Further, Dr. D. Ramamurthy, M.D., chairman, The Eye Foundation, Tamil Nadu, India, and president elect, All India Ophthalmological Society (AIOS), shared some tips and tricks for a successful SMILE procedure but also warned surgeons about some 'traps' intraoperatively that are better avoided.
Overall, Dr. Ramamurthy emphasized the importance of identifying and properly removing the lenticule in the SMILE procedure. "Once you have mastered that then you will be comfortable doing the procedure," he said.
From his clinical experience, Dr. Ramamurthy advised on identifying the cleavage plane under high magnification and performing the dissection in front. He also mentioned that in some cases, difficulty in lenticule separation can happen when laser energy has not been passed on uniformly. In this case he advised on the crucial importance of titrating the sufficient energy needed.
Further, Dr. Ramamurthy particularly noted the incision size: that an incision between 2 to 5 mm is allowed. But surgeons, he said, because of "hangover" from phaco days tend to extract the lenticule at 2 mm thinking that the smaller the incision the better the results are.
"Please remember that this procedure doesn't have an astigmatic component attached into it. In my clinic, I have standardized it to 3 mm incision because by reducing the size of the incision to 2 mm, you may risk ripping the incision," he explained.
Finally, Dr. Ramamurthy highlighted that slit lamp examination [after lenticule removal] will ensure that there is no lenticule remnant ̶ a step, he emphasized, that SMILE beginners better not skip.
Meanwhile, the era of all-femto surgery which is free of mechanical keratome, noted Prof. Li Ying, Ph.D., professor, Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, China, avoids complications related to flap creation such as corneal edema and haze.
"Nowadays, the popularity of SMILE can be attributed to its advantages," she added. SMILE, highlighted Prof. Ying, has little effect on the biochemical stability of the cornea and has less injury to corneal nerve fibers which prevents incidence of dry eye after surgery.
The accuracy of the SMILE procedure allows better predictability and leads to less refractive regression. More importantly, according to Prof. Ying, the surgery [using SMILE] can be customized for certain patients hence enabling better outcomes.
However, Prof. Ying reminded SMILE beginners to be careful during each step of the operation as this is crucial for the success of the surgery. "We must pay attention to the design of the operation and be careful during surgery," she explained.
Fast suction and separation of lenticule are critical steps, noted Prof. Ying. "Also, in-time and careful management of complications [should they arise] will avoid permanent visual impairment," she added.
Overall the experts highlighted the flap-free, minimally invasive features of SMILE that highly contributed to the safety of the procedure.
"Some patients still have reservations on a new refractive procedure such as SMILE, but safety, accuracy and precision are features that resonate well with them," concluded Dr. Ramamurthy.