My ReLEx SmILE laser eye surgery experience instead of LASIK (USA)

Note: this is being written  shortly after undergoing the SmILE procedure. I will be updating and adding to it until it seems like my vision has stabilized.

I'm writing this in December of 2017 because I found so little information online in the US for ReLEx SmILE even though that was the procedure I was to undergo (and have since undergone). In the hopes of providing useful information that people in the world care about (which sort of explains my career choice or makes my career choice totally ironic - you choose), I'm putting this post together for the curious. I am not an optometrist, ophthalmologist, nor any other sort of medical professional. I don't think I even have a current CPR certification. I do have a doctorate, but that has basically helped me to know how little about the world I understand deeply. Anyway, that's my caveat.

What is SmILE surgery?

There are lots of interesting youtube videos and sites explaining the procedure. It's best understood in comparison to the more widely known LASIK procedure. Here is one in Spanish. And this one shows the procedure very vividly on someone's actual eye. I embedded it below.

In LASIK, a corneal flap is made. That means the cornea is sliced nearly all the way across (using a laser, but I guess some places still use an actual blade - creepy image of a horror movie comes to mind). The cornea is then flipped open like a book. THEN laser shaping of the exposed portion of the cornea is done. After that, the cornea is closed up again. The people I have talked to who have undergone this have described it as a moment where you see okay (with your impaired vision) and then when the flap is made and opened, your vision turns TERRIBLE, and then when the flap is closed, things look sort of back to normal again. The flap opening is sort of scary because you realize how much your vision depends on that tissue that is now dangling off of your eye.

In SMiLE, there is no "open-book" flap. Instead, the shaping lasers cut out a mini lens of tissue inside the cornea that will be extracted. That mini lens is called the lenticule. To get it out, a very small incision is made on the side of the cornea, and the idea is that using some very specialized instrument that looks like super precision pliers, the lenticular is pulled out. There should be much less exterior corneal healing required and risk of corneal damage because the incision on the cornea is much much smaller.

Why hasn't anyone heard about SmILE?

I haven't researched it extensively, but what I think I heard from my ophthalmologist is that it only got FDA approval in the US last year. The equipment and training for it is really expensive, and at least as of fall 2017, purportedly (according to my ophthalmologist), only 50 places in the US offer SMiLE surgery. However, it's 'the next big thing' and will be what most people get rather than LASIK because it's supposed to reduce the risk of the annoying side effects (halos, dry eyes) and have a much faster recovery.

 The Hoff.

The Hoff.

According to my ophthalmologist, it was - like David Hasselhoff - big overseas, in Europe, Australia, and elsewhere (the internet seems to say India is a big place too for it). (The Hoff comparison is mine, not the ophthalmologist's, but we were around the same age so we both know Hoff from Knight Rider rather than Baywatch). But doing it now would get me early on the trend before everyone else - sort of like being driving the US K-Pop bandwagon rather than being a passenger on it. 

Why did I decide to undergo a SmILE procedure?

I've needed corrective lenses for nearsightedness since I was 12 years old. I wore glasses until about age 16 when I finally got contacts. Since then, I have worn contacts near daily for over two decades. My vision was about -5.00 in one eye and -4.50 in the other eye. Many years ago, I was unsure about long term effects from LASIK, but enough time had passed that it sounds like there aren't long term effects that worry me. (Warning: don't look on YouTube for LASIK horror stories. People with bad experiences are very vocal.) Plus, many more people I know have had LASIK done and have raved about how it has changed their lives. In the good way. 

Anyway, I was running out of contacts and decided that I'm getting close to the age were I would need reading glasses, traveled a lot and got tired of having to keep track of all the eye care stuff I needed, and did enough outdoor activities where I had lost a contact lens (swimming, skiing, falling on my face, etc) that I just didn't want to worry about it anymore. I wanted some years where I could go without any corrective lenses before old age got me and required me to wear reading glasses.

