Ophthalmic Medical Education Summit 2025 Beyond Routine: Complex Surgical Cases and Lessons Learned

This study examines the safety, efficacy, and efficiency of cataract surgery using the Zeiss Quatera platform in patients with known pre-existing retinal conditions.

Key endpoints for the study include the time and energy used during phacoemulsification, any change in retinal pathology post-surgery, and the ability to recognize pathology on the IOL Master. Dr. Ayres suggests that the best way to test phaco platforms is on challenging patients, such as those with retinal pathology.

In two case examples, using the QUATERA system was found to be safe and efficient, with no observed complications or progression of pre-existing retinal disease (AMD and Fuchs' endothelial dystrophy). Although the IOL Master 700's OCT function is not for diagnosis, Dr. Ayres believes it can reveal recognizable pathology, prompting the practitioner to obtain a full OCT of the patient.

This patient had a known history of macular degeneration and received injections for that. Her best corrected visual acuity (BCVA) was 20/200 OD and 20/400 OS. “Now, when we compare the standard OCT here, the one done on the Heidelberg machine, if we look at the little fixation OCT where you're supposed to catch the macula, you do see a little bit of pathology on both the right and left eye. So in a case like this, I do think that there is enough recognizable on the IOLMaster to at least warn a technician or warn a practitioner. Hey, you might want to get a traditional OCT on this patient to make sure there's not significant pathology,” says Dr. Ayres.

Figures 1 and 2 show standard OCT in an IOLMaster compared to OCT with Heidelberg OCT.

Phacoemulsification time was 4 minutes and 26 seconds. A capsule tension ring was used due to a dense cataract and some zonular laxity. Post-surgery, her vision improved from a baseline of 20/200 OD to 20/30, enabling her to return to day and nighttime driving vision. Her VA did not change OS because of the macular pathology. The Fuchs' endothelial dystrophy did not progress after the surgery.

This patient had BCVA of 20/200 OD and 20/40 OS. Phacoemulsification time was 1 minute and 58 seconds. Standard OCT on the IOLMaster showed retina pathology. Patient’s BCVA improved from 20/200 to 20/100 OD, and 20/40 to 20/20 OS.

Dr. Ayres adds, “So in summary, cataract surgery done in patients with retinal pathology using the QUATERA cataract system seems to be safe and efficient even in these patients, who probably have overall worse cataracts than average and pathology preexisting in the back of the eye. We've not seen any complications from the cataract surgery so far. We've not seen any progression of retinal disease with an excellent safety profile. Now, as we continue the study, we'll be able to tabulate more data. And eventually this should come as a publication or a presentation at either one of the large meetings or in one of the commonly reviewed journals.”

Optic capture is a useful technique for managing capsular rents, as it provides a stable, predictable, effective lens position.

This technique is used to stabilize an IOL, particularly a toric lens, when a posterior capsular rent is present at the haptic placement site, thereby reducing the risk of lens dislocation. The haptics of the one-piece IOL are left in the capsular bag, and the optic is prolapsed over the anterior capsular rhexis to hold it centered and stable (Figure 3).

“One-piece lenses can never go in the ciliary sulcus. They have thick square-edge haptics that are designed to fibrose into the capsule bag and prevent posterior capsule opacification, which they're really, really effective at. But if you leave those haptics initially sulcus the movement of the iris over that lens will chase the iris,” says Dr. Schallhorn. This can cause pigment dispersion, cystoid macular edema, and unhappy patients.

The standard protocol for a posterior capsular rent is to insert cohesive or dispersive viscoelastic, suture the main incision, and then perform a vitrectomy. After the posterior vitrectomy, residual cortical material should be removed.

The incision should be enlarged to insert a sulcus lens without causing high pressure.

A monofocal lens is typically the only option when the posterior capsule is completely blown out. The lens is then secured using optic capture to ensure centration and a predictable, effective lens position.

In the event of a posterior capsular rent, the most important thing is to take deep breaths and remember your training.

Dr. Moarefi recounted a case where the patient moved during the anterior pass of the SMILE procedure, resulting in a decentered anterior cut. Since the posterior cut (the refractive cut) was excellent, he proceeded with the dissection and successfully removed the entire lenticule, leading to a perfectly normal visual outcome for the patient.

The critical takeaway for surgeons is that if any movement or suction loss occurs during the posterior plane, the case must be aborted. “The most important is the posterior plane dissection. Okay. If it's just performed, it's okay to proceed if you feel comfortable. If there's suction loss or movement on that posterior plane, just abort. And so, if it does happen in the posterior plane, you can convert to LASIK right then and create a flap. Or you can pause and come back another day and either perform LASIK or PRK based on your comfort level,” says Dr. Moarefi.

Dr. Moarefi noted soft epithelium at the wound entry point during removal of the lenticule in the contralateral eye, which, if left unaddressed during the procedure, could lead to epithelial ingrowth.

A 37-year-old female patient's vision in the right eye decreased from 20/20 to 20/40 two months post-SMILE due to epithelial ingrowth, as confirmed by topography and OCT (Figure 4). “I find the OCT to be helpful in helping us see how thick and dense it is. And also, we can track the growth of it,” says Dr. Tabanfar.

