u/eyeSherpa

Within the first few weeks after SMILE, you may find that from one moment to another vision fluctuates from being clear to being a little blurry. This is due to the effects of an unstable tear film. While SMILE does have improvements in dry eye and less of this than other laser eye surgeries such as lasik, it still does have some impact.

The layer of tears on the surface of the cornea, known as the tear film, is the first thing that light passes through on its way through the eye. When the tear film is smooth, light passes through with ease and is focused by your newly corrected cornea perfectly to the back of your eye. But if this tear film dries out, breaks up and becomes irregular, it is uneven and scatters light. This blurs vision. The interesting thing about this is that this could be happening even if your eyes don’t really feel “dry”. But this is actually a sign that the eyes are drying out.

(Of note: this is something that surgeons can actually evaluate in office through something known as the “Tear Break Up Time” or TBUT.)

Because of this, it is important to use preservative-free artificial tears after SMILE even if your eyes don’t feel dry. These artificial tears replenish or fortify the natural tears on your eye. This helps to reduce the fluctuation of vision but also helps reduce the build-up of dry eye to ensure that your eyes continue to heal up. And before long, that tear film settles down, becomes stable and your vision remains sharp throughout the day.

Travel doesn’t pose any major issues for ICL. And technically you could even fly the day after ICL surgery without any issue. But there are a few considerations and you may not want to plan a ton of travel immediately after ICL.

After ICL surgery, you will have a follow-up schedule with your surgeon. Typically this means a visit one day out, one week out and one month out to ensure that the pressure inside the eye looks good and that the ICL is sitting in an appropriate location with a good vault. Traveling is fine between those visits, but you’ll just want to ensure that you won’t be skipping these important checks. If you do travel, you’ll also want to ensure that you have access to emergency medical care in the rare event that it is needed.

When flying, the biggest issue is that the airplane cabins are very dry environments. Your eye will be more dry right after ICL. So on the plane, you’ll want to use preservative free artificial tears frequently to keep them from drying out.

Travel involves suitcases. And it’s important to pay attention to restrictions on heavy lifting and exertion after ICL which are typically for a week or two. Because of this, you’ll want to use rolling suitcases and don’t be afraid to ask for help to put your bag in the overhead bin.

Perhaps you are planning a vacation to enjoy your newly corrected vision. Be aware that there will be some restrictions on swimming after ICL. The incisions with ICL surgery heal up quickly, but most surgeons will recommend avoiding swimming for at least two weeks after ICL surgery to reduce the risk of infection. And even after the two-week mark, it is often recommended to wear goggles for another month just to reduce irritation from chlorinated pool water or ocean water on the healing eyes.

With some precautions, travel can be done after ICL. But often it may be better to wait a little further out for your big planned vacations.

I recently ran into an issue with this new feature allowing users to hide their posts and comments.

So, if a user posts or comments in a subreddit I moderate, I am able to see their posts and comments for the next 30 days (from their most recent post or comment).

However, I have a user with a hidden profile and no recent activity in my subreddit who created a post 115 days ago. This post was recently reported for spam.

Unfortunately given my inability to actually see the users posts and comments from other subreddits, I can't make an accurate determination whether this post is spam or not. It's the type of post that is "organic-looking".

This "feature" of hiding posts and comments needs some tweaking to allow moderators to be able to moderate.

One goal when SMILE was developed was to create a procedure that better preserves the strength of the cornea. And the small incision decision was designed to take advantage of some unique properties of the cornea.

Within the cornea are densely packed collagen fibers. It turns out that the anterior (or front-most) portion of these fibers provide the biggest contribution to the structural integrity of the cornea.

In Lasik, the laser making the flap cuts through these fibers. These collagen fibers never regain their full strength. So in the end, the overall strength of the cornea is reduced. This comes into play when thinning the cornea a large amount with a large treatment or if the cornea already has some structural weakness. This can lead to the cornea weakening further - called ectasia.

With SMILE, a small incision is used to remove the lenticule deeper within the cornea. This leaves a “cap” of the strong anterior corneal fibers intact. This theoretically preserves the structural strength of the cornea more.

However, in the real world, this biomechanical advantage of SMILE may be smaller than originally thought. Cases of ectasia can still happen even after SMILE. So while SMILE may technically have an advantage over Lasik, it still isn’t going to be the ideal choice for those with thin or irregular corneas.

