Visual and Refractive Outcomes Following SMILE to Correct Myopia Performed by Surgeons in Training

Abstract

PURPOSE: To assess visual outcomes and complications following small incision lenticule extraction (SMILE) performed by cornea fellows under the supervision of experienced surgeons. METHODS: This retrospective, noncomparative case series was designed to assess outcomes following SMILE procedures performed at a large surgical center by cornea fellows between May 1, 2012 and March 30, 2015. Preoperative and postoperative uncorrected distance visual acuity (UDVA), preoperative and postoperative corrected distance visual acuity (CDVA), spherical equivalent (SE) up to −10.00 diopters (D), and complications were recorded. RESULTS: A total of 114 patients (228 eyes) met the inclusion criteria. The mean preoperative SE was −5.79 ± 1.95 D (range: −1.75 to −10.00 D) and the mean cylinder was −2.21 ± 1.43 D (range: 0.00 to −5.50 D). At the last follow-up visit (average: 6.4 months), 94% of the patients achieved a UDVA of 20/30 or better and 96% of the patients achieved stability in their vision. Adverse events were encountered in 40 eyes (17.5%), with epithelial defect being the most common. Two patients required a second intervention to improve visual outcomes. CONCLUSIONS: SMILE performed by cornea fellows under the supervision of an experienced surgeon is an effective and safe refractive procedure with a short learning curve and excellent visual outcomes. [ J Refract Surg . 2022;38(1):28–34.]

A Literature Review of the Incidence, Management, and Prognosis of Corneal Epithelial-Related Complications After Laser-Assisted In Situ Keratomileusis (LASIK), Photorefractive Keratectomy (PRK), and Small Incision Lenticule Extraction (SMILE)

“…Also, Ramirez-Miranda et al’s study surveilled 160 eyes undergoing SMILE for postoperative complications and found that the most common postoperative complication was epithelial defect, representing 11.2% incidence. Once again, the authors attributed this to surgical experience as these defects occurred with surgeons that were acclimating to the technique required to dissect and extract a lenticule, noting that after 4-6 SMILE surgeries, the defect disappeared [ 25 ].…”

“…Epithelial defects occur less frequently in SMILE compared to LASIK [24][25][26][27]. Visual prognosis following treatment is generally favorable [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38].…”

“…Epithelial defects occur less frequently in SMILE compared to LASIK [24][25][26][27]. Visual prognosis following treatment is generally favorable [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]. The average incidence of epithelial defects in SMILE is 3.3% with a reported incidence range of 0.17%-17.5%, based on nine studies (Figure 5 and Table 2) [24][25][26][27][28][29][30]37,38].…”

Incidence and Management of Epithelial-Related Complications After SMILE

“…Incidence for epithelial defects and abrasions after SMILE range from 0.17% 6 to 7.4%. 14 In another study, Ramirez-Miranda et al reported an incidence of 11.25% of epithelial defects after SMILE; however, the surgeons performing SMILE in this study were recently introduced to the SMILE surgical technique. 15 This technique included the use of a spatula to remove the lenticule; however, it is noted that forceps can also be used for this process while performing the surgery.…”

The evolution of refractive surgery training

“…The procedure involves femtosecond laser creation of a small lenticule of anterior stroma, which is subsequently removed through a 2 to 3 millimeter tunnel incision. Ramirez-Miranda et al published the first reported outcomes of SMILE performed by trainees, reviewing cases performed by 9 fellows [10 ▪▪ ]. They found that 97% of patients had 20/40 vision or better at 6 months postoperatively; however only 61% of patients had 20/20 vision or better.…”