Management of Suction Loss During SMILE in 12,057 Eyes: Incidence, Outcomes, Risk Factors, and a Novel Method of Same-Day Recutting of Refractive Lenticules

PURPOSE: To determine the incidence, management, outcomes, and risk factors of suction loss during femtosecond laser small incision lenticule extraction (SMILE) for the treatment of myopia and myopic astigmatism. METHODS: The study reviewed 12,057 consecutive eyes treated with SMILE. Eyes that developed suction loss (study group) or underwent uneventful SMILE (control group) were analyzed. Corneal topography, manifest refractions, and measurements of uncorrected (UDVA) and corrected (CDVA) distance visual acuities were evaluated preoperatively and postoperatively after 1 day and 12 months. Risk factors were determined for suction loss development. RESULTS: Twenty-seven of 12,057 eyes (0.22%) were enrolled in the study group and 50 eyes in the control group. Suction loss occurred in 14 eyes during the cutting of the refractive lenticule, 7 eyes during the cutting of the cap, and 6 eyes during the creation of the cap small incision. There was no statistically significant difference between the two groups in logMAR UDVA ( P = .52) or CDVA ( P = .59). A novel method of increasing cap thickness was applied to 8 eyes when suction loss occurred after more than 10% of the lenticule was cut. The eye being operated on first (the right eye) ( P = .02) and a thinner lenticule ( P = .006) were associated with a significantly higher risk of developing suction loss. CONCLUSIONS: The incidence of suction loss was low. The novel method achieved visual and refractive outcomes as favorable as those of uneventful SMILE procedures. The first eye that was operated on had a higher risk for the development of suction loss. [ J Refract Surg . 2020;36(5):308–316.]