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EW REFRACTIVE SURGERY 78 November 2015 Beyond continued from page 76 Are you a fan of EyeWorld? refractive surgery is the notion of what will happen if something goes wrong." Knowing that if this hap- pens there is recourse would likely make patients less apprehensive about having surgery, Dr. Yoo thinks. "It certainly would be beneficial to have that available so if you were faced with an outcome that was less than ideal, you would have the tools to fix it," she said. SMILE appearing The SMILE technique may also offer an alternative to the wavefront approach for some patients. This uses a femtosecond laser to create a lenticule in-situ, Dr. Yoo explained, adding that the lenticule is carefully dissected from the inner part of the cornea through a small incision. By removing this, physicians can get the desired refractive effect. This technique targets a group akin to wavefront, with similar myopic, myopic astigmatic, and hyperopic errors, she said. While not yet approved in the U.S., Dr. Yoo has been among the investigators of the approach. "Al- though we were just treating myopia in the clinical trials, the patients did very well," she said. Investigators found patients reported a great deal of comfort after the surgery. "They didn't have that 6–8 hours of severe photophobia, tearing, and foreign body sensation that some LASIK patients can have in the first few hours after surgery," Dr. Yoo said, adding that in the postoperative visits, it seemed as though patients didn't complain as much about dry eye symptoms, especially as they got further out from the surgery. Dr. Manche agreed that SMILE may be preferable for those prone to dry eyes. He pointed out that with SMILE, which preserves more corne- al nerves with its smaller incision, there is a faster recovery of corneal sensation. "If we look at the studies that examined sub-basal nerve densi- ty after LASIK and PRK, in the early postoperative period, it is better with SMILE than it is with LASIK. While more testing is needed, for someone with borderline dry eye, the SMILE technique may be favorable for this reason," he noted. SMILE also has a biomechanical advantage over LASIK, Dr. Manche pointed out. "You're removing tissue from the posterior stroma and that contributes less to tensile strength than the anterior stroma," he said. "From a biomechanical standpoint, the argument is it may be safer than LASIK." Still, the SMILE technique is not for everyone, he said, pointing out there will be a percentage of patients who do not end up seeing 20/20 with this approach. "With those patients, you're stuck," Dr. Manche said. While with LASIK you can lift the flap and easily do a touchup, traditionally with the SMILE tech- nique, PRK has been the retreatment approach, which may or may not be acceptable to patients. Dr. Manche expects SMILE to hit the U.S. market in 2017, with initial availability for treating spherical my- opia. He thinks the technique is an important addition to the refractive armamentarium. Dr. Manche said that at Stan- ford, they have plans to do a prospective, randomized, head-to- head, clinical trial comparing SMILE surgery to LASIK, beginning in 3–6 months and also including two oth- er major academic centers. EW Editors' note: Dr. Manche has financial interests with Abbott Medical Optics (Abbott Park, Ill.). Dr. Yoo has financial interests with Alcon, Abbott Medical Optics, and Carl Zeiss Meditec (Jena, Germany). Contact information Manche: edward.manche@stanford.edu Yoo: SYoo@med.miami.edu Like us on Twitter at twitter.com/EWNews

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