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Cover Focus | May/June '18

Starting Out With SMILE

Few words in the English language connote more positive energy than smile. Thus was my first experience learning about this procedure at the 2015 ASCRS meeting in San Diego. 

Upon returning to my practice, I updated a fellow colleague about this new advance in refractive surgery. He was bitten by the same excitement bug and immediately chose this topic for an upcoming presentation to a group of local optometrists. When SMILE was approved the following year, we were incredulous at the rapid progress through the FDA but excited that we could perform this procedure in the United States. 


Fast forward 12 months later, and I was wrapping up the 50-flap requisite on the »VisuMax femtosecond laser (Carl Zeiss Meditec) in preparation for my first SMILE case.

As with performing any procedure for the first time, I was surrounded by manufacturer’s reps, staff members, the patient’s family, and balloons. Despite the standard anxiety presented by this situation, I had a simple strategy to calm my patient’s and my own nerves: I reminded myself that the refractive lenticular cutting and creation are performed in entirety by the laser. So, if the patient could hold his eye still for the first 30 seconds, then the hard part would be over, and all I had to do was to remove the lenticule.

I also felt well prepared for my first case by Zeiss, first at the didactic training given by John Doane, MD, and then by practicing on pig eyes at the Zeiss booth and on the day before the actual procedure. Thanks to proper training and practice, I methodically dissected my first lenticule, taking my time, and delivered 20/20 vision to my first patient!

A Point of Advice

"When docking, centration on the pupil or, even better, the corneal vertex is of paramount importance for a good visual outcome. Unlike LASIK, where a slightly decentered flap has a negligible effect on final outcome, a slightly decentered dock with SMILE can affect the visual outcome by inducing cylinder and higher-order aberrations.  

As a new SMILE surgeon, it is important to know that the dissection of the posterior and anterior planes is not to be rushed. A rushed dissection can result in torn and retained lenticule, the creation of a new corneal plane, or a slow visual recovery from too much tissue manipulation."

Luke Rebenitsch, MD


Six months and 100 SMILE eyes later, I can anecdotally discuss the advantages of SMILE and dispel some myths. I have found the procedure to be very accurate, and my percentage of 20/20 eyes is over 95%—close to the 88% achieved during the FDA trial. I had the benefits of having a better nomogram adjustment and correcting on the spherical equivalence, whereas the surgeons participating in the clinical trial did not. The four eyes that did not achieve 20/20 were of a -10.00 D myope, in whom I could not compensate with nomogram adjustment due to the upper limit allowed, and of a patient with residual astigmatism not detected preoperatively.

Postoperative visual recovery was rapid, with the majority of my day 1 postops seeing 20/20 in both eyes and occasionally 20/15. I have had more patients achieve a BCVA of 20/15 on postoperative day 1 after LASIK, but SMILE outcomes have been quite close. I attribute this rapid recovery to keeping the corneal epithelium constantly hydrated during surgery, performing gentle dissection intraoperatively, and having patients keep their eyes closed for the first 4 hours postoperatively. I also have not found centration on the visual axis to be an issue, as reported by other surgeons.

The claim to fame for SMILE is fewer dry eye issues postoperatively, which I can confirm in my experience. In fact, I operated on a pair of identical twins, one undergoing LASIK and one undergoing SMILE, both with similar prescriptions. At the 1-year checkup, the LASIK twin had superficial punctate keratitis, whereas at all the postop visits the SMILE twin did not.  

We found the conversion of patients who qualify for SMILE to be relatively easy. Our staff members and counselors have bought into the advantages of the procedure, and their enthusiasm comes across to patients. Likewise, patients are excited to qualify, and this, in turn, makes the surgeon eager to deliver even better results. It’s a win-win situation, where a good procedure begets excellent outcomes and excellent outcomes generate excited patients.

Gregory H. Phan, MD