What to Expect Before, During, and After SMILE Eye Surgery

What is SMILE Eye Surgery?

Small incision lenticule extraction (SMILE) is a type of laser eye surgery. It provides clearer vision by reshaping the cornea. SMILE laser eye surgery is a treatment for:

• Myopia (nearsightedness). This causes blurry vision when looking at distant objects but clear up-close vision.
• Astigmatism. This is when your eye is more oval-shaped than round.

Myopia and astigmatism are common refractive errors. A refractive error is when the shape of your eye's cornea or lens prevents light from bending as it should. When this happens, the light can't focus images on your retina properly, and you have blurred vision. 

The Food and Drug Administration (FDA) approved SMILE for nearsightedness in 2016 and astigmatism in 2018. 

How Does SMILE Eye Surgery Work?

SMILE treats refractive errors by reshaping the cornea. Your eye surgeon uses a laser to change the curve of your cornea. This causes light rays to focus properly on your retina, improving your vision.

Undergoing a SMILE procedure can reduce your need for eyeglasses or contact lenses. In some cases, you may be able to stop wearing corrective lenses entirely.

SMILE Eye Surgery Procedure

Before Surgery

Before the procedure, your ophthalmologist will examine your eyes to assess your vision and take measurements. This may include:

• Vision test. Your doctor will measure how high your nearsightedness is and ensures your vision hasn’t changed.
• Eye health exam. Your doctor will check for other eye problems that might disqualify you from SMILE surgery, such as glaucoma.
• Eye measurements. This involves precise measurements of your cornea and pupil size.

During SMILE Surgery

SMILE surgery typically takes 10 to 15 minutes. During the procedure, you can expect:

1. Your eye surgeon will program the laser with specific measurements from your eye
2. You receive eye drops to numb your eyes, so you feel no pain
3. Your surgeon places an eyelid holder on your eye to prevent blinking
4. A suction ring raises and flattens your cornea and prevents your eye from moving
5. The laser creates a lenticule (a disc-shaped piece of tissue) in your cornea
6. The laser makes a tiny incision in your cornea, which your surgeon uses to access the lenticule
7. Your eye surgeon removes the lenticule through the small opening; this changes the shape of your cornea

The laser treatment part of the procedure takes about 30 seconds.

After Surgery

You’ll need to have someone drive you home after SMILE eye surgery. Plan to take it easy the rest of the day. You should be able to resume normal activities after a day or two. Things to remember include:

• Keep your eyes away from water for a few days
• Follow your surgeon’s instructions for aftercare and take any eye drops they prescribe
• Blurry vision is common right after SMILE eye surgery and usually resolves in a few days or weeks

How Much Does SMILE Surgery Cost?

People generally spend between $2,000 and $3,000 per eye for SMILE surgery. This is comparable to other laser refractive surgeries, including LASIK.

Like any laser vision correction procedure, the cost of SMILE surgery will change based on different factors, including:

• Location. The cost of living where your eye doctor’s office is located will affect the price of the procedure, office visits, and any exams you may need before and after.
• Doctor’s experience. Eye surgeons with more expertise and strong reputations may charge more for their time.
• Eye health. If you have other vision problems or health conditions requiring additional exams, medications, or visits, you may pay more.
• Exclusive discounts, financing offers, or payment plans. Your eye surgeon’s office might offer flexible payment plans or discounts.

Remember that price is only one factor to consider when exploring different refractive surgery types. Consulting an eye doctor can help you decide which surgical route is best for you.

Does Health Insurance Cover SMILE Eye Surgery?

Most health insurance plans don’t cover elective procedures like SMILE or LASIK. However, an FSA or HSA can make them more affordable.

Flexible Spending Account (FSA)

An FSA is a benefit program through your employer. You can contribute money on a pre-tax basis and use it to pay for healthcare expenses. Usually, you must use the money in an FSA by the end of the year.

Health Savings Account (HSA)

An HSA also allows you to save money on a pre-tax basis for medical expenses. You don’t have to use all the money in one year, and it grows tax-free. You must meet certain requirements to enroll in an HSA, such as having a high-deductible health insurance plan.

Common Side Effects of SMILE 

Side effects will not vary much from those found with LASIK or other laser surgical procedures. Individuals who undergo SMILE may expect to experience:

• Glare
• Halos surrounding lights
• Dry eye
• Tissue inflammation
• Infection 
• Debris where the tissue was removed
• Over-correction or under-correction 
• Eye pain/soreness
• Loss of best spectacle-corrected visual acuity (BSCVA) or contrast sensitivity

Potential Complications of SMILE

Complications during the SMILE procedure are rare. Some individuals have reported:

• Epithelial abrasions
• Small tears at the incision site
• Perforated caps

Vision over-correction or under-correction may occur. In such cases, contact lenses or glasses may be suitable. Other times, you might consider retreatment with a laser-guided procedure or surface PRK. 

