FEATURE 12 EWAP MARCH 2023 by Ellen Stodola Editorial Co-Director A discussion on SMILE W hen any new technology enters the market, physicians spend time determining how it fits into their practice. Lance Kugler, MD, and Audrey Talley Rostov, MD, shared with EyeWorld how they did this with small incision lenticule extraction (SMILE), also called laser-assisted lenticular extraction (LALEX), which was approved for Carl Zeiss Meditec (ReLEx SMILE) in 2016. They discussed how they have incorporated it into practice, what they’ve learned, and issues that may occur. They also addressed advancements and future innovation. ‘Innovation will propel everyone forward’ Dr. Kugler has been using SMILE more in his practice over the past couple of years. “We started with SMILE in 2016 but it was a small percentage of our cases. Some of the upgrades with the VisuMax femtosecond laser [Carl Zeiss Meditec] over the past few years have made it much more appealing as an option for patients,” he said. “I think that refinement of the nomogram has delivered more consistent results for us as well.” Dr. Kugler added that over time, he and his team have been able to improve how they introduce the option of SMILE to patients. Patients may spend years considering the procedure, overcoming fears, costs, and other barriers. “I think we’ve gotten better at introducing SMILE into the discussion.” Dr. Kugler said he likes to use SMILE for low to moderate myopes with a low to moderate amount of cylinder. “I like it for people who may have a reason why an intrastromal procedure is better than having a flap,” he said, adding that this might include someone who doesn’t want to deal with some of the precautions generally taken with LASIK, such as avoiding eye makeup or swimming. There is still some debate on whether the dry eye recovery is any different; in general, people who have had eye surgery may feel dry for a while. This is true for both SMILE and LASIK, but he thinks that SMILE patients recover sooner than LASIK patients. Dr. Kugler said that in the very low myope, LASIK might offer more consistent outcomes compared to SMILE. He thinks the same about those with high amounts of cylinder. Additionally, he may be more likely to use LASIK if he is concerned that there is a higher chance of enhancement for a particular patient. “I may be more likely to use LASIK because it’s a little easier to enhance down the road than SMILE,” he said. “Our understanding and comfort with how to enhance SMILE has improved, but LASIK is still a bit easier to enhance if needed. This enters into the decision process.” Dr. Kugler said that his enhancement rate for SMILE is low, even lower than for Contact information Kugler: lkugler@kuglervision.com Rostov: atalleyrostov@nweyes.com This article originally appeared in the December 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Day 1 postop photo of SMILE. Source: Audrey Talley Rostov, MD
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