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2026, Vol: 10, Issue: 9
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Review Article
Online Published: 07 Sep 2026
 


Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis

Meaad Ahmed Alshamrani, Bushra Khalid Al Sannah, Abdalrhman Saud Alblwan, Areej Mutlaq Alosaimi, Mohannad Abdulkhaleq Alshehri, Omar Gharmallah Alghamdi, Rana Mansour Almutairi, Tala Abdulaziz Almeghiwli, Yousef Alotaibi, Yousef Amin Alsayed.


Abstract
Introduction: Myopia is a common refractive error worldwide, and small incision lenticule extraction (SMILE) has become an established surgical option because of its favorable visual outcomes and better preservation of corneal biomechanics. Prophylactic corneal collagen cross-linking combined with SMILE (SMILE-Xtra) has been introduced to enhance corneal stability in patients at increased risk of postoperative ectasia. However, the available evidence regarding its safety and efficacy remains inconclusive.
Objective: To evaluate the safety and efficacy of SMILE-Xtra compared with conventional SMILE in patients with myopia, focusing on refractive outcomes, corneal stability, and postoperative complications.
Methods: A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed/MEDLINE, Scopus, and Web of Science (WOS) were systematically searched from inception to May 2026. Comparative studies evaluating SMILE-Xtra versus conventional SMILE in patients with myopia or myopic astigmatism were included. Pooled mean differences (MDs) with 95% confidence intervals (CIs) were calculated using a random-effects model.
Results: Seven studies were included in the review. No significant differences were found between SMILE-Xtra and conventional SMILE regarding spherical equivalent refraction, central corneal thickness, or mean keratometry. However, SMILE-Xtra demonstrated a significantly lower postoperative refractive cylinder. Overall, the included studies reported favorable safety outcomes with no evidence of increased major complications following SMILE-Xtra.
Conclusion: SMILE-Xtra appears to be a safe and effective adjunct to conventional SMILE, particularly for patients at higher risk of postoperative corneal ectasia, while maintaining comparable refractive outcomes. Further prospective randomized studies with standardized protocols and longer follow-up are required to confirm its long-term safety and efficacy.

Key words: Keywords: Myopia; SMILE; SMILE-Xtra; Corneal collagen cross-linking; Systematic review; Meta-analysis.


 
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How to Cite this Article
Pubmed Style

Alshamrani MA, Sannah BKA, Alblwan AS, Alosaimi AM, Alshehri MA, Alghamdi OG, Almutairi RM, Almeghiwli TA, Alotaibi Y, Alsayed YA. Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis. IJMDC. 2026; 10(9): 2856-2866. doi:10.24911/IJMDC.51-1783777528

Web Style

Alshamrani MA, Sannah BKA, Alblwan AS, Alosaimi AM, Alshehri MA, Alghamdi OG, Almutairi RM, Almeghiwli TA, Alotaibi Y, Alsayed YA. Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis. https://www.ijmdc.com/?mno=327471 [Access: September 19, 2026]. doi:10.24911/IJMDC.51-1783777528

AMA (American Medical Association) Style

Alshamrani MA, Sannah BKA, Alblwan AS, Alosaimi AM, Alshehri MA, Alghamdi OG, Almutairi RM, Almeghiwli TA, Alotaibi Y, Alsayed YA. Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis. IJMDC. 2026; 10(9): 2856-2866. doi:10.24911/IJMDC.51-1783777528


Vancouver/ICMJE Style

Alshamrani MA, Sannah BKA, Alblwan AS, Alosaimi AM, Alshehri MA, Alghamdi OG, Almutairi RM, Almeghiwli TA, Alotaibi Y, Alsayed YA. Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis. IJMDC. (2026), [cited September 19, 2026]; 10(9): 2856-2866. doi:10.24911/IJMDC.51-1783777528


Harvard Style

Alshamrani, M. A., Sannah, . B. K. A., Alblwan, . A. S., Alosaimi, . A. M., Alshehri, . M. A., Alghamdi, . O. G., Almutairi, . R. M., Almeghiwli, . T. A., Alotaibi, . Y. & Alsayed, . Y. A. (2026) Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis. IJMDC, 10 (9), 2856-2866. doi:10.24911/IJMDC.51-1783777528


Turabian Style

Alshamrani, Meaad Ahmed, Bushra Khalid Al Sannah, Abdalrhman Saud Alblwan, Areej Mutlaq Alosaimi, Mohannad Abdulkhaleq Alshehri, Omar Gharmallah Alghamdi, Rana Mansour Almutairi, Tala Abdulaziz Almeghiwli, Yousef Alotaibi, and Yousef Amin Alsayed. 2026. Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis. International Journal of Medicine in Developing Countries, 10 (9), 2856-2866. doi:10.24911/IJMDC.51-1783777528


Chicago Style

Alshamrani, Meaad Ahmed, Bushra Khalid Al Sannah, Abdalrhman Saud Alblwan, Areej Mutlaq Alosaimi, Mohannad Abdulkhaleq Alshehri, Omar Gharmallah Alghamdi, Rana Mansour Almutairi, Tala Abdulaziz Almeghiwli, Yousef Alotaibi, and Yousef Amin Alsayed. "Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis." International Journal of Medicine in Developing Countries 10 (2026), 2856-2866. doi:10.24911/IJMDC.51-1783777528


MLA (The Modern Language Association) Style

Alshamrani, Meaad Ahmed, Bushra Khalid Al Sannah, Abdalrhman Saud Alblwan, Areej Mutlaq Alosaimi, Mohannad Abdulkhaleq Alshehri, Omar Gharmallah Alghamdi, Rana Mansour Almutairi, Tala Abdulaziz Almeghiwli, Yousef Alotaibi, and Yousef Amin Alsayed. "Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis." International Journal of Medicine in Developing Countries 10.9 (2026), 2856-2866. Print. doi:10.24911/IJMDC.51-1783777528


APA (American Psychological Association) Style

Alshamrani, M. A., Sannah, . B. K. A., Alblwan, . A. S., Alosaimi, . A. M., Alshehri, . M. A., Alghamdi, . O. G., Almutairi, . R. M., Almeghiwli, . T. A., Alotaibi, . Y. & Alsayed, . Y. A. (2026) Safety and efficacy of small incision lenticule extraction combined with prophylactic corneal cross-linking (SMILE-Xtra) for myopia: a systematic review and meta-analysis. International Journal of Medicine in Developing Countries, 10 (9), 2856-2866. doi:10.24911/IJMDC.51-1783777528




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