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Arboleda N, Yi J, Kang JJ. The evolution of refractive surgery training. Curr Opin Ophthalmol 2023; 34:275-279. [PMID: 37070524 DOI: 10.1097/icu.0000000000000958] [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: 04/19/2023]
Abstract
PURPOSE OF REVIEW Although refractive surgery is one of the most commonly performed ophthalmic procedures, there is a relative paucity of literature on residency and fellowship refractive surgery education. The purpose of this article is to review the current state and recent updates to refractive surgery education and to evaluate the safety and visual outcomes of trainee performed refractive procedures. RECENT FINDINGS Currently, there is no standard refractive surgery curriculum in the United States apart from required mandatory minimum refractive requirements for residents and fellows. Our survey of residency programs confirms that refractive training is extremely varied, ranging from a dedicated refractive rotation with direct surgical experience to only didactics or observation of procedures. There is a proposed standardized framework for refractive surgery training for the military, which may be a starting point in developing a more comprehensive refractive surgery curriculum in residency education. Multiple studies have reinforced the safety of resident and fellow performed refractive surgery. SUMMARY Refractive surgery is an increasingly popular procedure and a more comprehensive refractive education is paramount. Future studies are needed to determine how best to provide the fundamental training and surgical experience for trainees in the fast-changing landscape of refractive surgery.
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Affiliation(s)
- Nathan Arboleda
- Department of Ophthalmology and Visual Sciences, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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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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Huang Q, Liu L, Ma P, Sun Y, Wang Z, Bai J, Liu T. Grading for suction loss in small incision lenticule extraction. Int Ophthalmol 2023; 43:665-675. [PMID: 36044110 DOI: 10.1007/s10792-022-02456-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 07/31/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION To observe the characteristics of suction loss in small-incision lenticule extraction (SMILE) and analyze the factors affecting the stability of the suction ring, classify and grade suction loss, and determine the principles for its prevention and control. METHODS This study enrolled patients who underwent SMILE between June 2014 and June 2017. The relationship between the stability of the suction ring and suction loss was ascertained using surgical records and video recordings. The suction loss was classified and graded according to its characteristics and relationship with eye or head movement. The effect of target intervention on suction loss was observed. RESULTS Suction loss can be divided into sudden and progressive types. According to the severity, the latter was divided into three grades (grade 1A or 1B, 2 and 3). Of the 1200 eyes (608 patients), two (0.17%) had sudden suction loss, and 132 (11%) had progressive suction loss. The superior part, inferior part, and other parts accounted for 63.4%, 19.3%, and 17.3% of progressive suction loss, respectively. The proportion of grades 1A, 1B, 2, and 3 suction loss was 53%, 34%, 12%, and 1%, respectively. The location of the threatened suction loss was opposite to the direction of the patient's head movement. After the intraoperative intervention, grades 1 and 2 did not develop into "actual" suction loss. CONCLUSIONS Progressive suction loss was the most frequently observed suction loss during SMILE procedure. Grading suction loss can elucidate its underlying mechanism, which can guide targeted intervention measures to effectively control and reduce suction loss-induced damage, and further improve the safety and efficacy of SMILE.
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Affiliation(s)
- Qing Huang
- Department of Ophthalmology, Army Medical University of People's Liberation Army, Chongqing, China
| | - Lina Liu
- Chongqing Baiji Eye Hospital Management Co. LTD, Chongqing, China
| | - Pingqi Ma
- Department of Ophthalmology, Army Medical University of People's Liberation Army, Chongqing, China
| | - Yulin Sun
- Department of Ophthalmology, Army Medical University of People's Liberation Army, Chongqing, China
| | - Zhiqiang Wang
- Department of Ophthalmology, Army Medical University of People's Liberation Army, Chongqing, China
| | - Ji Bai
- Chongqing Baiji Eye Hospital Management Co. LTD, Chongqing, China
| | - Ting Liu
- Department of Ophthalmology, Army Medical University of People's Liberation Army, Chongqing, China.