I originally signed up for LASIK, but the eye care practice where I went had a sudden staffing change, and I got a brand new ophthalmologist. (Brand new to the practice, not like a Doogie Houser kid fresh out of eyeball school.) The eye assistants got all the pre-op readings for the week of the LASIK procedure - corneal thickness, visual acuity tests, etc, and then my new ophthalmologist came in and - perhaps in the most opto-nerdy way possible - looked at the data and gushed about my corneas. ("Beautiful" is the word I think he used to describe them). He then said I was a perfect candidate for SMiLE and explained the benefits. In my case at least, he said it would be the same price as the LASIK, and he expected it to be better in terms of side effects and risks.

 not my beautiful cornea, but a nice one nonetheless

not my beautiful cornea, but a nice one nonetheless

So moved was I by hearing I had beautiful corneas, I agreed to do SMiLE instead. However, there was a catch - we had to reschedule because the specialized engineers who handled it (I'm guessing they were from the laser company and were there to make sure that all the equipment was used properly and whatever laser algorithms were input properly) needed to be on site. They didn't live nearby (I learned later the engineer for my procedure was coming from a neighboring state), so we had to find a later date that would work.

The punchline of this is that I had bad vision, I was told this was a new and potentially better procedure, it made sense in the description that was given, and it would cost the same. So I did it. #YOLO, right?

What was the procedure like?

Well, first I got valium to make sure I was calm. And so from that moment, everything seemed fiiiiiiiiiiiiine.....

But this is what happened. I got more measurements done again just to make sure all the numbers were right. I went to a room where I lay down on something that looked like a partial MRI machine - it was all white and had this half circle thing that was what did the laser work.

visumax.jpg

 

They then did the "Clockwork orange" prop the eye open thing with some sticky tape and maybe some creepy metal eye-propper-opener and put in some numbing drops and I think artificial tears.

Staying completely still, I was instructed to stare at this green globby light shape that looked to me like a mass of tangled protein and keep things - like my eyeball - completely still. Some robot voice said 'suction on' and then as I stared at the green glob, things began to dim and things went dark. That was maybe 30 seconds. Then the robot voice said "suction off" and then lenticular things were removed from my eye. Same thing happened for the other eye. I found the other eye harder to keep focused on the green glob and that had me a little nervous. But the robot voice came on and the doctor and the surgical assistants seemed to voice approval at my stillness, so I guess we were good?

Then I could feel gentle jabbing at the top of my eye while the doctor went to work. I suspect it was the incision and extracting the lenticule. For the right eye, it didn't hurt. Sometimes a little uncomfortable but not painful. I was instructed to look in certain directions at different times and felt some pressure on my eye from different directions. My guess is they were making sure the lenticule was detached and moving away from where it had been attached to my cornea. Eventually, I noticed something like an invisible screen slide past my field of view, and the doctor said the lenticure was out.

For the other eye, it was much the same but a bit more painful. Not extraordinarily painful, but I was wincing a number of times and the doctor said that the incision seemed to be next to a corneal nerve. I got more numbing drops. I was sympathetic - every person's eye is different and the exact location of something that is in proximity of a nerve is probably uncertain. The doctor was careful to try to avoid hitting it, but that eye took a lot longer to get the lenticule out and there were still a few moments when the nerve was hit. Sincerely, though, I feel like that was just circumstance based on how my eye and cornea are laid out. I don't think the doctor did anything wrong (Although still thinking that my corneas were 'beautiful', I might have been willing to forgive a lot).

I had spectators. Some other ophthalmologists from a different practice came in to observe while the lenticule was being extracted, so that tells me this is new. Or that my corneas are just that beautiful, and everyone needs to see them in person.

There was murmur of 'the flap folding' at the end after the lenticule was removed, which I took to mean that part of the opening was folded on itself so they had to make sure it lay flat on the cornea before I was done. There were several more moments of eyedrops and extra numbing drops on that eye all throughout.

After, I was taken back to an exam room where I was given Tylenol PM and sat for 15 minutes and spaced out with my eyes closed and wearing sunglasses (remember, I had valium). Then the doctor came and looked, said everything looked okay, and we discussed follow up times. It was a Friday, so my follow up was going to be on Monday.

How was the recovery?

Day of the procedure.

