Eyeworld

50 | EYEWORLD | DECEMBER 2022 R EFRACTIVE by Ellen Stodola Editorial Co-Director About the physicians Lance Kugler, MD Kugler Vision Omaha, Nebraska Audrey Talley Rostov, MD Northwest Eye Surgeons Seattle, Washington for a while. This is true for both SMILE and LASIK, but he thinks that SMILE patients recov- er sooner than LASIK patients. Dr. Kugler said that in the very low myope, LASIK might offer more consistent outcomes compared to SMILE. He thinks the same about those with high amounts of cylinder. Addition- ally, he may be more likely to use LASIK if he is concerned that there is a higher chance of enhancement for a particular patient. "I may be more likely to use LASIK because it's a little eas- ier to enhance down the road than SMILE," he said. "Our understanding and comfort with how to enhance SMILE has improved, but LASIK is still a bit easier to enhance if needed. This enters into the decision process." Dr. Kugler said that his enhancement rate for SMILE is low, even lower than for LASIK. "I think the nomograms, accuracy, and consistency have improved in general," he said. There are potential complications that can occur during the SMILE procedure that surgeons should be on the lookout for. These include issues with the lenticule. Dr. Kugler said he has experienced a thin lenticule in a low myope that has torn, and he's had to take it out in a few pieces. This is not a big deal, he said, but the important thing is to recognize when it happens and realize you didn't get the whole lenticule. When you do remove the lenticule, it's important to lay it out flat and make sure you've gotten it all. "It seems like a waste of time when you don't find a problem, but occasionally you might find that it's not a perfect circle, and there's still a partial fragment that needs to be removed." As far as other potential complications, "If you're going in and out of the SMILE pocket/in- terface several times in the procedure, either to retrieve part of the lenticule or for some other reason, there is an increased chance of epithe- lial ingrowth," Dr. Kugler said. "I've seen a few cases of this happen." He added that this prob- lem is fairly easy to manage if it does occur, and its incidence seems to decrease with experience. A discussion on SMILE W hen any new technology enters the market, physicians spend time determining how it fits into their practice. Lance Kugler, MD, and Audrey Talley Rostov, MD, shared with EyeWorld how they did this with small incision lenticule extraction (SMILE), also called laser-assisted lenticular extraction (LALEX), which was approved for Carl Zeiss Meditec (ReLEx SMILE) in 2016. They discussed how they have incorporated it into practice, what they've learned, and issues that may occur. They also addressed advancements and future innovation. 'Innovation will propel everyone forward' Dr. Kugler has been using SMILE more in his practice over the past couple of years. "We started with SMILE in 2016 but it was a small percentage of our cases. Some of the upgrades with the VisuMax femtosecond laser [Carl Zeiss Meditec] over the past few years have made it much more appealing as an option for patients," he said. "I think that refinement of the nomo- gram has delivered more consistent results for us as well." Dr. Kugler added that over time, he and his team have been able to improve how they intro- duce the option of SMILE to patients. Patients may spend years considering the procedure, overcoming fears, costs, and other barriers. "I think we've gotten better at introducing SMILE into the discussion." Dr. Kugler said he likes to use SMILE for low to moderate myopes with a low to moderate amount of cylinder. "I like it for people who may have a reason why an intrastromal procedure is better than having a flap," he said, adding that this might include someone who doesn't want to deal with some of the precautions generally taken with LASIK, such as avoiding eye makeup or swimming. There is still some debate on whether the dry eye recovery is any different; in general, people who have had eye surgery may feel dry

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