD , Jakar- ta, Indonesia, presented “SMILE Learning Curve.” He shared the theory that explains why, how, and at what rate an idea of technology spreads, and he stressed that it’s important to position yourself as an early adopter of new technol- ogy. Dr. Hutauruk discussed his experience adopting SMILE at his practice in Jakarta. In 2016, his practice did 286 SMILE procedures. In 2017, that number jumped to 1,352, and from the beginning of the year until June 2018, they did 909 SMILE procedures. Dr. Hutau- ruk also discussed his experience using PRK, LASIK, LASEK, crosslink- ing, SMILE, and other procedures, noting that his hospital is often an early adopter of new procedures. Between 2013 and 2018, thousands of laser vision correction procedures were performed, however, he noted a flattening of the number of LASIK procedures between 2015 and 2016. Originally, there was some concern in introducing SMILE at the practice because of the increased price, but overall, the number of laser vision correction procedures has increased with the introduction of SMILE. Dr. Hutauruk spoke about some of the differences between SMILE and LASIK, notably pain after the procedures and SMILE’s small incision, which does make it more difficult. He did a small study of 30 patients to determine pain the day after surgery and found there was satisfaction with the amount of pain associated with SMILE. The SMILE learning curve starts at docking. Dr. Hutauruk said it’s important to maximize patient comfort and minimize additional steps. His technique is to insert the speculum when the patient’s eye has approached the VisuMax patient interface by approximately 3 cm during docking. Dr. Hutauruk suggested wash- ing the interface because it may help to reduce the risk of epithelial ingrowth. Dr. Hutauruk conducted Full spectrum of laser vision correction Supplement to EyeWorld Asia-Pacific Spring 2019 APACRS a small study of 30 patients and compared the right and left eyes, with the right eye washed and the left not. There was no difference in visual acuity. Dr. Hutauruk also spoke about gradually decreasing the incision size. Start with a 4-mm incision, and for every 100 eyes, reduce by 0.5 mm. The smallest incision size Dr. Hutauruk advocated for is 2 mm. Ekktet Chansue, MD , Bangkok, Thailand, discussed how to opti- mize SMILE for fast visual recovery. He was one of the first adopters, and there were only a few places around the world doing the pro- cedure at the time. At first, there was a risk of losing best corrected vision on the first day or week after surgery, which he thinks may have hampered widespread use of the procedure. But improvements in the procedure and instrumentation have helped to address this. Dr. Chansue added the importance of word of mouth after laser vision correction procedures, and that most referrals occur in the first few days after the procedure. In his practice, about 93% of patients with SMILE see 20/20 or better on the first day after surgery, and there are many steps physicians can take to help ensure a faster recovery. Dr. Chansue described his routine with SMILE, starting with laser settings. The refractive treat- ment setting is not the same in each laser due to nomogram effects. Even within the same laser, different surgeons use different nomograms. Know your nomograms, he said, be- cause different refraction techniques might cause necessary adjustment for laser parameter input. When first adopting SMILE, Dr. Chansue learned that his machine tended to undercorrect, and the higher he went, the more undercorrection there was. The energy setting is also im- portant, he said, suggesting using the lowest energy level you can without getting too many black spots/patches. Thinner caps do give faster visual recovery, Dr. Chansue said, adding that short-term vision is better with thinner caps. “I try to keep the eye moist until we’re ready to dock,” Dr. Chansue said. He discussed his preoperative routine with femto The news magazine of the Asia-Pacific Association of Cataract & Refractive Surgeons 0 1100 2200 3300 4400 2013 2014 2015 2016 2017 2018 2.370 4.296 3.845 3.848 3.630 3.191 Number of procedures 286 1,352 909 ReLEx SMILE Jakarta Eye Center laser vision correction procedures Source: Johan Hutauruk, MD The left eye is taped shut during the laser cut in the right eye. Source: Ekktet Chansue, MD There is a learning curve with SMILE, Dr. Sachdev said, adding that complications will be rare, manageable, and usually there is no loss of best corrected visual acuity. Appropriate knowledge of management is key.