SMILE VS LASIK

What is LASIK eye surgery?

LASIK eye surgery corrects vision by reshaping the cornea with a device called an excimer laser. LASIK stands for Laser Assisted In-Situ Keratomileusis. Keratomileusis is a greek term that means “corneal reshaping” and reshaping the cornea with the excimer laser is what enhances patients vision. In Situ means “on site” which just means that the procedure is performed on the eye without removing the eye to perform it. This procedure was originally FDA approved in 1995. LASIK can correct nearsightedness, farsightedness, and astigmatism. In the case of nearsighted treatments we create a flap in the cornea (only with a laser at Las Vegas Eye Institute), lift this flap, and then ablate (aka remove) tissue in the shape of a lens to decrease nearsightedness. The flap is put back into place and the vision is substantially improved immediately and continues to improve for one week to one month.

What is SMILE eye surgery?

SMILE stands for SMall Incision Lenticule Extraction. SMILE does not utilize an excimer laser which means that it does not remove tissue via ablation. SMILE instead uses a femtosecond laser that fires millions of pulses into the cornea in about 20 seconds. These very low energy pulses carve the shape of a lens into the cornea. This lens shape (or lenticule) is then removed by your surgeon through a very small incision (currently 4mm.) Because the excimer laser ablates the shape of a lens in LASIK and in SMILE a lens is carved and removed, both procedures really accomplish the same thing. They remove power from the cornea to treat nearsightedness. They both allow the correction of astigmatism as well. Since both procedures accomplish the same result some doctors actually refer to SMILE as SMILE LASIK, so that patients can realize that they are similar procedures. Most doctors that perform SMILE (Dr. Swanic included) also perform LASIK because LASIK still has an important role for many forms of refractive errors.https://share.rendia.com/whitelabel/load/aHR0cHM6Ly9sYXN2ZWdhc2V5ZWluc3RpdHV0ZS5jb20vc21pbGUtZXllLXN1cmdlcnkvc21pbGUtdnMtbGFzaWsv/4a7c6ee6-4298-424a-4f90-40094f8c4347

Brief video showing how the SMILE procedure is performed.

What are the advantages of SMILE eye correction Surgery?

The advantages of SMILE eye surgery are primarily derived from the fact that it has a much smaller incision compared to LASIK. The incision size in LASIK does have some variability based on the size that is planned by your surgeon but it generally extends for about 300 degrees (about 60 degrees remain for the hinge of the flap) and amounts to an incision length of approximately 22mm. In SMILE the incision length in the United States is currently 4mm due to FDA regulation but throughout most of the world it can be set as low as 2mm. This is an over 80% reduction in length of incision. This reduction is thought to be important to help preserve strength of the cornea and to help decrease cutting of corneal nerve fibers. Our cornea has some of its strongest fibers in the front of the cornea which is where the LASIK or SMILE incision is placed. So if we cut less of these fibers this should leave the cornea stronger after SMILE than LASIK. We also have the greatest percentage of cornea nerve fibers running in the front of the cornea, this would make sense since it is important to know if something is touching or is about to touch our delicate corneal tissue. By cutting less of these fibers studies have shown a much more rapid recovery of corneal sensation. Typically our corneal sensation takes approximately 12 months to fully recover after LASIK. This recovery time in SMILE was found to be about 3 months. This faster nerve recovery is thought to lead to a more comfortable post operative course compared to LASIK (which is already quite comfortable.) Some people refer to a period of dry eye after LASIK. This dry eye is not permanent or severe but can be irritating to the patient. Our experience at Las Vegas Eye Institute is that this temporary dryness recovers at a more rapid rate than with LASIK.https://share.rendia.com/whitelabel/load/aHR0cHM6Ly9sYXN2ZWdhc2V5ZWluc3RpdHV0ZS5jb20vc21pbGUtZXllLXN1cmdlcnkvc21pbGUtdnMtbGFzaWsv/1aa00a6c-4ac3-4ed7-4baa-4f994f47482f

Brief Video Showing creation of LASIK incision.

Is SMILE laser eye surgery more expensive than LASIK?

