SMILE: Surgical Pearls for Optimal Outcomes

We describe the surgical technique of small-incision lenticule extraction (SMILE) with tips to facilitate easy lenticule dissection and extraction. Surgical steps involve docking, femtosecond laser application, lenticule dissection, and extraction. Disparity between cap and lenticule cut is visible as peripheral rings after femtosecond laser application. A side-cut incision is opened with the hooked end of the lamellar dissector. Identifying the lenticule edge is the most critical step. A "meniscus sign" is created by pushing the lenticule edge away from the side cut and it serves as a landmark to guide dissection in the proper plane. The anterior plane is dissected first, followed by the posterior plane. It is essential to leave small areas of undissected tissue in the periphery to provide counter-traction during lenticule separation from the overlying cap. Separated lenticule can be extracted easily with forceps or dissector. Lenticule is examined for its completeness after extraction and cap apposition is assessed with built-in slit-illumination.