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EW MEETING REPORTER 162 Reporting from the Asia-Pacific Academy of Ophthalmology (APAO) Congress, February 8–11, Hong Kong incidence of 0.94% required more study. Suction loss can occur at different points, and management depends on when it occurs. If it occurs within the first 10% of the first cut, Dr. Shah said that the surgeon can simply redock and proceed with the SMILE procedure. On the other hand, if it occurs later, she recommended converting to a flap and proceeding with a femto LASIK. If suction loss occurs during the final incision, Dr. Shah noted that it is important to have the correct centration; otherwise the surgeon will have difficulty separating the lenticule. Postoperative complications include transient dry eye (13.9%), persistent dry eye (2.6%), epithelial ingrowth (one eye), DLK (0.48%), and steroid response (4%). Intracorneal ring segments and keratoconus Vilavun Puangsricharern, MD, Bangkok, Thailand, defined ker- atoconus as a slowly progressive, non-inflammatory, corneal ectatic disease that manifests during puber- ty and progresses through the third and fourth decades of life. There are, she said, two goals in the management of keratoconus: thickness preoperatively, possibly due to tension release upon disrup- tion of stromal collagen lamellae during lenticule creation, Dr. Zhang said. There was, she added, "re- markable" interindividual differ- ences observed, and the higher the refraction, the greater the difference postoperatively. Dr. Zhang conclud- ed that it is necessary to design the nomogram according to the relative factors of predictability to achieve long-term satisfactory results, espe- cially with higher degrees of myopia. Nevertheless, she said, SMILE surgery is safe, effective, predict- able, and stable for the correction of myopia in the study's Chinese population. While at 2.7% the enhance- ment rate for SMILE is lower than for LASIK, Yu-Chi Liu, MD, Singa- pore, said that in their experience, enhancements have been necessary due to overcorrection, undercorrec- tion, regression, and complications, and enhancements were related to patients' expectations, degree of re- fractive error, laser nomogram used, and surgeon experience. She said that the mechanisms and risk factors for enhancement are not yet fully understood but have been found to be associated with age (>35 years), preop MRSE >–6.0 D, preop myopia >–6.0 D, preop astigmatism >–3.0 D, intraoperative suction loss, and first eye surgery. Dr. Liu described the options for enhancement, which include surface ablation—the simplest, most straightforward approach—sec- ondary LASIK anterior to primary SMILE, secondary SMILE anterior to primary SMILE, sub-lenticule extraction, and conversion to flap using the CIRCLE software (Carl Zeiss Meditec, Jena, Germany). Over the years, experience with SMILE for the correction of myopia has grown, but the correction of hyperopia with the procedure is still a relatively new treatment. The correction of hyperopia with SMILE, according to Sri Ga- nesh, MD, Bangalore, India, is "vir- tually the same" as the correction of myopia, differing only in terms of target corneal geometry; rather than flattening the cornea, the goal is to steepen it, placing the area of high tissue subtraction in the periphery rather than the center. This, he said, requires a transition zone between the actual refractive cut and the lenticule edge to create a gradually thinning lenticule rim rather than a steep edge. Dr. Ganesh said that a global multicenter trial involving eight study centers and a planned study population of 374 eyes has been ini- tiated with results set to be reported after a 1-year follow-up period. In the meantime, he said, SMILE is expected to provide refractive and visual outcomes similar to LASIK while bringing potential advantages to hyperopic correction through the elimination of fluence projection and truncation errors. Evaluating safety, Rupal Shah, MD, Vadodara, India, reported the results of a retrospective analysis of the intraoperative and postoperative complications of SMILE in her prac- tice. Though generally safe, she said that there have been "some special situations" that have needed to be addressed. Intraoperatively, the forma- tion of an opaque bubble layer was most common, with an incidence of 3.9%; however, while this made lenticule separation more difficult, no additional management was nec- essary. Rather, suction loss with an March 2018 View videos from the 2018 APAO Congress: EWrePlay.org Sheetal Brar, MD, discusses the utility of SMILE as a modality for bioptic treatment. continued on page 164 Sponsored by

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