Adam C Reynolds MD

ak FLEX evolved to SMILE — this is also an abbreviation, meaning “minimally invasive lenticular extraction”. That is, cutting out the lens inside the eye and then getting it out.

How exactly this happens, you can see here (I was asked several times to warn, so it is probably better not to look at the link for food, although there is really nothing terrible there).

In 2007, my first SMILE was made, then with two cuts of 5 millimeters each — it was assumed that the second was needed so that when washing the lenticular cavity in the stroma, the liquid could freely exit. Two of 5 is 10, not 20, as was done for FLEX or FemtoLASIK, which means that much more nerves were preserved inside the eye and Bowman’s membrane was much less injured.

Quite quickly, it was possible to reduce the incisions to 2.5 millimeters. And then Rupal Sha of India proved that just one is enough. Today, most experienced surgeons work from 2 to 3 millimeters (but most Russian surgeons work from 3 to 4.5 mm).


If FemtoLASIK and SMILE are excellent at solving nearsightedness problems, then farsightedness or more complex effects are not so easy. But having the ability to cut out the lenticule inside the eye, you can use not only the effect of collapsing the stroma and forming a new lens shape. You can insert something new and interesting into this cavity. The same indefatigable Soviet surgeon, Academician S. N. Fedorov, invented the operation (in the future it was called ICL-implantable contact lens). He inserted lenses either in the back chamber of the eye, or in front of the lens-the benefit of the operation of implantation of the lens was already well mastered. But Academician S. N. Fedorov did not have modern materials, so every fourth patient received an unpleasant side effect: due to the deterioration of the nutrition of his own lens, its opacity began.

In the United States, a new copolymer was created — partly silicone, partly pig. More precisely, pig collagen was used there. From 25% of side cataracts managed to get away to 3%. The operation became massive, and a mass of improvement branches began. Dozens of models appeared and disappeared due to complications. Since then, the manufacturing companies have changed their name a couple of times, but 90% of the market is still the same “half pig”. Although, of course, the lenses are now made flexible to be inserted through a small incision.

Today, a stable operation of this kind was developed by Jan Vorst from the Netherlands — he has a lens with “claws”, it catches on the iris and is held in the front camera. Professor Secundo, by the way, specially went to Jan Vorst in Holland for training and understanding of manufacturing technology at the Ophtech factory, which is now run by Vorst Jr.

What are they doing today in Russia and in the world

In Germany, the situation 5 years ago was as follows:

PRK for rare indications and for cities where there is no separate ophthalmology (“As we joke, the operation of PRK is very simple, even a cat can master it with proper assistance,” says Professor Secundo).
LASIK is for those who do not have money for FemtoLASIK.
FemtoLASIK and its derivatives for standard cases.
SMILE is for those who are willing to reduce risks for an additional fee (as a VIP operation with experienced surgeons).

Over the next 2 years, SMILE began to be made about as often as FemtoLASIK.

At the moment, the situation has changed somewhat. The fact is that due to the increase in the frequency of the laser and the improvement of energy parameters, the accuracy of SMILE has become significantly higher, and 2-3 years ago it equaled FemtoLASIK at corrections from -2 (on smaller FemtoLASIK it is more accurate, and the PRK is ideal for accuracy for -1). There is still the question of high prices, and there is little that will change due to the fact that only Zeiss is able to make the necessary optics so far. One turn on of the laser for SMILE surgery for one eye costs 300 euros.

Now in Germany in the same network, this is what happened:

PRK is kept in the region of 7-10% (thin cornea, a number of complex cases, small corrections of about -1 diopter, plus advertising “no one will even touch you”, a huge clinical practice).
Ordinary LASIK even patients consider almost barbaric, and it is no longer there.
Next in popularity is FemtoLASIK with analogs, about 10% of operations.
FLEX-units per year, since this is already an unnecessary evolutionary stage.
And then-SMILE, its about 80%.

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