Laser eye surgery procedures for those with a predisposition to dry eyes or existing mild dry eye, SMILE eye surgery probably sounded like the obvious answer. That instinct is understandable: SMILE is a flapless refractive procedure, and many studies and reviews suggest it may cause less early postoperative dry-eye burden than femtosecond LASIK. But “may” is the right word. SMILE is not a universal dry-eye solution, and candidacy still depends on the ocular surface you actually have before surgery. [1][2][3][4]
Why do people hope SMILE means less dryness?
People usually ask about SMILE because they are worried about nerve disruption, tear-film instability, and feeling worse after surgery than they do now. That concern has a physiologic basis: corneal nerves help regulate tear reflexes and ocular-surface homeostasis, and LASIK creates more early corneal denervation than SMILE in randomized data.
In the 2022 contralateral-eye trial, LASIK showed greater early corneal denervation, but there was no difference in OSDI self-reported dry-eye symptoms between LASIK and SMILE at any visit. Earlier comparative work also found that SMILE still caused short-term dry-eye symptoms and tear-film instability, even though it showed less corneal staining and less reduction in corneal sensation than femtosecond LASIK. [2][3][4]
SMILE is not a shortcut. It is a different path.
What the evidence actually says so far
The cleanest summary is that the literature points in one direction but not with absolute certainty. The 2023 dry-eye update reports that postoperative dry eye after SMILE is generally lower, less severe, and recovers faster than after LASIK, and it identifies pre-existing dry eye as the most important preoperative risk factor for postoperative dry eye after refractive surgery.
A 2024 systematic review likewise describes post-refractive dry eye as a significant issue and emphasizes individualized risk assessment and management. At the same time, the randomized 2022 trial found no significant difference in self-reported dry-eye symptoms between SMILE and LASIK, even though corneal denervation was greater after LASIK. [2][4][5]
When studies disagree, your best protection is individualized screening and expectation setting.
Who is not a candidate, even for SMILE
Dry-eye risk does not automatically make SMILE the right answer, and severity matters. StatPearls lists severe dry eye among conditions for which SMILE is not approved, alongside other exclusion factors such as active inflammation or infection and corneal problems that make the procedure unsafe. Corneal imaging and risk assessment matter here too: candidacy is shaped by tomography, pachymetry, and ectasia-risk evaluation, not by the word “flapless” alone. [1][6][7]
Flapless does not mean risk-free. It means different trade-offs.
Dry eye prep that improves the odds
Preparation is not cosmetic. It is clinical. The 2023 refractive-surgery dry-eye review says surgeons should identify patients at risk, optimize the ocular surface before surgery, and even consider alternative procedures in more severe cases. That same review notes that pre-existing dry eye is the most important risk factor for postoperative dry eye after refractive surgery. Meibomian gland disease matters here too because it contributes to ocular discomfort, tear-film instability, and visual disturbance. [2][10]
Those ideas apply to SMILE planning just as much as they apply to LASIK planning. A dry-eye-prone surface can still create fluctuating vision and uncomfortable healing even when the incision is small. [1][2][10]
Recovery expectations when you already feel dry
Recovery is not only about acuity. It is also about comfort and stability. A 2024 refractive-surgery overview notes that clinical recovery after SMILE is generally slower than LASIK and warns against claiming that SMILE is categorically superior in all cases. The same review also argues that patient factors should drive the choice between SMILE and LASIK. [8]
That matters for dry-eye-prone patients because a small incision does not guarantee a fast-feeling recovery, especially if the ocular surface was already struggling before surgery. [2][8]
A fast procedure does not guarantee a fast-feeling recovery.
Questions that protect you from hype
The most useful questions are practical ones:
- What dry-eye tests were done? What did they show?
- Is meibomian gland dysfunction part of the picture?
- How severe is the dryness on exam versus symptoms alone?
- What is the plan if dryness gets worse for a while after surgery?
Those questions follow directly from what the evidence says matters most: preoperative dry eye, ocular-surface status, nerve-related effects, and candidacy based on real measurements rather than generic marketing language. [1][2][4][10]
A good consult leaves you with a plan, not just a price.
The next step that confirms candidacy
The next step is a candidacy evaluation that includes tomography, pachymetry, ocular-surface testing, and a discussion of alternatives when the surface or tissue plan does not support SMILE. PRK remains a valid alternative because it avoids a flap, and it can be useful in eyes where LASIK is not ideal, although it comes with its own recovery trade-offs. [9]
The point of the consultation is not to prove that SMILE can be done. It is to confirm whether SMILE is the safest fit for the cornea and surface you actually have. [1][6][9]
References
[1] Majid Moshirfar et al., “Small Incision Lenticule Extraction,” updated February 26, 2024.
[2] Sridevi Nair, Manpreet Kaur, Namrata Sharma, and Jeewan S. Titiyal, “Refractive Surgery and Dry Eye – An Update,” 2023.
[3] M. Li et al., “Comparison of Dry Eye and Corneal Sensitivity Between Small Incision Lenticule Extraction and Femtosecond LASIK for Myopia,” 2013.
[4] K. K. Ma et al., “Corneal Sensitivity and Patient-Reported Dry Eye Symptoms in a Prospective Randomized Contralateral-Eye Trial Comparing Laser In Situ Keratomileusis and Small Incision Lenticule Extraction,” 2022.
[5] S. K. Dossari et al., “Post-refractive Surgery Dry Eye: A Systematic Review Exploring Pathophysiology, Risk Factors, and Novel Management Strategies,” 2024.
[6] Majid Moshirfar, Anne Duong, and Yasmyne Ronquillo, “Corneal Imaging,” updated July 24, 2023.
[7] Mohamed Tarek El-Naggar et al., “Assessment of Preoperative Risk Factors for Post-LASIK Ectasia Development,” December 4, 2023.
[8] Bharat Gurnani et al., “Recent Advances in Refractive Surgery: An Overview,” 2024.
[9] Bharat Gurnani and Bhupendra C. Patel, “Photorefractive Keratectomy,” updated September 14, 2025.
[10] K. Kaur et al., “Meibomian Gland Disease,” 2025.
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