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Lenticule Extraction: The Time Is Now!

It’s with a great deal of joy and a small degree of wistfulness that we bring you the fourth and final Anchorman webinar series supported by ZEISS, with Media MICE’s irreplaceable CEO Matt Young playing said Anchorman. 

The topic of this discussion is lenticule extraction, which astute readers may have noted in the title. So, why is now the time to implement lenticule extraction in your clinic, if it hasn’t been done yet?? What can it bring to ophthalmologists and patients around the world?

Joining Mr. Young were three distinguished speakers. In no particular order, these were:

  • Dr. Cyrille Temstet, corneal specialist, Centre Ophtalmologique Ternes Monceau, France
  • Dr. Sri Ganesh, chairman and managing director, Nethradhama Hospital, India
  • Dr. Dan Reinstein, founder, London Vision Clinic, U.K.

Now that you have joined us as well, let’s explore the discussion. We highly recommend watching the entire video, which is full of (sometimes impassioned) insights on the topic and how it relates to both patients and other procedures. 

Benefits of offering lenticule extraction, as well as LASIK and PRK

So, question one: What are the benefits of offering SMILE as well as LASIK and PRK? Dr. Reinstein was the first to field the question, and his answer was quite enlightening. As he expounded: “Patients come to us for vision correction. PRK is a great procedure, LASIK is a great procedure, and SMILE is a great procedure — but they’re not the same. Some may say that SMILE is a better procedure, but I don’t see it like that. I just say that it has advantages over LASIK and PRK.” 

Each has its own advantages, so they’re each appropriate for different patients in different situations. Being able to offer all three is the best, says Dr. Reinstein, as it allows for a greater degree of flexibility. While 80% of patients in his clinic who could have LASIK or SMILE end up having SMILE, for example, LASIK is still the appropriate procedure for the other 20%. Reasons to choose SMILE are many-fold, mostly coming from the benefits it offers being due to being a flap-free procedure. For reference, PRK represents less than 1% of Dr. Reinstein’s procedures. 

Dr. Ganesh concurred, pointing out that his clinic offers comprehensive refractive solutions, including the above procedures, phakic IOLs, and more. Like Dr. Reinstein, Dr. Ganesh suggested that around 80% of patients in his clinic undergo SMILE treatment when there are no complicating factors. 

Dr. Temstet echoed the concept that offering all options was the best way forward since each procedure can be customized to the patient, but that SMILE offers advantages, like its flapless nature. 

How have patients responded to SMILE? 

It’s hard to argue with Dr. Reinstein’s point that the whole, well, point of vision correction is just that — vision correction. As he noted, it shouldn’t be up to the patient to decide which procedure is right for them because they’re not medically qualified to do so. So, if a patient comes to him convinced that they’re right for SMILE but they’re better suited for LASIK, he’ll discuss the reasons why they’re better suited for LASIK. This information bleeds out into the general public. 

What does that have to do with the question, you ask? We’ll refer you back to Dr. Reinstein’s original point: It’s all about vision correction. If the patient can see well after the operation, they’ll be satisfied. 

SMILE is the fastest of the three procedures (especially with the Visumax 800), Dr. Ganesh noted, and pain and discomfort are minimal. Additionally, there are hardly any restrictions on patients within 24 hours after SMILE since it is a flapless procedure. In Dr. Ganesh’s experience, the patient experience is best with SMILE. 

Lenticule extraction learning curve

Dr. Temstet suggested that, while there might be more of a learning curve to lenticule extraction than LASIK or PRK, it’s still easier than keratoplasty or phaco. So, while it’s not hard, it does require some surgical skill. 

If you’re looking for trendsetters, look no further than Dr. Reinstein in this case. He helped lead the charge to make SMILE a viable option rather than a “would be nice” option, and he has indeed trained hundreds if not thousands of other surgeons on SMILE. While lifting a flap may be easier than taking a lenticule out, he noted, putting it back isn’t quite as easy. Average LASIK may seem to be easier than lenticule extraction at the outset, for example, but managing an excimer laser is far more difficult than managing the Visumax 800. So, for Dr. Reinstein, LASIK is far more difficult to teach than SMILE. 

