How to Offer SMILE to Patients

Kathryn M. Hatch, MD, and R. Luke Rebenitsch, MD, join Marguerite McDonald, MD, FACS, to discuss small-incision lenticule extraction. Learn how they present this form of laser vision correction to patients and how the procedure fits among their practice offerings.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.

MARGUERITE: This podcast is called Informed Consent: Getting to Yes. It’s about the specific, fair, and balanced explanations leading eye surgeons give to their patients so they will say “yes” to the course of action that the surgeons propose. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island in Lynbrook, New York, and today’s episode is about SMILE.

KATIE: I was really interested in the technology and the idea of doing potentially a new refractive procedure that is flapless, potentially with a quick recovery. And to really be able to offer my patients the most current refractive procedures available. So, I became really interested in SMILE for that reason.

MARGUERITE: That’s Dr. Katie Hatch. She is Director of Refractive Surgery at Mass Eye and Ear, Assistant Professor of Ophthalmology at Harvard Medical School, and Site Director of the Mass Eye and Ear extension in Waltham, Massachusetts.

LUKE: Our practice was a 100% laser vision correction practice from approximately the year 2002 to 2016, at which point we added all the rest of the forms of vision correction. We felt that SMILE was a necessary addition to our practice because of its many benefits. Potentially the ability to treat more patients and higher refractions.

MARGUERITE: And that’s Dr. Luke Rebenitsch, Medical Director and Owner of Clear Sight Center, in Oklahoma City, Oklahoma.

LUKE: We also felt that it may be more comfortable, during the procedure, for our patients.

MARGUERITE: So, were you involved in clinical trials?

LUKE: We were not, but we were the first in Oklahoma to offer SMILE. We are glad that we did. Our volumes been increasing ever since.

MARGUERITE: So, patients usually go to Doctor Google, and they've been Googling about LASIK for years. So, do you find that a lot of them, when they come in, already know about SMILE?

KATIE: So, some patients have found the practice through SMILE and do know that I'm doing SMILE. I would say the majority of patients are still coming to the practice just interested in laser vision correction. So, they're really interested in the best procedure for them. Most patients come to the office just seeking the freedom from glasses and contact lenses. And they really want the doctor to tell them what procedure to have.

MARGUERITE: So, in your practice if you find somebody who you think is great candidate for SMILE. We'd love to hear what you say to them. So, I'm going to ask you to pretend I'm Mrs. Smith and you've decided I’m a great candidate for SMILE. What exactly do you say to me?

KATIE: So, Mrs. Smith, I feel that you're a very good candidate for laser vision correction. And we do have different options for laser vision correction.

LUKE: Well Mrs. Smith, congratulations you are a candidate for laser vision correction. Now most people have heard of LASIK and PRK. These forms of vision correction have been around for many years

KATIE: You may have heard of LASIK—it's probably the most famous of the procedures—and what we're doing in this procedure is making a flap in the cornea, lifting the flap, reshaping the eye, and putting the flap back down. And so that's probably the most commonly performed refractive procedure. So, we know that the flaps do sometimes, they heal well, but there can be some very small risks of having a problem with the flap.

LUKE: What I'm going to recommend for you is SMILE. It's a form of vision correction very similar to LASIK. Rather than using two lasers, we use one laser for both steps.

KATIE: And instead of making a flap in the cornea, we're actually making a small pocket and then lasering a little lenticule, a little disk of tissue out of the cornea, removing it.

LUKE: One of the many benefits for SMILE is that it's easier for you in the first 24 to 48 hours. It tends to be a bit more comfortable. The outcomes are exactly the same as LASIK and PRK. And, although you may be a candidate for those, I believe that your best option would be SMILE.

KATIE: The big advantage to that, in my opinion, is that it's a flapless procedure, so there really are no restrictions at all after the procedure. We don't have to worry about any issues with the flap. And you may also be reducing the risk of dry eyes. So, we are making a smaller incision and so we may be affecting the nerve tissue in the cornea a little bit less, which can potentially lead to less issues with dry eye.

