Small incision lenticule extraction

Small incision lenticule extraction
SpecialtyOphthalmology

ReLEx Small incision lenticule extraction (SMILE), second generation of ReLEx Femtosecond lenticule extraction (FLEx), is a form of laser based refractive eye surgery developed by Carl Zeiss Meditec used to correct myopia, and cure astigmatism. Although similar to LASIK laser surgery, the intrastromal procedure uses a single femtosecond laser referenced to the corneal surface to cleave a thin lenticule from the corneal stroma for manual extraction.[1]

Process

The lenticule to be extracted is accurately cut to the correction prescription required by the patient using a photodisruption laser-tissue interaction.[2] The posterior intrastromal plane is created first and the anterior plane second. To allow better separation, the two lenticule faces are cut by the laser head moving in a spiral fashion - conventionally outside in for the posterior face and respectively inside out for the anterior one. The minimum lenticule edge thickness is usually set at 15 μm, to avoid the risk of lenticule rupturing during detachment and subsequent extraction.[3] The method of extraction was via a LASIK-type flap in ReLEx FLEx, but in SMILE a flapless technique makes a small tunnel incision in the corneal periphery, that does not (mostly) destroy Bowman's layer.[4] One conspicuous difference between SMILE and LASIK is the size and shape of the corneal incision. In LASIK, the surgeon performs a 270-degree, 20 mm long incision, while in SMILE the so-called "side cap cut", which is the incision through which the surgeon extracts the lenticule, is usually about 4 mm long.[5]

Currently in the US the procedure is only approved for nearsightedness, but is used for hypermetropia too in other countries.[6]

After the femtosecond laser has separated the lenticule, a blunt spatula is inserted through the incision between the lenticule and the stroma and carefully rotated to ensure that the lenticule is completely detached prior to removal by forceps.

History

The femtosecond lenticule extraction (FLE then FLEx) procedure was first introduced at the American Academy of Ophthalmology Annual Meeting in 2006 by Walter Sekundo and Marcus Blum, and was first published in 2008 by Walter Sekundo et al.[7][8][9]

The small incision lenticule extraction (SMILE) procedure was first published in 2011 by Walter Sekundo et al.[7][10]

Various modifications of the procedure have since then been described which aim to reduce the duration of the procedure, reduce the risks of the lenticules being incorrectly cut or make the procedure easier to learn.[8]

Effectiveness

The procedure has been described as safe and predictable in treating myopia and astigmatism.[11]

Because SMILE treatment is relatively new compared with other laser correction treatments, result studies are limited, but postoperative five year (SMILE) outcomes indicate that the results have been stable after 5 years of follow-up.[12]

Risks

Further research

As lenticule extraction techniques evolve, there is a possibility that extracted lenticules can be cryogenically preserved either for future donation,[13] or re-implantation.[1] Proof of concept has been carried out on primates where lenticules were extracted from monkeys and allogenically transplanted into other monkeys with positive results.[14]

Comparison with LASIK

Some theoretical advantages are that the technique is minimally invasive compared with LASIK and no collateral damage occurs to surrounding tissue due to the high speed of the femtosecond laser. There are limited studies on corneal wound healing and inflammatory response after this treatment has been carried out. There is a suggestion that the expression of fibronectin which is associated with wound healing is less in this method compared with femtosecond-LASIK.[2]

In some cases post operative tear secretion and dry eye syndrome have been observed along with similar post operative complications seen in LASIK surgery.[1][6]

Like PRK and LASEK, SMILE prevents the flap-related risks for example in contacts sports.[8]

