Gazing into a Lenticule-Based Future

Femto-LASIK remains the gold standard for refractive surgery, but an increase in uptake of lenticule-based procedures may be on the horizon driven by recent femtosecond platform developments, according to Béatrice Cochener-Lamard MD, PhD.

Providing predictions about the landscape of refractive surgery in 2030, Prof Cochener-Lamard said, “Looking into my crystal ball, I think lenticule-based surgery has a promising future and may become competitive with LASIK, but I cannot tell if lenticule-based surgery will replace LASIK. I do guarantee, however, that PRK will not become obsolete because there will continue to be specific indications for choosing a surface ablation procedure.”

Factors that could lead to the expansion of lenticular procedures in the future include the introduction of cyclotorsion compensation (like on the VISUMAX 800 laser), the anticipated approval of software for the VISUMAX 800 to treat hyperopia/hyperopic astigmatism, and the availability of lenticule-based procedures to treat myopia/myopic astigmatism using other femtosecond laser platforms—e.g., SILK with the Elita laser, Smartsight with the ATOS laser, and CLEAR with the FEMTO LDV Z8 and FEMTO Z8 NEO lasers.

“Finally, with these new platforms, a product (SMILE) is becoming a concept, and it might attract more surgeons to try lenticule-based refractive surgery,” Prof Cochener-Lamard said.

She noted that compared with the VisuMax, the VISUMAX 800 features ergonomic enhancements to provide time-saving benefits and make the procedure more comfortable for patients and surgeons. The laser also introduces new surgeon support functions, including aids for centration and cyclotorsion adjustment. Most importantly, it has a fourfold faster pulse frequency than the VisuMax.

“The beauty of the VISUMAX 800 is it makes lenticule extraction a much faster procedure.”

The safety, efficacy, predictability, and stability of SMILE for hyperopia/hyperopic astigmatism were proven in a multicentre 12-month study in which Prof Cochener-Lamard was an investigator.¹ Even though the procedures were performed using the VisuMax laser without cyclotorsion control, good results were achieved treating patients with up to 4.0 D of astigmatism. Study results also showed patients were subjectively happy with their outcomes and had less halo and glare compared to reports for hyperopic LASIK.

There are caveats, however. “The results are encouraging, but we still wonder about stability over the longer term, and for a variety of reasons, SMILE for hyperopia is more challenging than SMILE for myopia,” she added.

Another dimension of lenticular surgery

Looking ahead, Prof Cochener-Lamard discussed the emergence of lenticular implantation procedures (addition keratoplasty) that use tissue removed from myopic SMILE or a corneal button. Applications in development within this category could include treatment of keratectasia, aphakia, pathological corneal thinning, and even hyperopia and presbyopia.

“Feasibility has been demonstrated with respect to bioavailability, but the predictability of refractive outcomes needs to be refined,” she said. “In addition, work is still needed on lenticule preservation methods that will guarantee the best behaviour when the tissue is reused.”

Prof Cochener-Lamard spoke at the 2023 ESCRS Congress in Vienna.

Béatrice Cochener-Lamard MD, PhD is Professor and Head of the Department of Ophthalmology, CHU Morvan Brest – UBO University, Brest, France. beatrice.cochener-lamard@chu-brest.fr

1. Reinstein DZ, Sekundo W, Archer TJ, et al. “SMILE for hyperopia with and without astigmatism: results of a prospective multicentre 12-month study.” J Refract Surg. 2022; 38(12): 760–769.