This will depend on the practice that you see. At Las Vegas Eye Institute we feel that certain patients are better LASIK candidates, others are better SMILE candidates, and others should really be treated with PRK. Since this determination is complicated we do not want our patients to make their decision based on price. As such the price at Las Vegas Eye Institute is the same for all three procedures: LASIK, SMILE, or PRK. SMILE eye surgery can only be performed with Zeiss Visumax Laser which is one of the most advanced lasers in ophthalmology. The Visumax Laser is one of the most expensive in Laser Eye Surgery and is how we perform SMILE as well as how we create our LASIK flaps.

How long does SMILE eye surgery last? Does it last as long as LASIK?

SMILE laser eye correction is essentially permanent. Many myths exist regarding the permanence of LASIK eye surgery. Many people think that LASIK “fades” over time. Like all myths this one is based in some reality. The original LASIK lasers did not create the same ablation profiles as the modern lasers of today. The original laser profiles created in the 1990’s were much smaller and they did not take into account the body’s normal healing response. At Las Vegas Eye Institute we only used the most advanced LASIK ablations utilizing the Visx iDeisgn 2.0 platform that was released in 2018. Similarly, our SMILE technology is also based on the latest SMILE FDA approval in 2018 that allows for the correction of astigmatism as well as nearsightedness (or myopia.) These new technologies create larger optical zones that are also designed to resist the bodies natural desire to regress the treatment. Dr. Swanic had PRK laser eye surgery in 2010 and his correction has not changed over the last 10 years.

What procedures can be performed with SMILE vs LASIK?

SMILE is only FDA approved for the correction of Nearsightedness and Nearsightedness with Astigmatism. This approval allows us to treat approximately 80% of the refractive errors in the United States as most people are nearsighted. The other 20% of Americans have farsightedness or astigmatism without nearsightedness. Both of these conditions can be treated with LASIK but not with SMILE. We correct both of these with our advanced iDesign 2.0 excimer laser platform.

I was told my correction was too small for SMILE. What does this mean?

SMILE can correct nearsightedness down to 1 diopter and many surgeons do perform it for that level of correction. Dr. Swanic is currently limiting his correction to about 3 diopters of nearsightedness. As the correction goes down the thickness of the lens that is removed continues to get thinner. This could create issues with removing it. As such we are currently only removing the thicker lenticules created for higher corrections and for low corrections utilizing our femtosecond laser LASIK procedure.

Is the visual quality better with SMILE vs LASIK?

No. The visual quality with LASIK is excellent and we are finding similar visual acuities after SMILE as after LASIK.

IS SMILE eye surgery new? How many of these procedures have been performed?

SMILE eye surgery has been performed throughout the world since 2010. It has been performed in the United States since 2016. It has an excellent track record and over 2 million people have had SMILE performed worldwide.

Does SMILE eye surgery have a flap?

SMILE eye surgery does not have a flap. This can be important for people who are concerned about LASIK flap dislocation. Flap dislocation is extremely rare with LASIK even with very powerful injuries including car accidents, sports injuries, and even air big inflation. However, the absence of a flap with SMILE makes this an impossibility that may make some people more comfortable with this procedure.

I have very high astigmatism can I still get SMILE?

It depends on how high the astigmatism level is. SMILE is FDA approved for astigmatism correction up to 3 diopters. This is quite a high level and accommodates most patients that present to our clinic for refractive surgery evaluations. However we do have patients with even higher levels of astigmatism and we correct them with the iDesign 2.0 LASIK procedure that can correct up to 5 diopters of astigmatism.

I am over 40 and have presbyopia. Can I still get SMILE?

Yes. Over the age of 40 the lens inside of our eye naturally loses its ability to focus on near objects and this is called presbyopia. This condition is actually helped substantially by blended vision. people used to refer to blended vision as “monovision.” This is a misnomer as we can often make the distance vision much better while simultaneously aiding the near vision by a well planned undercorrection in our patient’s non dominant eye. This undercorrection can be performed with SMILE or LASIK and is an excellent option for nearsighted patients over the age of 40.

I have bad dry eye. Is SMILE a good option for me?