I was in sunglasses and got a ride home and blabbered about the procedure and how I couldn't really tell anything different although things seemed clearer than when I looked at things without any corrective lenses on. I then went straight to sleep right when I got home. 

I had to wake up and participate in a videoconference for work about 4 hours later and things seemed blurry and I could see things on the computer screen by magnifying them or sticking my face up close to the screen. I couldn't see things on my phone very well but could make out words if I stared long enough.

Then I went back to sleep, getting up for some dinner and then sleeping again. My ophthalmologist called me to check on how I was doing, advised me to take some tylenol for a little bit of discomfort, and said I should feel like my vision is about 80% better the next day. At the time, my vision was blurry but I could tell things that were farther away looked more clear. Near vision was still blurry. I slept through the night.

1 Day after the procedure

I woke up and my distance vision seemed better although a bit blurry. (I have to sleep with these goggles that look like very thin ski goggles. They had fogged up a little bit in my sleep). After putting in some eye drops, things afar looked more clear. Distance vision then actually seemed pretty sharp. I can see things far away with a clarity that I don't think I have had in a while - even with glasses or contacts on. The near vision is still a bit weird - I feel like as I type this, I see something in between blurry and double. My eye that required more time for surgery  and had the stronger prescription (the left) doesn't seem to show near things as sharply as my other eye when I close one or the other and compare. I do feel I can drive roads that are familiar to me and I was able to read all street signs fine. I did drive some that day. 

I don't really feel pain although there is a tiny bit of discomfort in the left eye where the nerve was struck. Not quite like having a speck on a contact lens but close to it. I've been using eye drops a lot, not because my eye feels dry but because it's doctor's orders. More to come on progress over the next days.

2 Days after the procedure

Woke up and immediately put in eyedrops. I have a stash of Systane and Refresh branded preservative-free eyedrops. I'm using the Systane ones first. I didn't figure this out till partway through yesterday, but the dropper can be resealed. (I tried to seal it that way but it wasn't sealing. After the ophthalmologist  insisted they could be re-sealed and still used within 24 hours during his courtesy call, I persisted and figured it out. Here are some pictures in case you couldn't figure it out immediately either.

 The top twists off, then you have to cap it by placing the top back on at a right angle from how it was on their originally. It may take a little jiggling, but it does eventually snap back on.

The top twists off, then you have to cap it by placing the top back on at a right angle from how it was on their originally. It may take a little jiggling, but it does eventually snap back on.

So while my eyes don't feel dry, I'm trying to put drops in every 15 minutes like I was told. I also do 3 compound drops a day for recovery. As far as vision goes, distance vision still looks solid. Reading is not great.  Computer use is a bit of a chore. My right eye sees fine. My left eye sees blurriness up close. When I look at my phone, I have to hold it about 18 inches to read it comfortably. The discomfort in my left eye is more mild than before.

Last night, the lights everyone had on their houses (it's December) did not look as sharp as they used to. I didn't see anything I'd call a halo around them, but I couldn't clearly identify the bulbs whereas I had been able to before the procedure. I could read street signs fine though.

3 Days after the procedure

I went in for a follow up exam. My vision seems okay in the morning but staring at the phone was a little difficult, which is my breakfast routine.

At the doctor's office, we did the 'cover 1 eye and read letters' and with that test, my right eye was around 20/40 and my left eye was not so much at that.

The doctor peeked at my eyes and said things were looking good but he wanted me to switch from compound eyedrops to a stronger steroid one (prednisolone), just to prevent something with cells growing somewhere they shouldn't. I said that I was having a hard time using the computer and asked about reading glasses for the time being. They wouldn't hurt my recovery, and according to him, everything was looking great - I should see substantial improvement over the next several days. I commented that I wasn't seeing halos unless my night vision where I wasn't seeing the holiday lights as crisply as before counted. He said it was still early.

The optician gave me a freebie pair of reading glasses - dark tortoise shell - that I now use for computer and reading tasks. I don't get to do any strenuous exercise for 2 weeks (contrary to what a bunch of online websites say), and that includes skiing - which is too bad since my season pass resort opens in 2 days. But that's a total first world problem. So are laser eye surgery side effects.