And then the other reason is that the cornea may be a little bit more of a stable procedure. So, when we're making, what we call biomechanic rationale in terms of that, it is because we are making a smaller incision. We may actually be preserving some of that strength of the cornea which may reduce the risk of problems in the future. Like thinning condition or a condition called ectasia, which we really would like to avoid.

LUKE: People don't want to feel that they're getting something experimental. Over one million SMILE procedures have been performed worldwide. In many ways this is a form of LASIK. I tell patients that this is either very similar to LASIK or a form of LASIK. Patients do ask how long this has been around. But what I've been finding is that they don't see it as new. They see it as more advanced or a newer form of LASIK.

We don't denigrate LASIK. LASIK is able to treat far more people, at this point, than SMILE can in the United States. But there are benefits for SMILE, and there's typically a reason that we recommend it specifically for patients.

KATIE: At this point I'm really offering SMILE to all of my patients who really have about a half diopter or less of astigmatism, as their primary procedure, if they're a candidate. I'll occasionally do a patient with three-quarters of a diopter with-the-rule. Especially if they're very young because I know if they end of up with a little bit of residual with-the-rule, that's not going to be a problem for them, going forward. Especially if they're young, like in their you know, 20s and 30s. And occasionally I'll do one SMILE in one eye and LASIK in the other, if you know someone has more in one eye. And that works out well also.

MARGUERITE: Do you find that your percentage for SMILE is going up every month? What would it be now, the SMILE versus LASIK ratio? Roughly?

LUKE: So, at this point the SMILE versus LASIK ratio is fairly static. We treat about one SMILE for every 20 LASIK. The primary reason for that is not that SMILE can't get the same result as LASIK, but until we're able to treat astigmatism, hyperopia, or essentially able to treat the same parameters that we can treat with LASIK, we're really not promoting it to the same level that we are other forms of laser vision correction.

KATIE: I do think there's a learning curve. I think there's a learning curve with the VisuMax in general. So, I think they're having the 50-flap cutoff of doing, being very comfortable with LASIK is very important because the centration is very different than—centering and docking—is a little bit different than other lasers. So, I do think there's a learning curve just with the VisuMax in general.

I think if you know your landmarks, and have a stepwise approach every time, it's actually a very simple, fast procedure. It's actually even faster for me than LASIK because at this point my patients have LASIK, they have to have the flap and then I have to walk them over to my exit mark. So, it actually takes longer for me to do LASIK than SMILE at this point, in my office.

LUKE: The way that I see SMILE is how LASIK was in its infancy. It is a wonderful technology that can be further developed. I believe that, once we can further modify the energy settings, the incision sites, the cap thickness, as well as treat aberrations of astigmatism and hyperopia, I believe that SMILE will be at least equivalent if not surpass LASIK at some point in the future. That could be 3 years. That could be 20 years in the future.

MARGUERITE: Do you think there will also be economic savings for surgeons because you've got one laser instead of two?

LUKE: Absolutely. That being said, SMILE, like other forms of laser vision correction, will have the need to be enhanced in the future. In the meantime, it's necessary to have another laser to treat patients. Even with SMILE.

KATIE: I don't think we'll ever stop doing LASIK. I think we will always be able to offer LASIK as a procedure, but I do think that, I know I'm going to be offering it to my astigmatic patients as well. I'm excited about potential future applications like, what can be done with the lenticule? I mean that's a whole ’nother area to think about. So, like the tissue that we remove may have a lot of future applications, in treating hyperopes and maybe treating presbyopia. I mean there are a lot of potential future applications.

MARGUERITE: Yes, and I've heard refractive surgeons say, “Well, even if you go 100% SMILE, you're going to have to keep your excimers to do PRK touch-ups.”

KATIE: PRK. Oh, oh definitely. Yeah, no, we're not getting rid of the excimers anytime soon.

MARGUERITE: Well, I want to thank both of you so much. I know I learned a lot, so I’m sure our listeners did, too.

KATIE: Thank you so much. I've really enjoyed talking with you.

LUKE: Bye.

MARGUERITE: You’re both welcome. And thank you to our listeners as well, and please keep an eye out for our next Informed Consent: Getting to Yes podcast.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.