Eyeworld Supplements

SUPPLEMENT TO EYEWORLD | DECEMBER 2021 | 3 Sponsored by Carl Zeiss Meditec are much more densely packed, so there's more tensile strength," Dr. Rostov said. "So when you talk about residual stromal bed with SMILE, you're talking about the 120 microns of anterior cap plus the residual stromal bed. There's a lot more tensile strength there." Several studies have been published comparing the biomechanical proper- ties of SMILE and LASIK. These studies acknowledged that both procedures affect and alter corneal biomechanics but sug- gest that SMILE has less of an effect. 2–4 Recovery The postop recovery period is distinctive with SMILE as well. Dr. Goel said he's had patients call him saying the office forgot to provide goggles or shields for night- time wear postop. They're thinking of their friends who had to wear protection after LASIK, he said. "I say, 'No, we didn't forget. You don't need them,'" he said. The physicians said their recom- mendations for getting back to normal activities is faster with SMILE. Dr. Rostov tells her patients to restrict physical activ- ity for 3 days postop because she doesn't want dust or dirt to enter the eye. It also helps remind the patient to be gentle with the eye. "You did make a very small incision, and I don't want them to get infected," she said. Dr. Goel said the return to activities, after 24 hours, is one of the selling points for his SMILE patients. As long as they've taken the drops, Dr. Goel said they have no restrictions activity wise. "They are back to the normal activ- ities the next day. They can hit the gym, hit the beach, the pool, and wear eye makeup. This messaging resonates with them," he said. Another benefit of SMILE that Dr. Goel experienced is fewer postop com- plications, making the co-management experience with ODs positive and even giving these ODs more confidence with the procedure. "I had a couple of co-managing ODs say, 'I've checked the vision, looked at the cornea, only see a small incision, and all is well. There is no dry eye and the pa- tient is happy. Am I supposed to be doing anything else?' I tell them that is all there is to do and to see them back in 1 year or sooner if needed," he said. SMILE yields superior visual outcomes SMILE first received FDA approval as a corneal refractive procedure for myopia in 2016 (it was later expanded for cor- rection of myopic astigmatism in 2018). Since then, many physicians who have adopted SMILE say it quickly became their preferred laser refractive surgery. For Dr. Liu, it took less than a year for SMILE to become the most common procedure at the refractive clinic where she now practices in the Los Angeles met- ropolitan area. SMILE was introduced to the practice slowly and neutrally, yet within 6 months, based on results and patient experience, it became the dominant refractive pro- cedure. The practice's clinic counselors began seeing the benefits of SMILE and the impact the procedure had on the clin- ic day and the patient experience. "Once they're convinced, they're very good at conveying to the patients what the best procedure is for them," she said. A nomogram brings more cases closer to target Dr. Liu shared data from her most recent 100 eyes (excluding 14 that had de- creased BCVA at baseline, non-compli- ance issues, etc.). The average spherical equivalent at baseline was –4.5 D. At postop day 2–3 (the practice's COVID-19 SMILE follow-up protocol), 90% of pa- tients had 20/20 UCVA and 100% were 20/25. Dr. Liu used a practice-specific nomo- gram to achieve these results and offered some thoughts on how to get started. The general consensus, based on literature and practical experience, is to increase the sphere and cylinder by 10% out of the box. Each laser, however, has its own "personality," and nomograms tend to be laser-specific vs. surgeon-specific as it is for LASIK. There are instances of lasers doing very well without any adjustment, Dr. Liu said. To avoid clinically significant overcorrection prior to getting enough data, consider starting with younger patients, she added. Before using a nomogram adjust- ment, Dr. Liu's data showed that 100% of her cases were within 1 D of target and 91% were within 0.5 D of target. After implementing the nomogram adjustment, all of her cases have been within 0.5 D of target. Dr. Liu acknowledged that obtaining data to create and refine a nomogram Examples of postop day 1 SMILE patients Source: Audrey Talley Rostov, MD continued on page 4

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