As another option, surgeons can also perform an additional SMILE procedure, known as sub-cap-lenticule-extraction (Sub-Cap-LE), which is an off-label use. However, in a case report researchers described this modified SMILE in a 53-year-old woman who initially underwent bilateral SMILE for moderate myopia.
Just as with the initial procedure, a refractive lenticule and small incision are created inside the intact cornea in one step. The lenticule is then removed through this small incision, leaving the remainder of the superficial cornea intact.
However, during the second procedure, the surgeon used the previously created interface as the new superior plane of the new lenticule. Postoperatively, uncorrected visual acuity improved from 20/63 to 20/16. Certainly, more research is needed to develop a consistent surgical protocol.
The only difference between the first and second procedure is that the second procedure should be performed anteriorly or posteriorly to the initial one depending on how deep the SMILE pocket is. From a theoretical point of view, the procedure should work well, but surgeons may resist this approach because they do not know where all the laser spots are going and where they will end.