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Modified Technique for Small-Incision Lenticule Extraction: Ye's Swing Technique. Ophthalmol Ther 2023; 12:365-376. [PMID: 36402902 PMCID: PMC9834450 DOI: 10.1007/s40123-022-00612-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION This study aimed to evaluate the lenticule integrity and refractive outcomes of a new technique, Ye's swing technique, during small-incision lenticule extraction (SMILE). METHODS This prospective study enrolled patients who underwent the SMILE procedure using a modified technique for lenticule dissection. Per the standard SMILE procedure, the cap cut was opened using a hook, and an anterior dissection was performed with a counterclockwise swing, from 8 to 12 o'clock. A posterior dissection was then performed by swinging counterclockwise, leaving a thin band of the peripheral rim undissected, from 8 to 4 o'clock. The counterclockwise swing was continued to separate the edges of the rim from 4 to 12 o'clock, after which microforceps were used to extract the lenticules. The primary outcome measures were safety and lenticule integrity at the end of the surgery, and the secondary outcome measure was efficacy. Changes in the ocular parameters from the preoperative visit to 1 month postoperative, including uncorrected and corrected distance visual acuity, manifest refraction, lenticule quality, and lenticule residual, were assessed using optical coherence tomography. RESULTS A total of 246 patients (490 eyes) with myopia and myopic astigmatism were included in the present study. The dissected lenticules ranged in size from 52 to 148 µm. Postoperatively, the lenticule was completely and successfully extracted in all cases. There was no incisional edge tearing during lenticule separation. CONCLUSIONS Ye's swing technique is a safe and effective procedure for lenticule dissection and refractive outcomes. We have now adopted this technique as our routine method for performing the SMILE procedure.
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Agarwal R, Puri P, Bafna RK, Chetan C, Sharma N. Inverse centripetal dissection: A rescue technique for mis-dissected lenticule during SMILE. Eur J Ophthalmol 2021; 31:3537-3541. [PMID: 34030503 DOI: 10.1177/11206721211018347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Management of mis-dissected lenticule during Small-incision lenticule extraction (SMILE) is technically challenging and might be experienced more by novice surgeons especially in eyes with low refractive errors and thin lenticules. Presently, we describe a rescue method of inverse centripetal dissection (ICD) to manage mis-dissected lenticules. In this technique, after inadvertent dissection of posterior plane prior to anterior plane, the double-ended SMILE dissector is rotated along its shaft axis clockwise from the left upper margin of the mis-dissected lenticule to form an inversely folded lenticule which is then subsequently dissected centripetally till midline. This is then extracted by performing lenticulorrhexis with a pair of microforceps. We performed this technique in 10 eyes of 10 patients and the lenticule extraction was accomplished successfully in all eyes. At six months follow-up, the uncorrected visual acuity was 20/20 with a clear interface in all eyes. The ICD approach might serve as a useful rescue technique for managing mis-dissected lenticules.
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Affiliation(s)
- Rinky Agarwal
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences New Delhi, India
| | - Prabhav Puri
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences New Delhi, India
| | - Rahul Kumar Bafna
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences New Delhi, India
| | - Chetan Chetan
- Department of Optometry, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences New Delhi, India
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Sachdev GS, Ramamurthy S. Decade - long journey with small incision lenticule extraction: The learnings. Indian J Ophthalmol 2020; 68:2705-2710. [PMID: 33229646 PMCID: PMC7856951 DOI: 10.4103/ijo.ijo_2622_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Over the past decade, small incision lenticule extraction (SMILE) has revolutionized the field of keratorefractive surgery. With the promise of superior corneal biomechanics and reduced postoperative dry eye, SMILE afforded a distinct advantage over flap-based procedures. Our evolving understanding of the surgical technique and management of its unique complications has further enhanced the outcomes. This review will highlight specific pearls on various preoperative and intraoperative principles allowing optimization of outcomes with SMILE.
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Affiliation(s)
- Gitansha S Sachdev
- Refractive Services, The Eye Foundation, RS Puram, Coimbatore, Tamil Nadu, India
| | - Shreyas Ramamurthy
- Refractive Services, The Eye Foundation, RS Puram, Coimbatore, Tamil Nadu, India
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Arba Mosquera S, Verma S. A review of clinical outcomes following SMILE for the treatment of astigmatism. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1810017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Samuel Arba Mosquera
- Biomedical Engineering Office, Research and Development, SCHWIND Eye-tech-solutions GmbH, Kleinostheim, Germany
| | - Shwetabh Verma
- Biomedical Engineering Office, Research and Development, SCHWIND Eye-tech-solutions GmbH, Kleinostheim, Germany
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Kind R, Kiraly L, Taneri S, Troeber L, Wiltfang R, Bechmann M, Meyer B, Greene B, Sekundo W. Flushing versus not flushing the interface during small-incision lenticule extraction. J Cataract Refract Surg 2019; 45:562-568. [PMID: 30846349 DOI: 10.1016/j.jcrs.2018.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/29/2018] [Accepted: 12/02/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To assess the differences in outcomes between interface flushing with a balanced salt solution after refractive lenticule removal in simultaneous uneventful bilateral small-incision lenticule extraction (SMILE). SETTING Six study centers in Germany. DESIGN Prospective case series. METHODS Patients with myopia or myopic astigmatism of similar magnitude in both eyes with a spherical equivalent less than or equal to 10.0 diopters (D), preoperative corrected distance visual acuity (CDVA) of 0.80 decimal or better, and anisometropia less than or equal to 2.0 D were enrolled and followed for 3 months. One eye of each patient was treated with interface flushing after dry extraction of the lenticule. Flushing was performed with 1.0 cc balanced salt solution using a single-use 27-gauge cannula. The uncorrected distance visual acuity (UDVA) at 1 day, 1 week, and 3 months; the CDVA at 3 months; and postoperative differences at the slitlamp examination were recorded. Statistical analyses were performed with logarithm of the minimum angle of resolution values using paired t tests. The P value for significance was less than 0.05. RESULTS The study analyzed 470 eyes. One day postoperatively, the mean UDVA was 0.81 in the non-flush group and 0.83 in the flush group (P = .110). At the last visit 3 months postoperatively, the mean UDVA was 1.04 and 1.05, respectively (P = .172). No significant differences in the rate of postoperative complications were found. CONCLUSION Interface irrigation with 1.0 cc of balanced salt solution after the removal of the refractive lenticule has neither advantages nor disadvantages in terms of visual recovery, postoperative complications, or final visual acuity.
