Ectasia After Small-Incision Lenticule Extraction: Management and Lessons Learned (Black-Box Thinking)

This chapter describes a case of iatrogenic keratectasia (corneal ectasia) after small-incision lenticule extraction (SMILE) and its management with a combination of intracorneal ring segment implantation associated with Epi-ON crosslinking. It highlights the importance of an enhanced assessment of ectasia risk before laser vision correction (LVC) procedures using multimodal imaging. The goal of ectasia risk assessment goes beyond, not over, detecting mild (subclinical or fruste) keratoconus using front surface topography. Characterizing the predisposition or susceptibility for biomechanical failure and ectasia progression has to be considered along with the impact of the LVC procedure on the cornea. The role of an enhanced ectasia risk assessment was demonstrated through the retrospective evaluation of the clinical data. The philosophy of black-box thinking draws from aviation with investigating the data “black” box recordings after accidents to understand the root causes and design processes to avoid recurrences, i.e., learning from complications and faults to improve safety. Applying black-box thinking to this case strengthens our ability to identify risk factors and prevent progressive keratectasia after refractive corneal surgery.