Learning Curve of Small Incision Lenticule Extraction: Challenges and Complications

Titiyal, Jeewan S; Kaur, Manpreet; Rathi, Anubha; Falera, Ruchita; Chaniyara, Manthan Hasmukhbhai; Sharma, Namrata

doi:10.1097/ico.0000000000001323

Cited by 73 publications

(71 citation statements)

References 17 publications

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“…However, the steep learning curve of SMILE may prove to be challenging especially for beginners. 11 , 12 A stepwise approach consisting of observation, initial wetlab training, and flap-based refractive lenticule extraction (femtosecond lenticule extraction [FLEx] and pseudo-SMILE) may help to familiarize the novice surgeon with lamellar separation and handling the refractive lenticule. 1 , 11 , 13 A high incidence of intraoperative complications may be observed during the initial learning phase, and the majority of these are a result of difficult lenticule dissection and extraction.…”

Section: Introductionmentioning

confidence: 99%

Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives

Titiyal¹,

Kaur²,

Shaikh³

et al. 2018

OPTH

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Refractive lenticule extraction is becoming the procedure of choice for the management of myopia and myopic astigmatism owing to its precision, biomechanical stability, and better ocular surface. It has similar safety, efficacy, and predictability as femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and is associated with better patient satisfaction. The conventional technique of small incision lenticule extraction (SMILE) involves docking, femtosecond laser application, lenticule dissection from the surrounding stroma, and extraction. It has a steep learning curve compared to conventional flap-based corneal ablative procedures, and the surgical technique may be challenging especially for a novice surgeon. As SMILE is gaining worldwide acceptance among refractive surgeons, different modifications of the surgical technique have been described to ease the process of lenticule extraction and minimize complications. Good patient selection is essential to ensure optimal patient satisfaction, and novice surgeons should avoid cases with low myopia (thin refractive lenticules), difficult orbital anatomy, high astigmatism, or uncooperative, anxious patients to minimize complications. A comprehensive MEDLINE search was performed using “small incision lenticule extraction,” “SMILE,” and “refractive lenticule extraction” as keywords, and we herein review the patient selection for SMILE and various surgical techniques of SMILE with their pros and cons. With increasing surgeon experience, a standard technique is expected to evolve that may be performed in all types of cases with optimal outcomes and minimal adverse effects.

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Section: Introductionmentioning

confidence: 99%

Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives

Titiyal¹,

Kaur²,

Shaikh³

et al. 2018

OPTH

Self Cite

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“…For comparison with other studies, a literature review was performed to find all reports of suction loss in SMILE. Twenty-two studies were identified and the suction loss incidence is summarized in Table 5 Wang et al 2013Wang et al , 2014Wang et al , 2017Ganesh & Gupta 2014;Ivarsen et al 2014;Sekundo et al 2014;Wong et al 2014, Kamiya et al 2015Ramirez-Miranda et al 2015;Xu & Yang 2015;Donate & Thaeron 2016;FDA, 2016;Liu et al 2016;Osman et al 2016;Pradhan et al 2016;Yildirim et al 2016; Gab-Alla 2017; Park & Koo 2017;Pedersen et al 2017;Taneri et al 2017;Titiyal et al 2017;Damgaard et al 2018). For studies with large populations of more than 1500 procedures (Ivarsen et al 2014;Liu et al 2016;Osman et al 2016;Pradhan et al 2016;Park & Koo 2017;Wang et al 2017), the incidence was similar to the 0.50% in the current study, ranging from 0.17% (Pradhan et al 2016) to 0.20% (Park & Koo 2017), 0.41% (Liu et al 2016), 0.78% (Ivarsen et al 2014), up to 0.93% (Wang et al 2017), and a highest value of 2.10% (Osman et al 2016).…”

Section: Discussionmentioning

confidence: 99%

Suction stability management in small incision lenticule extraction: incidence and outcomes of suction loss in 4000 consecutive procedures

Reinstein

Archer

Vida

et al. 2019

Acta Ophthalmologica

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Purpose: To report the incidence and outcomes of suction loss during small incision lenticule extraction (SMILE). Methods: The incidence of suction loss was measured over 4000 consecutive SMILE procedures and categorized by cause, the interface in which suction was lost and management (restart/continue SMILE, re-SMILE thinner cap, convert to laser in-situ keratomileusis [LASIK]). One-year outcomes were compared to the fellow eye where no suction loss occurred. Results: There were 20 cases of suction loss (0.50%): during the lenticule interface in seven eyes, lenticule side cut in one eye, cap interface in nine eyes and small incision for three eyes. Small incision lenticule extraction (SMILE) was continued in seven eyes, thinner cap SMILE in four eyes, LASIK in eight eyes, and the small incision was manually completed in one eye. Suction loss was caused by a Bell's reflex in 10 eyes, fixation light tracking in six eyes, patient anxiety in two eyes, a nociceptive reflex in one eye and false suction in one eye. There was no difference in results for suction loss and fellow eyes, respectively: uncorrected distance visual acuity was 20/20 or better in 100% in both groups, spherical equivalent was within AE0.50 D in 85% and 79%, one line loss of corrected distance visual acuity in 5% and 0%, and no eyes lost two lines. Conclusion: Suction loss can be managed depending on the interface during which suction is lost. Treatment was completed on the same day in all instances. Visual and refractive outcomes were unaffected compared to the fellow eye in this series. PatientsThis was a retrospective non-comparative case series of all myopic SMILE e72 Acta Ophthalmologica 2020

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Section: Refractive Lenticule Extraction (Relex)mentioning

confidence: 99%

“…Lenticule dissection and extraction is the most challenging step and can lead to complications, such as tear of anterior cap or side cut, posterior stromal damage, and partially or completely retained lenticule [39]. However, these complications are related to inexperience and may decrease with the learning curve [37,39]. Complications, including suction loss, incisional bleeding, OBL, and inaccurate laser pulse placement, have also been reported; however, these can mostly be resolved with appropriate management [40].…”

Section: Refractive Lenticule Extraction (Relex)mentioning

confidence: 99%

Application of Femtosecond Laser in Anterior Segment Surgery

Han

Liu

Mohamed-Noriega

2020

Journal of Ophthalmology

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Femtosecond laser (FSL) is a near-infrared laser that can create reliable and reproducible tissue cutting with minimal damage to adjacent tissue. As the laser can also create incisions with various orientations, depths, and shapes, it is expected to be a useful tool for anterior segment surgery, such as cornea, refractive, and cataract surgery. In this review, the authors will introduce the application of FSL in various anterior segment surgeries and discuss the results of studies regarding the efficacy and safety of FSL in cornea, refractive, and cataract surgery. Experimental studies regarding the potential use of FSL will also be introduced. The studies discussed in this review suggest that FSL may be a useful tool for improving the prognosis and safety of surgeries of the anterior segment.

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Learning Curve of Small Incision Lenticule Extraction: Challenges and Complications

Abstract: The learning curve of SMILE is surgically challenging. Lenticule dissection and extraction is the most difficult step and leads to a multitude of complications. Most complications that result in delayed visual recovery are observed in the initial 50 cases.

Cited by 73 publications

References 17 publications

Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives

Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives

Suction stability management in small incision lenticule extraction: incidence and outcomes of suction loss in 4000 consecutive procedures

Application of Femtosecond Laser in Anterior Segment Surgery

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