References

  1. ^ a b c Ivarsen, Anders; Hjortdal, Jesper (2014). "New Developments in the Lenticule Extraction Procedure". European Ophthalmic Review. 08 (1): 31. doi:10.17925/EOR.2014.08.01.31. ISSN 1756-1795.
  2. ^ a b Walter Sekundo (2015-08-03). Small Incision Lenticule Extraction (SMILE): Principles, Techniques, Complication Management, and Future Concepts. Springer. p. 15. ISBN 978-3-319-18530-9.
  3. ^ Tityal, Jeewan S. (5 September 2018). "Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives". Clinical Ophthalmology. 12: 1685–1699. doi:10.2147/OPTH.S157172. PMC 6134409. PMID 30233132.
  4. ^ Ang, Marcus; Chaurasia, Shyam S.; Angunawela, Romesh I.; Poh, Rebekah; Riau, Andri; Tan, Donald; Mehta, Jodhbir S. (2012). "Femtosecond Lenticule Extraction (FLEx): Clinical Results, Interface Evaluation, and Intraocular Pressure Variation". Investigative Ophthalmology & Visual Science. 53 (3): 1414–1421. doi:10.1167/iovs.11-8808. ISSN 1552-5783. PMID 22323464.
  5. ^ Stephenson, Michelle (15 April 2021). "The Current State of SMILE vs. LASIK". Review of Ophthalmology. Retrieved 2 July 2024.
  6. ^ a b "SMILE (small incision lenticle extraction)". Lasercare Eye Center.
  7. ^ a b Han, Tian; Zhao, Liang; Shen, Yang; Chen, Zhi; Yang, Dong; Zhang, Jiaoyan; Sekundo, Walter; Shah, Rupal; Tian, Jinhui; Zhou, Xingtao (2022-09-08). "Twelve-year global publications on small incision lenticule extraction: A bibliometric analysis". Frontiers in Medicine. 9. doi:10.3389/fmed.2022.990657. ISSN 2296-858X. PMC 9493269. PMID 36160168.
  8. ^ a b c Titiyal, Jeewan S.; Kaur, Manpreet; Nair, Sridevi (2021-10-30). Current Concepts in Refractive Surgery: Comprehensive Guide to Decision Making & Surgical Techniques. Jaypee Brothers Medical Publishers. p. 125. ISBN 978-93-5465-213-4.
  9. ^ Sekundo, Walter; Kunert, Kathleen; Russmann, Christoph; Gille, Annika; Bissmann, Wilfried; Stobrawa, Gregor; Sticker, Markus; Bischoff, Mark; Blum, Marcus (September 2008). "First efficacy and safety study of femtosecond lenticule extraction for the correction of myopia: Six-month results". Journal of Cataract and Refractive Surgery. 34 (9): 1513–1520. doi:10.1016/j.jcrs.2008.05.033. ISSN 0886-3350. PMID 18721712.
  10. ^ Sekundo, Walter; Kunert, Kathleen S.; Blum, Marcus (2011-03-01). "Small incision corneal refractive surgery using the small incision lenticule extraction (SMILE) procedure for the correction of myopia and myopic astigmatism: results of a 6 month prospective study". British Journal of Ophthalmology. 95 (3): 335–339. doi:10.1136/bjo.2009.174284. ISSN 0007-1161. PMID 20601657.
  11. ^ Shah R, Shah S, Sengupta S (2011). "Results of small incision lenticule extraction: All-in-one femtosecond laser refractive surgery". J Cataract Refract Surg. 37 (1): 127–37. doi:10.1016/j.jcrs.2010.07.033. PMID 21183108. S2CID 43781436.
  12. ^ Blum, Marcus; Täubig, Kathrin; Gruhn, Christin; Sekundo, Walter; Kunert, Kathleen S (2016). "Five-year results of Small Incision Lenticule Extraction (ReLEx SMILE)". British Journal of Ophthalmology. 100 (9): 1192–1195. doi:10.1136/bjophthalmol-2015-306822. ISSN 0007-1161. PMID 26746577. S2CID 23860546.
  13. ^ Moshirfar M, McCaughey MV, Reinstein DZ, Shah R, Santiago-Caban L, Fenzl CR (2015). "Small-incision lenticule extraction". J Cataract Refract Surg. 41 (3): 652–65. doi:10.1016/j.jcrs.2015.02.006. PMID 25804585.
  14. ^ Liu R, Zhao J, Xu Y, Li M, Niu L, Liu H, Sun L, Chu R, Zhou X (2015). "Femtosecond Laser-Assisted Corneal Small Incision Allogenic Intrastromal Lenticule Implantation in Monkeys: A Pilot Study". Invest. Ophthalmol. Vis. Sci. 56 (6): 3715–20. doi:10.1167/iovs.14-15296. PMID 26047173.

low-energy SMILE, high-energy SMILE and LASIK for myopia and myopic astigmatism in the United States]

Incision Lenticule Extraction (SMILE) | Official Zeiss Publication]

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