A nice benefit of having ICL surgery over laser eye surgeries such as lasik is the significantly lower issue of dry eye. Because ICL doesn’t involve any corneal flap or removal of any corneal tissue, the corneal nerves responsible for triggering tear production remain largely intact. But this does not mean that ICL is “dry eye free”. There will still be some post-operative dry eye with ICL.

Dilating drops and antiseptic used prior to the surgery irritate the surface of the eye. On top of this, during surgery, the eye is held open while the surgeon places the ICL lens. This causes the eye to dry out a little more. So immediately after ICL, the cornea is more irritated and dry just from going through a procedure.

Additionally, ICL involves a small incision in the cornea. This incision does disrupt a small localized amount of nerves within the cornea. These nerves within the cornea are important to signal tear production when the eye is drying out. So until these nerves regenerate, the cornea is a little less sensitive and less capable to responding to dry eye.

But the biggest contributing factor to dry eye after ICL is the post-op eye drops. After ICL, many of the prescribed antibiotic and steroid eye drops contain preservatives to prevent the eye drop from going bad. Preservatives are known to irritate the cornea. And so the use of these drops after the surgery will cause some additional corneal irritation and dry eye. (But not enough to outweigh the benefit of the medication in the drop. Still continue to follow your doctor’s instructions).

Fortunately this post-operative dry eye after ICL surgery is usually very transient and once the post-operative eye drops are finished, the cornea heals up and the dry eye improves. In the meantime, however, using preservative-free artificial tears can help with the recovery to minimize this post-operative dry eye as much as possible and allow for the quickest healing.

ICL offers a unique advantage for individuals with Keratoconus. Other procedures such as Lasik remove corneal tissue to reshape the eye. For corneas that are already structurally compromised, this can potentially accelerate the Keratoconus and make it worse. However, ICL does not involve any removal of corneal tissue, it preserves the existing corneal architecture. This makes it much safer option with Keratoconus. But there are some things to consider.

ICL doesn’t “cure” Keratoconus. It can only correct the prescription. And so one of the most important requirements for ICL is having a stable prescription. Because Keratoconus is a progressive condition, placing an ICL into an eye that is still changing is a sure way to lead to the development of residual prescription in the future. So it’s critically important to make sure the Keratoconus is done progressing. If you are at risk for progression you may need corneal cross-linking (CXL) prior to ICL surgery to stop the progression of the Keratoconus to ensure that the prescription doesn’t change after ICL.

Additionally, it’s also important to understand limitations regarding irregular astigmatism. Toric ICL lenses correct what’s known as “regular” astigmatism. This is the type of astigmatism that glasses can correct. Irregular astigmatism comes from an asymmetric shape to the cornea - such as the “cone-shaped” cornea in Keratoconus. ICL can’t correct that irregular shape. (However, of note there are other surgeries that are designed to reduce that irregular shape in Keratoconus to reduce this irregular astigmatism; ICL isn’t one of them though).

If you need hard contact lenses or scleral contact lenses to get good vision, you probably have a lot of irregular astigmatism and ICL won’t be able to match those lenses (but it can still reduce the amount of prescription that you have). But if you see well with glasses or soft contact lenses, you likely don’t have much of this irregular astigmatism and ICL can work well for you.

Nothing is 100% accurate and even though ICL does a pretty nice job, there are still times when one may have some residual prescription or astigmatism after ICL surgery. Usually somewhere around 1-2% of cases. This residual prescription can blur vision and be bothersome; but there are ways to correct it.

The most common method by far is doing a laser vision correction procedure such as Lasik or PRK. You may be thinking “But I wasn’t a candidate for those procedures”. If you had a high prescription prior to ICL, this would be because the high treatment would need to remove a significant amount of cornea tissue. And removing too much corneal tissue can lead to problems such as a weakening of the cornea called ectasia.

But after ICL, if you have a residual prescription, it will be a much smaller prescription and require very little corneal tissue to treat. This makes lasik and PRK a very easy and highly accurate way to get rid of that remaining prescription.

But not everyone is suited for a laser enhancement procedure. The cornea may show suspicious signs of weakness or have bad dry eye. And the ICL is removable. So an alternative way to correct things is to exchange out the ICL lens for one with a different power to correct the prescription. But if lasik or PRK can be performed, it will usually be able to more accurately get rid of the small residual prescription, so ICL exchange for residual prescription is less commonly done.

Regardless of the approach, it is pretty common for the surgeon to give some time to allow the prescription to stabilize in order to ensure the treatment is the most accurate.