- What’s new in refractive surgery
- Adding keratorefractive lenticule extraction to your practice
- Enhancement options after small incision lenticule extraction (SMILE) surgery
- Developments in glaucoma
What’s new in refractive surgery
Seth Pantanelli, MD, kicked off a refractive session on Friday at the AAO Annual Meeting, discussing what’s new in lens extraction.
Phaco has many advantages, but it’s still not perfect, he said. It uses a small incision and is highly engineered, but it can be expensive, there’s endothelial cell loss, it generates heat, there’s limited applicability in the developing world, and it also produces a lot of medical waste.
The innovation in lens extraction continues, Dr. Pantanelli said, going on to discuss three innovations in this area: the Alcon UNITY, the Zeiss MICOR 700, and the Rayner Sophi.
The Alcon UNITY offers 4D phaco and better followability. It oscillates the phaco needle in an elliptical pattern, which brings pieces toward the surgeon more efficiently, Dr. Pantanelli said. There is also reduction in ultrasound energy compared to torsional ultrasound. The UNITY has thermal sentry. Ultrasound tip vibration can produce thermal energy and increase wound temperature. The UNITY has a novel thermal algorithm to maintain the selected temperature threshold.
Meanwhile, the Zeiss MICOR 700 is fully disposable and ultrasound free. It’s a non-ultrasound lens extraction technology, Dr. Pantanelli said, and it’s also minimally invasive. It oscillates longitudinally at 40 Hz, and you can control it with your finger (there’s no foot pedal). There is a lot less energy production with MICOR, Dr. Pantanelli said, adding that this requires the surgeons to be proficient at chopping.
The Rayner Sophi focuses on sustainability. A traditional phaco uses a new cartridge, balanced salt solution bag, and tubing for every case. The Sophi, on the other hand, uses a single cassette for up to 10 cases. This helps decrease waste, he said.
Editors’ note: Dr. Pantanelli has financial interests with Bausch + Lomb and Zeiss.
Adding keratorefractive lenticule extraction to your practice
John Doane, MD, discussed how to add keratorefractive lenticule extraction (KLEx) to your practice. He first highlighted the “how” and “why” for KLEx. With KLEx, there is no flap (so no physical activity restrictions), it offers greater biomechanical strength, there is less dry eye, and a lower enhancement rate.
In order to perform KLEx, Dr. Doane said you need to be proficient in corneal refractive surgery. You also need to understand the technology. It’s important to familiarize yourself with the laser system. Currently, the only system available in the U.S. for this is the VisuMax (Zeiss). One needs to understand the mechanics of the lasers, the laser parameters, and the lenticule creation process.
Formal training and certification from the manufacturer are required, he said, adding that this could involve enrolling in a training program offered by the equipment manufacturers. Didactic lectures and wet labs are helpful, as are supervised procedures on the front end. Shadowing a surgeon is important to observe the live procedures and which patients and techniques to use.
The patient selection process and preoperative assessment are also key for these procedures, Dr. Doane said. It’s important to learn to identify suitable candidates, and these considerations could include patients with myopia or myopic astigmatism, stable refraction, and adequate corneal thickness. It’s also important to master preoperative diagnostics, including corneal topography, pachymetry, and wavefront analysis, to ensure optimal outcomes.
Dr. Doane noted that hands-on practice is key, and wet labs can help the surgeon practice with lenticule creation and extraction. Perform initial cases with the supervision of an experienced manufacturer or experienced surgeon.
As a surgeon gains experience, Dr. Doane said it’s important to build stepwise experience. Begin with straightforward cases, like those with moderate myopia and no complex cornea issues. Then you can advance to lower myopia. Track outcomes and complications to refine skills and improve patient refractive precision and safety.
Wrapping up, Dr. Doane stressed the benefits of KLEx for both surgeons and patients. For surgeons, it uses a single laser and has great integrity of the upper corneal layers. It offers high precision and proven outcomes, and there is easy postop management. For patients, KLEx offers a gentle technique with a small incision and a relatively stress-free experience. It’s a possible option for patients with contact lens intolerance and dry eye tendency, and patients can quickly return to full physical activity.
Editors’ note: Dr. Doane has financial interests with Zeiss.
Enhancement options after small incision lenticule extraction (SMILE) surgery
Nandini Venkateswaran, MD, discussed options for enhancement with SMILE, noting that the rates in the literature are quite low, under 4%. Risk factors for higher rates of enhancement may include older age and higher preoperative manifest refractions.
