Predictability of SMILE over four years in high myopes

Feasibility study of treatment of mixed astigmatism with small-incision lenticule extraction (SMILE) by using research software

PURPOSE

To report the preliminary experience and initial clinical results following SMILE for the treatment of mixed astigmatism.

METHODS

Thirteen eyes of nine patients with a mean age of 27 ± 4.36 years were included in the series. In 8/13 eyes, myopic SMILE license and in 4/13 eyes, hyperopic SMILE license (available as part of an open/research software) was used for the treatment. The mean follow-up was 9.5 ± 8.7 (0.5-24) months, and the median follow-up was 6 months.

SETTING

Nethradhama Superspeciality Eye Hospital, Bangalore, India.

DESIGN

Exploratory study.

RESULTS

The mean preoperative sphere, cylinder, and spherical equivalent (SE) were 1.44 ± 1.63, -2.70 ± 2.30, and -0.24 ± 1.14 D, which changed to -0.03 ± 0.30, -0.28 ± 0.48, and -0.18 ± 0.49 D, respectively, 6 months postoperatively. Furthermore, 85% (11/13) eyes were within ± 0.50 D, 92% (12/13) eyes were within ± 1.00 D, while all eyes were within ± 1.50 D of SE correction. All eyes were within ± 1.00 D of cylinder correction. In addition, 92% (12/13) eyes had UDVA better than 20/32, with 54% (7/13) eyes having UDVA 20/20 or better. Safety and efficacy indices were 1.08 and 0.92, respectively. No eyes lost more than 1 line of CDVA. The mean corneal higher order aberrations (HOA) increased from 0.111 ± 0.048 to 0.209 ± 0.056 (P < 0.001). The mean objective scatter index (OSI) did not show a significant change (pre = 0.71 ± 0.69, 6 months = 0.89 ± 0.20; P = 0.35).

CONCLUSION

Early experience showed that SMILE was feasible for the management of eyes with mixed astigmatism, without any intraoperative complications, unique to the procedure.

Five-year results of refractive outcomes and vision-related quality of life after SMILE for the correction of high myopia

AIM

To evaluate the long-term visual, refractive outcomes and vision-related quality of life after small incision lenticule extraction (SMILE) for the correction of high myopia.

METHODS

Thirty patients (60 eyes) with high myopia who underwent SMILE more than 5y were selected as the SMILE group. Another 30 high myopia patients (60 eyes) who had worn corrective spectacles for more than 5y were selected as the control group. In SMILE group, the postoperative follow-up time were 3, 6mo, 1 and 5y. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE), and ocular axial length (AL) were analyzed. The Chinese version of the National Eye Institute Visual Function Questionnaire-25 (CHI-NEI-VFQ-25) was used to evaluate the vision-related quality of life in the SMILE group and the control group.

RESULTS

In SMILE group, the mean preoperative SE was -7.29±0.87 D (range -6.00 to -9.125 D). At 5-year follow up, the efficacy index and safety index of SMILE were 1.09±0.18 and 1.19±0.12, respectively. Five years postoperatively, 44 eyes (73%) obtained a visual acuity of 20/20 or better. There were no eyes with CDVA loss of one or more Snellen lines. Forty-nine eyes (82%) and 57 eyes (95%) were within ±0.50 and ±1.00 D of attempted correction at 5-year follow-up, respectively. Forty-eight eyes (80%) had astigmatism <0.50 D at 5-year follow-up. The postoperative mean SE values at 3, 6mo, 1, and 5y were 0.11±0.44, 0.07±0.45, -0.02±0.41, and -0.15±0.46 D, respectively. No significant change was observed in the ocular AL from before operation to 5y postoperatively (26.08±0.96 mm vs 26.01±0.94 mm, P=0.068). Compared to the control group, the SMILE group showed a significantly higher total score on the CHI-NEI-VFQ-25 (90.14 vs 81.43, P<0.001).

