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Sachdev MS, Shetty R, Khamar P, Malik R, Schwam BL, Wang Y, Fu H, Voorhees AP, Laron M. Safety and Effectiveness of Smooth Incision Lenticular Keratomileusis (SILK TM) Using the ELITA (TM) Femtosecond Laser System for Correction of Myopic and Astigmatic Refractive Errors. Clin Ophthalmol 2023; 17:3761-3773. [PMID: 38089649 PMCID: PMC10715007 DOI: 10.2147/opth.s432459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/30/2023] [Indexed: 05/18/2024] Open
Abstract
Purpose To evaluate visual outcomes following the Smooth Incision Lenticular Keratomileusis (SILKTM) procedure for correction of myopic refractive errors with and without astigmatism, using the ELITATM Femtosecond Laser System. Patients and Methods A prospective, multicenter, single-arm, open-label clinical study was conducted. Eighty-five myopic subjects (n = 170 eyes), aged 18 years or older, with manifest refractive spherical equivalent (MRSE) up to -12.00 D and astigmatism up to -6.00 D, were treated binocularly using the ELITA femtosecond laser and followed up for 6 months. Intended correction was emmetropia for all eyes. The primary outcome measures included post-operative uncorrected and corrected distance visual acuity (UDVA and CDVA). Secondary outcome measures included surgeon's rating for ease of lenticule extraction, predictability, safety, and stability. Results A total of 170 eyes of 85 patients underwent SILK. Preoperative mean MRSE was -4.14 D ± 1.32 D (range -1.38 D to -8.88 D) and the mean cylinder was -0.77 D ± 0.62 D. Intraoperative surgeon ease of lenticule dissection was rated as grade 0 or 1 in 85.3% of eyes (no/only mild dissection needed). UDVA at 1 day, 1 week, 1 month, and 6 months was 20/20 or better in 65.9%, 85.4%, 91.5%, and 96% of eyes, respectively. No eyes lost any lines of CDVA at 6 months compared to the preoperative. The postoperative MRSE was stable over time, ranging from -0.34 D ± 0.24 D at 1 month to -0.33 D ± 0.23 D at 6 months. MRSE predictability (± 0.50 D) was 93.5% (129/138) at 3 months and 91.1% (113/124) at 6 months. No serious adverse events were noted. Conclusion The SILK procedure with the ELITA Femtosecond Laser System is safe and effective for the treatment of myopic refractive errors with and without astigmatism. Fast visual recovery was demonstrated, with stability achieved by 3 months.
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Affiliation(s)
| | - Rohit Shetty
- Narayana Nethralaya Eye Hospital, Bangalore, India
| | - Pooja Khamar
- Narayana Nethralaya Eye Hospital, Bangalore, India
| | | | - Brian L Schwam
- Johnson and Johnson Surgical Vision, Inc, Milpitas, CA, USA
| | - Ying Wang
- Johnson and Johnson Surgical Vision, Inc, Milpitas, CA, USA
| | - Hong Fu
- Johnson and Johnson Surgical Vision, Inc, Milpitas, CA, USA
| | | | - Michal Laron
- Johnson and Johnson Surgical Vision, Inc, Milpitas, CA, USA
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Pradhan KR, Arba Mosquera S. Comparing high and low energy outcomes on day one for SmartSight myopic-astigmatism treatments with the SCHWIND ATOS: a retrospective case series. BMC Ophthalmol 2023; 23:328. [PMID: 37464345 DOI: 10.1186/s12886-023-03076-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/12/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Impact of low energy asymmetric spacings vs. high energy symmetric spacings on the immediate/early (postoperative day 1 (POD1)) outcomes of SmartSight lenticule extraction for myopic astigmatism with a new femtosecond laser system. METHODS The first 112 eyes of 56 patients consecutively treated using low energy asymmetric spacings (Group A; Study group) were compared at POD1 to the last 112 eyes of 56 patients consecutively treated using high energy symmetric spacings (Group S; Controls). Mean age of the patients was 28 ± 5 years with a mean spherical equivalent of -4.41 ± 1.76 diopters (D) and a mean magnitude of refractive astigmatism of 0.89 ± 0.82 D. RESULTS Laser Energy was -25 ± 1nJ lower for asymmetric treatments (p < .0001); Spot and Track distances were + 0.7 ± 0.1 µm larger and -0.8 ± 0.1 µm tighter for asymmetric treatments, respectively (p < .0001 for both). At POD1, astigmatism was -0.08 ± 0.02D lower for asymmetric treatments (p < .0003); uncorrected and corrected visual acuities (UDVA and CDVA, respectively) were -0.03 ± 0.01logMAR better for asymmetric treatments (p < .0007); differences between postop UDVA and preop CDVA along with change in CDVA were + 0.3 ± 0.1lines better for asymmetric treatments (p < .0003). CONCLUSIONS Lenticule extraction treatment using SmartSight is safe and efficacious already at POD1. Findings suggest that low energy asymmetric spacings may further improve the immediate and short-term outcomes of SmartSight lenticule extraction in the treatment of myopic astigmatism compared to conventional settings (high energy symmetric spacings).
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Affiliation(s)
- Kishore Raj Pradhan
- Matrika Eye Center, Dhunge Dhara Marg, Ward number 9, Kathmandu, 44600, Nepal
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Reinstein DZ, Archer TJ, Potter JG, Gupta R, Wiltfang R. Refractive and Visual Outcomes of SMILE for Compound Myopic Astigmatism With the VISUMAX 800. J Refract Surg 2023; 39:294-301. [PMID: 37162399 DOI: 10.3928/1081597x-20230301-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
PURPOSE To report the first refractive and visual outcomes of small incision lenticule extraction (SMILE) using the VISUMAX 800 femtosecond laser (Carl Zeiss Meditec AG). METHODS This was a retrospective analysis of consecutive eyes treated by SMILE using the VISUMAX 800 femtosecond laser at London Vision Clinic, EuroEyes Group, London, United Kingdom. Inclusion criteria were patients aged younger than 45 years, a corrected distance visual acuity (CDVA) of 20/20 or better, and the 3-month postoperative timepoint data being available for analysis. Standard outcomes analysis and vector analysis by the Alpins method were performed. RESULTS During the study period, 128 eyes of 66 consecutive patients were treated. Three-month data were available for 118 eyes (92%), and 10 eyes (8%) were lost to follow-up. The mean attempted spherical equivalent refraction (SEQ) was -4.65 ± 1.91 diopters (D) (range: -1.90 to -10.05 D) and the mean cylinder was -0.98 ± 0.78 D (range: 0.00 to -4.00 D). The mean age was 30 ± 5 years (range: 20 to 43 years), with 54% women and 46% men. Postoperative SEQ was within ±0.50 D in 86% and ±1.00 D in 100% of eyes. Uncorrected distance visual acuity was 20/20 or better in 91% of eyes. One line of CDVA was lost in 8% of eyes, and no eyes lost two or more lines. There was a small but statistically significant increase in contrast sensitivity at 3, 6, 12, and 18 cpd. CONCLUSIONS Early outcomes data for SMILE with the second generation VISUMAX 800 femtosecond laser demonstrated an effective and safe option equivalent to published first generation VisuMax outcomes for the treatment myopia and astigmatism. [J Refract Surg. 2023;39(5):294-301.].
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Gan ATL, Fenwick EK, Ang M, Mehta JS, Lamoureux EL. Bilateral sequential small-incision lenticule extraction and LASIK result in similar short-term quality-of-life outcomes. J Cataract Refract Surg 2023; 49:305-311. [PMID: 36730347 DOI: 10.1097/j.jcrs.0000000000001103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 11/16/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE To compare quality of life (QoL) between patients who receive bilateral small-incision lenticule extraction (SMILE) or laser in situ keratomileusis (LASIK) vs bilateral sequential SMILE-LASIK (BSSL) surgery. SETTING Singapore National Eye Centre, Singapore. DESIGN Retrospective cohort study. METHODS 2 patient cohorts were recruited (2010-2012; 2014-2016). The bilateral SMILE (BS) and bilateral LASIK (BL) groups comprised patients (mean ± SD age: 30.3 ± 6.5, 50% male) from a prospective nonrandomized study who chose SMILE and LASIK, respectively. The BSSL group comprised patients (mean ± SD age: 28.6 ± 6.2, 64.3% male) randomized to receive SMILE in 1 eye and LASIK in the other. Rasch-scaled scores of the QoL Impact of Refractive Correction questionnaire between groups postoperatively at 1 and 3 months were compared. RESULTS At month 1, scores on 3 QoL without emotional well-being items were worse in the BSSL (n = 70) compared with the BL group (n = 25), specficially, "using sunglasses" (β: -20.6, 95% CI, -34.3 to -6.9), "reliance on refractive correction" (-23.1, 95% CI, -40.9 to -5.4), and "medical complications from optical correction" (β: -14.8, 95% CI, -27.9 to -1.7). Emotional well-being (overall), and items "feeling able to do things" (β: 11.0, 95% CI, 1.6-20.4) and "feeling eager to try new things" (β: 14.1, 95% CI, 3.6-24.6) were better in the BSSL compared with the BS group (n = 25). No substantive differences were observed at month 3. CONCLUSIONS Refractive correction-related QoL differences at month 1 between BSSL and BS/BL patients attenuated by month 3. Bilateral sequential SMILE-LASIK surgery appeared unlikely to negatively affect QoL beyond 3 months.