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Affiliation(s)
- Ralf Kind
- Department of Ophthalmology, Philipps University of Marburg, Marburg, Germany.
| | | | - Suphi Taneri
- SMILE EYES, Muenster, Germany; SMILE EYES, Zentrum Fuer Refraktive Chirurgie, Muenster, Germany
| | | | | | | | | | - Brandon Greene
- Institute of Medical Biometry and Epidemiology, Philipps University of Marburg, Marburg, Germany
| | - Walter Sekundo
- Department of Ophthalmology, Philipps University of Marburg, Marburg, Germany; SMILE EYES, Marburg, Germany
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Titiyal JS, Kaur M, Shaikh F, Gagrani M, Brar AS, Rathi A. Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives. Clin Ophthalmol 2018; 12:1685-1699. [PMID: 30233132 PMCID: PMC6134409 DOI: 10.2147/opth.s157172] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Refractive lenticule extraction is becoming the procedure of choice for the management of myopia and myopic astigmatism owing to its precision, biomechanical stability, and better ocular surface. It has similar safety, efficacy, and predictability as femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and is associated with better patient satisfaction. The conventional technique of small incision lenticule extraction (SMILE) involves docking, femtosecond laser application, lenticule dissection from the surrounding stroma, and extraction. It has a steep learning curve compared to conventional flap-based corneal ablative procedures, and the surgical technique may be challenging especially for a novice surgeon. As SMILE is gaining worldwide acceptance among refractive surgeons, different modifications of the surgical technique have been described to ease the process of lenticule extraction and minimize complications. Good patient selection is essential to ensure optimal patient satisfaction, and novice surgeons should avoid cases with low myopia (thin refractive lenticules), difficult orbital anatomy, high astigmatism, or uncooperative, anxious patients to minimize complications. A comprehensive MEDLINE search was performed using “small incision lenticule extraction,” “SMILE,” and “refractive lenticule extraction” as keywords, and we herein review the patient selection for SMILE and various surgical techniques of SMILE with their pros and cons. With increasing surgeon experience, a standard technique is expected to evolve that may be performed in all types of cases with optimal outcomes and minimal adverse effects.
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Affiliation(s)
- Jeewan S Titiyal
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Manpreet Kaur
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Farin Shaikh
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Meghal Gagrani
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Anand Singh Brar
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Anubha Rathi
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
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Moshirfar M, Murri MS, Shah TJ, Linn SH, Ronquillo Y, Birdsong OC, Hoopes PC. Initial Single-Site Surgical Experience with SMILE: A Comparison of Results to FDA SMILE, and the Earliest and Latest Generation of LASIK. Ophthalmol Ther 2018; 7:347-360. [PMID: 29959753 PMCID: PMC6258580 DOI: 10.1007/s40123-018-0137-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction The primary objective was to show our initial surgical single-site experience with small incision lenticule extraction (SMILE) after the official enrollment in March 2017 following Food and Drug Administration (FDA) approval for simple myopia in late 2016 in the United States and, subsequently, compare our results to the earliest and most advanced generation of excimer platforms for laser-assisted in situ keratomileusis (LASIK) surgery. Methods This was a retrospective single-site study of 68 eyes from 35 patients who had SMILE surgery. The patients’ preoperative and postoperative uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest sphere, manifest cylinder, intraoperative complications, and preoperative and postoperative visual symptoms were collected. We compared our findings to the results from the FDA SMILE study, and to the three earliest (1999–2000) and three of the most updated (2013–2016) platforms for LASIK. Results The cumulative UDVA was 20/20 and 20/40 or better in 74% and 100% of patients, respectively. The intended target refraction was within ± 0.5 and ± 1.00 D in 80% and 93% of cases, respectively. The prevalence of dry eyes decreased by nearly half from 1-week to the 6-month postoperative interval. Patients noted improvement in glare (17%), halos (17%), fluctuation (25%), and depth perception (8%) at the 6-month interval compared to preoperative levels. Conclusions This study’s findings are consistent with current SMILE reports. Notably, the results are superior to the earliest generation of LASIK, however inferior to the latest excimer platforms. SMILE does meet the efficacy and safety criteria met by FDA; however, there is a definite need for further improvement to reach the superior refractive outcomes produced by the latest generation of LASIK platforms.
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Affiliation(s)
- Majid Moshirfar
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA. .,Utah Lions Eye Bank, Murray, UT, USA. .,HDR Research Center, Hoopes Vision, Draper, UT, USA.
| | - Michael S Murri
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tirth J Shah
- University of Arizona College of Medicine, Phoenix, Phoenix, AZ, USA
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