Eyeworld

20 | EYEWORLD | APRIL 2022 by Tyler Friske, MD, Jacob Warmath, MD, and David Jackson, MD ASCRS/EYEWORLD JOURNAL CLUB ASCRS NEWS Review of "Small incision lenticule extraction in the U.S. military: prospective study of visual and military task performance" criteria included pregnant or nursing patients, patients with an active or recurrent ocular dis- ease or corneal abnormalities, and patients with a history of prior ocular surgery, eye trauma, or medical conditions that could impact postoper- ative healing. The SMILE procedure was performed by two experienced surgeons. The laser parame- ters and surgical technique were standardized. Patients underwent a comprehensive preopera- tive screening examination. Patients were then examined postoperatively at 1 and 7 days, in addition to 1 month and 3 months. Outcome measures included uncorrected and corrected distance visual acuity (UDVA and CDVA, respectively), changes in higher order aberrations, low-contrast visual acuity (LCVA), binocular contrast sensitivity, and patient-re- ported outcome measures evaluated by validat- ed questionnaires. Fourteen patients were also evaluated for changes in marksmanship perfor- mance using a standardized grading system. Summary of results Participants in this study were predominantly male (58 of 74 eyes) with a low to moderate amount of myopia and astigmatism (mean manifest sphere: –3.00 SD 1.58; mean manifest cylinder: –0.43 SD 0.39; mean manifest spheri- cal equivalent: –3.22 SD 1.59). Most cases were performed by a single surgeon (64 of 74 eyes); 93.2% (69/74) of all cases were uncomplicated. Intraoperative complications included two eyes with cap tears, one eye with a partial cap tear involving the central axis, and two eyes with difficult dissection. Ninety-six percent of eyes achieved an UDVA of 20/20 or better at the 3-month postoperative evaluation. The efficacy index measured as the ratio of mean postoperative UDVA to mean preoperative CDVA was 0.96. The safety index measured as the ratio of mean postoperative CDVA to mean preoperative CDVA was 1.03. There was a statistically significant increase in total higher order aberrations in S mall incision lenticule extraction (SMILE) is a corneal refractive pro- cedure involving the use of a femto- second laser to create an intrastromal corneal lenticule that is manually extracted as a single piece through a small incision. The precursor to modern SMILE was first described by Ito et al. in 1996. 1 With the introduction of the VisuMax femtosecond laser (Carl Zeiss Meditec) in 2007, safety and effica- cy results of femtosecond lenticule extraction were first reported by Sekundo et al. 2 Follow- ing the development of femtosecond lenticule extraction, SMILE was developed to eliminate the need for flap creation. The first prospective studies of SMILE were reported in 2011. 3–5 SMILE was approved for spherical myopic cor- rections by the FDA in the U.S. in 2016 and for compound myopic astigmatism in 2018. 6 SMILE was first performed at a U.S. mili- tary-specific refractive surgery center in 2017. Sia et al. reported 1-year retrospective data not- ing vision outcomes similar to PRK and LASIK in addition to possible improvements in speed of visual recovery and predictability of visual out- comes. 7 However, prior to the study reviewed in this article, there were no prospective military studies of SMILE to aid in establishing guide- lines for U.S. military service members. The purpose of this study was to evaluate early clinical, patient-reported, and profession- specific outcomes of SMILE in active duty U.S. military service members. Design and methods This prospective, single-center observational study included 74 eyes of 37 patients who un- derwent SMILE at the Warfighter Refractive Eye Surgery Program & Research Center and Night Vision and Electronic Sensors Directorate in Fort Belvoir, Virginia. Inclusion criteria included active duty U.S. military service members 22 years or older with manifest refractions within the FDA-approved parameters for SMILE and a stable refraction for at least 1 year. Exclusion R. Michael Siatkowski, MD Residency Program Director Dean McGee Eye Institute Oklahoma City, Oklahoma Tyler Friske, MD Resident Dean McGee Eye Institute Oklahoma City, Oklahoma

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