Small-Incision Lenticule Extraction (ReLEx SMILE) Periprocedural Care

A standard ReLEx SMILE patient education pamphlet is given to and reviewed with the patient.

The video below depicts animation of ReLEx SMILE.

SMILE animation. Courtesy of ZEISS (http://www.zeiss.com/corporate/en_us/home.html).

The video below shows the key steps during the surgical procedure.

A standard refractive surgery consent form is given to, reviewed with, and signed by the patient.

Refractive surgery suitability screening should address the following:

• Baseline systemic evaluation to rule out any contraindications and/or relative contraindications (see Contraindications)
• Refraction (automated, manifest, cycloplegic)
• Lid margin and meibomian gland function
• Ocular pressure
• Tear film and ocular surface evaluation, including tear film inspection, tear breakup time (TBUT), and ocular surface staining
• Lens, vitreous, retina, and optic nerve status
• Lensometry
• Optical biometry
• Specular microscopy
• Corneal topography
• Aberrometry
• Tomography
• Pupillometry
• Color fundus photos
• OCT macula
• OCT optic nerve
• Color vision testing
• Contrast sensitivity testing

The ReLEx SMILE procedure, as with other refractive surgery procedures, is elective. The author includes color fundus photography, OCT macula, and OCT optic nerve documentation in all refractive surgery suitability screenings.

The refractive surgery planning sheet information is transferred to the VisuMax® planning software.

The following parameters can be selected by the surgeon when planning the ReLEx SMILE treatment:

• Cap thickness (the current trend is to make this thicker, 120-140 microns)
• Cap diameter (usually 1 mm larger than the optical zone)
• Cap side-cut angle
• Refractive correction
• Lenticule diameter (optical zone, ideally minimum of 6.5 mm)
• Lenticule side-cut angle (the author of this article preferentially has it both at 120°, allowing dominant right hand to dissect the lenticule)
• Minimum lenticule thickness (it is easier to identify the anterior and posterior lenticule plane if it is thicker)

Equipment used for ReLEx SMILE treatment is depicted in the images below.

Carl Zeiss VisuMax Femtosecond Laser. Published with permission from St Luke's Medical Center Global City Tan Eng Gee Eye Institute.

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The VisuMax Femtosecond Laser, used in performing ReLEx SMILE, is part of the Carl Zeiss VisuMax MEL80 (or MEL90) Refractive Laser Surgery Suite. Published with permission from St Luke's Medical Center Global City Tan Eng Gee Eye Institute.

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Topical ocular anesthetic is administered to the patient, who is placed on a slit-lamp biomicroscope, and the corneal limbus is marked with a surgical marker at 0° and 180°. It is important that the head of the patient be aligned properly to avoid tilt and erroneous marking. The patient is then seated and given a facial povidone iodine facial and eyelid scrub and is given perioperative antibiotic ophthalmic solutions.

The post-SMILE follow-up schedule at the authors’ center is as follows:

• Day 0: Evaluate for any residual foreign body (eg, lint, epithelium) in the pocket
• Day 1: Side-cut epithelialization, uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), topography, slit lamp examination (SLE), tonometry
• Day 7: UCVA, BCVA, topography, tomography, SLE, tonometry
• Month 1: UCVA, BCVA, topography, tomography, SLE, tonometry
• Month 3: UCVA, BCVA, topography, tomography, SLE, tonometry
• Month 6: UCVA, BCVA, topography, tomography, SLE, tonometry
• Month 9: UCVA, BCVA, topography, tomography, SLE, tonometry
• Month 12: UCVA, BCVA, topography, tomography, SLE, tonometry