34 EyeWorld Asia-Pacific | September 2024 the lenticule is the thinnest and you can actually perforate it if you are not careful. This case is the opposite of myopic patients in which the lenticule is the thickest in the center,” he said. “Integration of hyperopic SMILE with the new VisuMax® 800 should be available any day now and will provide a new excellent option for laser vision correction (LVC) of hyperopia and hyperopic astigmatism,” Dr. Ganesh said. “With the VisuMax® 800, we can expect a lot less suction loss, faster surgery times, and tracking for centration and cyclotorsion.” Clinical Experience and Patient Results of SMILE Pro Tang Seng Fai, MD (Malaysia) For Tang Seng Fai, MD (Malaysia), SMILE Pro has been a new toy since October 2023 at his eye care center, Optimax Eye Specialist, the only SMILE Pro provider in Malaysia. The transition period since October, Dr. Fai describes, has involved upgrading patients from SMILE to SMILE Pro and adapting to the surgeon experience. From October 2023 to April 2024, Dr. Fai was able to collect data on patients who underwent SMILE Pro procedures and ReLEx SMILE surgery. In his comparison, Dr. Fai looked at 1,197 eyes that underwent SMILE Pro and 1,156 eyes that underwent ReLEx SMILE. What he found was that SMILE Pro resulted in better outcomes for patients at postoperative day 1, week 1, and month 1. “Visual improvement following SMILE Pro was consistently superior to that of ReLEx SMILE,” he said, “with higher treatment accuracy for both spherical and cylindrical power.” In terms of refractive outcomes, SMILE Pro yielded a treatment time of less than 10 seconds, which means less chance for eye movement. Furthermore, greater treatment centration with SMILE Pro means better visual outcomes. Because no suction loss occurred during either surgical procedure, SMILE Pro or ReLEx SMILE, the surgery complication rate remained insignificant in both groups. Surgeons from Dr. Fai’s center provided feedback on their experience with performing SMILE Pro. Many reported experiencing no more suction loss in addition to less fear of suction loss. Some commented on better ergonomics and better patient comfort due to an extremely fast laser time. Finally, one surgeon said, A Zeiss dinner symposium was held on Wednesday May 29, 2024 before the official start of the APACRS 2024 Chengdu in which five renowned surgeons of the Asia Pacific region shared their insight on the newest innovations in refractive and cataract surgery. “Here, we will discuss cutting-edge technologies,” moderator Naren Shetty MBBS, MS (Ophth) (India) said, “and Zeiss has always been the pioneer and leader in refractive and cataract surgery.” What is Coming Next for Hyperopic SMILE? Sri Ganesh MBBS, DNB, DSC(Hon), FRCS, FWCRS (India) “Hyperopic small incision lenticule extraction (SMILE) is something we have been waiting on for a long time,” Dr. Ganesh said as he began his presentation. “Zeiss is a leader in lenticule extraction, so we can expect nothing less from this technology.” Dr. Ganesh remarked that hyperopic SMILE has always been a debate - that it is not possible to treat hyperopia with lenticule extraction - but Zeiss is now introducing this technology so that surgeons can treat myopia, myopic astigmatism, hyperopia, and hyperopic astigmatism. Sekundo et al (2016)1 conducted the first study on nine hyperopic eyes using the 500 kHz femtosecond laser and the femtosecond lenticule extraction (ReLEx FLEx) technique. In this prospective study, the results were acceptable with 70% of eyes having a refractive predictability of ± 0.5 D and 89% of eyes within 1.0 D. Further studies were conducted,2,3,4 and surgeons were able to achieve very good centration using a 6.3 mm to 6.7 mm optical zone. “A 6.3 mm optical zone with SMILE corresponds to a 7 mm optical zone with laser-assisted in situ keratomileusis (LASIK), so you effectively get a larger optical zone, and the advantage is lower spherical aberration,” Dr. Ganesh said. In a multicenter study that has been completed and submitted for publication, patients from eight different medical centers (countries included Germany, China, United Kingdom, India, Czech Republic, and France) with hyperopia or hyperopia with astigmatism and a predicted postoperative keratometry of ≤ 51 D underwent lenticule extraction. Dr. Ganesh’s medical center, Nethradama Super Specialty Eye Hospital in Jayanagar, India, participated in this study, and the results were promising. Over a 12-month follow-up period, patients showed an improvement in the safety index and contrast sensitivity remained within the normal range, although there was a slight drop from preoperative values. Regarding efficacy, 88% of postoperative eyes were 20/25 or better, and 68% of eyes were 20/20 or better. Additionally, 77% of eyes showed no change in Snellen lines of corrected distance visual acuity (CDVA), 10% of eyes gained one line, and two or more lines were lost in 1.2% of eyes. At the 12-month mark, 81% of eyes were within 0.5 D and 93% of eyes were within 1.0 D. Some amount of regression could be seen after 9 months: 9% of eyes changed more than 0.5 D between 9- to 12-month follow-up, which Dr. Ganesh attributed to late epithelial healing. However, astigmatic values over 1.0 D were well-corrected: seventy-five percent of eyes were ≤ 0.5 D and 93% of eyes were ≤ 1.0 D after surgery. Dr. Ganesh concluded that these results fared much better than previous hyperopic FLEx and SMILE studies, showing marginally better refractive outcomes with slightly less regression. In a patient case video, Dr. Ganesh provided some tips when using the VisuMax® 500 for the laser cut. “My technique is to dissect more in the periphery. In hyperopic patients, you should be careful with dissecting in the center. That is where From Dr. Ganesh’s multicenter study, 88% of eyes showed 20/25 or better and 68% of eyes showed 20/20 or better visual acuity. In terms of safety, 77% of eyes showed no change in Snellen lines of CDVA. Supplement to EyeWorld Asia-Pacific September 2024 Introducing the Forefront Technologies in Refractive and Cataract Surgery
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