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Reinstein DZ, Archer TJ, González-Méijome JM, Vida RS, Gupta R. Changes in Light Disturbance Analyzer Evaluation in SMILE for High Myopia and Astigmatism. J Refract Surg 2022; 38:725-732. [DOI: 10.3928/1081597x-20221019-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Clinical outcomes of the immediate reapplication of small-incision lenticule extraction without adjusting the surgical parameters after suction loss. Sci Rep 2022; 12:15973. [PMID: 36153404 PMCID: PMC9509434 DOI: 10.1038/s41598-022-20403-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/13/2022] [Indexed: 11/23/2022] Open
Abstract
This study was to analyze the clinical outcomes of immediate reapplication of small-incision lenticule extraction (SMILE) without adjusting the surgical parameters after suction loss and to compare the outcomes with contralateral eyes that underwent uneventful SMILE. A total of 74 patients who underwent uneventful SMILE in one eye (Uneventful group) and immediate reapplication of SMILE without adjusting the surgical parameters after suction loss in the contralateral eye (Suction loss group) were included. Suction loss occurred during the posterior lenticule surface cut in 39 eyes (53%) and the cap cut in 35 eyes (47%). Surgical outcomes, including visual acuity, manifest refraction, keratometry, and corneal wavefront aberrations, were evaluated at 6 months postoperatively. The mean uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and spherical equivalent were − 0.02 ± 0.07, − 0.04 ± 0.04, and − 0.10 ± 0.46 diopters (D), respectively, in the Suction loss group and − 0.02 ± 0.07, − 0.04 ± 0.05, and − 0.19 ± 0.53 D, respectively (P = 0.965, 0.519, and 0.265, respectively), in the Uneventful group. Changes between the preoperative and 6-month postoperative total corneal aberrations, spherical aberrations, and horizontal and vertical coma did not significantly differ between the Suction loss and Uneventful groups. Immediate reapplication of SMILE without adjusting the surgical parameters after suction loss resulted in good surgical outcomes that were comparable with those of uneventful SMILE.
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Reinstein DZ, Carp GI, Archer TJ, Vida RS, Yammouni R. Large Population Outcomes of Small Incision Lenticule Extraction in Young Myopic Patients. J Refract Surg 2022; 38:488-496. [PMID: 35947004 DOI: 10.3928/1081597x-20220623-01] [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 evaluate the outcomes of small incision lenticule extraction (SMILE) for myopia in a large population of young adults. METHODS In this retrospective case series, the patient population consisted of the first 4,138 consecutive SMILE treatments using the VisuMax femtosecond laser (Carl Zeiss Meditec) between 2012 and 2018 at the London Vision Clinic. Inclusion criteria were myopic spherical equivalent up to -9.00 diopters (D), cylinder up to 6.00 D, corrected distance visual acuity of 20/20 or better, age younger than 40 years, and follow-up of 12 months. Outcomes analysis was performed using the Standard Graphs for Reporting Refractive Surgery. RESULTS Data were available at 12 months in 3,722 eyes (90%), and 416 eyes (10%) were lost to follow-up. Mean attempted spherical equivalent refraction (SEQ) was -4.61 ± 1.84 D (range: -1.12 to -9.00 D). Mean cylinder was -0.78 ± 0.66 D (range: 0.00 to -6.00 D). Postoperatively, the mean SEQ relative to target was -0.13 ± 0.30 D (range: -1.35 to +1.25 D) and was within ±0.50 D in 88.1% and ±1.00 D in 99.6% of eyes. Uncorrected distance visual acuity was 20/20 or better in 95.4% of eyes and 20/25 or better in 98.7% of eyes. One line of CDVA was lost in 3.0% of eyes, and 0.08% (n = 3) lost two or more lines of CDVA, for which CDVA was restored following phototherapeutic keratectomy treatment. There was a statistically significant improvement of 0.05, 0.06, 0.07, and 0.07 log units for contrast sensitivity at 3, 6, 12, and 18 cycles per degree, respectively (P < .001). CONCLUSIONS SMILE achieved excellent outcomes for myopia up to -9.00 D with cylinder up to -5.50 D for a large population in patients without presbyopia. [J Refract Surg. 2022;38(8):488-496.].
