Bilateral Ectasia After SMILE Combined With Accelerated Corneal Cross-linking (SMILE-Xtra)

Purpose To present the first reported case of bilateral ectasia following small incision lenticule extraction (SMILE) associated with corneal cross-linking (CXL). Methods A 20-year-old woman was referred for bilateral corneal ectasia 2 years after uneventful bilateral SMILE combined with accelerated CXL (SMILE-Xtra) for myopic correction. The preoperative refraction was −3.00 −0.75 × 10° in the right eye and −2.50 −0.50 × 165° in the left eye. The preoperative corneal topography showed a minimum corneal thickness of 488 µm in the right eye and 498 µm in the left eye. Results Initial follow-up results showed stable visual acuity, but she presented 24 months later with reduced vision in the left eye, revealing bilateral ectasia. Scheimpflug examination confirmed central ectasia in the left eye and subtle initial ectasia in the right eye. Biomechanical analysis demonstrated altered parameters and epithelial mapping revealed epithelial thinning. Conclusions This study challenges previous assertions about the efficacy of SMILE-Xtra in preventing ectasia, because it presents the first documented case of this complication. The findings emphasize the importance of exercising caution in treating corneas at risk, regardless of the association of CXL, especially when the cornea is considered suspicious. This highlights a broader concern that all refractive surgeries may carry a risk of inducing ectasia, underscoring the necessity for careful patient selection and continuous refinement of surgical protocols for optimal safety outcomes. [ Journal of Refractive Surgery Case Reports. 2024;4(4):e40–e45.]