Published in Refractive Surgery

SMILE Revolution: A Perspective on Advancing Eyecare

This post is sponsored by Carl Zeiss Meditec

Jeffrey Augustine, OD; Lamont  Bunyon, OD; and Kathleen Jee, MD weigh in on SMILE, why it can be an exceptional choice for patients, and the importance of collaborative care.

SMILE Revolution: A Perspective on Advancing Eyecare
Doctors Augustine, Bunyon, and Jee would all agree—when treating refractive error, it all comes down to what’s right for the patient. Through a collaborative care approach involving both optometrists and ophthalmologists, eyecare providers today can embrace glasses, contact lenses, and refractive surgical options. What is recommended for any given case depends on whether a patient has myopia, presbyopia, astigmatism—as well as their age, health, and vision goals.
For myopes—especially myopes with astigmatism—Drs Bunyon and Augustine have exceptional success recommending small incision lenticule extraction (SMILE). Not only does SMILE quickly achieve a patient’s vision goals, the benefits of SMILE include a flapless procedure, minimal downtime, and a lower risk of dry eye post surgery.

Identifying patients for SMILE

When SMILE initially became available, it was only indicated for use with simple myopes. Today, the FDA-approved parameters have expanded. To be a SMILE candidate currently, a patient must have myopia between -1.00 D to -10.0 D, and astigmatism correction should be a minimum of -0.75 D up to -3.00 D of correction. The majority of patients who come in for refractive surgery consultations fall within these parameters.

SMILE is the refractive surgical technique of choice for patients with dry eye

Many eyecare professionals are used to patients dealing with eye dryness following laser vision corrections. In fact, it is one of the most common complications post-surgery. What makes SMILE different is that it’s a flapless procedure that leverages a smaller corneal incision. This means fewer corneal nerves are transected during the surgery, theoretically making it less prone to cause eye dryness.3
Drs Augustine and Jee have seen this born out with SMILE patients having fewer complaints of dry eye than LASIK patients. This is likely due to the fact that LASIK surgery creates a flap that has to be healed as part of the post-op process. With SMILE, the healing process is more comfortable, and in general, patients don’t have the challenges they may have with LASIK or PRK. Informally, patients who have the SMILE procedure reach their expectation of clear, comfortable vision more quickly than anticipated.

A closer look at the SMILE procedure

Dr. Jee breaks down the SMILE procedure in a case example:

  1. The eye is docked on the femtosecond laser (total laser time 15-20 seconds)
  2. The posterior aspect of the lenticule is cut from the periphery to center
  3. The side cut of the lenticule is created
  4. The anterior aspect of the lenticule is cut
  5. The anterior aspect of the lenticule is dissected by the surgeon
  6. The posterior aspect of the lenticule is dissected by the surgeon
  7. The lenticule is removed from the cornea via the small superior incision

How to talk to patients about SMILE

Drs Bunyon and Augustine have enjoyed incredible success with SMILE, which has been a game-changer for their practices. However, despite its benefits, many eyecare providers remain unfamiliar with the SMILE procedure or how to refer a patient to a surgeon who routinely performs SMILE. 

SMILE in the family

“William Wiley, MD, recently performed the SMILE procedure on my son. His father performed refractive surgery on my eyes 20 years ago, so in a way, it was seeing vision care come full circle—but even better because the technology has progressed so much in that time.”

— Jeffrey Augustine, OD

For all surgical procedures, it’s important to work with trusted doctors and clinicians. That’s something Drs. Augustine and Jee recommend for every optometrist, whether working in a primary care or refractive surgery center.
Patients are definitely interested in SMILE, and many will seek out a SMILE surgery center or surgeon on their own. It  can greatly benefit practice success and patient loyalty if ECPs can recommend a SMILE surgeon to patients.
In Dr. Augustine’s practice, as a rule, he provides comprehensive information about the advantages and disadvantages of PRK, LASIK, and SMILE. It’s never a one-size-fits-all, and patients appreciate having a deeper understanding of all possible options. While he works with LASIK and PRK patients, he finds that for myopes with astigmatism who fit the SMILE criteria, it’s really been a game-changer for them.
Drs Augustine and Bunyon both believe that it is important to take a proactive approach to discussing refractive surgery with patients. Because so many patients wrongly think that because they have astigmatism, they aren’t candidates for refractive surgery, it’s always important to bring up the possibilities of refractive surgery for any potential candidate who meets the criteria. On average, the doctors see about 6-8 patients on any given day who are candidates for SMILE, whether because they are myopes in monovision contacts or in careers like the military, where they would be better served by refractive surgery. They believe it’s the job of optometrists to let patients know about all of the options available for them.
When these patients come in for routine vision exams, it’s always a good idea to bring up the topic of refractive surgery as it’s impossible to know how many patients may desire those benefits but think they don’t qualify. It’s really important to let patients know about SMILE and make them aware of the advantages of this procedure.