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Affiliation(s)
- Alfred T L Gan
- From the Singapore Eye Research Institute and Singapore National Eye Centre, Singapore (Gan, Fenwick, Ang, Mehta, Lamoureux); Duke-NUS Medical School, Singapore (Fenwick, Ang, Mehta, Lamoureux); National University of Singapore, Singapore (Lamoureux); Faculty of Medicine, Dentistry and Health Sciences University of Melbourne, Australia (Lamoureux)
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Pradhan KR, Arba Mosquera S. Twelve-month outcomes of a new refractive lenticular extraction procedure. JOURNAL OF OPTOMETRY 2023; 16:30-41. [PMID: 34949535 PMCID: PMC9811368 DOI: 10.1016/j.optom.2021.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/02/2021] [Accepted: 11/11/2021] [Indexed: 06/07/2023]
Abstract
BACKGROUND To evaluate the 12-month refractive and visual outcomes of Small Incision Guided Human-cornea Treatment (SmartSight®, SCHWIND eye-tech-solutions, Kleinostheim, Germany) in the treatment of myopia corrections with low to moderate astigmatism with the use of a new femtosecond laser system. METHODS 221 eyes of 114 patients consecutively treated with SmartSight lenticule extraction were assessed. The mean age of the patients was 28±6 years at the time of treatment with a mean spherical equivalent refraction of -6.26±2.17D and mean astigmatism of 0.92±0.68D. Monocular corrected distance visual acuity (CDVA), uncorrected distance visual acuity (UDVA) were assessed pre- and post-operatively. Refractive changes have been determined in terms of changes in refraction, as well as changes in keratometric readings. The changes in central epithelial thickness have been determined. RESULTS At twelve months post-operatively, mean UDVA was 20/21±2. Spherical equivalent showed a residual refraction of +0.48±0.31D with refractive astigmatism of 0.13±0.18D postoperatively. There was a slight decrease of -0.1 Snellen lines at 12-months follow-up. The same correction was determined using changes in refraction, as well as changes in keratometric readings. The central epithelial thickness increased by +3±2µm. Spherical equivalent correction within ±0.50D was achieved in 199 eyes (90%), and cylindrical correction in 221 (100%). Preoperative corrected distance visual acuity (CDVA) was 20/20 or better in 213 eyes (96%), and postoperative uncorrected (UDVA) was 20/20 or better in 205 eyes (93%). No eye had lost two or more Snellen lines of CDVA. CONCLUSIONS Myopic astigmatism correction with SmartSight provided good results for efficacy, safety, predictability, and visual outcomes at the twelve months of follow up. The central epithelial thickness barely increased by 3±2µm.
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Affiliation(s)
- Kishore Raj Pradhan
- Matrika Eye Center, Dhunge Dhara Marg, Ward number 9, Kathmandu 44600, Nepal.
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Reinstein DZ, Sekundo W, Archer TJ, Stodulka P, Ganesh S, Cochener B, Blum M, Wang Y, Zhou X. SMILE for Hyperopia With and Without Astigmatism: Results of a Prospective Multicenter 12-Month Study. J Refract Surg 2022; 38:760-769. [PMID: 36476297 DOI: 10.3928/1081597x-20221102-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate the safety and effectiveness of small incision lenticule extraction (SMILE) in patients who have hyperopia with or without astigmatism. METHODS This was a prospective multicenter trial including 374 eyes of 199 patients treated by SMILE for hyperopia using the VisuMax femtosecond laser (Carl Zeiss Meditec AG). Inclusion criteria were sphere up to +6.00 diopters (D), cylinder up to 5.00 D, and maximum hyperopic meridian up to +7.00 D, with preoperative corrected distance visual acuity (CDVA) of 20/25 or better. The optical zone was 6.3 mm with a transition zone of 2 mm. The minimum lenticule thickness was set at 25 µm in the center and at 10 µm at the edge. Patients were examined at 1 day, 1 week, and 1, 3, 6, 9, and 12 months after surgery. Standard refractive surgery outcomes analysis was performed. RESULTS The preoperative spherical equivalent was +3.20 ± 1.48 D (range: +0.25 to +6.50 D). At the 12-month follow-up visit, 81% of eyes treated were within ±0.50 D and 93% of eyes were within ±1.00 D of intended correction. A total of 1.2% of eyes lost two or more lines of CDVA at the 12-month follow-up visit, and 83% were at least 20/20, corresponding to a safety index of 1.005 at 12 months. Of the 219 eyes with plano target, 68.8% had an uncorrected distance visual acuity of 20/20 or better and 88% were at least 20/25 uncorrected at 12 months. There were no statistically significant changes in contrast sensitivity. CONCLUSIONS SMILE was found to be an effective treatment method for the correction of compound hyperopic astigmatism, demonstrating a high level of efficacy, predictability, safety, and stability. [J Refract Surg. 2022;38(12):760-769.].
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Han T, Zhao L, Shen Y, Chen Z, Yang D, Zhang J, Sekundo W, Shah R, Tian J, Zhou X. Twelve-year global publications on small incision lenticule extraction: A bibliometric analysis. Front Med (Lausanne) 2022; 9:990657. [PMID: 36160168 PMCID: PMC9493269 DOI: 10.3389/fmed.2022.990657] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose To analyze the development process of small incision lenticule extraction (SMILE) surgery in a 12-year period. Methods We conducted a literature search for SMILE research from 2011 to 2022 using the Science Citation Index Expanded (SCIE) of the Web of Science Core Collection (WoSCC). The VOS viewer, and CiteSpace software were used to perform the bibliometric analysis. Publication language, annual growth trend, countries/regions and institutions, journals, keywords, references, and citation bursts were analyzed. Results A total of 731 publications from 2011 to 2022 were retrieved. Annual publication records grew from two to more than 100 during this period. China had the highest number of publications (n = 326). Sixty-five keywords that appeared more than four times were classified into six clusters: femtosecond laser technology, dry eye, biomechanics, visual quality, complications, and hyperopia. Conclusion The number of literatures has been growing rapidly in the past 12 years. Our study provides a deep insight into publications on SMILE for researchers and clinicians with bibliometric analysis for the first time.
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Affiliation(s)
- Tian Han
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China
- Research Center of Ophthalmology and Optometry Shanghai, Shanghai, China
- Shanghai Engineering Research Center of Laser and Autostereoscopic 3D for Vision Care (20DZ2255000), Shanghai, China
| | - Liang Zhao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
- Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- The School of Nursing, Lanzhou University, Lanzhou, Gansu, China
| | - Yang Shen
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China
- Research Center of Ophthalmology and Optometry Shanghai, Shanghai, China
- Shanghai Engineering Research Center of Laser and Autostereoscopic 3D for Vision Care (20DZ2255000), Shanghai, China
| | - Zhi Chen
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China
- Research Center of Ophthalmology and Optometry Shanghai, Shanghai, China
- Shanghai Engineering Research Center of Laser and Autostereoscopic 3D for Vision Care (20DZ2255000), Shanghai, China
| | - Dong Yang
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China
- Research Center of Ophthalmology and Optometry Shanghai, Shanghai, China
- Shanghai Engineering Research Center of Laser and Autostereoscopic 3D for Vision Care (20DZ2255000), Shanghai, China
| | - Jiaoyan Zhang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
- Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- The School of Nursing, Lanzhou University, Lanzhou, Gansu, China
| | - Walter Sekundo
- The Department of Ophthalmology, Philipps University of Marburg, Marburg, Germany
| | - Rupal Shah
- New Vision Laser Centers, Vadodara, Gujarat, India
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
- Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- *Correspondence: Jinhui Tian,
| | - Xingtao Zhou
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China
- Research Center of Ophthalmology and Optometry Shanghai, Shanghai, China
- Shanghai Engineering Research Center of Laser and Autostereoscopic 3D for Vision Care (20DZ2255000), Shanghai, China
- Xingtao Zhou,
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Ex-vivo study on the surface quality of corneal lenticule and stroma after low energy femtosecond laser lenticule extraction. Sci Rep 2022; 12:10034. [PMID: 35705567 PMCID: PMC9200215 DOI: 10.1038/s41598-022-13468-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/24/2022] [Indexed: 11/26/2022] Open
Abstract
This study aimed to assess the surface quality of cap, stroma and lenticular surfaces created using low-energy femtosecond laser lenticule extraction (Ziemer FEMTO LDV Z8). Twenty-four porcine eyes were divided into four groups (n = 6 each): two with optimal laser power (32%) with posterior curvature equivalent to a spherical correction of -2D and -5D, respectively and the other two with high power (64%) with spherical correction of -2D and -5D respectively. Samples were analysed using scanning electron microscopy (SEM). Surface morphology was evaluated using a standard scoring system; surface relief, surface regularity, extent and position of irregularities were graded by four independent clinicians. Eyes with 32% power and -2D correction had significantly less size of the irregular area than those with -5D; however, no significant difference was found between the two groups with 64% power. When comparing eyes with -2D correction, the size of the irregular area was lesser with 32% power. Surface relief was lesser with -5D correction with 32% power than 64% power. Low-energy femtosecond laser lenticule extraction (Ziemer FEMTO LDV Z8) produces good surface quality results. There is a tendency for smoother surface stromal quality with lower power settings than a higher power.
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Chiang B, Valerio GS, Manche EE. Prospective, Randomized Contralateral Eye Comparison of Wavefront-Guided Laser In Situ Keratomileusis and Small Incision Lenticule Extraction Refractive Surgeries. Am J Ophthalmol 2022; 237:211-220. [PMID: 34788593 DOI: 10.1016/j.ajo.2021.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE Wavefront-guided laser in situ keratomileusis (WFG-LASIK) and small incision lenticule extraction (SMILE) are keratorefractive surgeries that can improve uncorrected visual acuity in myopic patients. Comparison of visual outcomes in myopic patients treated with LASIK and SMILE is needed. DESIGN Prospective, randomized contralateral eye-controlled trial. METHODS We performed a single-center prospective, randomized contralateral eye comparison of WFG-LASIK and SMILE (NCT03067077). Myopic patients with low levels of astigmatism were treated with WFG-LASIK in one eye and SMILE in the fellow eye from March 2017 to March 2021. Treatments were randomized by ocular dominance. WFG-LASIK and SMILE were performed. Postoperative evaluation at 1 day consisted of uncorrected distance visual acuity (UDVA), wavefront aberrometry, and a slit-lamp examination. On subsequent postoperative visits at 1 month, 3 months, 6 months, and 12 months, UDVA, manifest refraction, 5% and 25% low-contrast visual acuity, wavefront aberrometry, and slit-lamp examination were performed. MAIN OUTCOME MEASURE The primary outcome measure was UDVA at 12 months. RESULTS Eighty-eight eyes of 44 patients with myopia were enrolled in the study. Seventy-four eyes of 37 patients had successful treatments and completed 12 months of follow-up. At postoperative month 12, there were a significantly higher proportion of WFG-LASIK eyes that had ≥20/20 UDVA compared with SMILE eyes (94% vs 83%, P < .05). There was no difference between spherical equivalent between WFG-LASIK eyes and SMILE eyes (-0.17 ± 0.25 vs -0.29 ± 0.38, P > .05); there was no difference in higher order aberrations, including coma, trefoil, and spherical aberrations (P > 0.05); and there were a significantly higher proportion of WFG-LASIK eyes that had improved 5% and 25% low-contrast visual acuity compared with SMILE eyes (P < 0.05). CONCLUSIONS WFG-LASIK and SMILE both offered marked improvements in corrected distance visual acuity and excellent predictability in both eyes. Compared with SMILE, WFG-LASIK resulted in faster visual recovery, better low-contrast visual acuity, and greater gains in uncorrected visual acuity.