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Reinstein DZ, Archer TJ, Vida RS, Carp GI, Reinstein JFR, McAlinden C. Objective and Subjective Quality of Vision After SMILE for High Myopia and Astigmatism. J Refract Surg 2022; 38:404-413. [PMID: 35858192 DOI: 10.3928/1081597x-20220516-03] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To report subjective and objective quality of vision (QoV) results for high myopic small incision lenticule extraction (SMILE) between -9.00 and -13.00 diopters (D). METHODS This was a prospective study recruiting 114 patients undergoing SMILE with attempted spherical equivalent refraction (SEQ) correction from -9.00 to -13.00 D, and cylinder up to 5.00 D. Patients were informed before surgery of the increased risk of QoV symptoms. Patients completed the Rasch validated QoV questionnaire. Objective QoV was assessed by corneal and whole eye aberrations, HD Analyzer Objective Scatter Index (OSI) (Keeler), and contrast sensitivity. Patient satisfaction was assessed on a scale from 0 (very dissatisfied) to 10 (very satisfied). Individual item and total Rasch-scaled scores for the three subscales (frequency, severity, and bothersomeness) of the QoV questionnaire were calculated before and 12 months after surgery. RESULTS The mean patient satisfaction score was 9.27 ± 1.18 (range: 2 to 10), 8 or higher in 93%, and 7 or higher in 98% of patients. One patient with a satisfaction score of 2 had a simple refractive error re-treatment and then reported a satisfaction score of 10. The total mean ± standard deviation Rasch-scaled QoV score for the frequency, severity, and bothersomeness subscales before surgery was 24 ± 19, 20 ± 16, and 19 ± 18, respectively. Scores increased after surgery to 41 ± 18, 32 ± 16, and 30 ± 21, respectively (P < .001). Corneal aberrations (6 mm, OSI) increased on average by 0.39 µm for spherical aberration, 0.41 µm for coma, and 0.56 µm for higher order aberrations root mean square. OSI increased on average by 0.58. There was a small but statistically significant improvement in contrast sensitivity at 3, 6, 12, and 18 cycles per degree. There were no statistically significant correlations found between subjective scores for starbursts and objective measurements. CONCLUSIONS Satisfaction was high following SMILE for high myopia. As expected, there was an increase in QoV symptoms, mainly glare and starbursts. The acceptance of QoV symptoms for high myopic SMILE was high, indicating that residual refractive error and visual acuity are the major drivers for patient satisfaction with appropriate preoperative informed consent. [J Refract Surg. 2022;38(7):404-413.].
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Reinstein DZ, Archer TJ, Vida RS, Carp GI, Reinstein JFR, McChesney T, Potter JG. Small Incision Lenticule Extraction (SMILE) for the Correction of High Myopia With Astigmatism. J Refract Surg 2022; 38:262-271. [PMID: 35536712 DOI: 10.3928/1081597x-20220314-01] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To report the outcomes of small incision lenticule extraction (SMILE) for high myopia between -9.00 and -14.00 diopters (D). METHODS This was a prospective study of SMILE for high myopia using the VisuMax femtosecond laser (Carl Zeiss Meditec). Inclusion criteria were attempted spherical equivalent refraction (SEQ) between -9.00 and -14.00 D, cylinder up to 7.00 D, corrected distance visual acuity (CDVA) of 20/40 or better, age 21 years or older, and suitable for SMILE. The sub-lenticule thickness was 220 µm or greater, and the total uncut stromal thickness was 300 µm or greater. Patients were to be followed up for 1 year. Standard outcomes analysis was performed using 12-month data where available or 3-month data otherwise. RESULTS Of 187 eyes treated, data were available at 12 months for 181 eyes (96.8%) and 3 months for 4 eyes (2.1%), and 2 eyes (1.1%) were lost to follow-up. Mean attempted SEQ was -10.55 ± 1.00 D (range: -9.00 to -12.99 D). Mean cylinder was -1.19 ± 0.83 D (range: 0.00 to -4.00 D). Preoperative CDVA was 20/20 or better in 73% of eyes. Postoperative uncorrected distance visual acuity was 20/20 or better in 57% and 20/25 or better in 82% of eyes. Mean SEQ relative to target was -0.22 ± 0.48 D (range: -1.63 to +1.38 D), 66% ± 0.50 D and 93% ±1.00 D. Mean SEQ 12-month change was -0.08 ± 0.34 D (range: -1.75 to +0.88 D). There was loss of one line of CDVA in 4% of eyes, and no eyes lost two or more lines. Contrast sensitivity was unchanged. Patient satisfaction was 8 or more out of 10 in 94% and 6 or more in 99% of patients. CONCLUSIONS Outcomes of SMILE for myopia greater than -9.00 D at 3 to 12 months showed excellent efficacy, safety, stability, and predictability, with high patient satisfaction. [J Refract Surg. 2022;38(5):262-271.].
