Eyeworld

EW FEATURE 54 Controversies in ophthalmology • June 2016 Dr. Sekundo said he has not seen a single suction loss in the last 4 years, when the fast energy settings were implemented in his routine. In the future, he thinks the procedure will get down to around 10 seconds, with the high quality of cuts. It's unfair to compare LASIK and SMILE, Dr. Sekundo said, because it's comparing an old and well-proven technology—LASIK—to a new tech- nology—SMILE. However, he noted that SMILE has been around for nearly a decade now and is continu- ing to evolve. EW Reference 1. Zhang Y, et al. Clinical outcomes of SMILE and FS-LASIK used to treat myopia: a meta- analysis. J Refract Surg. 2016;32:256–65. Editors' note: Dr. Ganesh and Dr. Sekundo have financial interests with Carl Zeiss Meditec. Dr. Hjortdal has no financial interests related to his comments. Contact information Ganesh: chairman@nethradhama.org Hjortdal: jesper.hjortdal@clin.au.dk Sekundo: sekundo@med.uni-marburg.de Dr. Ganesh recently worked on a study that will be published short- ly comparing SMILE to PRK for low myopia. With PRK, there may be pain for a couple of days following surgery, and there is a need for long- term medication. Some patients may develop haze. "In our study, we found that the safety was better with SMILE," he said. PRK is now widely being used for low myopia, Dr. Ganesh added. Though refrac- tive results were similar between the 2, he said that quality of vision in terms of aberrations was better with SMILE. Dr. Sekundo added that PRK is a great procedure but not for higher myopia; SMILE is preferable in these cases. When he counsels patients, Dr. Sekundo provides all of the options. However, for patients who have certain degrees of myopia, he won't offer PRK or LASIK because he doesn't think they are good choices. Future applications of SMILE Dr. Ganesh said that although SMILE cannot currently be used for hyperopia and enhancements, trials for hyperopia applications seem "quite promising." It's an evolving procedure that's getting more re- fined, he said. At this point in time, LASIK is very refined, while SMILE is still in its infancy. "But even SMILE in its infancy is as good or better than advanced LASIK," Dr. Ganesh said. "As it keeps developing, it's going to get better." Dr. Hjortdal said that the indica- tions for the SMILE procedure could possibly expand to include hyper- opic treatments and an optimization of astigmatic corrections. "Refractive corrections for presbyopia, such as 'blended vision' may also be possi- ble," he added. Dr. Sekundo is currently con- ducting the second phase of a study looking at SMILE in hyperopic patients, and he said different SMILE possibilities have been explored by Indian, Egyptian, and Singaporean colleagues. "SMILE requires a skilled sur- geon," he said. Dr. Sekundo added that he sees SMILE as better in the long term. Short-term results are usually equal to LASIK, but beyond 6 months, SMILE seems better. Initially, SMILE took around 2 minutes to perform, but currently, the procedure takes 24 seconds. acuity on the first day after surgery. "With increasing refinement of laser settings, this difference is very small," Dr. Hjortdal said. "After 1 week, most experienced surgeons do not find a difference." Centration could be a possible issue in SMILE, Dr. Hjortdal said, but he noted that studies have shown a comparable increase in coma-like aberrations after SMILE and LASIK. "Complications related to lenticule removal are a potential concern in SMILE surgery, but this occurs very rarely," he said. How SMILE compares to other procedures For correction of low myopia (less than 3 D) there are possibly no differences between the outcomes of modern surface ablation techniques, LASIK and SMILE, Dr. Hjortdal said, but prospective controlled studies are needed. "Concerning higher myopia (more than 6 D), we have found SMILE superior to LASIK in predictability and safety," he said. "We do more than 95% of our sur- geries for higher myopia as a SMILE procedure." SMILE continued from page 53

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