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Affiliation(s)
- Bryce Chiang
- From the Department of Ophthalmology, Byers Eye Institute at Stanford, Stanford University, Palo Alto, California, USA
| | - Gabriel S Valerio
- From the Department of Ophthalmology, Byers Eye Institute at Stanford, Stanford University, Palo Alto, California, USA
| | - Edward E Manche
- From the Department of Ophthalmology, Byers Eye Institute at Stanford, Stanford University, Palo Alto, California, USA..
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Liu ET, Sella R, Goernert P, Kim K, Chen H, Lin RT. Refractive results with SMILE using lower energy settings in the United States. PLoS One 2021; 16:e0258835. [PMID: 34679121 PMCID: PMC8535172 DOI: 10.1371/journal.pone.0258835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/07/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To report the visual and refractive results of small incision lenticule extraction (SMILE) with low energy settings in the United States (US) and to evaluate outcomes for low astigmatism treatment. Setting Private clinical practice. Design Retrospective cohort study. Methods This study retrospectively reviewed 462 consecutive eyes that underwent SMILE with lower energy settings. Inclusion criteria included all patients between the ages of 19–39 with myopic astigmatism up to -11.25 diopters (D) spherical equivalent (sphere up to -10.00 D, astigmatism up to -3.00 D), and corrected distance visual acuity of at least 20/25. Eyes with low astigmatism (0.25 D-0.50 D) were also included. Outcome analysis was performed according to the Standard Graphs for Reporting Refractive Surgery at postoperative month (POM) 1, and POM 3–6 when data were available. Results The mean preoperative spherical equivalent treated was -4.96 ± 2.07; at POM 1, 92% of eyes achieved uncorrected visual acuity (UCVA) of 20/20 or better and maintained visual stability throughout the remainder of the study. At last visit, 431 eyes (93%) achieved UCVA of 20/20 or better, and 461 eyes (99.8%) were 20/25 or better. Ninety-seven (21%) eyes gained at least 1 Snellen line of corrected distance visual acuity and no eyes lost 2 or more lines. Almost all eyes (n = 453, 98%) were within 0.5D of target; 85% of eyes with low astigmatism had ≤0.25 D at last visit compared to 80% of eyes with moderate astigmatism. Conclusions SMILE with U.S.-approved low energy settings is safe, predictable, and efficacious and provides patients with a fast visual recovery.
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Affiliation(s)
- Erica T. Liu
- IQ Laser Vision, City of Industry, California, United States of America
- * E-mail:
| | - Ruti Sella
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Kevin Kim
- IQ Laser Vision, City of Industry, California, United States of America
| | - Henry Chen
- College of Osteopathic Medicine of the Pacific, Western University, Pomona, California, United States of America
| | - Robert T. Lin
- IQ Laser Vision, City of Industry, California, United States of America
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Damgaard IB, Sejersen H, Ivarsen A, Hjortdal J. 7-Year Results of SMILE for High Myopia: Visual and Refractive Outcomes and Aberrations. J Refract Surg 2021; 37:654-661. [PMID: 34661473 DOI: 10.3928/1081597x-20210712-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the 7-year visual, refractive, and optical outcomes following small incision lenticule extraction (SMILE) for high myopia and myopic astigmatism. METHODS Sixty-nine eyes (69 patients) undergoing SMILE between March 2011 and January 2012 at Aarhus University Hospital were included. Preoperative, 3-month, 3-year, and 7-year evaluation included: manifest refraction and uncorrected (UDVA) and corrected (CDVA) distance visual acuities, total corneal refractive power (TCRP), average keratometry (Km), aberrations, and central corneal thickness (CCT). RESULTS Preoperative spherical equivalent averaged -7.53 ± 1.18 diopters (D). Twenty-seven eyes were targeted emmetropia. In the emmetropic eyes, the postoperative logMAR UDVA remained stable (P = .11). When including all eyes, UDVA became worse from 3 to 7 years (3 months: 0.050 ± 0.16 logMAR; 3 years: 0.044 ± 0.21 logMAR; 7 years: 0.131 ± 0.29 logMAR; P < .027), whereas CDVA remained stable (3 months: -0.07 ± 0.09 logMAR; 3 years: -0.09 ± 0.08 logMAR; 7 years: -0.09 ± 0.08 logMAR, P > .99). At 7 years, 59.4% and 81.2% were within ±0.50 and ±1.00 D of target refraction, respectively. Average refractive regression was significant from 3 months to 7 years (-0.34 ± 0.69 D) and from 3 to 7 years (-0.25 ± 0.41 D, P < .05). After exclusion of three outliers with high myopic correction (< 9.63 D) and considerable regression (<-1.50 D), the average regression over 7 years was -0.25 ± 0.49 D (P = .004) with no significant change from 3 to 7 years (P = .069). Average CCT, TCRP, and anterior Km significantly increased (P < .001), whereas the posterior Km and total corneal aberrations remained stable (P > .092). CONCLUSIONS The long-term visual outcome remained stable after SMILE, but with an average regression of -0.34 D over 7 years. A minor group with high myopic correction exhibited considerable refractive regression years after SMILE. [J Refract Surg. 2021;37(10):654-661.].
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Abstract
A lenticule of intrastromal corneal tissue was cut together with 2 small incisions of 3.0 mm using a low-energy femtosecond laser system, FEMTO LDV Z8; 1 incision led to the posterior plane and 1 to the anterior, allowing dissection of the lenticule. When needed, recentering of the treatment area was possible without repeating the docking stage. Five eyes were operated, and a complete dissection and removal of the lenticule was achieved in all cases without any intraoperative complications. In addition, at postoperative day 1, all patients had a clear cornea. In conclusion, guided lenticule extraction using a low-energy femtosecond laser was a promising and easy procedure.
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13
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Corneal Stroma Thickness Changes after Myopic Laser Corneal Refractive Surgery. J Cataract Refract Surg 2021; 48:334-341. [PMID: 34326281 DOI: 10.1097/j.jcrs.0000000000000765] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/21/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the postoperative behavior of the central corneal stroma thickness after myopic femto-LASIK and SMILE by using a combined anterior segment-OCT and placido disc topographer, and to compare the accuracy of both laser machines in predicting the real stromal change . SETTING Vissum Miranza, Alicante, Spain. STUDY DESIGN Prospective, observational, comparative study. METHODS The Visumax-500kHz femtosecond laser (FS), and the Amaris-750 excimer laser were used for the correction of myopia with or without myopic astigmatism. Central and paracentral stromal thicknesses (ST) and 6mm-corneal aberrometry were obtained with the MS39 topographer. Laser predicted stromal consumption was recorded (maximum lenticule thickness for SMILE and central ablation depth for LASIK). Visual and refractive outcomes were also evaluated. Total follow-up was 6 months. RESULTS 77 LASIK-eyes were matched with 77 SMILE-eyes. Mean preoperative spherical equivalent (SE) was -3.92±1.67D for LASIK and -4.02±1.63D for SMILE;p=0.356. After LASIK, ST parameters showed a significant rethickening between months 1-3 (+4.38µm for central-ST;p<0.001), remaining stable thereafter. After SMILE, all ST parameters remained stable from month-1. Stromal ablation prediction was higher for SMILE compared to LASIK for all SE ranges, although postoperatively such differences were significant only for ametropias≤4D. At 6 months, mean SMILE laser prediction error was -13.21±7.00µm, while LASIK prediction showed better accuracy (+0.92± 8.16µm; p<0.001). CONCLUSIONS The accuracy of the Amaris-750 excimer laser in predicting the stromal consumption after LASIK was better than the VisuMax-FS laser for SMILE. While SMILE stromal thicknesses remained stable from month-1, after LASIK a mild stromal rethickening was observed up to the third month.
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Wan KH, Lin TPH, Lai KHW, Liu S, Lam DSC. Options and results in managing suction loss during small-incision lenticule extraction. J Cataract Refract Surg 2021; 47:933-941. [PMID: 33315737 DOI: 10.1097/j.jcrs.0000000000000546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/20/2020] [Indexed: 11/25/2022]
Abstract
Suction loss is an intraoperative complication in small-incision lenticule extraction (SMILE) that presents a management challenge for the refractive surgeon. The purpose of this review is to evaluate the visual, refractive, and wavefront outcomes after suction loss across the different stages of SMILE with various respective surgical treatments. Surgical management options include immediate re-SMILE by redocking or delayed re-SMILE, with or without adjustment of the laser parameters, conversion to femtosecond laser in situ keratomileusis, transepithelial photorefractive keratectomy, refractive lenticule extraction, or pseudo-SMILE. The restart treatment module on VisuMax provides appropriate retreatment recommendation. Most retreatment options for suction loss, immediate or delayed, resulted in effective, safe, and predictable outcomes, and patients were satisfied with their outcomes. Based on available level II evidence, immediate re-SMILE with or without adjustment to the laser settings achieve favorable visual and refractive outcomes in handling this intraoperative complication across all stages of SMILE.
