Refractive surgery real talk on SMILE, LASIK, PRK, RLE, and ICL

Debunking the misinformation driven by trends and clickbait often takes meeting patients where they are. Image credit: AdobeStock/blackday

In the age of TikTok takes and Instagram infographics, patients walk into our clinics with no shortage of opinions and preconceived notions on refractive surgery, many of them ill-informed. Between viral videos of personal testimonials of LASIK and X threads touting implantable collamer lens (ICL) as “the bionic eye,”, clickbait is outpacing clinical nuance. But meeting patients where they are is important, and some of our colleagues have taken to social media outlets to help set things straight. Let us break down the current landscape of refractive surgery: what is available, what is misunderstood, and what we, as optometrists, need to help our patients.

LASIK: Still the poster child, still misunderstood

LASIK continues to be the most recognizable refractive procedure and arguably the most maligned on social media. The flap-based procedure reshapes the cornea using an excimer laser, offering rapid recovery and high satisfaction rates.¹

Despite this, LASIK has become the scapegoat for nearly every dry eye complaint this side of Reddit. Although LASIK can exacerbate or induce dry eye, particularly in the early postoperative period, most patients see significant improvement within 3 to 6 months.² Preexisting ocular surface disease is often a more reliable predictor of postoperative dry eye than the procedure itself.³

Another popular myth is that LASIK only lasts 10 years. In reality, LASIK permanently reshapes the cornea. The natural crystalline lens and zonules change over time, leading to dysfunctional lens syndrome, including both presbyopia and cataracts.⁴ This is not LASIK wearing off; it is simply the normal course of aging.

SMILE: Small incision, big potential

Small incision lenticule extraction (SMILE) is the sleek, flapless alternative patients are seeing all over TikTok. Approved by the FDA in the US since 2016, SMILE offers unique benefits, chiefly no flap, which may reduce postoperative dry eye due to less disruption of corneal nerves.⁵

But SMILE is not one-size-fits-all. It has more nuanced centration requirements due to the absence of real-time eye tracking during the laser portion.⁶ Additionally, enhancements after SMILE can be trickier, often requiring surface ablation. Patients often perceive SMILE as inherently “safer” or “more modern” than LASIK, but like any procedure, its suitability depends on anatomy, refractive error, and patient expectations.

PRK: The OG is back

Photorefractive keratectomy (PRK), one of the original refractive surgeries, is gaining popularity again, especially for patients with thinner corneas, corneal irregularities, or those in professions with risk for high-impact where flap dislocation is a concern. PRK removes the epithelium entirely before reshaping the cornea with an excimer laser. Recovery is slower, with greater discomfort in the first week, but the long-term outcomes rival those of LASIK.⁷ Social media has dubbed PRK “the safe LASIK,” but that oversimplifies the story. PRK carries its own risks, including postoperative haze if not managed properly.

Refractive lens exchange: More than a cataract fix

Refractive lens exchange (RLE), or clear lens extraction, is often dismissed as “early cataract surgery” but is increasingly popular among patients in their 40s and 50s seeking alternative treatments for presbyopia and hyperopia. With the advent of modern presbyopia-correcting and increased range of vision IOLs, RLE is a viable lifestyle procedure. However, it is not without risk. Despite what Instagram influencers might claim, RLE is not a “forever fix.” As with any intraocular surgery, risks include retinal detachment, dysphotopsias, and loss of all accommodation.⁸ When done for the right reasons in the right patient, RLE can be life changing. But informed consent must include the reality, not just the reels.

ICL: The social media darling that deserves the spotlight

ICLs are having a moment and gaining popularity with patients, and it is not just hype. For patients with high myopia, thin corneas, or dry eye, ICLs are a great option and can offer great visual outcomes.⁹ Newer models, such as the EVO ICL, eliminate the need for peripheral iridotomy and offer broader refractive ranges. But do not forget that this is intraocular surgery. While the newer design of the EVO ICL reduce risk for angle closure, potential complications include cataract formation, elevated IOP, and endothelial cell loss.¹⁰ Yes, ICLs are technically “removable”, and this narrative is often touted online, but we should not trivialize this still involves intraocular surgery.

Myth-busting: What social media gets wrong

Let us set the record straight on some of the most persistent on and offline refractive surgery myths:

1. Refractive surgery makes you go blind. The risk of complications leading to permenant vision loss related to refractive surgery is small. ¹¹ Most complications are preventable with proper screening and follow-up.
2. You cannot have LASIK if you have astigmatism. All major procedures, LASIK, PRK, SMILE, ICL, and even RLE, can correct astigmatism, with better visual results for some refractive errors than glasses.¹²
3. Your vision will go back to what it was. Patients often confuse refractive regression with aging. Presbyopia and cataract formation are not signs of surgical failure; they are part of the natural aging process.
4. It is just cosmetic. Refractive surgery can improve quality of life, reduce contact lens complications, and address lifestyle limitations. That is a medical and psychological benefit, not necessarily a cosmetic one.