There's a rare risk of worse vision (even with eyewear) and blindness.

Unlike LASIK, there’s no risk of corneal flap displacement. The SMILE procedure does not require the formation of such a flap. 

Who is a Good Candidate for SMILE Eye Surgery?

SMILE eye surgery will be suitable for some individuals more than others. For example, if individuals have an active lifestyle or job, SMILE may prove better than LASIK or related procedures. With SMILE, there is no risk of corneal flap displacement.  

However, more criteria can help determine eligibility for SMILE eye surgery, including:

• 22 years or older
• No change in eye prescription during the past year
• Myopia should be between -1 and -10, and no more than 3 diopters of astigmatism
• Good eye health, especially the corneas
• Realistic expectations about procedure outcomes for vision correction

Who Should Not Get SMILE Eye Surgery?

Individuals who are not good candidates for SMILE eye surgery include those with:

• Skin or other diseases that may affect recovery
• A cataract that affects eyesight
• Uncontrolled diabetes
• Advanced glaucoma
• Corneal abrasions
• A history of particular eye infections 
• Excessive scarring or keloid formation (overgrowth of scar tissue)
• Women who are pregnant or nursing

Pros and Cons of SMILE 

Advantages

SMILE eye surgery has more advantages than downsides. Benefits of SMILE include:

• Small corneal incision. The incision is only 2 to 3 mm, which minimizes tissue damage.
• Fast recovery. Sensation in your eye returns quicker than with LASIK.
• Less dry eyes. The dry eye side effect is less common and lasts for a shorter time with SMILE than with other laser-guided procedures.

Many advantages of SMILE have to do with the fact that this procedure uses a smaller incision. This contrasts with LASIK, which involves cutting a corneal flap. Risk and side effects are reduced by minimizing disturbance to the cornea’s surface.

Disadvantages

The primary disadvantages of SMILE include:

• New procedure. Because SMILE is newer than other laser eye surgeries, less research supports its uses.
• Only for myopia and astigmatism. SMILE surgery is currently approved to treat nearsightedness and astigmatism. People with hyperopia (farsightedness) will need a different procedure, such as LASIK or PRK.

LASIK vs. SMILE vs. PRK

LASIK, SMILE, and PRK are all procedures that help to correct refractive errors. However, one surgical procedure may be better for some people than others.

Speaking with an ophthalmologist and undergoing an eye exam can help determine the best procedure for an individual’s unique needs.

LASIK

Laser in situ keratomileusis (LASIK) reshapes the cornea by cutting a flap of tissue. This is done with an excimer laser.

Who Could Benefit?

LASIK can treat all types of refractive errors, including:

• Myopia (nearsightedness)
• Hyperopia (farsightedness
• Astigmatism
• Presbyopia

To be eligible for LASIK, you must have adequate corneal tissue.

SMILE

SMILE is as effective as LASIK while being less invasive. This procedure uses a femtosecond laser to form a lenticule (disk-shaped corneal tissue) for extraction. It doesn’t require cutting a corneal flap.

No corneal flap means SMILE involves less tissue damage than LASIK. This makes the recovery faster and easier. In one study, 80% of individuals who underwent SMILE didn’t need lubricating eye drops after 6 months post-op, while 43% of individuals who underwent LASIK still did.

Who Could Benefit?

SMILE is approved to treat myopia and astigmatism. People with hyperopia may opt for LASIK or PRK.

PRK

Photorefractive keratectomy (PRK) doesn’t require cutting a corneal flap. Instead, your eye surgeon removes the cornea's outer layer (epithelium). Then, they use an excimer laser to reshape the corneal tissue.

Like SMILE, PRK doesn’t disturb as much corneal tissue as LASIK does.

Who Could Benefit?

PRK is an excellent option for people with thin corneas or corneal surface irregularities. These conditions may disqualify you from LASIK and SMILE procedures.

Like LASIK, PRK treats:

• Myopia
• Hyperopia
• Astigmatism
• Presbyopia

Summary

• Small incision lenticule extraction (SMILE) is a laser refractive procedure that treats nearsightedness and astigmatism
• The average cost of SMILE eye surgery is between $2,000 and $3,000 per eye
• Health insurance plans typically don’t cover SMILE eye surgery, but HSAs and FSAs can help
• SMILE eye surgery offers similar visual outcomes as LASIK, with a faster and easier recovery
• People with hyperopia (farsightedness) might benefit from a different procedure, such as LASIK or PRK