CONCLUSION

In the present study, in a long-term follow-up we demonstrate that correcting high myopia with SMILE is safe, effective, and predictable. Vision-related quality of life after SMILE is better in the SMILE group than in the control group who wore corrective spectacles.

Four-Year Outcomes of Small Incision Lenticule Extraction for Extreme High Myopia and Myopic Astigmatism

Purpose: To evaluate the long-term safety, efficacy, predictability, and stability of small incision lenticule extraction (SMILE) for the treatment of high myopia and myopic astigmatism >−10.0 D.

Methods: This was a prospective study that incorporated 35 consecutive patients (35 eyes) undergoing SMILE from September 2015 to March 2016. These patients had a mean preoperative spherical equivalent refraction of −10.06 ± 0.64 D. Patients were followed over a 4-year period and assessed for outcomes including uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, and corneal topography.

Results: At 4 years post-SMILE, respective efficacy and safety indices were 1.01 ± 0.19 and 1.07 ± 0.15. In total, 97% of operated eyes achieved an UDVA of 20/25 or better. ≥1 line was gained for 9 eyes (26%), with 25 eyes (71%) remaining stable. Twenty-four (69%) and 33 (94%) eyes, respectively, were within ±0.50 D and ±1.0 D of target refraction. From 3 months to 4 years postoperatively, a mean refractive regression of −0.22 D (−0.06 D per year) was detected, whereas no significant changes in mean corneal back curvature or posterior central elevation were detected (P = 0.617 and 0.754, respectively). We detected significant increases in higher-order aberrations (HOAs) of the anterior and total cornea (all P < 0.001), with spherical aberrations and vertical coma being particularly common, whereas posterior corneal HOA remained fairly stable (all P < 0.05).

Conclusion: SMILE is a safe, effective, predictable, and stable means of correcting high myopia and myopic astigmatism over a 4-year postoperative period.

Refractive and visual outcomes of small incision lenticule extraction (SMILE) in eyes with thin corneas

OBJECTIVES

To report the refractive and visual outcomes of small incision lenticule extraction (SMILE) with the thinnest corneal thickness (CCT) of less than 500 µm and evaluate it in terms of safety and efficacy.

SETTING

Refractive Surgery Clinic of University of Health Sciences Beyoglu Eye Training and Research Hospital, Istanbul, Turkey.

DESIGN

Retrospective case series.

METHODS

The pre-and-postoperative examinations of all patients with thin corneas (preoperative CCT <500 µm) who underwent the SMILE procedure and had a minimum of 24 months of follow-up records were reviewed from medical files. The main outcome measures of the refractive and visual outcomes and the effect on corneal high order aberrations (HOAs) were evaluated.

RESULTS

The study included 55 eyes of 39 patients. The mean preoperative uncorrected visual acuity (UDVA) was 1.3 ± 1.5 logMAR, and the mean postoperative UDVA was significantly improved to 0.05 ± 0.80 logMAR at the last visit (p < 0.001). At the last follow-up, 84% of the eyes were within ± 0.50D, and 96% of the eyes were within ±1.00D of attempted SE refraction. The HOAs of coma (p < 0.001), secondary astigmatism (p = 0.015), spherical aberration (p < 0.001), and RMS (p < 0.001) aberrations increased significantly from the baseline to the postoperative last visit. The increase in trefoil was not significant (p = 0.32). No sight threatening complications or ectasia were observed during the follow-up time.

CONCLUSION

SMILE is a safe and effective technique with long-term stability for treatment of myopia in eyes with a thin cornea, and satisfactory results can be obtained if candidates for surgery are selected carefully with particular emphasis on normal preoperative corneal topography.

Short and long term outcomes after small-incision lenticule extraction: A tertiary referral centre experience

PURPOSE

The objective of this study is to evaluate the preoperative and short- and long-term postoperative results in terms of visual acuity, refractive error, and corneal wavefront aberrations in patients with myopia and myopic astigmatism undergoing small incision lenticule extraction (SMILE).