We do not feel people with severe dry eye are good candidates for any refractive surgery procedure (LASIK, SMILE, or PRK) if we cannot get the condition adequately controlled. Studies have never shown that LASIK causes dry eye, and in fact most patients report significant improvement in dry eye symptoms after refractive surgery because they are no longer wearing contact lenses. However, we are concerned that any form of refractive surgery can exacerbate this disease. That being said, if you have dry eye symptoms and are considering refractive surgery a consultation at Las Vegas Eye Institute can still be appropriate as we have many treatments for dry eye that may make SMILE an appropriate procedure for you.

Is the visual recovery faster for LASIK vs SMILE?

The recovery for some patients is faster with LASIK than it is with SMILE, but both procedures offer very fast visual recovery. Many LASIK patients can have vision even better than 20/20 on our eye chart the very next day after LASIK. This can also occur with SMILE but we generally find that it is less frequent. Most SMILE patients will have about the same vision as LASIK patients at the one week visit and nearly all have the same vision at the one month postoperative visit.

I am interested in a consultation for SMILE. What do I do next?

SMILE and LASIK are both amazing procedures. Call our office  or visit our scheduling page for a free consultation. We will inform you which procedure may be best for you.

HOW LONG DOES LASIK LAST?

There are many myths out there regarding the permanence of LASIK eye surgery. We will try to debunk these myths, but at the same time give you absolutely essential knowledge on LASIK surgery, its effectiveness, its safety, and most importantly how long it is likely to last. As a general rule though, modern LASIK is permanent vision correction and you can expect far longer than 10 years of great vision.

Why do people think LASIK doesn’t last?

Much of this has to do with the original LASIK eye surgery that was being performed in the 1990s. It’s hard to believe but LASIK is an established procedure that has now been performed for 25 years. Just as cars, cell phones, and computers have come along way so too has LASIK vision surgery.

LASIK improves your existing vision by either flattening the central cornea in the case of myopic LASIK for nearsightedness or by steepening the central cornea for hyperopic LASIK to treat farsightedness. In the case of nearsightedness, which accounts for 85% of LASIK procedures, the eye has too much power. This is why people with poor distance vision from myopia wear glasses or contact lenses with negative power. The eye has too much power and LASIK decreases that power by removing a minimal amount of central corneal tissue. LASIK lasers cannot add tissue to the eye; they can only remove tissue. So, for farsighted treatments, our LASIK lasers remove tissue in a donut shape peripherally and barely touch the center of the cornea. This removal of tissue causes the center of the cornea to steepen and gives the eye more power. This idea is key to understand how this technology works and how modern LASIK platforms have improved to make LASIK last a very long time.

The original LASIK lasers performed what is now referred to as “conventional ablations” and these were very effective, but they had small optical zones and did not include something called a “blend zone.” Modern LASIK has completely moved away from these small optical zones because we found out the body didn’t like them, and a phenomenon known as regression would occur. This regression would not make eye surgery completely ineffective but a small return of myopia was sometimes seen. Regression is a loss of effect and it was happening because the body was trying to smooth out something that it felt didn’t belong (ie a central flattening of the cornea.) Thus, LASIK surgeons and laser manufacturers moved to larger optical zones that blended into the surrounding tissue so the body didn’t feel there was anything it needed to smooth out. For comparison, 1990s LASIK could have a 5.0-5.5mm optical zone with no blend zone. In today’s modern LASIK, nearly all treatments have a 6.5mm optical zone that blends all the way out to 8 or 9mm (our cornea is about 12mm in diameter) which makes LASIK last and not regress. Dr. Swanic had his LASIK performed about 10 years ago in 2010 and he still has the exact same 20/20 vision today as he did back then.

How long does LASIK last for farsightedness?

The short answer is that farsighted LASIK lasts just as long but it takes us a bit longer to get to our intended effect. As we discussed earlier farsighted LASIK is a very different procedure in which peripheral corneal tissue is removed which forces the central cornea to steepen. There is a limit to how much farsightedness we can treat with LASIK. Generally, LASIK lasers only allow us to program them to a correction of about 6 diopters for farsightedness. The good news is that corrections over 6 diopters of farsightedness are quite rare.  It can be difficult to make corrections over about 3 diopters to be stable long term. Still, most patients seeking farsighted LASIK consultations actually have under 3 diopters of farsightedness in their glasses or contact lenses.