So, what are the options if you need to do an enhancement? Dr. Venkateswaran said in theory, you could reperform SMILE, but there are limited case reports of this option being used.
Surface ablation/PRK can be a good option. This preserves the flap-free approach of the traditional SMILE surgery and is tissue sparing. However, Dr. Venkateswaran noted that patients need to be counseled about slower visual recover time with this option. Epithelial thickness mapping can be helpful to determine if a patient is a good candidate for surface ablation, and it may be beneficial to use an anti-metabolite (like MMC) to reduce the risk of haze.
Thin-flap LASIK is another option, which Dr. Venkateswaran said is usually around 80–90 microns, which leaves around 30–40 microns of stromal bed. There may be a risk of perforation into the initial SMILE interface. Additionally, you must counsel the patient that they’re converting to a flap-oriented procedure. Anterior segment OCT can help understand where thin-flap LASIK would be.
Thick-flap LASIK was the last option that Dr. Venkateswaran mentioned for SMILE enhancement, but she said you need to know if the cornea can have a 120-micron flap created. She noted the CIRCLE technique (used outside the U.S.) and cap to flap techniques that can be used in the U.S. This option offers quicker recovery, but you need to ensure the patient is fine with having a flap created.
Editors’ note: Dr. Venkateswaran has financial interests with Zeiss.
Developments in glaucoma
During a glaucoma session, Terri Young, MD, MBA, discussed how close gene therapy for glaucoma is.
Gene therapy must either target common downstream pathways or be personalized, she explained. Gene therapy involves the insertion, removal, or modification of genetic material within cells to repair or compensate for the loss of a gene’s function. It describes a process or technology that enables the genetic modification of cells to produce a therapeutic effect. There are several different approaches: gene replacement, gene silencing, gene editing, and gene addition. Dr. Young explained that there are different ways of introducing genetic material into cells, notably using viral vectors or non-viral vectors.
She noted several ocular targets including rejuvenation of retinal ganglion cells, neuroprotection of the optic nerve, alteration of aqueous humor producing cells, and bolstering support of the angle structure tissue/cells that are developmentally arrested.
Gene therapy has shown promising results in pre-clinical studies (using SIRT1 to enhance neuroprotection). There are some clinical trials being done now, two specifically glaucoma-focused and two that are “glaucoma adjacent.”
Glaucoma is genetically complex, Dr. Young said. Preservation of RGCs has been the primary target, and gene therapy can address IOP-dependent and independent mechanisms.
She also mentioned pitfalls to avoid: over reliance on IOP models alone, ignoring the immune and inflammatory response, assuming uniform disease progression, and underestimating delivery challenges.
Anna Momont, MD, discussed some of the developments from 2025 that she applies to clinical practice. She broke this down into using effective interventions early in glaucoma care, applying technology to improve clinical workflow, and collaborating to take the pressure off the glaucoma specialists.
In terms of early interventions, Dr. Momont mentioned laser trabeculoplasty and noted that the LiGHT trial showed significant benefit of using this as first-line treatment for open angle glaucoma. DSLT is another exciting new tool, she said, adding that cataract surgery and MIGS can also be employed as early interventions.
When applying technology to improve clinical workflow, Dr. Momont mentioned things like virtual scribes, telehealth and technician-only visits, and AI-assisted charting and text creation.
Finally, Dr. Momont highlighted the importance of collaborating to take the pressure off the glaucoma specialist, adding that collaborating with optometry, comprehensive, and other subspecialties can be helpful.
Andrew Williams, MD, provided some insights on new tools to help with medication adherence in glaucoma, stressing that half of glaucoma patients are non-adherent with drops. Poor adherence means faster disease progression.
First, you need to identify adherence challenges, and he mentioned new evidence for education and coaching, adding that there are two recent randomized trials.
Reminder messages can be helpful in increasing adherence with drops. A third of patients with glaucoma use reminders, and there are automated dosing reminders and apps available to help with this.
Better adherence through better drops can also help, and Dr. Williams said using preservative-free or fixed combination products can be useful.
He also noted the importance of eye drop instillation aids to “ease the squeeze.” He said that 43% of patients with glaucoma have a condition that can affect self-administration, and ineffective eye drop instillation leads to greater odds of progression. There are many options available to help with instillation.
Finally, Dr. Williams mentioned sustained drug delivery, which can really make a difference because the medication is available all the time, as it is administered at a controlled rate over a prolonged period of time.
Editors’ note: Dr. Young and Dr. Momont have no relevant financial interests to their presentations. Dr. Williams has financial interests with Alcon and Glaukos.
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