My eyes are getting drier midday. It almost seems like the side effects are appearing a day or two later than I would expect them to, but the ophthalmologist says this is all normal. 

I get a follow up appointment in two weeks. I'll continue to report delay my vision changes so that interested (read: anxious) readers know what's going on.

4 Days after...

MY EYEBALL FELL OUT!

No, it didn't. Everything is pretty routine. No obvious changes. Getting more used to new vision, computer use is still challenging. Using the new eyedrops. My follow-up regimen involves using artificial tears less frequently, so I can stop squirting my eyes mid-sentence.

5 days after

yesterday I was pretty itchy on certain parts of my body (skin). I was wondering if that might be a side effect of the new eyedrops but that would be very weird for a steroid which usually reduces inflammation and itching usually is tied to inflammation. So, maybe a coincidence? 

i did take OTC Benadryl in response to the itch. When I woke up, my sleep goggles had ridden up my face and the bottom was right at my eyes, which is probably the worst place for them to be. I’ll try to tighten the goggles and be more unconsciously diligent about adjusting them. It did make me glad I had the SmILE procedure done instead of lasik sincerely it seems the cornea has less opportunity to slide. 

When I woke up, my vision overall seemed crummy. This could be because my goggles were on my eyes, because I took Benadryl which usually dries me up, or because it was first thing waking up or any combo of those. I immediately used some eye drops, which made my vision immediately blurry. Now, about an hour later, things look more like they did yesterday.  

my left eye near vision is still well behind the right. My guess is 20/80 or 20/100 but I’m grasping at straws for numbers. 

Check in 2 hours after this last update: my computer vision seems a little better than the past few days, but I am still going to use reading glasses because I have to stare at the screen for a long time.

6 days after

Last night, I think I convinced myself that my near vision is seeming better. Still using the reading glasses but I could have imagined going without.

My experience has been nothing like this, thankfully.

7 Days After

I'm allowed to sleep without the goggles now. I'm allowed to speed walk. I *think* that my near vision is getting a little better, but I also might be trying to convince myself that it is.

10 days after

i *feel* like I am at my new normal. My left eye still sees noticeably less sharply than the right eye at reading distance. I can’t focus with my right eye closed any closer than about 12 inches in front of me. 

 

Eyesrop regimen has been pretty strictly followed. No discomfort. Eager to have follow up and see what the professional assessment is. That’s in 4 days.  

14 days later 

strangest thing happened - my right eye went from being my better eye to being my worse eye. Did some vision screening and hit 20/30 but everything was blurry in the right eye. Got to a blurry 20/20 in the left eye.  

The doctor did some checking of my vision and I guess it looks like an astigmatism has formed in my right eye. This is unusual.  

Anyway, the plan is to give it another month with eye drops and see if any odd healing takes care of itself - after which point, some corrective work with a femtolaser or with EKT will be done. As the doctor says, we are close and this is not unheard of. I should have had really clear and sharp vision pretty shortly after surgery and especially by now.  

My feeling on this is some disappointment but - and perhaps it’s because the dr is so friendly about everything - acceptance. This is done with lasers and computer programs and should work a certain way but for some people of course things will recover differently. It seems like I am one of those people. I can’t imagine there was something done wrong in the procedure especially when my eyes have now switched which one is the better one.

I am relieved to get back to the gym though.  

If things change in any noticeable way, I’ll update. My reading seems a bit better but I think I am also holding things farther from my face.  

One month later

I think things are as stable as they will get. Right eye seems to be a bit blurry (astigmatism that came as a result of how my eye healed following laser surgery). Left eye is good - pretty close to what I think is my ideal. I'm expecting that a small femotlaser adjustment on the right eye is coming in the future, but I don't see it as urgent. I can read fine (haven't pulled out the reading glasses) and no serious side effects I can tell. It may be that the night vision lights aren't as sharp as they used to be, but I think I've gotten used to it - it doesn't bug me. Next update if I get femtolaser correction, which will be some months from now given schedule constraints on my side.