Two Cases of Small-Incision Lenticule Extraction-Related Corneal Opacity Resolved Without Invasive Intervention

Purpose: To report two cases of corneal opacity associated with small-incision lenticule extraction (SMILE) and to evaluate the differential diagnosis and clinical course following conservative treatment.Case summary: We report two cases of clinically significant corneal opacity. In Case 1, the opacity was caused by recurrent herpes simplex virus stromal keratitis following SMILE, whereas in Case 2, it developed after additional refractive surgery performed following SMILE. Although best-corrected visual acuity was preserved in both patients, they complained of glare and decreased contrast sensitivity. Slit-lamp examination revealed diffuse stromal opacity without epithelial erosion. Anterior segment optical coherence tomography demonstrated hyperreflective deposits at the cap-stromal interface and adjacent deep stroma in Case 1, and hyperreflective deposits confined to the interface in Case 2. As there were no signs of active infection or corneal ectasia, conservative treatment consisting of oral antiviral therapy and topical medications was administered without invasive intervention. Gradual clinical improvement was observed in both cases without complications.Conclusions: In cases of delayed-onset corneal opacity following SMILE, accurate localization of the lesion and exclusion of active infection using slit-lamp examination and anterior segment optical coherence tomography are essential. With appropriate evaluation, corneal opacity may improve and visual acuity can remain stable with conservative treatment alone, thereby avoiding the need for invasive intervention.