METHODS

Seventy-nine eyes of 52 myopes with or without astigmatism (41 right and 38 left) were enrolled in this retrospective study. The measurements included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE) and wavefront aberrations. All the measurements before and after SMILE surgery were systematically recorded.

RESULTS

Mean preoperative UDVA was 1.19±0.24 logMAR and improved to 0.06±0.17 logMAR at the 3-year postoperative follow-up. At the conclusion of the 3-year follow-up, UDVA was better than or equal to 20/20 and 20/25 in 73% and 84% of eyes, respectively. At 1 month postoperatively, CDVA was 0.05±0.23 logMAR and significantly lower than the preoperative CDVA, 0.02±0.04 log MAR (P>0.05). However, at 1 year and 3 years after surgery, CDVA showed a significant increase compared to preoperative CDVA. At the conclusion of the 3-year follow-up, SE was -0.47 D, and 69.6% and 83.5% of the eyes were within±0.50 D and±1.00 D, respectively, of the intended correction. HOA's, coma, and spherical aberration increased significantly. No significant change in trefoil was detected.

CONCLUSION

This study showed that SMILE produces a stable, safe outcome for surgical treatment of myopia and myopic astigmatism.

Small Incision Lenticule Extraction (SMILE) for Moderate and High Myopia: Seven-Year Outcomes of Refraction, Corneal Tomography, and Wavefront Aberrations

Purpose

To investigate the long-term outcomes of refraction, corneal tomography, and wavefront aberrations after small incision lenticule extraction (SMILE) for moderate and high myopia.

Methods

Prospective, nonconsecutive case series. A total of 26 patients (26 eyes) who underwent SMILE from May 2010 to March 2013 at the Fudan University Eye and ENT Hospital (Shanghai, China) were enrolled. The periods of follow-up were 1 month, 1 year, 5 years, and 7 years after surgery. The routine eye examinations included uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), manifest refraction, and corneal tomography.

Results

All surgeries were executed without any complications. At the final visit, an UDVA of 20/20 or better was achieved in 26 eyes (100%) and 11 eyes (42%) exhibited no change in CDVA. 9 eyes (35%) gained one line, 6 eyes (23%) gained two lines, and no eyes lost CDVA. 24 eyes (92%) and 26 eyes (100%) were within ±0.5 D and ±1.00 D of the target refraction, respectively. A mean refractive regression of −0.17 D was observed between 1 month and 7 years postoperatively. Mean corneal front curvature (MCFC) was significantly decreased between pre- and post-SMILE surgery (P < 0.0001). Higher-order aberrations (HOAs) and vertical coma were significantly increased after SMILE compared to those measured before surgery (all P < 0.001). There were no significant differences in trefoil and spherical aberration between pre- and post-SMILE surgery (all P > 0.05).

Conclusion

SMILE is an effective, safe, and stable procedure for moderate and high myopia, with relatively constant corneal stability and wavefront aberrations. This trial is registered with ChiCTR-ONRC-13003114.

Small-Incision Lenticule Extraction (SMILE) for the Correction of Myopia with Astigmatism: Outcomes of the United States Food and Drug Administration Premarket Approval Clinical Trial

PURPOSE

To present outcomes of the United States Food and Drug Administration premarket approval clinical trial of small-incision lenticule extraction (SMILE) for the correction of myopia and astigmatism.

DESIGN

Prospective, multicenter clinical trial.

PARTICIPANTS

The study included 357 eyes of 357 patients treated with SMILE (50 for myopia and 307 for myopia with astigmatism). Preoperative sphere ranged between -1.00 and -10.00 diopters (D), with manifest spherical equivalent (MSE) of up to -11.50 D and refractive cylinder of up to -3.00 D.

METHODS

-Participants were followed up for 12 months. Corrected distance visual acuity (CDVA) and uncorrected distance visual acuity (UDVA), stability of the manifest refraction, and vector analysis of refractive cylinder are presented for the 307 eyes treated for myopia with astigmatism. Adverse events (AEs) are presented for all 357 eyes.