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Affiliation(s)
- Kelvin H Wan
- From the Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong (Wan, Lam); Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong (Lin); C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong (Lai, Liu, Lam); International Eye Research Institute of The Chinese University of Hong Kong (Shenzhen), Shenzhen, China (Lam); C-MER (Shenzhen) Dennis Lam Eye Hospital, Shenzhen, China (Lam)
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Pradhan KR, Arba-Mosquera S. Three-Month Outcomes of Myopic Astigmatism Correction With Small Incision Guided Human Cornea Treatment. J Refract Surg 2021; 37:304-311. [PMID: 34044692 DOI: 10.3928/1081597x-20210210-02] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate refractive and visual outcomes of small incision guided human cornea treatment (SmartSight; SCHWIND eye-tech-solutions) in the treatment of myopic astigmatism with the use of a new femtosecond laser system. METHODS This retrospective, observational case series study included 104 eyes of 56 patients who underwent SmartSight to correct myopic astigmatism and completed the 3-month follow-up. Procedures were performed with a SCHWIND ATOS femtosecond laser. RESULTS Preoperatively, mean manifest spherical equivalent refraction was -6.12 ± 1.99 diopters (D) (range: -3.00 to -11.50 D) and astigmatism was 1.02 ± 0.56 D (range: 0.25 to 2.75 D). Three months postoperatively, it was +0.47 ± 0.32 D (range: -0.75 to +1.00 D) and 0.27± 0.22 D (range: 0.00 to 0.75 D), respectively (both P < .05). Spherical equivalent correction within ±0.50 D was achieved in 62 eyes (60%), and cylindrical correction in 90 eyes (87%). Preoperative corrected distance visual acuity (CDVA) was 20/20 or better in 94 eyes (90%) and postoperative uncorrected distance visual acuity was 20/20 or better in 96 eyes (92%). No eye lost two or more Snellen lines of CDVA. CONCLUSIONS Myopic astigmatism correction with Smart-Sight provided good results for efficacy, safety, predictability, and visual outcomes in the first 3 months of follow-up. [J Refract Surg. 2021;37(5):304-311.].
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Brar S, Ganesh S, Gautam M, Meher S. Feasibility, Safety, and Outcomes With Standard Versus Differential Spot Distance Protocols in Eyes Undergoing SMILE for Myopia and Myopic Astigmatism. J Refract Surg 2021; 37:294-302. [PMID: 34044689 DOI: 10.3928/1081597x-20210121-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To study the feasibility, safety, comparison of intraoperative ease of dissection, and immediate visual outcomes with standard versus differential small incision lenticule extraction (SMILE) spot settings in eyes undergoing bilateral SMILE for myopia or myopic astigmatism. METHODS One hundred eyes of 50 patients (mean age: 25.4 years) were randomized to receive standard settings (4.5-µm spot and track spacing in cap and lenticule interface) in one eye and differential settings (4.5-µm spot and track spacing in cap interface and 4.2 µm in lenticule interface) in the contralateral eye. Opaque bubble layer (OBL) was graded using a new grading system and a surgeon questionnaire was obtained to grade the ease of dissection (from 0 to 5, with 5 being the easiest) at the end of each surgery. Visual results and optical quality were analyzed at 1 day, 2 weeks, and 3 months postoperatively. RESULTS The mean OBL score was significantly lower in the differential group (26.3%) compared to the standard group (35.3%) (P < .01). Consequently, the mean dissection score was significantly higher in the differential group (4.01) compared to the standard group (3.57) (P < .01). The uncorrected distance visual acuity, Objective Scatter Index, modulation transfer function cut-off, and higher order aberrations were comparable with no statistically significant difference between both groups at 1 day, 2 weeks, and 3 months postoperatively (P > .05 for all parameters). No eye in either group had any intraoperative or postoperative complication affecting visual recovery. CONCLUSIONS Differential spot settings resulted in less intraoperative OBL and easy separability. However, the visual results and optical quality were comparable between groups. [J Refract Surg. 2021;37(5):294-302.].
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Fuest M, Mehta JS. Advances in refractive corneal lenticule extraction. Taiwan J Ophthalmol 2021; 11:113-121. [PMID: 34295616 PMCID: PMC8259523 DOI: 10.4103/tjo.tjo_12_21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 01/31/2023] Open
Abstract
Refractive errors are the leading cause of reversible visual impairment worldwide. In addition to the desired spectacle independence, refractive procedures can improve quality of life, working ability, and daily working performance. Refractive corneal lenticule extraction (RCLE) is a relatively new technique, dependent only on a femtosecond laser (FS). This leads to potential benefits over laser-assisted in situ keratomileusis (LASIK) including a quicker recovery of dry eye disease, a larger functional optical zone, and no flap-related complications. SMILE, available with the VisuMax FS (Carl Zeiss Meditec AG, Jena, Germany), is the most established RCLE application, offering visual and refractive outcomes comparable to LASIK. SmartSight (SCHWIND eye-tech-solutions GmbH, Kleinostheim, Germany) and CLEAR (Ziemer Ophthalmic Systems AG, Port, Switzerland) are two new RCLE applications that received Conformité Européenne (CE) approval in 2020. In this article, we review refractive and visual outcomes, advantages, and disadvantages of RCLE and also report on the latest advances in RCLE systems.
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Affiliation(s)
- Matthias Fuest
- Department of Ophthalmology, RWTH Aachen University, Aachen, Germany
| | - Jodhbir S Mehta
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore.,Singapore National Eye Centre, Singapore.,Eye-Academic Clinical Program, Duke-National University of Singapore Graduate Medical School, Singapore.,School of Material Science and Engineering, Nanyang Technological University, Singapore
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Brar S, Ganesh S, Gautam M, Devi RC. Comparison of Clinical Outcomes and Visual Quality Using a Medium Versus Small Contact Glass in Patients Undergoing SMILE With Large Corneal Diameters. J Refract Surg 2021; 37:150-157. [PMID: 34038297 DOI: 10.3928/1081597x-20201222-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare the clinical outcomes and visual quality using a small (S) versus medium (M) size contact glass in eyes with large white-to-white (WTW) distance undergoing bilateral small incision lenticule extraction (SMILE) for myopia correction. METHODS This contralateral eye study involved 60 eyes of 30 patients (mean age: 27.20 years) undergoing bilateral SMILE for myopia/myopic astigmatism with a WTW distance of 12 mm or greater in both eyes, which were randomized to receive treatment with an S-contact glass in one eye and an M-contact glass in the fellow eye. Opaque bubble layer (OBL) was graded using a new grading system. On postoperative 1 day, 2 weeks, and 3 months, UDVA, CDVA, contrast sensitivity, Objective Scatter Index, and modulation transfer function cut-off values were compared between the two groups. RESULTS The mean OBL score was significantly lower in the S-contact glass group (28.18%) compared to the M-contact glass group (67.13%) (P < .01). At 1 day postoperatively, the UDVA, Objective Scatter Index score, and contrast sensitivity values for all spatial frequencies were significantly better in eyes treated with the S-contact glass compared to the M-contact glass (P ⩽ .05). At 3 months postoperatively, however, the UDVA, Objective Scatter Index score, modulation transfer function cut-off, and contrast sensitivity values were comparable for both groups. No eye in either group had intraoperative complications such as suction loss, incision/lenticule tears, or lenticule retention. CONCLUSIONS In corneas with a WTW distance of 12 mm or greater, docking with the S-contact glass resulted in significantly better immediate visual results due to less OBL formation and smoother tissue dissection compared to the M-contact glass. [J Refract Surg. 2021;37(3):150-157.].
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The correction of conjunctivochalasis using high-frequency radiowave electrosurgery improves dry eye disease. Sci Rep 2021; 11:2551. [PMID: 33510304 PMCID: PMC7844232 DOI: 10.1038/s41598-021-82088-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/31/2020] [Indexed: 11/29/2022] Open
Abstract
We aimed to determine the clinical impact of conjunctivochalasis (CCh) and its correction using high-frequency radiowave electrosurgery (HFR-ES), for signs and symptoms of dry eye disease (DED). Forty patients diagnosed with symptomatic CCh were prospectively enrolled. As a result, patients with CCh had moderate to severe DED and most of them exhibited meibomian gland dysfunction (MGD). Corneo-conjunctival fluorescein staining score (CFS) and all lid-parallel-conjunctival-folds scores (LIPCOFs) were positively correlated. Nasal LIPCOF significantly correlated with symptoms and tear volume. Central, temporal, and total LIPCOF significantly correlated with MG loss, MGD stage, and lipid layer thickness. Independent significant factors associated with total LIPCOF included CFS, tear break-up time, and MGD stage. One month following HFR-ES, CCh was completely resolved in all cases. Patient age and preoperative nasal LIPCOF were determinants of outcomes associated with postoperative improvements in symptoms. Ocular surface parameters significantly improved, but MGD-related signs did not. Collectively, CCh associated with MGD severity deteriorates not only tear film stability and reservoir capacity, leading to DED exacerbation. Therefore, CCh should be corrected in patients with DED and MGD. Younger patients with nasal CCh are likely to experience more symptomatic relief after HFR-ES. Particularly, management for MGD should be maintained after CCh correction.
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Hamilton DR, Chen AC, Khorrami R, Nutkiewicz M, Nejad M. Comparison of early visual outcomes after low-energy SMILE, high-energy SMILE, and LASIK for myopia and myopic astigmatism in the United States. J Cataract Refract Surg 2021; 47:18-26. [PMID: 32769749 DOI: 10.1097/j.jcrs.0000000000000368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/21/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE To compare uncorrected distance visual acuities (UDVAs) and induced higher-order aberrations (HOAs) in the early postoperative period between low-energy (LE) small-incision lenticule extraction (SMILE), high-energy (HE) SMILE, and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) procedures. SETTING University based refractive surgery center. STUDY DESIGN Retrospective cohort study. METHODS Records of patients who underwent SMILE or FS-LASIK were retrospectively reviewed. SMILE patients were separated into 2 groups: HE settings (125 nJ, 3.0 μm spot spacing) and LE settings (125-130 nJ, 4.5 μm spot spacing). UDVA was measured at postoperative day (POD) 1. Corneal HOAs and UDVA were measured at postoperative month (POM) 1. Induced spherical aberration, vertical coma, horizontal coma, total coma, and total HOAs were calculated. RESULTS The study included 147 eyes of 106 patients, 49 in each group. For SMILE patients, the difference in mean UDVA at POD1 was highly statistically significant in favor of the LE group (-0.003 vs 0.141, P < .0001). No significant difference in mean UDVA at POD1 was noted between the LE group and FS-LASIK group (-0.003 vs -0.011, P = .498). Induced change in spherical aberration was less in LE SMILE than that in FS-LASIK (0.136 vs 0.186 μm, P = .02) at POM1. No significant differences in POM1 mean UDVA (-0.033 vs -0.036) or induced change in all other HOAs were noted between LE SMILE and FS-LASIK. CONCLUSIONS LE settings were associated with significantly improved POD1 UDVA. POD1 and POM1 UDVA were comparable with those of FS-LASIK. Spherical aberration induction was less with LE SMILE than that with FS-LASIK, whereas all other induced HOAs were comparable with FS-LASIK.