Epithelial ingrowth is a rare post-operative complication with SMILE. “It is possible for some of the epithelial cells to get under at the interface and grow. And it's not visible, and you won't be able to see them on day one. No matter how hard you look, they're tiny. The best time to visualize these things, depending on how fast they grow, is somewhere between month one and month two,” says Dr. Tabanfar

Since the patient’s vision was affected, Dr. Moarefi removed the ingrowth, and the patient's vision returned to 20/20 one month later, with no visible ingrowth. Dr. Tabanfar adds, “even though there is no flap with smile, we still sometimes might come across some of these rare cases. And often, if the vision is not involved and the growth is not really growing, then we might want to leave them alone. But as soon as the vision gets affected, then there's really not a whole lot of reason to not go through removing it.”

Performing corneal topography as a follow-up can help identify these rare situations. Dr. Tseng states, “I think we really rarely notice any flap complications when there is no flap, you know, being involved in smile. So things that we really want to pay attention to are just on their follow-up, whether that's one month or two months, to make sure we take our topography, even if it's very, very small, we want to be able to catch and monitor anything.”

Dr. Moarefi points out that epithelial ingrowth is uncommon even in LASIK, as good surgical technique is necessary. “And so we do a really good job of making sure we're very thorough in making sure that if there is any epi defect at the incision point, we're making sure that we fully irrigate and that we check closely, because if there is anything that we see, we go and just remove it at that time. So we don’t have to deal with this later on.”

SMILE is a minimally invasive, flapless procedure. Its advantages include a faster recovery, with most patients achieving 20/20 vision the day after the surgery. Additionally, patients experience reduced reliance on artificial tears and lubrication due to less disruption of corneal nerves. This procedure also eliminates concerns related to flap complications. The quick recovery and reduced likelihood of dry eyes make it a great option for individuals with active lifestyles.

For optometrists, the post-operative care is easier because there is no flap to worry about (e.g., microstriae or DLK), allowing for confident co-management from day one. Dr. Tabafar states, “So I think in, as far as being able to incorporate it into our co-management, SMILE lends itself beautifully to ODs being able to take charge of… post-operative care, with confidence and without a whole lot of concerns about ‘oh do I need to send the patients back to the surgeon or not?’ So it becomes more of maintaining our patients and our independence of managing our patients.”

Brandon Ayres, MD, discusses the transition from LASIK to SMILE with Drs. Amoarefi, Tseng, and Tabanfar.

While there is a learning curve for surgeons transitioning from LASIK to SMILE, the procedure becomes "more fun" and efficient. Dr. Moarefi comments, “I always say that if LASIK and PRK had a baby, it would be SMILE… Like any procedure, when you first start, there is a learning curve. It is important to kind of start slow, do maybe more higher prescription cases. So there's a thicker lenticule just to get comfortable and then work your way down to a slightly thinner lenticule.”

Dr. Moarefi explains that while LASIK is generally a more straightforward procedure than SMILE, SMILE's minimally invasive nature, which causes less disruption to corneal nerves, can be advantageous for patients.

He likens the difference between SMILE and LASIK to the comparison between laparoscopic surgery and open-incision surgery.“It's the same way, like when people used to get appendicitis back in the day, we used to make, like, a large incision in their abdomen, and now it's laparoscopic. We make three tiny little incisions SMILE. I look at it like a laparoscopic LASIK and like when the old surgeons had to switch from an appendectomy to a laparoscopic appendectomy, there was a learning curve. And there are certain things that we have to watch out for. Overall, though, I think it's very simple. You just start, you know, with cases that are easier to perform, you get the hang of it, but it becomes a lot more fun,” says Dr. Moarefi.

SMILE provides a rapid recovery, with most patients achieving 20/20 vision the day after the procedure. Patients typically experience less reliance on artificial tears and lubrication during the recovery phase. Many choose SMILE because it is less invasive, involves minimal downtime, and reduces the risk of flap complications, such as accidentally rubbing the eye. “Seeing how the patients, you know, recover and have less dry eyes, and really what the patients want as much as you have a great relationship with them, they don't really want to see you again. So the less that they have to come back to the office and visit us for post-operative visits, for dry eyes, for, you know, any flap-related complications, it's just better overall for the patient,” says Dr. Moarefi.

Dr. Moarefi notes that LASIK will not be replaced, as it offers an advantage due to its larger treatment window, but SMILE is a valuable addition to a surgeon's tool belt.

SMILE eliminates the need for a flap and the complications associated with it, disrupting fewer corneal nerves. Unlike LASIK enhancements, where ingrowth may return, epithelial ingrowth after a primary SMILE procedure is typically "one and done" after removal, with no regrowth.

“There's generally two reasons for it. One is where the incision has been made to remove the lenticule, sometimes we get some epi cells moving in. And the second rare occasion that can happen is if there's any perforation of the cornea during the cap. So if the instrument can, perforate the cornea and then we can get some small cells in” Dr. Tabanfar states. “Generally, it's not an open channel that cap closes. And, also when the incision heals, we don't really get a constant inflow on the micro channels that are open for the cells to feed. So we usually don't see a chronic [case],” says Dr. Tabanfar.