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Reinstein DZ. The Time Has Come for Refractive Surgery to Be Included in the Fight Against Global Visual Impairment Due to Uncorrected Refractive Error. J Refract Surg 2022; 38:6-8. [PMID: 35020541 DOI: 10.3928/1081597x-20211109-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ramirez-Miranda A, Mangwani-Mordani S, Hernandez-Bogantes E, Abdala-Figuerola A, Olivo-Payne A, Larrea J, Navas A, Graue-Hernandez EO. Visual and Refractive Outcomes Following SMILE to Correct Myopia Performed by Surgeons in Training. J Refract Surg 2022; 38:28-34. [PMID: 35020540 DOI: 10.3928/1081597x-20211209-01] [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 assess visual outcomes and complications following small incision lenticule extraction (SMILE) performed by cornea fellows under the supervision of experienced surgeons. METHODS This retrospective, noncomparative case series was designed to assess outcomes following SMILE procedures performed at a large surgical center by cornea fellows between May 1, 2012 and March 30, 2015. Preoperative and postoperative uncorrected distance visual acuity (UDVA), preoperative and postoperative corrected distance visual acuity (CDVA), spherical equivalent (SE) up to -10.00 diopters (D), and complications were recorded. RESULTS A total of 114 patients (228 eyes) met the inclusion criteria. The mean preoperative SE was -5.79 ± 1.95 D (range: -1.75 to -10.00 D) and the mean cylinder was -2.21 ± 1.43 D (range: 0.00 to -5.50 D). At the last follow-up visit (average: 6.4 months), 94% of the patients achieved a UDVA of 20/30 or better and 96% of the patients achieved stability in their vision. Adverse events were encountered in 40 eyes (17.5%), with epithelial defect being the most common. Two patients required a second intervention to improve visual outcomes. CONCLUSIONS SMILE performed by cornea fellows under the supervision of an experienced surgeon is an effective and safe refractive procedure with a short learning curve and excellent visual outcomes. [J Refract Surg. 2022;38(1):28-34.].
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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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Abstract
Two cases of epithelial implantation after small-incision lenticule extraction (SMILE) treated by Nd:YAG laser and interface sweeping are described. A 40-year-old woman and 33-year-old man underwent SMILE and subsequently were noted to have epithelial cells implanted into the surgical interface. One case was treated using Nd:YAG laser. The laser was focused to the level of the interface with an energy level of 0.3 mJ. The treatment covered the entire area of epithelial implantation. The second case was treated by opening the original SMILE incision and sweeping the residual epithelial cells from the interface followed by a washout. Both the Nd:YAG laser and interface sweeping proved to be effective in reducing or eliminating the epithelial cells from the SMILE interface. Further studies are needed to report on overall safety and efficacy of these 2 techniques.
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Steinwender G, Shajari M, Mayer WJ, Kook D, Dirisamer M, Kohnen T. SMILE – Small Incision Lenticule Extraction. AUGENHEILKUNDE UP2DATE 2020. [DOI: 10.1055/a-1075-9225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungDie SMILE (small incision lenticule extraction) zählt zu den Verfahren der
refraktiven Lentikel-Extraktion und hat sich im letzten Jahrzehnt zu einem
etablierten Bestandteil des modernen refraktivchirurgischen Spektrums
entwickelt. Dieser Beitrag gibt einen Überblick über Patientenselektion,
Operationsmethode, mögliche Komplikationen und klinische Ergebnisse dieser
Methode.
