SMILE Eye Surgery: Who It Suits, What Recovery Is Like and What Drives the Cost

SMILE (small incision lenticule extraction) corrects nearsightedness, with or without astigmatism, by removing a small disc of tissue from inside the cornea through an incision a few millimeters long. There is no flap. In clinical trials its results are broadly similar to LASIK, and measures of dry eye tend to be better in the first months. It treats a narrower range of prescriptions than LASIK, it isn’t approved for farsightedness in the U.S., and fewer practices offer it.

How SMILE works

LASIK and PRK both reshape the cornea by removing tissue with computer-controlled pulses from an excimer laser. SMILE does it differently. A femtosecond laser cuts a thin, lens-shaped disc of tissue (the lenticule) inside the cornea, then cuts a small tunnel incision to the surface, typically 2 to 3 millimeters long. The surgeon separates the disc and draws it out through that opening, and removing it changes the cornea’s curvature.

Because there is no flap and only a short incision, fewer of the corneal nerves near the surface are cut. That is the main reason SMILE is associated with less early dry eye, and the reason there is no flap that a blow to the eye could dislodge.

In the U.S., SMILE is performed with ZEISS’s VisuMax femtosecond laser. The FDA approved it for SMILE in September 2016 and widened the approval in October 2018 to cover nearsightedness with astigmatism. A newer version, often marketed as SMILE pro, runs on ZEISS’s VisuMax 800, which uses a faster laser and adds guidance for centering and eye rotation. Other manufacturers have their own lenticule procedures, and ophthalmologists now group them under the umbrella term keratorefractive lenticule extraction (KLEx). If a practice advertises “SMILE,” ask which laser it uses.

Who SMILE is for

The FDA’s approved range for SMILE, from the October 2018 approval, is:

The approval covers nearsightedness only. If you are farsighted, LASIK, PRK or a lens-based procedure is the route to ask about.

Meeting the numbers isn’t enough on its own. Your corneas need to be healthy and your eyes generally healthy. The American Academy of Ophthalmology (AAO) lists people who usually aren’t candidates, including those with:

• a prescription that is still changing;
• skin or other diseases that affect healing, or a history of excessive scarring or keloids;
• corneal abrasions or disease;
• advanced glaucoma, or a cataract that affects vision;
• uncontrolled diabetes;
• a history of eye disease, eye surgery or certain eye infections; or
• pregnancy or nursing.

SMILE tends to come up for people who don’t want a flap. The AAO points to very active lifestyles and jobs where a blow to the eye is possible, including combat. EyeWiki’s overview also lists people with pre-existing dry eye, because of SMILE’s smaller effect on the corneal nerves. Your surgeon’s measurements of corneal thickness and shape still decide whether it is safe for your eyes.

SMILE vs LASIK: what the evidence shows

Results in the U.S. approval trial. The FDA trial behind the 2018 approval treated 357 eyes, 307 of them for nearsightedness with astigmatism. At 12 months, 89% of the astigmatism eyes saw 20/20 or better without glasses, and 95.3% of eyes were within half a diopter of the target. No eye lost two or more lines of best-corrected vision. The authors noted a slight undercorrection when larger amounts of astigmatism were treated, and 3 procedures were stopped because the suction holding the eye was lost.

Head-to-head trials. A 2023 meta-analysis of 11 randomized trials comparing SMILE with LASIK found similar safety and similar uncorrected vision. LASIK put somewhat more eyes within half a diopter of target, making it slightly more predictable, while SMILE induced less spherical aberration, a type of optical imperfection.

Dry eye. A 2025 meta-analysis of 18 studies found better tear-film stability at 3 and 6 months after lenticule extraction than after femtosecond LASIK, along with better-preserved corneal sensitivity. Patient-reported symptom scores were slightly lower after SMILE, but that difference wasn’t statistically significant. In other words, the eye’s surface measures better after SMILE, and how much difference you feel varies.

For a side-by-side look at all three laser procedures, see LASIK vs. PRK vs. SMILE.

The procedure, step by step

Before surgery. Your surgeon checks that your prescription has been stable, looks for other eye problems that could affect healing or be made worse, and measures the thickness and shape of your cornea. Those measurements program the laser.

During surgery. The AAO describes the procedure as taking about 10 to 15 minutes. An eyelid holder keeps you from blinking, and a suction ring gently holds and flattens the cornea so the eye can’t move. The laser then shapes the disc and makes the small incision; the laser part takes about 30 seconds. Your surgeon removes the disc through the incision.