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Affiliation(s)
- D Rex Hamilton
- From the Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles (Chen, Khorrami, Nejad), Los Angeles, and Hamilton Eye Institute (Hamilton, Nutkiewicz), Los Angeles, California, USA
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21
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Sachdev GS, Ramamurthy S. Decade - long journey with small incision lenticule extraction: The learnings. Indian J Ophthalmol 2020; 68:2705-2710. [PMID: 33229646 PMCID: PMC7856951 DOI: 10.4103/ijo.ijo_2622_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Over the past decade, small incision lenticule extraction (SMILE) has revolutionized the field of keratorefractive surgery. With the promise of superior corneal biomechanics and reduced postoperative dry eye, SMILE afforded a distinct advantage over flap-based procedures. Our evolving understanding of the surgical technique and management of its unique complications has further enhanced the outcomes. This review will highlight specific pearls on various preoperative and intraoperative principles allowing optimization of outcomes with SMILE.
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Affiliation(s)
- Gitansha S Sachdev
- Refractive Services, The Eye Foundation, RS Puram, Coimbatore, Tamil Nadu, India
| | - Shreyas Ramamurthy
- Refractive Services, The Eye Foundation, RS Puram, Coimbatore, Tamil Nadu, India
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22
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Asif MI, Bafna RK, Mehta JS, Reddy J, Titiyal JS, Maharana PK, Sharma N. Complications of small incision lenticule extraction. Indian J Ophthalmol 2020; 68:2711-2722. [PMID: 33229647 PMCID: PMC7856979 DOI: 10.4103/ijo.ijo_3258_20] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The procedure of small incision lenticule extraction (SMILE) was introduced in 2011, and since then there has been an increase in the number of cases undergoing this procedure worldwide. The surgery has a learning curve and may be associated with problems in the intraoperative and postoperative periods. The intraoperative problems during SMILE surgery include the loss of suction, the occurrence of altered or irregular opaque bubble layer and black spots, difficulty in lenticular dissection and extraction, cap perforation, incision-related problems, and decentered ablation. Most of the postoperative problems are similar as in other laser refractive procedures, but with decreased incidence. The identification of risk factors, clinical features, and management of complications of SMILE help to obtain optimum refractive outcomes.
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Affiliation(s)
- Mohamed Ibrahime Asif
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Kumar Bafna
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jodhbir Singh Mehta
- Singapore Eye Research Institute; Singapore National Eye Centre, 168751; Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Jagadesh Reddy
- Cataract and Refractive Services, Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Jeewan Singh Titiyal
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Prafulla K Maharana
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Tay E, Bajpai R. Visual recovery after small incision lenticule extraction (SMILE) in relation to pre-operative spherical equivalent. Graefes Arch Clin Exp Ophthalmol 2020; 259:1053-1060. [PMID: 33047249 DOI: 10.1007/s00417-020-04954-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/16/2020] [Accepted: 09/25/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To assess visual recovery after small incision lenticule extraction (SMILE) in relation to pre-operative spherical equivalent. METHODS Two hundred fourteen eyes of 107 patients were enrolled. Following surgery, patients were examined pre-operatively, 1 day, 2 weeks, 1 month and 3 months later. High myopia was defined as pre-operative spherical equivalent ≤ - 5 D. A linear mixed-effects model was used. RESULTS Mean ± standard deviation pre-operative spherical equivalent was - 5.30 ± 1.36 D that reduced significantly to 0.04 ± 0.70 D (p < 0.001) at 1 month and - 0.02 ± 0.66 D (p < 0.001) at 3 months. Mean pre-operative LogMAR uncorrected distance visual acuity ± SD was 0.97 ± 0.09 that improved significantly to 0.04 ± 0.06 at 2 weeks (p < 0.001), 0.01 ± 0.04 at 1 month (p < 0.001) and 0.01 ± 0.04 at 3 months (p < 0.001). Eighty-eight eyes (41.2%) had uncorrected distance visual acuities of 0.0 at 1 day, 154 eyes (72.0%) at 2 weeks,194 eyes (90.7%) at 1 month and 199 eyes (93.0%) at 3 months. Significantly more eyes with low myopia (> - 5 D) achieved acuities of 0.0 at 1 day and 2 weeks (p = 0.041 and p < 0.001). Post-operative acuities were not associated with refractive targets, laser cut energy settings or other variables. Two hundred nine eyes (97.7%) were within ± 0.5 D of target and 213 eyes (99.5%) were within ± 1 D. CONCLUSIONS SMILE for low myopia had faster visual recovery in the early post-operative period with no significant differences between groups detected by 1 and 3 months.
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Affiliation(s)
- Eugene Tay
- Singapore Eye Research Institute, The Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Ram Bajpai
- School of Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
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Alio Del Barrio JL, Parafita-Fernandez A, Canto-Cerdan M, Alio JL, Teus M. Evolution of corneal thickness and optical density after laser in situ keratomileusis versus small incision lenticule extraction for myopia correction. Br J Ophthalmol 2020; 105:1656-1660. [PMID: 32980816 DOI: 10.1136/bjophthalmol-2020-316601] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/19/2020] [Accepted: 09/06/2020] [Indexed: 11/04/2022]
Abstract
PURPOSE To compare the thickness and stromal optical density (OD) evolution of the flap and cap after femtosecond (FS-LASIK; Visumax) and small incision lenticule extraction (SMILE), respectively, for myopia correction. METHODS A prospective study comprising 78 eyes (n=39 per group) was performed. Anterior segment optical coherence tomography (MS39) images were collected at each postoperative visit (1 day, 1 week and 1 and 3 months) and flap/cap thicknesses were measured. Using ImageJ software, three regions were defined to measure OD (in grayscale units: flap/cap stroma, residual stromal bed (RSB) and all stroma (including flap/cap-stroma, surgical interface and RSB). RESULTS Mean central thickness significantly increased during the 3-month follow-up in both LASIK (5.43±4.23 μm; p=0.0118) and SMILE (2.76±5.61 μm; p=0.0118), with differences between both techniques statistically significant (p=0.020). All OD values showed a statistically significant reduction during SMILE follow-up: cap 48.96±5.55 versus 44.95±5.41 (p=0.19×10-6), RSB 50.26±7.06 versus 45.42±7.53 (p=0.00005), total stroma 50.34±6.49 versus 45.46±6.96 (p=0.5×10-5) at 1 day and 3 months, respectively, whereas no statistically significant changes were found during LASIK follow-up. No significant differences were observed in OD values between both techniques at any time point, although SMILE showed a tendency for higher OD values than LASIK within the first postoperative month. Visumax presented a tendency for thicker caps than target (11.48±7.85 μm), but not for flaps (2.73±8.93 μm) (p=0.00003). CONCLUSIONS Both LASIK flaps and SMILE caps show a significant postoperative rethickening. SMILE corneas present higher optical densities than LASIK corneas in the early postoperative period, with a significant decrease thereafter and up to 3 months. These findings correlate with the delayed visual recovery observed after SMILE.
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Affiliation(s)
- Jorge Luis Alio Del Barrio
- Cornea, Cataract and Refractive Surgery Unit, VISSUM (Grupo Miranza), Alicante, Spain.,Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain
| | - Alberto Parafita-Fernandez
- Ophthalmology Department, Complexo Hospitalario Universitario de Pontevedra, Pontevedra, Spain.,Clínica Oftalmológica Dr Parafita, Ribeira, A Coruña, Spain
| | - Mario Canto-Cerdan
- Cornea, Cataract and Refractive Surgery Unit, VISSUM (Grupo Miranza), Alicante, Spain
| | - Jorge L Alio
- Cornea, Cataract and Refractive Surgery Unit, VISSUM (Grupo Miranza), Alicante, Spain.,Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain
| | - Miguel Teus
- Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain .,Clínica Novovisión, Madrid, Spain
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Chong JK, Hamilton DR. SMILE for Myopic Astigmatism: Early Experience in the USA and International Advances. CURRENT OPHTHALMOLOGY REPORTS 2020. [DOI: 10.1007/s40135-020-00250-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Ang M, Gatinel D, Reinstein DZ, Mertens E, Alió Del Barrio JL, Alió JL. Refractive surgery beyond 2020. Eye (Lond) 2020; 35:362-382. [PMID: 32709958 DOI: 10.1038/s41433-020-1096-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/19/2020] [Accepted: 07/08/2020] [Indexed: 02/07/2023] Open
Abstract
Refractive surgery refers to any procedure that corrects or minimizes refractive errors. Today, refractive surgery has evolved beyond the traditional laser refractive surgery, embodied by the popular laser in situ keratomileusis or 'LASIK'. New keratorefractive techniques such as small incision lenticule extraction (SMILE) avoids corneal flap creation and uses a single laser device, while advances in surface ablation techniques have seen a resurgence in its popularity. Presbyopic treatment options have also expanded to include new ablation profiles, intracorneal implants, and phakic intraocular implants. With the improved safety and efficacy of refractive lens exchange, a wider variety of intraocular lens implants with advanced optics provide more options for refractive correction in carefully selected patients. In this review, we also discuss possible developments in refractive surgery beyond 2020, such as preoperative evaluation of refractive patients using machine learning and artificial intelligence, potential use of stromal lenticules harvested from SMILE for presbyopic treatments, and various advances in intraocular lens implants that may provide a closer to 'physiological correction' of refractive errors.