“With SMILE, the post-op can be a lot easier. When you have a flap, you have to be concerned that everything is in place, and with SMILE that isn’t a concern.”—Lamont Bunyon, OD

The importance of collaborative care and post-operative considerations

Drs Augustine and Bunyon both agree that just as you want to have a good relationship with your patients, it’s equally important to have that same kind of relationship with a surgeon you trust. A surgeon relies on an optometrist for referrals, and as optometrists, we rely on surgeons to provide the best care for our patients.
* US Food and Drug Administration Summary of Safety and Effectiveness Data (SSED): VisuMax Fentosecond Laser—P150040/5003.
** US Food and Drug Administration Summary of Safety and Effectiveness Data (SSED): STAR S4 IRTM Excimer Laser System iDesign Advanced WaveScan StudioTM System.
US Food and Drug Administration Summary of Safety and Effectiveness Data (SSED): ALLEGRETTO WAVE® Eye-Q Excimer Laser.
Dr. Jee shares a surgeon’s perspective. From her first-hand experience, she believes the SMILE procedure is very reliable and the enhancement rate is noticeably lower than for LASIK. As a result, with SMILE, there’s a low incidence of needing to go back to fine tune refractive error after the procedure—it's only about 1.3%. And patients can have visual acuity of 20/25 or 20 /20 on day one, with the ability to resume their normal activities like exercising and wearing makeup.

First, I want to make sure that a patient fits the FDA parameters for the SMILE procedure. But another consideration is if a patient has preexisting dryness or they are on tears or drops. There’s an inherent advantage with the SMILE procedure for these patients, because it can lead to fewer dry eye issues post-operatively. If they come in with that history, SMILE is certainly top of my list in terms of their options.

—Kathleen Jee, MD

The other thing Drs Augustine and Bunyon recommend is to see the procedure for yourself and become familiar with it. Once you see it, you can become confident that it’s quick, efficient, and very elegant. And with SMILE, post-op may even be easier as an optometrist because you don’t have a flap or any risk for a dislocation or the things we usually worry about. Both doctors encourage all optometrists to consider SMILE for their myopes who fit the parameters of this very effective procedure. Refractive surgery is such a dynamic field that is becoming better every year for the patient. As eyecare professionals, part of the job is to ride that edge and deliver the best possible outcomes.
1. Smile eye surgery: Everything you need to know. ZEISS. (n.d.).
2. VisuMax femtosecond laser small incision lenticule extraction (smile ... (n.d.-b).
3.Wong AHY, Cheung RKY, Kua WN, Shih KC, Chan TCY, Wan KH. Dry Eyes After SMILE. Asia Pac J Ophthalmol (Phila). 2019;8(5):397-405.
4. Denoyer A, Landman E, Trinh L, Faure JF, Auclin F, Baudouin C. Dry eye disease after refractive surgery: comparative outcomes of small incision lenticule extraction versus LASIK. Ophthalmology. 2015;122(4):669-676.
5. Independent Research. (Jobson).
6. Schallhorn JM, Seifert S, Schallhorn SC. SMILE, Topography-Guided LASIK, and Wavefront-Guided LASIK: Review of Clinical Outcomes in Premarket Approval FDA Studies. J Refract Surg. 2019;35(11):690-698.
7. Summary of safety and Effectiveness Data (SSED). (n.d.).
8. Summary of safety and effectiveness data (SSED) - food and drug ... (n.d.-b).
Jeffrey Augustine, OD
About Jeffrey Augustine, OD

Dr. Augustine attended Illinois College of Optometry. He went on to complete his optometry residency at the Cleveland VA Medical Center. Dr. Augustine then completed a fellowship at the Newman Eye Institute in DeLand, Florida, focused on optometric refractive surgery clinical management.

Dr. Augustine has devoted his entire career since to the perioperative optometric management of the refractive surgery patient. Beyond managing thousands of patients over two decades, Dr. Augustine has written several iconic articles on the optometric management of the refractive surgery patient. He continues to lecture throughout the United States and is involved in many clinical research projects.

Jeffrey Augustine, OD
Lamont Bunyon, OD
About Lamont Bunyon, OD

Lamont Tyler Bunyon is a graduate of Hampton University (1994) and the New England College of Optometry (1999). Dr. Lamont has practiced optometry in Prince George’s County and the Washington, DC area for over twenty years. His practice specialties include dry eye care and hard to fit contact lens services.

Dr. Bunyon was awarded the 2012 Optometrist of the Year by the Maryland Optometric Association for the State of Maryland for his outstanding leadership skills and service to the profession, patients and the community. He has been a staff optometrist for Kaiser Permanente and the Lasik Vision Institute. Dr. Lamont has served in the past as First Vice President, Maryland Optometric Association, President, Central Maryland Optometric Society, Secretary and Treasurer for the National Optometric Association.

Lamont Bunyon, OD
Kathleen Jee, MD
About Kathleen Jee, MD

Kathleen Jee, MD, graduated summa cum laude from the University of Maryland with a bachelor’s degree in bioengineering. While obtaining her medical degree at Johns Hopkins University School of Medicine, she found herself innately drawn to ophthalmology and the profound manner in which patients’ quality of life can be improved. She completed her ophthalmology residency at the Wilmer Eye Institute at Johns Hopkins University, widely recognized as one of the top programs in the country.

Kathleen Jee, MD
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