Meeting patients where they are

In today’s digital landscape, many patients walk into our clinics already having formed opinions, or at least questions, about refractive surgery based on what they have seen online. TikTok, Instagram, Reddit, and X are flooded with content about LASIK, SMILE, ICL, and even “laser eye surgery gone wrong” horror stories. Some videos are helpful and accurate. Many are not.

The hashtag #lasiksurgery has amassed over 70 million views on TikTok, featuring everything from flashy animations to first-person accounts of postoperative halos and dry eye. It is no surprise that patients come in asking, “Is LASIK actually safe?” or “I saw someone say their eyes were ruined, will that happen to me?”

These platforms are not going away, and neither is the misinformation. But instead of resisting the medium, many of our colleagues have chosen to meet patients where they are, using social media to debunk myths, explain procedures, and share real outcomes in an engaging, relatable format.

If you’re looking to do the same, here are a few practical tips for doing it well:

• Use everyday language. Ditch the medical jargon. Use the same words your patients do when they ask about SMILE vs LASIK in your chair.
• Lead with education, not fear. Correct bad information with calm, confident clarity. There is no need to argue, just to teach.
• Be visual. Use diagrams, animations, or even analogies. (Explaining how ICL is like a contact lens placed inside the eye? That sticks.)
• Keep it short and consistent. One 60-second video explaining PRK recovery can go further than a long blog post, especially when posted regularly.
• Do not chase virality, build trust. A small, engaged following that sees you as a trusted resource is far more valuable than going viral once.

At the end of the day, the goal is not to become a full-time influencer, it is to help patients make informed decisions. When optometrists have a presence on these platforms, we bring nuance, science, and clinical experience to a space that desperately needs them.

Also, don’t forget that our job does not end with the surgical referral. We are involved from begining to end, optimizing the ocular surface before surgery, counseling patients about realistic outcomes, and managing postoperative expectations. So, try not to roll your eyes when a patient says, “But I saw this thing on TikTok...” Instead, lean in. Our voice of reason may be the only thing standing between that patient and a decision they may regret. Lets help them make a good, correctly informed, one.

References:

1. Solomon KD, Fernández de Castro LE, Sandoval HP, et al; Joint LASIK Study Task Force. LASIK world literature review: quality of life and patient satisfaction. Ophthalmology. 2009;116(4):691-701. doi:10.1016/j.ophtha.2008.12.037

2. Albietz JM, McLennan SG, Lenton LM. Ocular surface management of photorefractive keratectomy and laser in situ keratomileusis. J Refract Surg. 2003;19(6):636-644. doi:10.3928/1081-597X-20031101-05

3. Denoyer A, Rabut G, Baudouin C. Tear film aberration dynamics and vision-related quality of life in patients with dry eye disease. Ophthalmology. 2012 Sep;119(9):1811-8. doi:10.1016/j.ophtha.2012.03.004.

4. Fernández J, Rodríguez-Vallejo M, Martínez J, Tauste A, Piñero DP. From presbyopia to cataracts: a critical review on dysfunctional lens syndrome. J Ophthalmol. 2018:4318405. doi:10.1155/2018/4318405

5. Sekundo W, Kunert KS, Blum M. Small incision corneal refractive surgery using the small incision lenticule extraction (SMILE) procedure for the correction of myopia and myopic astigmatism: results of a 6-month prospective study. Br J Ophthalmol. 2011;95(3):335-339. doi:10.1136/bjo.2009.174284

6. Ang M, Mehta JS, Chan C, Htoon HM, Koh JC, Tan DT. Refractive lenticule extraction: transition and comparison of 3 surgical techniques. J Cataract Refract Surg. 2014 Sep;40(9):1415-24. doi:10.1016/j.jcrs.2013.12.026

7. Murray A, Jones L, Milne AC, Fraser C. A systematic review of the safety and efficacy of elective photorefractive surgery for the correction of refractive error. Health Services Research Unit, University of Aberdeen. 2005.

8. Alió JL, Grzybowski A, Romaniuk D. Refractive lens exchange in modern practice: when and when not to do it? Eye Vis (Lond). 2014;1:10. doi:10.1186/s40662-014-0010-2

9. Sanders DR, Vukich JA. Comparison of implantable contact lens and laser assisted in situ keratomileusis for moderate to high myopia. Cornea. 2003 May;22(4):324-31. doi:10.1097/00003226-200305000-00009

10. Albo C, Nasser T, Szynkarski DT, et al. A comprehensive retrospective analysis of EVO/EVO+ implantable collamer lens: evaluating refractive outcomes in the largest single center study of ICL patients in the United States. Clin Ophthalmol. 2024;18:69-78. Published 2024 Jan 9. doi:10.2147/OPTH.S440578

11. Jabbour S, Bower KS. Refractive surgery in the US in 2021. JAMA. 2021;326(1):77–78. doi:10.1001/jama.2020.20245

12. Swaminathan U, Daigavane S. Comparative analysis of visual outcomes and complications in intraocular collamer lens, small-incision lenticule extraction, and laser-assisted in situ keratomileusis surgeries: a comprehensive review. Cureus. 2024 Apr 22;16(4):e58718. doi:10.7759/cureus.58718