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Affiliation(s)
- Marcus Ang
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore. .,Department of Ophthalmology and Visual Science, Duke-NUS Graduate Medical School, Singapore, Singapore.
| | | | - Dan Z Reinstein
- London Vision Clinic, London, UK.,Department of Ophthalmology, Columbia University Medical Center, New York, NY, USA.,Sorbonne Université, Paris, France.,Biomedical Science Research Institute, Ulster University, Belfast, UK
| | - Erik Mertens
- Medipolis-Antwerp Private Clinic, Antwerp, Belgium
| | - Jorge L Alió Del Barrio
- Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain.,Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain
| | - Jorge L Alió
- Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain.,Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain
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Liu L, Cheng W, Wu D, Chen L, Yu S, Zuo T, Zhang L, Yang K, Li H, Zhang H, Wei P, Ng ALK, Cheng GPM, Woo VCP, Yin J, Chiu K, Wang Y. The Differential Expression of Cytokines and Growth Factors After SMILE Compared With FS-LASIK in Rabbits. Invest Ophthalmol Vis Sci 2020; 61:55. [PMID: 32460319 PMCID: PMC7405797 DOI: 10.1167/iovs.61.5.55] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To investigate the differential expression of cytokines and growth factors in the cornea and aqueous humor after small incision lenticule extraction (SMILE) compared with femtosecond LASIK (FS-LASIK) using rabbit model. Methods Sixteen eyes of 16 rabbits in each group underwent SMILE or FS-LASIK with refractive correction of −6.00 DS/−1.00 DC. Eight additional rabbits served as controls. Pre- and 24 hours, 1 week, 1 month, and 3 months postoperatively, slit-lamp and anterior segment optical coherence tomography were performed, followed by cornea and aqueous humor collection. Apoptosis and proliferation were evaluated with TUNEL assay and Ki-67 immunostaining, respectively. The mRNA and protein expression of cytokines and growth factors was determined by RT-qPCR and Western blotting, respectively. Cytokine levels in the aqueous humor were detected with ELISA. Results Compared with FS-LASIK, SMILE induced less apoptosis and proliferation in the cornea within 1 week postoperatively. Levels of IL-1β, TNF-α, and EGFR in the cornea were significantly increased after FS-LASIK compared with SMILE within 24 hours. Levels of IL-8 in the aqueous humor remained elevated until 1 week after FS-LASIK but not SMILE. TGF-β1 level was elevated up to 1 month after both procedures, while BFGF level was kept high within 1 month after SMILE but not FS-LASIK. Conclusions SMILE could induce significantly less acute inflammation than FS-LASIK in the cornea and aqueous humor. The differential expression of TGF-β1 and BFGF between two procedures until 1 month might contribute to the post-SMILE delayed recovery and underline the importance of continued treatment postoperatively.
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Development of low laser energy levels in small-incision lenticule extraction: clinical results, black area, and ultrastructural evaluation. J Cataract Refract Surg 2020; 46:410-418. [PMID: 32050215 DOI: 10.1097/j.jcrs.0000000000000071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the outcomes of 4 low laser energy levels after small-incision lenticule extraction (SMILE) surgery. SETTING Zhongshan Ophthalmic Center, Guangzhou, China. DESIGN Prospective randomized clinical trial. METHODS This study evaluated consecutive patients who had SMILE to correct myopia or myopia with astigmatism. Eyes were placed into groups based on the laser energy used during surgery (ie, 105 nJ, 110 nJ, 115 nJ, or 120 nJ). All patients had a thorough ophthalmic examination preoperative and at 4 timepoints over 3 months postoperatively. Black areas and surface regularity of the extracted lenticules were observed and evaluated qualitatively and quantitatively. RESULTS The study comprised 124 eyes of 62 patients (40 women, 22 men), with 31 eyes in each laser energy group. The incidence of black areas was 45.16% (14 of 31 eyes), 12.90% (4 of 31 eyes), 16.13% (5 of 31 eyes), and 12.90% (4 of 31 eyes) for 105 nJ, 110 nJ, 115 nJ, and 120 nJ, respectively. The mean time for lenticule creation was the longest in the 105 nJ group (P = .015). The greatest increase in corneal thickness postoperatively occurred with 105 nJ (P < .05). Regression was highest in the 105 nJ group at 3 months (P < .01). However, corneal horizontal coma (C8) was lowest in the 105 nJ group at 1 week (P = .032). The lenticular surface in the 110 nJ group was the smoothest (P = .011). All contrast sensitivity values varied with time and recovered to preoperative levels by 1 week or 1 month. In all eyes, the uncorrected distance visual acuity and corrected distance visual acuity were good, with no statistically significant differences between the 4 energy groups. CONCLUSIONS The 105 nJ group, in which the lowest energy was used, had the highest risk for black areas, serious postoperative corneal edema, and a significant healing response.
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Weng S, Xiang D, Lin L, Lin H, Liu F, Liu Q. Optimal Parameters of Scanning Mode in Small Incision Lenticule Extraction (SMILE): Clinical Results and Ultrastructural Analysis. J Refract Surg 2020; 36:34-41. [DOI: 10.3928/1081597x-20191114-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/14/2019] [Indexed: 11/20/2022]
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Schallhorn JM, Seifert S, Schallhorn SC. SMILE, Topography-Guided LASIK, and Wavefront-Guided LASIK: Review of Clinical Outcomes in Premarket Approval FDA Studies. J Refract Surg 2019; 35:690-698. [DOI: 10.3928/1081597x-20190930-02] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/30/2019] [Indexed: 11/20/2022]
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Kim TI, Alió Del Barrio JL, Wilkins M, Cochener B, Ang M. Refractive surgery. Lancet 2019; 393:2085-2098. [PMID: 31106754 DOI: 10.1016/s0140-6736(18)33209-4] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/29/2018] [Accepted: 12/11/2018] [Indexed: 01/19/2023]
Abstract
Refractive surgery has evolved beyond laser refractive techniques over the past decade. Laser refractive surgery procedures (such as laser in-situ keratomileusis), surface ablation techniques (such as laser epithelial keratomileusis), and photorefractive keratectomy have now been established as fairly safe procedures that produce excellent visual outcomes for patients with low-to-moderate amounts of ametropia. Additionally, a broader selection of options are now available to treat a wider range of refractive errors. Small incision lenticule extraction uses a femtosecond laser to shape a refractive lenticule, which is removed through a small wound. The potential advantages of this procedure include greater tectonic strength and less dry eye. In the future, intracorneal implants could be used to treat hyperopia or presbyopia. Phakic intraocular implants and refractive lens exchange might be useful options in carefully selected patients for correcting high degrees of ametropia. Thus, physicians are now able to provide patients with the appropriate refractive corrective option based on the individual's risk-benefit profile.
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Affiliation(s)
- Tae-Im Kim
- Department of Ophthalmology, The Institute of Vision Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Jorge L Alió Del Barrio
- Cornea, Cataract and Refractive Surgery Unit, Research & Development Department VISSUM Innovation Alicante, Alicante, Spain; Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain
| | - Mark Wilkins
- Department of Ophthalmology, Moorfields Eye Hospital, London, UK
| | - Beatrice Cochener
- Department of Ophthalmology, University Hospital Morvan, Brest, France
| | - Marcus Ang
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Department of Ophthalmology and Visual Science, Duke-NUS Graduate Medical School, Singapore.
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Donate D, Thaëron R. SMILE With Low Energy Levels: Assessment of Early Visual and Optical Quality Recovery. J Refract Surg 2019; 35:285-293. [DOI: 10.3928/1081597x-20190416-01] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 04/15/2019] [Indexed: 11/20/2022]
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Reinstein DZ, Vida RS, Archer TJ, Carp GI. Aborted small-incision lenticule extraction resulting from false plane creation and strategy for subsequent removal based on corneal layered pachymetry imaging. J Cataract Refract Surg 2019; 45:872-877. [PMID: 30987783 DOI: 10.1016/j.jcrs.2019.02.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/05/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
We describe a complication of false plane creation during small-incision lenticule extraction (SMILE) and the surgical plan for subsequent lenticule removal. During a primary SMILE procedure to treat high myopia, the separator instrument entered a false lamellar plane as a result of an area of resistance caused by an area of opaque bubble layer (OBL). The procedure was aborted to avoid removing an irregular lenticule. Based on measurements of the anatomic landscape, a new inferonasal small incision was created. The lenticule was separated and removed without further incidence. The patient recovered as normal and at 6 months, the uncorrected distance visual acuity was 20/16-1. This case highlights the importance of monitoring the bubble layer creation and interface separation to avoid creating or removing an irregular lenticule. It also shows the importance of layered corneal imaging to analyze and diagnose complications as well as of aborting a procedure and planning lenticule removal at a later time if deemed appropriate.
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Affiliation(s)
- Dan Z Reinstein
- London Vision Clinic, London, United Kingdom; Biomedical Science Research Institute, Ulster University, Coleraine, United Kingdom; Columbia University Medical Center, New York, New York, USA; Sorbonne Université, Paris, France.
| | - Ryan S Vida
- London Vision Clinic, London, United Kingdom
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Reinstein DZ, Archer TJ, Vida RS, Carp GI. Suction Stability Management in SMILE: Development of a Decision Tree for Managing Eye Movements and Suction Loss. J Refract Surg 2019; 34:809-816. [PMID: 30540363 DOI: 10.3928/1081597x-20181023-01] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 10/22/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To develop a comprehensive protocol for suction stability management during small incision lenticule extraction (SMILE). METHODS This was a retrospective video review of all SMILE cases where suction loss occurred or eye movement was noted in the medical record. The different types of eye movement were collated. A suction stability grading scale was derived to represent the magnitude of eye movements. A decision tree protocol was developed to define the management in each scenario depending on the suction stability grading and the femtosecond laser cutting progress. RESULTS Eight types of eye movement were identified: fixation light tracking, Bell's reflex, saccades, oscillations, anxiety/uncooperative patient, nociceptive reflex movement, false suction, and nystagmus. Type I eye movements were defined as small movements that shift the corneal position by a clinically negligible amount. The surgeon may want to pause the femtosecond laser cutting, regain control of the patient, then continue. Type II eye movements were defined as large movements that shift the corneal position by a clinically relevant amount, in which case the surgeon may choose to release suction (ie, a surgeon-initiated suction loss). Type III eye movements were defined as those with sufficient force to break suction (ie, a patient-generated suction loss). A comprehensive decision tree was developed to cover all possible eye movement and suction loss scenarios. Example scenarios outside the preprogrammed machine restart treatment module include converting to laser in situ keratomileusis (LASIK) if there was tracking of the interface and restarting SMILE with a thinner cap if the original cap thickness was 135 μm or greater. CONCLUSIONS With appropriate management, it is possible for the SMILE procedure to be completed on the same day by either continuing with SMILE or converting to LASIK depending on the progress of the femtosecond laser cutting. [J Refract Surg. 2018;34(12):809-816.].
