Eyeworld

EW FEATURE 54 Refractive corrections • March 2019 AT A GLANCE • SMILE is now approved to correct up to 3 D of astigmatism. • A smaller incision size and new laser parameters are approved as well. • These new approvals hasten postoperative vision recovery and expand the patient population who are candidates for SMILE, according to physicians. • Physicians find postoperative enhancements rare among their SMILE patients. by Liz Hillman EyeWorld Senior Staff Writer Dry eye symptoms related to surgery also seem to resolve quicker with SMILE compared to LASIK, Dr. Hamilton said. He said he warns LASIK patients of the potential for dry eye symptoms for 6 to 12 months, whereas SMILE patients seem to see a resolution of these symptoms between 1 and 3 months. "That's huge. [Dry eye] is anoth- er barrier. … The fact that we now have a tool that directly addresses LASIK," Dr. Hamilton said. "Those patients used to be relegated to PRK, which is a fine procedure but has a long recovery in terms of the vision and is not an optimal choice for most patients." Ultimately, if a patient is an overall candidate for laser vision correction, choosing the right procedure for them comes down to the patient's lifestyle and personal needs, Dr. Stahl said. offering a dramatic advantage with regard to how fast the vision recov- ers," Dr. Hamilton said. Dr. Hamilton said that with these new parameters visual recov- ery to 20/20 is usually 1 to 2 days, as opposed to 1 to 2 weeks with the original FDA-approved parameters. "With the new settings, I have been able to lower the overall energy deposition by 57%. With this significant reduction in energy, dissection planes are cleaner and smoother, and there is less opaque bubble layer in the visual axis, which hastens the settling of the tissue planes. This has translated di- rectly to faster vision recovery in my patients. The vast majority of my patients are now seeing 20/20 on postop day 1," Dr. Hamilton said. "That has made a big difference in terms of patient acceptance and the confidence of the surgeon to be able to recommend the procedure," he added. In addition to bringing astig- matic correction to a new patient population for SMILE, Dr. Hamil- ton and Jon Dishler, MD, Dishler Laser Institute, Greenwood Village, Colorado, think SMILE is attractive to certain patients based on factors that have nothing to do with their refractive error. "The best candidates seem to be the millennial generation for a variety of reasons," Dr. Dishler said, a few of them being less discomfort, fewer postop issues, and a faster return to all activities. "There is crossover [with the LASIK popula- tion] but an additional group [seems to be] drawn to SMILE." From a physical standpoint, Jason Stahl, MD, Durrie Vision, Overland Park, Kansas, thinks that LASIK and SMILE candidates com- prise the same patient population, though he, Dr. Hamilton, and Dr. Dishler think SMILE has the ability to treat higher myopes. "Now that we have the 60-de- gree side cut incision, biomechani- cally we are not altering the cornea to the level that we do with LASIK with a 270-degree plus incision, so we are able to treat higher correc- tions in patients who we may not have been comfortable treating with Patient population for SMILE expanded to include astigmatism; new parameters speed recovery L ast year, the U.S. Food and Drug Administration (FDA) approved new indications and modalities for small incision lenticule extraction (SMILE) that not only expanded in- dications of the procedure but could result in faster visual recovery. In October 2018, just over 2 years since its initial FDA approval, Carl Zeiss Meditec (Jena, Germany) announced the FDA approval of the ReLEx SMILE procedure to treat up to 3 D of myopic astigmatism. While this opens the procedure, which involves use of the VisuMax femto- second laser (Carl Zeiss Meditec) to create a customized lenticule that is then extracted through a side pock- et, to more patients, Rex Hamilton, MD, Santa Monica Eye Medical Group, Santa Monica, California, said U.S. surgeons are also now able to use a smaller incision size and other new parameters. "We have the smaller incision going from 90 degrees down to 60 degrees, and maybe most important- ly, we have the outside U.S. parame- ters in terms of the spot spacing and energies. We are able to now widen the spot spacing, which allows for an overall lower energy deposi- tion when we create the lenticule, What's next for SMILE after new approvals The lenticule is extracted after dissection in SMILE. Source: Jon Dishler, MD " 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. " —Rex Hamilton, MD

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