As we mentioned before, regression of the effect of LASIK is now very rare with nearsighted treatments with modern lasers with blend zones. More importantly, if I program my laser to correct -6.00D of nearsightedness the effect will be immediate and the next day the vision will be close to 20/20. Farsighted LASIK is programmed as positive treatments so if I program +3.00D the next day the patient is typically overcorrected. This overcorrection is intentional by both the surgeon and the laser to help keep your vision good long term. The issue is that all farsighted treatments have some level of regression over the first few months to even a year so if we don’t overcorrect in the short term we will end up undercorrected in the long term.

How long does LASIK last for astigmatism?

LASIK surgery is very stable for astigmatism and you can expect to have very long term correction with modern LASIK platforms. Our Visx iDesign 2.0 system is FDA approved to correct up to 5 diopters of astigmatism and we have had excellent results on patients with high astigmatism. The iDesign procedure actually captures a custom wavefront of your eye in our office which is transferred to the laser days prior to your treatment. On the day of your treatment, the laser gets this wavefront precisely aligned to your eye based on tiny iris details that are unique to your eye. This technology is called “iris registration” and it helps us achieve high astigmatism corrections both safely and consistently.

What is a LASIK enhancement?

LASIK is a very safe and effective surgical procedure, but even the best and most modern LASIK lasers will occasionally have an occasional undercorrection or overcorrection. This varies based on the level of correction that was attempted. For instance, the incidence may be 1% on a correction of -2.00 but that can increase to 5-6% on a correction of -6.00. If this occurs we perform a procedure called a LASIK enhancement to improve the vision. This does not mean that the LASIK “didn’t last” because we usually know that enhancement will be necessary within the first month after the initial procedure. LASIK enhancements are typically performed about 3 months after the initial procedure to ensure the eye is stable and that the procedure is necessary.

Does Presbyopia affect how long LASIK lasts?

Presbyopia as a process is not completely understood but is thought to be due to a loss of elasticity of the natural lens of the eye. This leads to a loss of near vision at about the age of 40. The loss of near vision slowly progresses and by the age of 45 presbyopia often causes people to need reading glasses.

Presbyopia can make it seem like LASIK has worn off because the near vision has declined. However, the procedure is still working and the distance vision remains very good as this process occurs. Patients who have had LASIK previously can consider what Dr. Swanic refers to as “blended vision” on one eye to help regain some near vision and not be dependent on reading glasses. In blended vision our staff will determine which eye your body prefers to sight distance objects, we call this the dominant eye. We then do not treat this eye, but instead provide a hyperopic, or farsighted, treatment to the other non-dominant eye to boost near vision. We call this “blended vision” because we don’t overcorrect this eye like was sometimes seen in what people refer to as “monovision.”

As an example, Dr. Swanic has perfect vision in both eyes from his nearsighted LASIK procedure. As he ages his near vision will inevitably decline. He knows that his left eye is his dominant eye that his body prefers to target distance objects. He plans to see a LASIK surgeon to correct his right, non-dominant, eye to improve his near vision so that he doesn’t need reading glasses for all tasks. He will likely get some reading glasses for certain activities that require very fine vision and ease the strain of having one eye doing a majority of the near work.

Does a cataract affect how long LASIK lasts?

A cataract is a natural hardening of the lens inside of our eye. LASIK is a procedure that works on the cornea or outside of the eye. If you have LASIK surgery, it will not prevent a cataract. A separate surgery will be necessary to remove the clouded lens. Cataracts typically don’t affect vision until after age 60. Because LASIK surgery is a procedure performed outside of the eye it is not good for treating a cataract that occurs inside of the eye. Cataract surgery, which Dr. Swanic also performs, removes this hardened and cloudy lens and restores sight to the eye. When a cataract develops it will make a prior LASIK procedure no longer effective, but again it is not that the LASIK has worn off, it is simply that a different process is occurring. Fortunately, we have excellent treatment options to correct cataracts.