Eyeworld

55 EW FEATURE March 2019 • Refractive corrections Still only a few years from its initial FDA approval, Drs. Hamilton and Dishler said some patients are coming in requesting SMILE, but Dr. Hamilton said they are not the ma- jority, though he, Dr. Dishler, and Dr. Stahl expressed that they expect that to shift with time. "I think, in 2019, the ability to have the three different procedures available to offer patients is very useful," Dr. Hamilton said. "I think as we move forward and SMILE becomes more accepted and the knowledge expands in our patient base, we will be migrating more toward SMILE in the future." EW Editors' note: Drs. Hamilton and Dishler have financial interests with Carl Zeiss Meditec. Dr. Stahl has no financial interests related to his comments. Contact information Dishler: jond@dishler.com Hamilton: drhamilton@smeyegroup.com Stahl: jstahl@durrievision.com that concern is very attractive to patients," Dr. Hamilton said. "SMILE has broad appeal, but it is particularly well-suited for high myopes with extremely good accura- cy, certain occupational professions such as first responders, and sports enthusiasts. It also seems to be beneficial for dry eye, although not proven as an indication," Dr. Dishler said, summarizing his thoughts on the SMILE patient population. On the flip side, patients who might be better suited to LASIK, Dr. Hamilton said, are low myopes. "It is still a bit of a technical challenge to dissect a very thin lent- icule," he said. "I would still recom- mend LASIK at the very low end of myopia, but with regard to moderate to high myopes with up to 3 D of astigmatism, I am offering SMILE to those patients as my primary choice." Though a laser refractive proce- dure, like LASIK, Dr. Hamilton and Dr. Dishler noted a learning curve with SMILE. To get over this learning curve, Dr. Hamilton recommend- ed working with an experienced mentor on your first cases, sched- uling several back-to-back bilateral SMILE cases, and taking a course at an ophthalmic meeting. Dr. Ham- ilton also recommended becoming familiar with the VisuMax laser by performing several dozen LASIK flap cases before moving on to your first SMILE cases. "The other key point with SMILE is … we are treating the refractive error with this procedure, so the centration of the SMILE lent- icule is significantly more critical than the centration of the LASIK flap," Dr. Hamilton said, noting that he uses a printout from the Galilei topographer (Ziemer, Port, Swit- zerland) to show centration on the visual axis, which he uses as a visual representation of where he wants to see the fixation target within the pupil while centering the eye with the VisuMax laser. Take your time with your early SMILE cases, Dr. Hamilton said, stressing that speed with this proce- dure will come with experience. "It's amazing how fast it can be, but taking your time initially is important. It's amazing with each of your first 20 to 30 cases how much more you see with each case with regard to instrumentation, bubble pattern, depth, and tactile feed- back. All of those things are new, so taking your time is very important," he said. In terms of the new modalities, Dr. Stahl said if you are experienced in treating spherical corrections with the larger incision, there is not much of a difference to adding astigmatic correction or going to a smaller incision. "There are ad- vantages in marking the cornea in helping alignment of the treatment … but aside from that, it's essential- ly the same procedure," he said. Though the need for post- SMILE enhancement is rare—in the nearly 2 years and nearly 300 cases he has performed, Dr. Hamilton has performed one enhancement—there are options. He used PRK in this case, but said very thin flap LASIK is an option as well. However, he cau- tioned that given the required 120 µm cap thickness for SMILE in U.S. cases, you need to be careful with a LASIK enhancement on a SMILE cap. Dr. Stahl has also only per- formed one enhancement in his 2 years with SMILE, also using surface ablation in this case. Older laser settings with spots closer together and higher overall energy deposition leads to a "fluffy" lenticular side cut (small arrow) and a large amount of opaque bubble layer (OBL) in the visual axis (large arrow). Source: Rex Hamilton, MD Newer laser settings with spots further apart and lower overall energy deposition leads to "clean" lenticular side cut (small arrow) and a small amount of OBL in the visual axis (large arrow). Source: Rex Hamilton, MD

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