After surgery. You’ll need someone to drive you home, and the plan for the rest of the day is to rest. You’ll use prescribed eye drops for a period your surgeon sets.

Recovery

Your surgeon will tell you when you can drive, return to work and exercise. For a sense of how this compares with LASIK’s timeline, see LASIK recovery timeline.

Risks

Like any eye surgery, SMILE has risks. The AAO lists:

• glare and halos around lights, particularly at night;
• debris left where the disc was removed;
• inflammation within the treated area;
• infection;
• under- or overcorrection, which can often be improved with glasses, contacts or further laser treatment; and
• very rarely, worse vision than before even with glasses or contacts (loss of best-corrected vision).

During the procedure, the main problem specific to SMILE is losing suction while the laser is working, because the suction phase lasts longer than for a LASIK flap. Small tears of the cap or incision can also happen when the disc is hard to remove; in the FDA trial, the three that occurred had resolved by the next day without lasting effect. Corneal ectasia, a weakening and bulging of the cornea, has been reported after SMILE as after LASIK, mostly in eyes that were borderline or high risk to begin with, which is why the same careful screening applies. LASIK risks and complications explains how surgeons screen for it.

If you need an enhancement

A second SMILE isn’t the usual way to fine-tune a result. A 2019 review found that enhancements after SMILE are mostly done with a surface treatment like PRK, a thin-flap LASIK, or a technique called CIRCLE that converts the SMILE cap into a flap. EyeWiki notes that CIRCLE isn’t approved in the U.S. Surface treatment keeps the eye flap-free but brings PRK’s slower, more uncomfortable recovery; flap-based options recover faster but give up the no-flap advantage.

Before you book, ask how an enhancement would be done and whether it is included in your price. LASIK warranties and enhancement packages covers what to look for in the fine print.

What drives the cost of SMILE

There is no reliable national price for SMILE, and quotes vary by practice and city. These are the factors that move the number:

• The laser. SMILE needs a specific femtosecond laser platform, and not every practice owns one. Of the centers in LASIK Score’s directory, far fewer list SMILE than list LASIK or PRK, so in many cities there are fewer SMILE quotes to compare.
• What’s included. Check whether the quote covers the consultation, both eyes, follow-up visits, prescription drops and an enhancement if you need one.
• How an enhancement would be done. If it would be a PRK-style treatment at extra cost, factor that in.

A practical benchmark is the LASIK price in your area, since that is the procedure you’re most likely comparing SMILE against. LASIK cost by state and city shows LASIK prices near you, and the LASIK cost guide explains how to read a quote line by line.

SMILE is elective, so insurance rarely pays for it. IRS Publication 502 counts eye surgery to correct defective vision, such as laser eye surgery, as a medical expense, which is why HSA and FSA funds can generally be used; confirm with your plan. See does insurance cover LASIK? and LASIK financing and payment plans for the details.

Finding a SMILE surgeon

Start with the LASIK center directory. Each center’s page shows the laser procedures and other services in its listing, so you can shortlist the practices near you that list SMILE and then confirm with them directly. Then choose a surgeon the way you would for LASIK, looking at training, volume with this specific procedure and how complications and enhancements are handled; how to choose a LASIK surgeon has a checklist.

If you can, consult a practice that offers LASIK, PRK and SMILE. It can recommend the procedure that fits your eyes rather than the one it happens to have.

Questions to ask your surgeon

• Am I within the FDA-approved range for SMILE, and am I also a candidate for LASIK and PRK?
• Which laser do you use, and how many SMILE procedures have you performed?
• For my prescription and corneas, why would you choose SMILE over LASIK or PRK?
• What would you do if suction were lost during the procedure?
• If I need an enhancement, how would it be done, and is it included in the price?
• What does your quote include, and is it per eye or for both eyes?

Bottom line

SMILE is a flap-free alternative to LASIK for nearsightedness with or without astigmatism. Trial results are broadly similar to LASIK, early dry-eye measures tend to be better, and there’s no flap to dislodge. In exchange, the treatment range is narrower, enhancements usually mean a different procedure, and fewer practices offer it. If your eyes fall within its range and avoiding a flap matters to you, it is worth asking about; if you are farsighted or outside its range, LASIK, PRK or a lens-based option is the place to look.