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Steinwender G, Shajari M, Mayer WJ, Kook D, Dirisamer M, Kohnen T. [SMILE - Small Incision Lenticule Extraction]. Klin Monbl Augenheilkd 2020; 237:e15-e34. [PMID: 33207383 DOI: 10.1055/a-1291-9041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Refractive lenticule extraction is a corneal surgical technique that uses a femtosecond laser exclusively to create an intrastromal refractive lenticule for the correction of myopia and myopic astigmatism. In small incision lenticule extraction (SMILE) the generated refractive lenticule is subsequently extracted through a small incision. The reported efficacy, predictability and safety of the flap-less SMILE procedure is similar to those of femtosecond laser in situ keratomileusis (LASIK). Advantages of SMILE over LASIK include less iatrogenic dry eye, fewer induced higher-order aberrations, and potentially less biomechanical weakening of the cornea. However, there is a steeper surgeon learning curve for SMILE as the procedure is technically more challenging than LASIK. Furthermore, the current SMILE laser platform cannot use cyclotorsion control or eye-tracking technology and retreatment options are more complex compared to LASIK. This review looks at patient selection, surgical method, possible complications, retreatment options, and postoperative outcome of the SMILE technique.
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Huang TZ, Shen L, Yu XN, Jin HY. Risk factors and incidence of suction loss during small incision lenticule extraction (SMILE) in 8493 eyes. BMC Ophthalmol 2020; 20:412. [PMID: 33066752 PMCID: PMC7566065 DOI: 10.1186/s12886-020-01680-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To report the incidence and risk factors of suction loss during small incision lenticule extraction (SMILE). METHODS This retrospective comparative case control study included 8493 eyes of 4261 patients. Patients underwent SMILE surgery between January 2014 and September 2019 were included. Videos of suction loss were reviewed, and the direct causes of suction loss were noted. An independent samples t-test was used for comparisons between the suction loss group and the control group. A binary logistic regression model was used to determine the possible significant risk factors that might increase the likelihood of suction loss during SMILE surgery. RESULTS Suction loss occurred in 31 (0.37%) eyes of 30 patients; 23 (74.2%) cases occurred in the right eye (the first operative eye) and 8 (25.8%) cases occurred in the left eye. Among the 30 patients, 23 (76.7%) were male and 7 (23.3%) were female. The incidence in the six consecutive years were 0, 2.13, 0.34, 0.24, 0.22, and 0.25%. Head and eye movements during surgery caused suction loss in 16 (51.6%) and 15 (48.4%) eyes, respectively. Comparison between the suction loss group and the control group showed that the first operative eye and male sex are at a significantly high risk for suction loss (p < 0.05). CONCLUSIONS The risk factors of suction loss were first operative eye and male sex. Head and eye movements due to patient anxiety are the most common direct causes of suction loss. Surgeon's experience may help to reduce the incidence of suction loss. Preoperative education and better communication during surgery needs to be emphasized. TRIAL REGISTRATION Retrospectively registered. ChiCTR-ORC-17011040 . Registered 1 April 2017. Name of registry: The observation of clinical results after corneal refractive surgery. Data of enrolment of the first participant to the trial: 1 January 2014.
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Affiliation(s)
- Tian-Ze Huang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ling Shen
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, China
| | - Xiao-Ning Yu
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, China
| | - Hong-Ying Jin
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, No. 88 Jiefang Road, Hangzhou, China.
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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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Clinical outcomes of immediate transepithelial photorefractive keratectomy after suction loss during small-incision lenticule extraction. J Cataract Refract Surg 2020; 46:756-761. [DOI: 10.1097/j.jcrs.0000000000000123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhao Y, Zhao F, Han T, Zhao J, Zhou X. A pilot study: lenticule quality of hyperopic small incision lenticule extraction (SMILE) in rabbits. BMC Ophthalmol 2020; 20:158. [PMID: 32306923 PMCID: PMC7169024 DOI: 10.1186/s12886-020-01432-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate lenticule surface characteristics of small incision lenticule extraction (SMILE) for hyperopia correction in rabbits. METHODS The left and right eyes of 8 rabbits were divided into two groups. The right eyes were assigned to a myopia group, and the left eyes to a hyperopia group. The rabbits received SMILE procedures with + 3.00 D and - 3.00 D correction for the hyperopia and myopia groups, respectively. Extracted lenticules were examined via scanning electron microscopy. Lenticules from odd-numbered rabbits were accessed with the anterior surface, and lenticules from even-numbered rabbits were observed with the posterior surface. A previously established scoring system was used to evaluate lenticule surface characteristics. Statistical analysis was conducted to compare the scores between the two groups. RESULTS All procedures were performed successfully, and the lenticules were extracted smoothly. One myopia lenticule that was facing downward was handled failed in preparation for imaging, thus 15 lenticules were ultimately graded. Twelve lenticules exhibited smooth surfaces, and regularly arranged tissue bridges were observed in almost all regions. Three lenticules exhibited a partially rough surface and irregularities affecting more than 10% of the lenticules (2 in the hyperopia group and 1 in the myopia group). Rough lenticules occurred in twice as many lenticules in the hyperopia group compared to the myopia group. CONCLUSIONS Scan quality of lenticules after SMILE for hyperopia correction is comparable to that of myopia lenticules. The shape of hyperopic lenticule may increase the difficulty of surgical manipulation and result in surface roughness.
