Controversy and Consensus on Small Incision Lenticule Extraction (SMILE) by the Academy of Asia-Pacific Professors of Ophthalmology (AAPPO) and the Asia-Pacific Myopia Society (APMS)

Small incision lenticule extraction (SMILE) surgery was developed in 2008 as an extension of the femtosecond lenticule extraction procedure. Over the years, SMILE has become a highly popular laser refractive surgery offering a minimally invasive alternative to LASIK for correcting myopia and myopic astigmatism. Despite its benefits such as a flapless femtosecond laser procedure with reduced corneal nerve disruption, the procedure's relative novelty necessitates standardization. Given the myriads of emerging information and variability, a panel of 22 international experts is formed by the Asia Pacific Myopic Society (APMS) and the Academy of Asia-Pacific Professors of Ophthalmology (AAPPO) to explore the controversy and to work out a consensus on SMILE. This consensus manuscript arises from a systematic exploration of current literature and is supported by the collective insights of international experts in the field of refractive surgery. The panel convened to review the issues, engage in discussion, develop proposals, and vote to establish consensus across four areas: 1) preoperative assessment, 2) preoperative surgical planning, 3) intraoperative considerations, and 4) postoperative management in a five-point Likert scale (strongly agree, agree, neutral, disagree and strongly disagree). Consensus was achieved when at least 75 % of the experts had voted for "strongly agree" or "agree" on the consensus statement concerned. 63 consensus statements were discussed, with 51 (81.0 %) statements reaching consensus. By establishing standardized consensus, this paper aims to reduce variability and enhance predictability and safety in refractive outcomes. Ongoing research is encouraged on issues where consensus could not be reached among the international panel of experts (IPE).