Small incision lenticule extraction (SMILE) continues to evolve with the introduction of the VisuMax 800 and SMILE Pro, offering faster laser times and improved workflow.1,2 Despite these advances, one of the most common intraoperative challenges remains the same: reliable identification of the anterior (cap interface) and posterior (lenticule interface) dissection planes.
Incorrect plane identification can lead to difficult dissections, lenticule tearing, or unintended posterior plane manipulation.3 Over time, I have adopted a systematic, reproducible approach that allows me to confirm both planes early and proceed with confidence. This article outlines my technique, which is demonstrated step-by-step in the accompanying surgical video.
5 Steps to hard-stop plane identification
Step 1: Identify the lenticule edge from the superior SMILE opening incision
After docking and laser delivery, I begin by carefully identifying the lenticule edge from the superior opening incision. Rather than immediately dissecting, I take a moment to visually confirm the lenticule boundary, using the subtle interface bubbles as a guide.
This initial pause is important. Knowing where the lenticule begins frames every subsequent movement and reduces unnecessary manipulation.
Step 2: Open the SMILE incision pocket
Once the lenticule edge is identified, I gently open the SMILE opening incision pocket. At this stage, the goal is not full dissection but creating controlled access and maintaining orientation.
I avoid aggressive movements early, as premature dissection without clear plane identification is a common source of difficulty later in the case.
Step 3: Create a partial posterior plane pocket at the lenticule edge
From the incision, I advance the spatula centrally, positioning the tip at the edge of the lenticule (lenticule side-cut), guided by the visible bubble pattern.
The spatula is angled approximately 20 to 30° inferior to the corneal plane. From this position, I gently move to one side only—either left or right—creating a partial pocket, but intentionally not dissecting fully in both directions.
This step is deliberate. The goal is to establish a reference pocket without confusing planes or over-dissecting prematurely.
Step 4: Identify and sweep the anterior plane
Next, I move to the opposite side of the partial posterior pocket I just made in the previous step. Here, I gently lift the cap in the meniscus area (space between the outer cap cut and the inner lenticule cut), confirming that I am in the anterior plane.
Rather than performing a full anterior dissection, I sweep the spatula from the point of engagement (in my case, the right side) all the way to the opposite side, crossing the previously created partial posterior pocket. This provides spatial confirmation and ensures that one plane—the anterior plane—is fully and confidently identified.
At this point, one plane is definitively established.
Step 5 (crucial): Confirm both planes using a hard-stop test
This is the key step of the technique.
I return to the initial pocket created in Step 3, which should represent the posterior plane. From this position, I gently advance the spatula tip toward the opposite side.
- If I encounter a firm hard stop, I know with certainty that both planes have been identified.
- If there is no resistance, I know that I am still within the anterior plane and need to spend additional time identifying the true posterior plane before proceeding.
This simple maneuver removes ambiguity. Rather than guessing based on tissue feel alone, it provides a binary confirmation that prevents incorrect posterior dissection.
An additional advantage of this approach is that if resistance is not encountered and a true posterior pocket has not yet been created, the bubble patterns remain intact. These bubbles serve as a reliable visual guide, allowing re-engagement of the lenticule edge and accurate identification of the posterior plane without losing orientation or tissue landmarks.
Completing the case
Once both anterior and posterior planes are confidently identified, I proceed by fully dissecting the anterior plane first.
I then move to the posterior plane, deliberately leaving a few clock hours undissected to serve as a posterior plane anchor, which helps maintain orientation and lenticule stability.
After completing the majority of the posterior dissection, the remaining anchored segment is dissected last. With both planes fully dissected in this sequence, lenticule removal is smooth and controlled.
Final thoughts
SMILE Pro with the VisuMax 800 offers significant advantages, but plane identification remains a critical surgical skill. This method provides a repeatable framework rather than a subjective feel-based approach.
By intentionally creating reference pockets, fully establishing one plane, and using a hard-stop confirmation to identify the second, surgeons can reduce uncertainty and improve consistency.
I encourage surgeons to adapt this sequence to their own style while maintaining the core principle: confirm both planes before committing to full dissection.