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Affiliation(s)
- Yu Zhao
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, 83 Fenyang Road, Shanghai, 200031, PR China.,NHC Key Laboratory of Myopia (Fudan University); Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Feng Zhao
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, 83 Fenyang Road, Shanghai, 200031, PR China.,NHC Key Laboratory of Myopia (Fudan University); Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China.,Department of Ophthalmology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Tian Han
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, 83 Fenyang Road, Shanghai, 200031, PR China.,NHC Key Laboratory of Myopia (Fudan University); Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Jing Zhao
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, 83 Fenyang Road, Shanghai, 200031, PR China.,NHC Key Laboratory of Myopia (Fudan University); Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Xingtao Zhou
- Department of Ophthalmology, Eye and ENT Hospital of Fudan University, 83 Fenyang Road, Shanghai, 200031, PR China. .,NHC Key Laboratory of Myopia (Fudan University); Laboratory of Myopia, Chinese Academy of Medical Sciences, Shanghai, China. .,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China.
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Reinstein DZ, Archer TJ, Vida RS, Carp GI. Suction stability management in small incision lenticule extraction: incidence and outcomes of suction loss in 4000 consecutive procedures. Acta Ophthalmol 2020; 98:e72-e80. [PMID: 31448878 DOI: 10.1111/aos.14215] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/23/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To report the incidence and outcomes of suction loss during small incision lenticule extraction (SMILE). METHODS The incidence of suction loss was measured over 4000 consecutive SMILE procedures and categorized by cause, the interface in which suction was lost and management (restart/continue SMILE, re-SMILE thinner cap, convert to laser in-situ keratomileusis [LASIK]). One-year outcomes were compared to the fellow eye where no suction loss occurred. RESULTS There were 20 cases of suction loss (0.50%): during the lenticule interface in seven eyes, lenticule side cut in one eye, cap interface in nine eyes and small incision for three eyes. Small incision lenticule extraction (SMILE) was continued in seven eyes, thinner cap SMILE in four eyes, LASIK in eight eyes, and the small incision was manually completed in one eye. Suction loss was caused by a Bell's reflex in 10 eyes, fixation light tracking in six eyes, patient anxiety in two eyes, a nociceptive reflex in one eye and false suction in one eye. There was no difference in results for suction loss and fellow eyes, respectively: uncorrected distance visual acuity was 20/20 or better in 100% in both groups, spherical equivalent was within ±0.50 D in 85% and 79%, one line loss of corrected distance visual acuity in 5% and 0%, and no eyes lost two lines. CONCLUSION Suction loss can be managed depending on the interface during which suction is lost. Treatment was completed on the same day in all instances. Visual and refractive outcomes were unaffected compared to the fellow eye in this series.
