Almost since the very beginning of refractive surgery in the United States, surgeons have preached the importance of managing prospective patients’ expectations. They say that many gung-ho patients come in expecting to throw away their spec¬≠tacles and contact lenses, and to walk out seeing 20/20 or better in about 20 minutes or so. Surgeons say that if such patients don’t have their sky-high expectations brought closer (if not all the way down) to earth, and they don’t see like a peregrine falcon postop, you’re going to have a difficult time making them happy. Looking at the larger picture, though the economic downturns in the aughts didn’t do LASIK volume any favors, it’s possible that the fostering of these lofty expectations by some LASIK providers—and the subsequent negative articles on LASIK complications that started to appear in the consumer press and on some patients’ blogs—caused an overall souring of the public toward the procedure, and maybe helped touch off the FDA study into LASIK outcomes.

Fast forward to today, and we have new refractive procedures being approved in the United States, but with the same old temptation to build them up for patients, especially because now marketers can slap the classic “new and improved” label on them. This branding might lead patients to believe that this isn’t your father’s LASIK with those “gross eye flaps,” but something better. Some surgeons, such as Stanford University’s Edward Manche, MD, the author of this month’s review of small-incision lenticule extraction on page 32, implore their colleagues to avoid this impulse. “These patients assume that because SMILE is the newest surgery, it’s also the best one, an opinion that’s common when new technology arrives,” he says. He then raises an interesting point: If you spend your time building up SMILE as the latest and greatest, and either explicitly or by implication devalue PRK and LASIK in order to attract patients, what happens when the patient either isn’t a candidate for SMILE, or worse, needs his SMILE enhanced postop with PRK? “Not only will the patient’s procedure of choice have underperformed for him, but now you’re telling him he’s got to undergo PRK, the very same procedure you degraded during his preop visits,” Dr. Manche observes.

Instead, Dr. Manche says it’s better for refractive surgery in general, and the procedures individually, if new procedures such as SMILE are presented as complementary to the established ones, rather than as competitors. This message may not be what patients expect when an exciting new surgery gets approved, but it’s what they deserve.



—Walt Bethke, Editor in Chief