18 EyeWorld Asia-Pacific | December 2024 References 1. Kremer FB, Pronesti G, Solat J, et al. Prospective LASIK trial for myopia and myopic astigmatism: 1-year results. Ann Ophthalmol. 2001;33(4):315-322. 2. Yuen KH, Chan WK, Kho J, et al. A 10-year prospective audit of LASIK outcomes for myopia in 37,932 eyes at a single institution in Asia. Ophthalmology. 2010;117(6):12361244. 3. Stulting RD, Carr JD, Thompson KP, et al. Complications of laser in situ keratomileusis for the correction of myopia. Ophthalmology. 1999;106(1):13-20. 4. Melki SA, Azar DT. LASIK complications: etiology, management, and prevention. Surv Ophthalmol. 2001;46(2):95-116. 5. Donnenfeld ED. The best for LASIK. Paper presented at the: AAO Subspecialty Days; November 10-11, 2017; New Orleans. 6. Pasquali TA, Smadja D, Savetsky MJ, et al. Long-term follow-up after laser vision correction in physicians: Quality of life and patient satisfaction. J Cataract Refract Surg. 2014;40(3):395-402. 7. Solomon KD, Fernández de Castro LE, Sandoval HP, et al. LASIK world literature review. Ophthalmology. 2009;116(4):691-701. 8. Hashemi H, Roberts CJ, Elsheikh, et al. Corneal biomechanics after SMILE, femtosecond-assisted LASIK, and photorefractive keratectomy: a matched comparison study. Transl Visc Sci Technol. 2023;12(3):12. 9. Guo H, Hosseini-Moghaddam SM, Hodge W. Corneal biomechanical properties after SMILE versus FLEX, LASIK, LASEK, or PRK: a systematic review and meta-analysis. BMC Ophthalmol. 2019;19(1):167. 10. Wolle MA, Randleman JB, Woodward MA. Complications of refractive surgery: ectasia after refractive surgery. Int Ophthalmol Clin. 2016;56(2):129-141. 11. Ahn CS, Clinch TE, Moshirfar M, Weiss JR, Hutchinson CB. Initial results of photorefractive keratectomy and laser in situ keratomileusis performed by a single surgeon. J Cataract Refract Surg. 1999;25(8):1048-1055. 12. Wiley WM, Wiley RG. 10,000 LASIK Eyes Treated NIDEK. Paper presented at the: Carribbean Eye Meeting. March 2001; Cancun, Mexico. 13. Wiley WM, Moarefi A. Long-term outcomes of visual improvement after small-incision lenticule extraction for myopic correction. Paper presented at the: ASCRS/ASOA Annual Meeting; April 13-17, 2018; Washington, DC. 14. Tamimi A, Sheikhzadeh F, Ezabadi SG, et al. Post-LASIK dry eye disease: a comprehensive review of management and current treatment options. Front Med (Lausanne). 2023;10:1057685. 15. Li M, Niu L, Qin B, et al. Confocal comparison of corneal reinnervation after small incision lenticule extraction (SMILE) and femtosecond laser in situ keratomileusis (FSLASIK). PLoS One. 2013;9;8(12):e81435. 16. Wang D, Liu M, Chen Y, et al. Differences in the corneal biomechanical changes after SMILE and LASIK. J Refract Surg. 2014;30(10)702-707. 17. Charters L. SMILE offers low enhancement rate after nomogram adjustment. Ophthalmology Times. 2021;46(5). 18. Jeng Ting DS, Srinivasan S, Danjoux JP. Epithelial ingrowth following laser in situ keratomileusis (LASIK): prevalence, risk factors, management and visual outcomes. BMJ Open Ophthalmol. 2018;3(1):e000133. 19. Lohmann CP, Güell JL. Regression after LASIK for the treatment of myopia: the role of the corneal epithelium. Semin Ophthalmol. 1998;13(2):79-82. 20. Moshifar M, Parsons MT, Chartrand NA, et al. Photorefractive keratectomy enhancement (PRK) after small-incision lenticule extraction (SMILE). Clin Ophthalmol. 2022;16:3033-3042. 21. Siedlecki J, Luft N, Mayer WJ, et al. CIRCLE enhancement after myopic SMILE. J Refract Surg. 2018;34(5):304-309. 22. Decourcey M. Analysis of refractive outcomes in SMILE converted to LASIK (“cap to flap”) enhancements. Paper presented at the: 2023 American Society of Cataract and Refractive Surgeons annual meeting; May 5-8, 2023; San Diego. 23. Sedky AN, Wahba SS, Roshdy MM, Ayaad NR. Cap-preserving SMILE enhancement surgery. BMC Ophthalmol. 2018;18(1):49. 24. Brar S, Ganesh S, Bhargav S. Comparison of intraoperative time taken for docking, dissection, and overall workflow for SMILE procedure with VisuMax 800 versus the VisuMax 500 for femtosecond laser. J Refract Surg. 2023;39(9):648. FEATURE Pathways to Precision and Perfection – SMILE vs. LASIK SMILE enhancements, however, are much more flexible. PRK,20 thin-flap LASIK, and thick-flap LASIK are all options. Alternatively, the SMILE cap can be converted into a LASIK flap.21 My colleagues and I have demonstrated that converting a SMILE cap to a LASIK flap, the CIRCLE procedure, yields superior short- and long-term outcomes compared to flap lifts or PRK.22 Lastly, a cap-preserving enhancement procedure, or re-SMILE, is a promising development.23 Patient, Surgeon Experience Is A Key Differentiator In today’s experience economy, the patient experience matters just as much as the surgical results. Patients want a quick recovery and minimal disruptions to their daily lives, and SMILE delivers both. Because there is no flap, patients can resume normal activities like driving, returning to work, contact sports, swimming, and even wearing makeup much sooner than after LASIK. A small incision compared to a LASIK flap also means a faster healing process and less discomfort. From a surgeon’s perspective, SMILE also offers a more streamlined workflow. LASIK requires two laser steps: creating the flap with a femtosecond laser and reshaping the cornea with an excimer laser. In contrast, SMILE requires one step with the VisuMax femtosecond laser (Carl Zeiss Meditec). The entire lenticule creation process takes less than 10 seconds, and recent advancements in laser technology—like the VisuMax 800—reduce treatment times even further. In a recent study of 60 patients treated bilaterally comparing the overall workflow of the VisuMax 800 to the VisuMax 500, the overall surgical time improved from 9.52 ±1.72 minutes with the VisuMax 500 to 6.96 ±1.67 minutes with the VisuMax 800.24 Times for docking and lenticule dissection also improved from 194.11 ±47.59 to 133.63 ±38.88 seconds and 115.40 ± -45.03 to 99.06 ±20.19 seconds, respectively. There was no difference in uncorrected distance visual acuity between groups and no suction break in either group. Although this was conducted by experienced VisuMax users with fine-tuned surgical techniques, I think the VisuMax 800 will allow even less experienced surgeons to achieve premier results in a quicker time frame and with a shorter learning curve. Market Growth And Patient Demand More than 10 million SMILE procedures have been performed worldwide, and the market is growing. The reasons behind this are clear: excellent efficacy and advantages over LASIK such as no flap complications, fewer enhancements, reduced risk of dry eye, and better biomechanical stability. While LASIK continues to be an excellent choice for many patients, SMILE represents another evolution in corneal refractive surgery with further horizons to explore. Editors’ note: The procedure addresses some of the limitations of LASIK.
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