The learning curve of SMILE is surgically challenging. Lenticule dissection and extraction is the most difficult step and leads to a multitude of complications. Most complications that result in delayed visual recovery are observed in the initial 50 cases.

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Toric intraocular lenses (IOLs) are the procedure of choice to correct corneal astigmatism of 1 D or more in cases undergoing cataract surgery. Comprehensive literature search was performed in MEDLINE using “toric intraocular lenses,” “astigmatism,” and “cataract surgery” as keywords. The outcomes after toric IOL implantation are influenced by numerous factors, right from the preoperative case selection and investigations to accurate intraoperative alignment and postoperative care. Enhanced accuracy of keratometry estimation may be achieved by taking multiple measurements and employing at least two separate devices based on different principles. The importance of posterior corneal curvature is increasingly being recognized in various studies, and newer investigative modalities that account for both the anterior and posterior corneal power are becoming the standard of care. An ideal IOL power calculation formula should take into account the surgically induced astigmatism, the posterior corneal curvature as well as the effective lens position. Conventional manual marking has given way to image-guided systems and intraoperative aberrometry, which provide a mark-less IOL alignment and also aid in planning the incisions, capsulorhexis size, and optimal IOL centration. Postoperative toric IOL misalignment is the major factor responsible for suboptimal visual outcomes after toric IOL implantation. Realignment of the toric IOL is needed in 0.65%–3.3% cases, with more than 10° of rotation from the target axis. Newer toric IOLs have enhanced rotational stability and provide precise visual outcomes with minimal higher order aberrations.

Ragged morphology of proximal opening of CCI is the most important predictive factor for incision-site DMD. Femtosecond-laser CCIs have less incision-site DMD as compared to keratome-assisted CCIs. iOCT provides real-time assessment of CCI morphology and DMD.