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Siedlecki J, Luft N, Keidel L, Mayer WJ, Kreutzer T, Priglinger SG, Archer TJ, Reinstein DZ, Dirisamer M. Variation of Lenticule Thickness for SMILE in Low Myopia. J Refract Surg 2018; 34:453-459. [PMID: 30001448 DOI: 10.3928/1081597x-20180516-01] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/07/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To report the impact of increasing minimum lenticule thickness on the safety and efficacy of small incision lenticule extraction (SMILE) in low myopia up to -3.50 diopters (D). METHODS SMILE was performed in 76 eyes of 76 patients. Thirty-eight eyes of 38 patients with low myopia were prospectively operated on with a programmed minimum lenticule thickness of 15 to 30 μm (thicker lenticule group). Thirty-five eyes suitable for analysis were then retrospectively matched by spherical equivalent to 35 eyes operated on with a minimum standard setting of 10 μm (standard thickness group), as provided in the database of the SMILE Eyes Clinic Linz, Linz, Austria. Comparison of outcomes was performed with the Standard Graphs for Reporting Refractive Surgery and by analysis of higher order aberrations as provided by Scheimpflug imaging. RESULTS Apart from lenticule thickness, there was no significant difference in preoperative baseline or treatment parameters between both groups. Mean minimum lenticule thickness differed significantly (standard thickness = 10 ± 0 μm; thicker lenticule = 20 ± 5 μm; P < .0001). This also translated into a significant difference in maximum lenticule thickness (standard thickness: 54 ± 11 μm; thicker lenticule: 62 ± 8 μm; P = .0002). Mean SEQ preoperatively was -2.25 ± 0.51 (standard thickness) and -2.24 ± 0.46 (thicker lenticule) D, respectively, and changed to -0.11 ± 0.50 (standard thickness) and +0.01 ± 0.36 (thicker lenticule) D postoperatively (P < .0001 for both comparisons). Uncorrected postoperative visual acuity was -0.08 ± 0.35 (standard thickness) versus -0.10 ± 0.09 (thicker lenticule) logMAR (P = .706). After SMILE, the thicker lenticule group showed better safety (1.20 vs 1.08; P = .025) and efficacy (1.14 vs 0.96; P = .011) indices, translating into more eyes within ±0.50 D from target (91% vs 77%) and with at least 0.0 logMAR visual acuity (97% vs 86%), and fewer eyes losing one (3% vs 17%) and two (0% vs 3%) lines. CONCLUSIONS Increasing minimum lenticule border thickness seems to improve the safety and efficacy of SMILE in low myopia. [J Refract Surg. 2018;34(7):453-459.].
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Weng S, Yang X, Liu F, Lin H, Liu M, Liu Q. Development of a liquid dissection technique for small-incision lenticule extraction: Clinical results and ultrastructural evaluation. J Cataract Refract Surg 2018; 44:1080-1089. [PMID: 30060900 DOI: 10.1016/j.jcrs.2018.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/04/2018] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the effect of a liquid dissection technique on clinical outcomes with ultrastructural analysis of the lenticule surface in small-incision lenticule extraction (SMILE). SETTING Zhongshan Ophthalmic Center, Guangzhou, China. DESIGN Prospective case series. METHODS Consecutive patients with myopia scheduled for small-incision lenticule extraction were included. The liquid dissection technique was performed in 1 eye and the traditional dissection technique was performed in the other eye by randomized assignment. Ophthalmic examinations were evaluated preoperatively and at different timepoint follow-ups after small-incision lenticule extraction. Ten human corneal lenticules were analyzed using scanning electron microscopy. RESULTS The study comprised 29 patients (58 eyes). Uncorrected distance visual acuity (logarithm of the minimum angle of resolution) postoperative measurements at 2 and 4 hours were significantly better in the liquid dissection group than in the traditional dissection group (P < .001 and P = .001, respectively); however, there were no significant differences between the 2 groups at 1 day, 1 week, and 1 month postoperatively. Compared with the traditional dissection technique, the liquid dissection technique induced significantly fewer corneal aberrations at 2 hours and 1 month after the procedures (P = .031 and P = .016, respectively), the postoperative contrast sensitivity in the liquid dissection group was significantly higher after 1 day (P = .01). The liquid dissection samples showed smoother lenticule surfaces compared with the traditional dissection samples qualitatively and quantitatively (P = .004 and P < .001, respectively). CONCLUSION The liquid dissection technique was helpful in facilitating better visual acuity recovery and produced smooth cuts in the early postoperative period.
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Affiliation(s)
- Shengbei Weng
- From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China
| | - Xiaonan Yang
- From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China
| | - Fang Liu
- From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China
| | - Haiqin Lin
- From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China
| | - Manli Liu
- From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China
| | - Quan Liu
- From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-sen University, Guangzhou, China.
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Enhancement of refractive outcomes of small-incision lenticule extraction via tear-film control. Graefes Arch Clin Exp Ophthalmol 2018; 256:2259-2268. [PMID: 30056550 DOI: 10.1007/s00417-018-4074-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE To suggest that tear film is a refractive outcome predictor in small-incision lenticule extraction (SMILE) for myopia and describe methods of controlling the tear film and its effects on refractive outcomes. METHODS In this retrospective case-control study, the tear film was kept clear and appropriate in amount during tear-film-controlled SMILE (TFC-SMILE). In contrast, no special care to the tear film was given in direct-docking SMILE (DD-SMILE). Both procedures were performed by the same experienced surgeon, using the same surgical parameters, over defined periods. In select cases, scanning electron microscopy (SEM) of the lenticule and surgical videos of opaque bubble layers (OBLs) were obtained and compared. RESULTS Forty-one eyes had DD-SMILE and 55 eyes had TFC-SMILE. Multivariate analysis showed that TFC-SMILE and the patient's age were significant predictors of refractive outcomes. The refractive predictability of TFC-SMILE was better than that of DD-SMILE, and under-correction of high myopia was evident in the latter patients. The predictive errors of DD-SMILE became more myopic and variable during 1 year than those of TFC-SMILE. The lenticular surface on SEM was more serrated in DD-SMILE. Severe OBLs were evident in four cases of DD-SMILE and the OBL pattern was sporadic at the anterior surface of the lenticule. CONCLUSIONS The presence of a clear and appropriate tear film in SMILE enhanced predictability, minimized variability, and ensured stability of refractive outcomes. An uncontrolled tear film might render cutting imprecise and trigger severe OBL formation. TFC-SMILE had more predictable results than DD-SMILE.
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Li L, Schallhorn JM, Ma J, Cui T, Wang Y. Energy Setting and Visual Outcomes in SMILE: A Retrospective Cohort Study. J Refract Surg 2018; 34:11-16. [PMID: 29315436 DOI: 10.3928/1081597x-20171115-01] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 11/09/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess the independent effect of energy setting on postoperative uncorrected distance visual acuity (UDVA) in small incision lenticule extraction (SMILE) and further investigate an optimal energy setting for the 4.5-μm spot-track-distance, which is in wide clinical use. METHODS A total of 1,130 eyes were included in a retrospective cohort study from Tianjin Eye Hospital, Tianjin Medical University from April 2015 to July 2016. Energy settings and baseline characteristics were recorded and 3-month UDVA was tested by a nurse blinded to the energy settings used. Multiple regression analysis and generalized estimating equations were used to take into account the correlation between the measurements from two eyes. RESULTS The 3-month UDVA (mean ± standard deviation) of 125 to 160 nJ (by 5-nJ increments) was 1.39 ± 0.19, 1.40 ± 0.32, 1.33 ± 0.27, 1.36 ± 0.27, 1.34 ± 0.25, 1.29 ± 0.19, 1.36 ± 0.27, and 1.19 ± 0.22, respectively. Energy was significantly associated with postoperative logMAR UDVA in different models and the regression coefficient (β) was robust (β = 0.01, 95% confidence interval = 0.00 to 0.01). The regression coefficient β (0.01, 95% confidence interval = 0.00 to 0.02, P = .0029) of energy (125 to 150 nJ, by 5-nJ increments) on 4.5-μm spot-track-distance was still associated with the logMAR UDVA when adjusted for sex, age, myopia, astigmatism, mean keratometry, central corneal thickness, preoperative logMAR CDVA, and side spot-track-distance. CONCLUSIONS The lower end of the energy studied was associated with a better postoperative UDVA in this population. The spot-track-distance of 4.5 μm with 125 nJ energy was the optimal combination within this range. [J Refract Surg. 2018;34(1):11-16.].
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Kang DSY, Lee H, Reinstein DZ, Roberts CJ, Arba-Mosquera S, Archer TJ, Kim EK, Seo KY, Kim TI. Comparison of the Distribution of Lenticule Decentration Following SMILE by Subjective Patient Fixation or Triple Marking Centration. J Refract Surg 2018; 34:446-452. [DOI: 10.3928/1081597x-20180517-02] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 05/07/2018] [Indexed: 11/20/2022]
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Moshirfar M, Murri MS, Shah TJ, Linn SH, Ronquillo Y, Birdsong OC, Hoopes PC. Initial Single-Site Surgical Experience with SMILE: A Comparison of Results to FDA SMILE, and the Earliest and Latest Generation of LASIK. Ophthalmol Ther 2018; 7:347-360. [PMID: 29959753 PMCID: PMC6258580 DOI: 10.1007/s40123-018-0137-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction The primary objective was to show our initial surgical single-site experience with small incision lenticule extraction (SMILE) after the official enrollment in March 2017 following Food and Drug Administration (FDA) approval for simple myopia in late 2016 in the United States and, subsequently, compare our results to the earliest and most advanced generation of excimer platforms for laser-assisted in situ keratomileusis (LASIK) surgery. Methods This was a retrospective single-site study of 68 eyes from 35 patients who had SMILE surgery. The patients’ preoperative and postoperative uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest sphere, manifest cylinder, intraoperative complications, and preoperative and postoperative visual symptoms were collected. We compared our findings to the results from the FDA SMILE study, and to the three earliest (1999–2000) and three of the most updated (2013–2016) platforms for LASIK. Results The cumulative UDVA was 20/20 and 20/40 or better in 74% and 100% of patients, respectively. The intended target refraction was within ± 0.5 and ± 1.00 D in 80% and 93% of cases, respectively. The prevalence of dry eyes decreased by nearly half from 1-week to the 6-month postoperative interval. Patients noted improvement in glare (17%), halos (17%), fluctuation (25%), and depth perception (8%) at the 6-month interval compared to preoperative levels. Conclusions This study’s findings are consistent with current SMILE reports. Notably, the results are superior to the earliest generation of LASIK, however inferior to the latest excimer platforms. SMILE does meet the efficacy and safety criteria met by FDA; however, there is a definite need for further improvement to reach the superior refractive outcomes produced by the latest generation of LASIK platforms.
