Eyeworld

52 | EYEWORLD | DECEMBER 2022 R EFRACTIVE Contact Kugler: lkugler@kuglervision.com Rostov: atalleyrostov@nweyes.com Relevant disclosures Kugler: None Rostov: Alcon, Carl Zeiss Meditec, Johnson & Johnson Vision be as quiet as possible," she said, adding that she'll let patients know when it's particularly important to be very still. Dr. Rostov has only had a handful of suction breaks in more than 1,000 cases, and they oc- curred late in the procedure. With SMILE, there are four cuts that the laser does. The first is the refractive cut. "If you get a suction break during the refractive cut, you cannot do SMILE," she said. The second cut determines the thickness of the lenticule. The third is the cap, which is the top of the lenticule and is a non-refractive cut. Dr. Rostov has experienced suction breaks during the cap cut. "You can redock and redo it," she said, and in her cases, the procedure was still successful. There could also be problems during lenti- cule dissection, Dr. Rostov said. "If the epitheli- um is irregular or you have too much meibum on the surface, you can get 'black spots,' which are places where the laser is not going to be able to go through," she said. "When you see the laser pattern, you'll notice these spots where there was meibum or something like that, and if there's too much, that will make the lenticule dissection too difficult." Dr. Rostov has not ex- perienced this complication in her SMILE cases and noted that she's very careful in looking for it. "If I see it ahead of time, I'll rinse or wipe the surface," she said. In terms of a learning curve for SMILE, Dr. Rostov said it's a slightly different skillset than with LASIK. "I think for cornea-trained physi- cians, it's straightforward. If you're not cornea trained, it's fine, too," she said. There have also been updates to the laser platform to improve the SMILE treatment. It's now faster, so suction break is less likely to happen, and tissue cutting is more powerful, she said. "I think it's fun to be able to offer patients different options for refractive surgery, and I think SMILE is an excellent option. It's not for every patient, just as LASIK isn't for every patient. It expands the offerings for patients and gives a LASIK-like outcome while preserving greater corneal integrity." correction, any of the three procedures will give you a great outcome." Dr. Rostov said there are a few factors that she particularly likes about SMILE. First, she said it's less invasive, and she thinks there is less dry eye than with LASIK. There is no flap with SMILE, so you don't have to worry about late flap dislocation. You also don't have the concern about haze that you get with PRK or the delay in healing, she added. "I think there's some fallacies with SMILE, mostly from people who haven't done it and think you're not going to get the same results as LASIK and PRK, and that's just not true," Dr. Rostov said. "I think that as you refine your technique with SMILE, you can get those nice first-day 20/20 results." Dr. Rostov said that SMILE has similar criteria as LASIK and PRK. SMILE is approved for up to 3 D of astigmatism. "I find that above 2.0–2.25 D, when it gets to the higher amounts of astigmatism, in my practice LASIK does a better job." She added that if the patient has a small superficial scar within the SMILE treat- ment zone, she will choose LASIK because you need a pristine cornea with SMILE. "You can't have any scars or opacities within the treatment zone, and the reason is that the femtosecond laser is not able to go through opacities." Dr. Rostov noted that she might choose LASIK instead of SMILE for smaller prescrip- tions because the lenticule would be very thin in these cases and might be harder to dissect. You could do it, but it depends on the patient. "Especially if it's a thicker cornea and very low prescription, I might do LASIK instead," she said. Dr. Rostov agreed that there may be com- plications that come up, as with any procedure. She had one case where she was unable to get the lenticule out, and she proceeded with PRK. Another potential complication is a suction break. Dr. Rostov said to try to prevent this, she might use medications or "verbal anesthesia." "I tell patients to listen to my voice. I tell them ahead of time what to expect. I tell them just to listen to what I'm saying and to hold as still and continued from page 51

• Blank Page
• Blank Page (1)