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Affiliation(s)
- 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 Coleraine UK
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Pradhan KR, Reinstein DZ, Carp GI, Archer TJ, Dhungana P. Small Incision Lenticule Extraction (SMILE) for Hyperopia: 12-Month Refractive and Visual Outcomes. J Refract Surg 2019; 35:442-450. [DOI: 10.3928/1081597x-20190529-01] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/27/2019] [Indexed: 11/20/2022]
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Reinstein DZ, Pradhan KR, Carp GI, Archer TJ, Day AC, Sekundo W, Dhungana P. Small Incision Lenticule Extraction for Hyperopia: 3-Month Refractive and Visual Outcomes. J Refract Surg 2019; 35:24-30. [PMID: 30633784 DOI: 10.3928/1081597x-20181025-01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/22/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate visual and refractive outcomes of small incision lenticule extraction (SMILE) for hyperopia. METHODS This prospective study of vertex-centered hyperopic SMILE used the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany). Inclusion criteria were maximum attempted hyperopic meridian of between +1.00 and +7.00 diopters (D) and corrected distance visual acuity (CDVA) of 20/40 or better. Lenticule parameters were 6.3- to 6.7-mm diameter, 2-mm transition zone, 30-µm minimum thickness, and 120-µm cap thickness. Standard outcomes analysis was performed for the 3-month data, including contrast sensitivity using the Functional Vision Analyzer. RESULTS For 93 eyes treated, 3-month data were available for 82 (88%). Attempted spherical equivalent refraction was +5.62 ± 1.20 D (range: +1.00 to +6.90 D) and cylinder was -0.91 ± 0.68 D (range: 0.00 to -3.50 D). For eyes targeted for emmetropia (n = 36), uncorrected distance visual acuity was 20/40 or better in 89%. Spherical equivalent refraction relative to target was -0.17 ± 0.85 D (range: -2.20 to +3.00 D), with 59% within ±0.50 D and 76% within ±1.00 D. There was one line loss of CDVA in 17% of eyes, and one eye lost three lines (1.2%) but recovered to one line lost at 9 months. There was no clinically significant change in contrast sensitivity. CONCLUSIONS Refractive and visual outcomes 3 months after SMILE for hyperopia were promising, given the high degree of hyperopia corrected and relatively reduced CDVA in this population. Undercorrection of more than 1.00 D in 5 eyes might be partly explained by latent hyperopia in these young patients. [J Refract Surg. 2019;35(1):24-30.].
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Reinstein DZ, Stuart AJ, Vida RS, Archer TJ, Carp GI. Incidence and Outcomes of Sterile Multifocal Inflammatory Keratitis and Diffuse Lamellar Keratitis After SMILE. J Refract Surg 2019; 34:751-759. [PMID: 30428095 DOI: 10.3928/1081597x-20181001-02] [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: 08/02/2018] [Accepted: 10/01/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To report the incidence outcomes of sterile multifocal inflammatory keratitis and diffuse lamellar keratitis (DLK) after small incision lenticule extraction (SMILE) in a large population. METHODS This was a retrospective review of a population of 4,000 consecutive eyes treated by SMILE at the London Vision Clinic using the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany). The inclusion criterion was to have presented with inflammatory keratitis after SMILE. In some cases after SMILE, the inflammatory keratitis presented as sterile multifocal interface keratitis uncharacteristic of classic DLK. The incidence was measured and categorized as primary or secondary by presenting appearance, grade, and time to presentation. Patients were observed for 1 year after surgery and standard outcomes analysis was performed. RESULTS Of the 4,000 eye population, there were 18 cases (0.45%) of DLK grade 1 or 2. All cases were managed and resolved with topical steroid therapy. Of these, 12 cases (67%) were of classic appearance and 6 cases (33%) presented as sterile multifocal inflammatory keratitis. DLK was primary in nature in 11 cases (61%) and secondary in 7 cases (39%). Postoperative uncorrected distance visual acuity was 20/20 or better in 93% of eyes. No patients lost any lines of corrected distance visual acuity and there was no change in contrast sensitivity. CONCLUSIONS DLK occurred after SMILE with an incidence of 0.45% in this population. Topical steroid therapy resolved the DLK in all cases with no sequelae and no adverse effect on refractive or visual outcome at 1 year postoperatively. A unique type of DLK presentation can occur after SMILE, characterized by multiple focal sterile inflammatory spots. Management is the same as for classic DLK, but with a lower threshold for performing an interface washout. [J Refract Surg. 2018;34(11):751-759.].
