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SMILE: Another Opportunity to Make LVC Great

First experiences in the United States.

At Parkhurst NuVision, one of our fundamental philosophies is that refractive surgery is more about meeting the goals and needs of our patients than it is about the particular procedures we offer. We spend a lot of time listening to patients and thinking, examining, and educating them on what their anatomy tells us about the potential upsides and downsides of any given intervention unique to their optical system. Only after we have a good understanding of the patient’s needs, desires, and anatomy do we think about selecting a procedure.


Because our strategy is fitting the procedure to the patient, rather than the patient to the procedure, having a full menu of options has always been important to the way we approach refractive surgery. Whenever we decide to add a new procedure, first we study it and get a sense for what its advantages are. We read about it, and we talk to, and then visit, surgeons who have experience performing the procedure.

For example, I went to Singapore this past year to consult with Jodhbir S. Mehta, BSc(Hons), MBBS, FRCOphth, FRCS(Ed), FAMS, who has been performing small incision lenticule extraction, or SMILE, with the VisuMax femtosecond laser (ZEISS) for several years. I also talked to some surgeons from Southeast Asia about their experiences with SMILE and traveled to Europe to observe more procedures and to collect information on European results with SMILE. After talking with surgeons I trust, I became convinced that SMILE is going to be an important procedure for refractive surgery in the United States, just as it has been in Europe and Asia.

I performed my first SMILE in March 2017, and the day was especially memorable because it happened to be my 40th birthday. Being early adopters of advanced technology is part of our core values at Parkhurst NuVision, so we were proud to be one of the first 10 practices in the country to launch the procedure commercially. I had been using the VisuMax laser for LASIK flaps for 1 year prior to that, so I had adequate time to get used to the platform and its nuances, and I really love the platform for making flaps. The VisuMax continues to be the main laser I use, whether I am performing modern LASIK or whether I am performing SMILE. I really like that the platform is so versatile, meaning I can perform a variety of procedures depending on what is best for each individual patient.

Figure 1. Dr. Parkhurst (right) performing SMILE with the VisuMax.

Thus far in my experience, patient satisfaction has been excellent. I can recall one patient specifically who said that the SMILE surgery was so gentle that it was almost like nothing had happened, except that afterward she could see better. She related the patient experience to going in for an eye exam, but coming out with clear vision. The surgery is so comfortable that it is almost like a nonevent, which is a different experience than what patients are used to on the day of surgery with almost any other refractive procedure.


Right now, we are finding that only about 25% to 30% of our current refractive surgery patients are eligible for SMILE. That is going to grow dramatically, and it is going to grow soon. The reason that we have not performed SMILE more often thus far is because the current indication in the United States is only for spherical myopia between -1.00 and -8.00 D. This means that, in the United States, we are not able to treat patients with greater than 0.50 D astigmatism. As one can expect, that limits the patient pool significantly. Once the astigmatism indication is approved by the US FDA, I expect the volume of SMILE procedures that I perform to increase dramatically.

Currently I find that SMILE works best in patients who have moderate to high myopia (-3.00 to -8.00 D). This is because, when getting used to dissecting and extracting the lenticule, a higher treatment gives you a little more tissue to grasp ahold of and get into.


Rather than marketing one specific procedure as the best laser eye surgery available, we choose to focus our messaging on the fact that we have all the different options to ensure that the best surgical solution is chosen for each individual patient. There are situations when a patient is better suited for SMILE and others when a patient is better suited for modern LASIK. We want our patients to know what all of their options are before they make the transformative decision to undergo refractive surgery.

One thing we have done since we started performing SMILE is to do some TV interviews educating the community about what SMILE is. We have done some optometric seminars to introduce SMILE, so referring optometrists understand what it is, what it can offer their patients, and how it differs compared to some of our other procedures.

Our marketing strategy may seem a bit subtle, but it has been very effective. It is different from the way new technologies have been introduced into refractive surgery in the past. Take for instance what happened when the femtosecond laser was introduced for LASIK flap creation. The common messaging across the United States was, "Hey, you should get all-laser LASIK, and you should not trust the surgeon down the street who is still using a microkeratome blade. Come to me, because we do it all by laser." That was an underlying negative message, and it was a market-share play by the surgeons who invested in that laser technology. But what resulted from that negative messaging was fear and stagnation in the refractive surgery market, not growth. This time around, any marketing should be positive, and surgeons should try to be strategic about not positioning SMILE as the one procedure that everybody should get. Rather they should alert patients and doctors that they need to know about SMILE because it is in fact an optimal procedure for many people desiring to undergo laser vision correction.


There are a lot of people in this world who would benefit from refractive surgery who simply do not know it yet. Anything we can do to educate our patients about the transformative potential of refractive surgery and to bring excitement back into the specialty is beneficial. Introducing a new laser vision correction procedure to augment the surgeon's already expanding toolbox gives people another reason to think about refractive surgery again.

I believe SMILE, among other procedures, will be a catalyst of growth for refractive surgery. We have already seen some of this effect, as laser vision correction volume is up in many centers by 20% or more so far in 2017 and there has been a lot more positive messaging and chatter around refractive surgery in the United States in the past 12 to 18 months. I would attribute some of that to the introduction of SMILE, and perhaps even more to the collaboration and positive messaging taking place among refractive surgeons looking to expand the refractive surgery space.

I think the future of SMILE will have a much broader scope than it currently has in the United States, mostly because of the limitations in the indications for treatment that we can perform right now. By the time that the procedure has FDA approval for astigmatism correction, SMILE is going to become a really important procedure for refractive surgery patients because of the quick recovery, the comfort during surgery, and the excellent quality of vision it provides postoperatively.

Gregory D. Parkhurst, MD, FACS
Gregory D. Parkhurst, MD, FACS
  • Physician-CEO, Parkhurst NuVision, San Antonio, Texas
  • gregory.parkhurst@gmail.com
  • Financial disclosure: Consultant (Carl Zeiss Meditec)