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Affiliation(s)
- Majid Moshirfar
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA. .,Utah Lions Eye Bank, Murray, UT, USA. .,HDR Research Center, Hoopes Vision, Draper, UT, USA.
| | - Michael S Murri
- Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tirth J Shah
- University of Arizona College of Medicine, Phoenix, Phoenix, AZ, USA
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Possible Risk Factors and Clinical Outcomes of Black Areas in Small-Incision Lenticule Extraction. Cornea 2018; 37:1035-1041. [PMID: 29863541 DOI: 10.1097/ico.0000000000001649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the possible risk factors and clinical effects of black areas in small-incision lenticule extraction. METHODS Thirty-one cases and 126 controls were enrolled in a case-control study from the database of a single center from September 2012 to July 2017. A retrospective analysis of surgical procedures with video and medical records was performed. Logistic regression analysis was used to assess the possible risk factors for black areas between cases with black areas and controls without black areas. RESULTS In the study, 19 eyes (61.3%) with black areas were associated with the presence of surface debris, 10 of which had repeated suction during docking and centration (P < 0.001). There was a significant difference in the energy of the femtosecond laser used for the cases (133 ± 4.04 nJ) and controls (138 ± 3.26 nJ) (P < 0.001). The odds ratio for the energy of the laser was 0.180 (95% confidence interval, 0.099-0.328, P < 0.001). Eyes with black areas had poorer uncorrected vision at 1 and 7 days and 1 month postoperatively (0.06, 0.01, and 0.00 logMAR, respectively) compared with controls (-0.01, -0.07, and -0.05 logMAR, respectively) (P < 0.005). At month 3, the safety index was lower in the cases (1.14 ± 0.47) compared with controls (1.36 ± 0.28) (P = 0.003). The postoperative spherical equivalent in the cases was more myopic than in controls (P = 0.036), except for month 3 (P = 0.183). CONCLUSIONS Black areas in small-incision lenticule extraction could be caused by repeated suction, presence of surface debris, and a lower energy of the femtosecond laser. These factors could result in rough dissection and slower recovery of visual acuity.
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Garcia-Gonzalez M, Teus MA. Comments on Femtosecond Lenticule Extraction for Spherocylindrical Hyperopia Using New Profiles. J Refract Surg 2018; 34:431-432. [PMID: 29889298 DOI: 10.3928/1081597x-20180409-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Jun I, Kang DSY, Reinstein DZ, Arba-Mosquera S, Archer TJ, Seo KY, Kim TI. Clinical Outcomes of SMILE With a Triple Centration Technique and Corneal Wavefront-Guided Transepithelial PRK in High Astigmatism. J Refract Surg 2018. [PMID: 29522224 DOI: 10.3928/1081597x-20180104-03] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To comparatively investigate the clinical outcomes, vector parameters, and corneal aberrations of small incision lenticule extraction (SMILE) with a triple centration technique and corneal wavefront-guided transepithelial photorefractive keratectomy (PRK) for the correction of high astigmatism. METHODS This retrospective, comparative case series study included 89 eyes (89 patients) that received treatment for myopia with high astigmatism (≥ 2.50 diopters) using SMILE with a triple centration technique (SMILE group; 45 eyes) and corneal wavefront-guided transepithelial PRK (transepithelial PRK group; 44 eyes). Visual acuity measurement, manifest refraction, slit-lamp examination, autokeratometry, corneal topography, and evaluation of corneal wavefront aberration were performed preoperatively and at 1, 3, and 6 months after surgery. The safety, efficacy, vector parameters, and corneal aberrations at 6 months after surgery were compared between the two groups. RESULTS At 6 months after surgery, the transepithelial PRK and SMILE groups exhibited comparable mean uncorrected distance visual acuities (-0.06 ± 0.07 and -0.05 ± 0.07 logMAR, respectively), safety, efficacy, and predictability of refractive and visual outcomes. There was a slight but statistically significant difference in the correction index between the transepithelial PRK and SMILE groups (0.96 ± 0.11 and 0.91 ± 0.10, respectively). Whereas the transepithelial PRK group exhibited increased corneal spherical aberration and significantly reduced corneal coma and trefoil, no changes in aberrometric values were noted in the SMILE group. CONCLUSIONS Both SMILE with a triple centration technique and corneal wavefront-guided transepithelial PRK are effective and provide predictable outcomes for the correction of high myopic astigmatism, although slight undercorrection was observed in the SMILE group. The triple centration technique was helpful in astigmatism correction by SMILE. [J Refract Surg. 2018;34(3):156-163.].
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Comparing corneal higher-order aberrations in corneal wavefront-guided transepithelial photorefractive keratectomy versus small-incision lenticule extraction. J Cataract Refract Surg 2018; 44:725-733. [PMID: 29789156 DOI: 10.1016/j.jcrs.2018.03.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/02/2018] [Accepted: 03/25/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate the changes in corneal higher-order aberrations (HOAs) after corneal wavefront-guided transepithelial photorefractive keratectomy (PRK) and small-incision lenticule extraction (SMILE). SETTING Yonsei University College of Medicine and Eyereum Eye Clinic, South Korea. DESIGN Retrospective case series. METHODS Medical records of patients having either corneal wavefront-guided transepithelial PRK or small-incision lenticule extraction were examined. The root-mean-square total HOAs, 3rd-order coma aberration, and 4th-order spherical aberration were measured preoperatively and 6 months postoperatively. Independent t tests and analysis of covariance were used to compare changes in corneal HOAs between the 2 groups. RESULTS The study comprised 77 eyes having corneal wavefront-guided transepithelial PRK and 81 eyes having small-incision lenticule extraction. The total HOAs and spherical aberration increased after transepithelial PRK (all P < .001), whereas coma aberration was stable after transepithelial PRK. The total HOAs, spherical aberration, and coma aberration increased after small-incision lenticule extraction (P < .001 for total HOAs, spherical aberration; P = .004 for coma). At 6 months postoperatively, total HOAs and spherical aberration were significantly larger in the transepithelial PRK group than in the small-incision lenticule extraction group. Coma aberration was larger in the small-incision lenticule extraction group than in the transepithelial PRK group. Spherical aberration induction was significantly smaller in the small-incision lenticule extraction group than in the transepithelial PRK group (P < .001), and coma aberration induction was larger in the small-incision lenticule extraction group than in the transepithelial PRK group (P = .011). CONCLUSIONS Small-incision lenticule extraction demonstrated that the induction of total HOAs was comparable to corneal wavefront-guided transepithelial PRK, accompanied by smaller spherical aberration induction and larger coma aberration induction. During small-incision lenticule extraction, surgeons should aim to obtain optimum centration for smaller induction of corneal HOAs.
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Zhu X, He W, Zhang Y, Chen M, Du Y, Lu Y. Inferior Decentration of Multifocal Intraocular Lenses in Myopic Eyes. Am J Ophthalmol 2018; 188:1-8. [PMID: 29355482 DOI: 10.1016/j.ajo.2018.01.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 12/23/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate the tilt and decentration of multifocal intraocular lenses (MfIOLs) implanted in myopic eyes. DESIGN A prospective cohort study. METHODS Twenty-eight myopic eyes and 56 emmetropic eyes were evaluated. Phacoemulsification with Tecnis ZMB00 MfIOL (Abbott Medical Optics, Santa Ana, California, USA) implantation was performed. At 1 year post-surgery, routine postoperative examinations were performed, and tilt and decentration of the MfIOLs, high-order aberrations, and modulation transfer function (MTF) were evaluated using the OPD-Scan III aberrometer (Nidek Co, Ltd, Gamagori, Japan). Subjective symptoms were assessed with a Quality of Vision questionnaire. RESULTS Postoperative uncorrected distance visual acuity (VA), best-corrected distance VA, and uncorrected near VA did not differ between the 2 groups. The mean IOL tilt and horizontal decentration were not different between the control and myopic groups. However, the myopic group presented significantly inferior decentration in the capsular bag compared with the control group (-0.03 ± 0.22 mm vs -0.21 ± 0.29 mm, P = .002). The overall decentration values were 0.32 ± 0.14 mm in the controls and 0.40 ± 0.18 mm in the myopic group (P = .023). Axial length was negatively correlated with vertical decentration (r = -0.268, P = 0.014) and positively correlated with overall decentration (r = 0.334, P = .002). Worse aberration data, poorer MTF, and more subjective symptoms were also found in the myopic group than in the controls. CONCLUSION Greater inferior decentration of MfIOLs and a consequent decrease in visual quality were found in myopic eyes, indicating that the increasing incompatibility between IOL and capsular bag size with axial length elongation should not be underestimated.
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Effect of Cap-Lenticule Diameter Difference on the Visual Outcome and Higher-Order Aberrations in SMILE: 0.4 mm versus 1.0 mm. J Ophthalmol 2017; 2017:8259546. [PMID: 29270316 PMCID: PMC5705886 DOI: 10.1155/2017/8259546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/29/2017] [Accepted: 10/12/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate the effect of cap-lenticule diameter difference (CLDD) on the visual outcome and higher-order aberrations (HOAs) of small-incision lenticule extraction (SMILE). Methods A total of 132 patients who had bilateral SMILE for myopia or myopic astigmatism were included. The CLDD was 0.4 mm in 54 patients (group 1) and 1.0 mm in 78 patients (group 2). The refractive parameters, uncorrected (UDVA) and corrected distance visual acuity (CDVA), and HOAs were determined preoperatively and during six months follow-up. Results Group 1 had better CDVA (in logMAR) compared to group 2 at day 1 (−0.07 ± 0.07 versus 0.04 ± 0.07, resp.; p < 0.001) and week 1 (−0.07 ± 0.07 versus –0.04 ± 0.07, resp.; p = 0.001). The visual acuity improved more in group 1 than in group 2. The UDVA (in logMAR) was 0.07 ± 0.07 and 0.29 ± 0.09 at day 1 (p < 0.001) and −0.08 ± 0.07 and −0.06 ± 0.06 at six months (p = 0.038) in group 1 and group 2, respectively. Group 1 was associated with significantly less induction of HOAs (0.24 ± 0.08 μm and 0.32 ± 0.26 μm, resp.; p = 0.002). Conclusions In SMILE, 0.4 mm CLDD is associated with better visual outcome and less induction of HOAs than 1.0 mm. Narrow CLDD should be considered in SMILE to increase the visual acuity particularly in the early postoperative period.
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