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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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Role of laser refractive surgery in cross-subsidization of nonprofit humanitarian eyecare and the burden of uncorrected refractive error in Nepal: Pilot project. J Cataract Refract Surg 2018; 44:1012-1017. [PMID: 30037700 DOI: 10.1016/j.jcrs.2018.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To establish a refractive surgery unit at Tilganga Institute of Ophthalmology through support from international donations and provide knowledge transfer for doctors and management to make the unit self-sustaining, nonprofit laser refractive surgery, and financial support for other eyecare projects at Tilganga. SETTING Tilganga Institute of Ophthalmology, Kathmandu, Nepal. DESIGN Retrospective study. METHODS A foundation was created to establish a refractive surgery unit using a cost-recovery model; that is, patients are charged according to their financial status to cover running costs, patients without funds to pay for surgery, and other eyecare projects for the underprivileged population of Kathmandu, Nepal. Donations were obtained to fund refurbishment within Tilganga Hospital and purchase equipment and technology. A Nepalese surgeon was selected from Tilganga and completed an 8-month fellowship and proctorship of the first series of surgeries. The refractive surgery unit was opened in January 2012, and the cost-recovery model was evaluated up to December 2016. RESULTS During the period evaluated, 74.8% of patients were treated at full cost, 17.2% at subsidized cost, and 8.6% free of charge. The refractive surgery unit generated a profit representing 28% of the running cost in this period, which was used to reduce the deficit of the main hospital. Surgical outcomes achieved were comparable to those reported by groups in the developed world. CONCLUSION A self-sustaining nonprofit laser refractive surgery clinic, operating with high quality, was successfully implemented supported by international donations for initial setup costs and a cost-recovery model thereafter.
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Reinstein DZ, Pradhan KR, Carp GI, Archer TJ, Gobbe M, Sekundo W, Khan R, Dhungana P. Small Incision Lenticule Extraction (SMILE) for Hyperopia: Optical Zone Diameter and Spherical Aberration Induction. J Refract Surg 2017; 33:370-376. [DOI: 10.3928/1081597x-20170331-01] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/09/2017] [Indexed: 11/20/2022]
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Reinstein DZ, Pradhan KR, Carp GI, Archer TJ, Gobbe M, Sekundo W, Khan R, Citron K, Dhungana P. Small Incision Lenticule Extraction (SMILE) for Hyperopia: Optical Zone Centration. J Refract Surg 2017; 33:150-156. [PMID: 28264128 DOI: 10.3928/1081597x-20161220-01] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/16/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate optical zone centration of hyperopic small incision lenticule extraction (SMILE). METHODS This prospective study of 60 consecutive hyperopic SMILE procedures used the VisuMax femtosecond laser and matched LASIK procedures with the VisuMax and MEL 80 excimer lasers (Carl Zeiss Meditec AG, Jena, Germany). Inclusion criteria were maximum attempted hyperopic meridian of between +1.00 and +7.00 diopters (D) and astigmatism up to 6.00 D. For SMILE, the optical zone was between 6.3 and 6.7 mm, with a 2-mm transition zone. Two LASIK control groups (6.5- and 7-mm optical zone) were generated matched for spherical equivalent treated. In SMILE, the corneal vertex of the coaxially fixating eye was aligned with the vertex of the curved contact glass. In LASIK, the treatment was centered on the coaxially sighted corneal light reflex (first Purkinje image) with the contralateral eye (Seiler method). A tangential (instantaneous) curvature preoperative to 3 months postoperative difference map was generated for each eye. A fixed grid and set of concentric circles were superimposed on the difference map to measure the offset between the optical zone center and corneal vertex (0,0), and vector analysis was used for comparative analysis. RESULTS Mean attempted spherical equivalent was +5.61 ± 0.96 D (range: +3.20 to +6.50 D) and mean cylinder was -0.96 ± 0.62 D (range: 0.00 to -2.75 D) in the SMILE group. Mean age was 29 ± 7 years (range: 19 to 52 years) in the SMILE group. Mean centration offset was 0.23 ± 0.15 mm (range: 0 to 0.61 mm) for the SMILE group, 0.33 ± 0.14 mm (range: 0.14 to 0.85 mm) for the 6.5-mm LASIK group, and 0.31 ± 0.19 mm (range: 0.05 to 0.85 mm) for the 7-mm LASIK group. The mean centration offset for SMILE was less than that of both LASIK groups (P < .05). CONCLUSIONS Optical zone centration of hyperopic SMILE was found to be similar to eye-tracker-centered hyperopic LASIK with the MEL 80 laser. [J Refract Surg. 2017;33(3):150-156.].
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