Dr. Ganesh has performed north of 10,000 SMILE procedures over 10 years, and told us there was indeed a learning curve. He suggested it may take around 100-150 procedures to develop confidence. Again, that might be different nowadays with the new VISUMAX 800 and its surgeon-supporting functions. For the details, check around the 15 minute mark on the video. 

He also pointed out that Zeiss has an onboarding process and Dr. Reinstein has a large array of training materials for surgeons. Undergoing proper training for SMILE is crucial, but it’s definitely doable. 

What about lenticule extraction hesitancy?

SMILE has been proven a million times over, suggested Dr. Temstet, noting that more than five million eyes have been treated with the procedure and it’s shown great results in peer-reviewed papers. While unexpected situations can arise, that’s the case with any surgery. The recently-launched Visumax 800 even has surgeon-supported functions like centration aid cyclotorsion adjustment. It only takes around 10 seconds for a lenticule cut. From Dr. Temstet’s point of view, there’s no better time to start with lenticule extraction than now. This is why he has recently acquired the laser and can’t wait to offer lenticule extraction in his clinic. 

For Dr. Reinstein, it comes down to the surgeon. As he noted, there are studies that show that SMILE is better than LASIK and vice versa. From his studies, there are no differences in the outcome. If a surgeon gets better results from LASIK than SMILE, they’re simply not a good SMILE surgeon — and, again, vice versa. As he explained, there’s no reason to not add lenticule extraction to an ophthalmic arsenal from a commercial point of view — unless the market simply won’t support the investment. 

And that argument doesn’t really hold water: As Dr. Ganesh said, “I think SMILE is driving the refractive market. SMILE represents around 25% of refractive procedures today. Patients know about SMILE, they know it’s minimally invasive, and you don’t want to get left behind.”

An expanding patient base due to SMILE

Just 10 years ago, Dr. Ganesh was performing around 600-800 procedures per year with LASIK. Now, he’s performing some 1,400-1,800 procedures per year — and if you do the math, which readers will certainly be able to do in their head (go ahead!) — you’ll notice that’s a massive jump in procedures. The word is out with patients, so many are flocking to refractive clinics around the world seeking a quick, effective and easy procedure. 

Surgeons can also charge a premium for SMILE because it’s a newer procedure, and revenues for Dr. Ganesh’s hospital are up. 

Dr. Reinstein has seen a surge in younger patients post-pandemic due to SMILE — perhaps for the wrong reasons, since there was nothing wrong with LASIK. The fact remains: Perceptually, patients prefer the idea of not having a flap. 

The evolution of data technology in lenticule extraction

Overall, it’s become easier for surgeons to work with nomograms because of the improvement in data, said Dr. Reinstein. On top of that, the data collection, evaluation, and connectivity of the device, in general, simplifies lenticule extraction. The background service provided with the Visumax 800 makes life easier for surgeons who might not be able to optimize their outcomes manually with Excel or other manual post-op data-management programs. Data management, he said, is a great way to lead to happier patients and more promoters than detractors. 

Additionally, preoperative diagnostics have revolutionized the refractive field, especially epithelial mapping. It’s led to a significant increase in preoperative confidence in surgeons. 

Convincing docs to use the Visumax 800

Both Drs. Ganesh and Reinstein were instrumental in developing the technology behind the Visumax 800 — which has even gone beyond Dr. Ganesh’s expectations, he said. It’s a significant step forward, especially with all of the support that comes with it. 

Dr. Temstet, on the other hand, was hesitating to start with lenticule extraction. The introduction of the VISUMAX 800 brought lenticule extraction back into the game. And after carefully evaluating and trying the different technologies for lenticule extraction available on the market, his clear choice was to go with the market leader in laser vision correction and pioneer of lenticule extraction. 

Want to know more? Be sure to check out the whole discussion, which dives deep into detail on each question. We’ve been thrilled to be a part of this conversation, and can’t wait for more to come out on the topic. 

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