When I tell people I perform the SMILE procedure, the first thing I often have to clarify is that I’m not a dentist! Of course, for me, SMILE refers to small-incision lenticule extraction, which is quickly becoming the corneal refractive surgery of choice for the modern consumer who wants more than their parent’s LASIK. The general public is not the only population who is under-informed about this innovative procedure; as a recent addition to the refractive surgery catalog in the United States, awareness of SMILE has a ways to go even among eyecare professionals. And as a doctor who has seen SMILE’s excellent outcomes, low retreatment rates, and the robust recovery of my own patients, I am here to provide some of the most important facts and personal findings.
But first, some pertinent background on SMILE and my experience with it. Since debuting in 2008, SMILE has become the preferred laser vision correction (LVC) procedure in many countries around the world. The FDA approved it for use in the United States for myopia in 2016 and for astigmatism in 2018. The subsequent success of the surgery led all four branches of the US military to approve it for use within their personnel; they are conducting ongoing clinical trials as well.
Currently, SMILE is capable of correcting nearsightedness up to -10.00 diopters, and -3.00 diopters of astigmatism.
When I recently did an analysis of the first half of this year, from January through June, I determined that 80% of my patients coming through the door meet these criteria and qualify for SMILE.
As an ophthalmologist and the owner of Goel Vision, I have performed over 95,000 LASIK procedures over the last 22 years. When I found myself faced with a LASIK non-compete, I implemented SMILE for suitable patients. Originally, I looked at it as a stop gap until after my non-compete expired. However, over that one-year period I became enamored with SMILE, especially after witnessing the patient satisfaction surrounding all aspects of the procedure. At my practice, we haven't looked back.
There are several benefits to SMILE that I want to share with optometrists.
The SMILE procedure is less invasive
Pre-operatively, SMILE is identical to LASIK, with similar contraindications. However, when it comes to the actual procedure, there are some critical differences.
With LASIK, you're making a flap and lifting it up. Unless you're a very experienced surgeon who's got your technique down so it's exactly the same every single time, you can sometimes have uneven outcomes. With SMILE, everything's contained within the cornea, so you're not going to have those issues. Also, because the treatment takes place under contact with the patient’s cornea, environmental factors won’t impact the treatment, which both reduces the learning curve and minimizes the need for complex nomogram adjustments.
As opposed to an excimer ablation, SMILE is performed with the VisuMax laser from ZEISS, a single laser that requires no manual calibration checks. In addition, with SMILE it is possible to treat the center of fixation—the angle kappa—which leads to more accurate outcomes.
After the surgery, the patient only comes back for one postoperative in-office visit and a second remote follow-up visit, which proved especially effective during COVID-19. As for the retreatment rate, it is quite low.
Additionally, less postoperative dry eye is a big advantage of SMILE over LASIK. Because you're cutting fewer of the corneal nerves on the surface, dry eye risk is reduced and tolerability is increased.
SMILE optimizes patient comfort and convenience
For patients, SMILE presents pros during all three phases of the treatment process.
Preoperatively, simply knowing there will be no flap can help alleviate some of the fear that prevents consumers from pursuing LASIK.
During the actual procedure, the corneal-only suction used to stabilize the eye during treatment minimizes both IOP increase and the subconjunctival hemorrhage present with other platforms, making for a more comfortable experience.
Following the surgery, patients can enjoy a normal night’s sleep—no goggles required, even on that first evening. And, with no flap, they do not have to avoid touching their eyes or wearing eye makeup. Unlike LASIK, with SMILE, they can resume swimming, going to the beach, and working out at the gym within 24 hours. And, as with other LVCs, patients can return to work the next day.
ODs are already equipped to co-manage SMILE
As with all co-management, the focus is on providing the patient with education, tailored treatment, and continuity of care.
Prior to surgery, it is ideal for the optometrist to address any corneal surface and dry eye issues. An OD’s education, experience, and available in-office equipment—such as intense pulsed light (IPL) and LipiFlow—make them well-equipped to diagnose the specific type of eye dryness and properly treat it. Often, when a patient comes to us with undiagnosed dry eye, we'll offer a general diagnosis and then send them back to their referring doctor for management.
Co-managing SMILE is a positive patient referral strategy
When an optometrist refers a patient, I realize their reputation is also on the line. If I'm a jerk or deliver a bad outcome or bad care, that individual is going to go back and tell the OD about it . . . and they should.
Offering an empowering experience and outlining options is really key to keeping patients happy. Therefore, it is important to educate patients on the pluses and minuses of all three laser vision correction procedures—SMILE, LASIK, and PRK—and to let them know they may not be a viable candidate for their top choice. When referring to a surgeon, this is critical, as you cannot be certain what the ophthalmologist's recommendation will be.
The conversation could entail explaining, “I think you're an excellent candidate for refractive surgery. I can refer you to this doctor who has access to all the best technology and offers more than one procedure.”
By offering multiple solutions, you can make certain the LVC is customized to the patient. That being said, I have found in my practice that eligible patients within the parameters are choosing SMILE 100% of the time and returning happy with their results.
Looking to the future
As for the future, keep an eye on ZEISS, which will be releasing the updated version of the VisuMax that promises to be even faster and more economical. Currently, the SMILE procedure takes about 25 seconds of laser time; the new laser is going to complete the job in 8 seconds. Other companies, including SCHWIND, Ziemer, J&J Vision, and Alcon could also be offering alternatives. We can also look out for an upcoming topography-guided version of SMILE.
With contact lens intolerance at an all-time high at 15%—that’s 30 million contact lens wearers—more and more people are turning to laser vision correction. Due to the favorable factors listed above, SMILE is quickly becoming the LVC procedure of choice outside of the US, where over 4 million procedures have been performed in over 80 countries. In the US, SMILE is gaining popularity among doctors and patients alike.
For optometrists competing with low-cost LASIK clinics, SMILE can become a blue ocean strategy to prevent losing patients to corporate chains. It can also prove a path for building business and growing relationships with ophthalmologists in your area.
And while it cannot completely replace LASIK and PRK, SMILE is definitely an invaluable addition to the refractive surgery arsenal of eyecare providers everywhere.