MAIN OUTCOME MEASURES

Corrected distance visual acuity, uncorrected distance visual acuity, manifest refraction, astigmatic outcomes, and adverse events.

RESULTS

Of the 307 astigmatic eyes enrolled in the study, 304 were treated successfully. In 3 eyes, the procedure was aborted because of intraoperative suction loss. The mean MSE reduced from -5.39±2.30 D at baseline to -0.01±0.24 D at 12 months. Of all eyes, 95.3% were within 0.50 D of emmetropia at 12 months. The percentage of eyes with UDVA of 20/20 or better was 89.0%. No loss of 2 or more lines of CDVA was observed at the 12-month visit. The refractive cylinder reduced from -1.53±0.70 D at baseline to -0.18±0.31 D at 12 months. The mean correction ratio of refractive cylinder was 0.96±0.16 and a slight undercorrection was apparent for higher attempted corrections of astigmatism. Three intraoperative AEs associated with difficult lenticule removal and resultant cap tear occurred, and all resolved without sequelae at postoperative day 1. During the postoperative period, 8 AEs were recorded, but none of them had significant consequences.

CONCLUSIONS

Small-incision lenticule extraction for the treatment of myopia and astigmatism was safe and effective, and the reported AEs had no significant impact on visual acuity. Slight undercorrection of refractive cylinder requires further attention.

Visual and refractive outcomes of 100 small incision lenticule extractions (SMILE) in moderate and high myopia: a 24-month follow-up study

PURPOSE

We aimed to present the visual results obtained in 100 small incision lenticule extraction (SMILE) refractive surgeries, demonstrate whether the technique is effective in the treatment of moderate and high myopia, and observe the follow-up of these patients over 24-month period.

METHODS

One hundred eyes of 50 consecutive patients were treated with SMILE. The preoperative spherical equivalent refraction was - 5.64 ± 1.23 D. During the postoperative period, patients were examined at 3, 6, 12, and 24 months. We analysed the efficacy, safety, predictability, and stability of the technique.

RESULTS

The Snellen visual acuity of 99% of the patients was 20/20 or better after 24 months of follow-up. Two eyes had a loss of two lines of visual acuity; 1% of the patients had a loss of one line of visual acuity. The postoperative spherical refraction was - 0.04 ± 0.35 D (- 1.00 to 0.50 D). The postoperative spherical equivalent refraction was - 0.19 ± 0.38 D (- 1.25 to 0.50 D). Eighty-three percent of the eyes were within ± 0.50 D, and 87% obtained a residual astigmatism of 0.50 D or less.

CONCLUSION

The SMILE technique was demonstrated to be an effective, predictable, safe, and stable technique in the treatment of moderate-to-severe myopia during the 24-month follow-up. Long-term follow-up should be undertaken to observe possible refractive regressions.

Verisyse versus Veriflex Phakic Intraocular Lenses: Refractive Outcomes and Endothelial Cell Density 5 Years after Surgery

Purpose

To compare refractive stability, central endothelial cell density (ECD), and complications between Verisyse (Abbott Medical Optics, Netherlands) and Veriflex (Abbott Medical Optics, Netherlands) phakic intraocular lenses (pIOL) over five years.

Methods

We retrospectively reviewed the medical records of patients who underwent Verisyse or Veriflex pIOL implantation for surgical correction of myopia. Patients with a 5-year follow-up period were included in the study. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent of manifest refraction (SE), and ECD were compared between the groups preoperatively and 1, 3, and 5 years postoperatively.

Results

The study included 47 eyes in the Verisyse group and 50 eyes in the Veriflex group. There was no significant difference in mean SE, UDVA, CDVA, and ECD preoperatively or postoperatively. In both groups, there was a statistically significant myopic shift between 1-year and 5-year visits (−0.25 ± 0.30 D and −0.23 ± 0.48 D in the Verisyse and Veriflex groups, respectively). There was no significant difference between the groups in terms of efficacy and safety indexes at 5 years. ECD loss was highest during the first year (3.9% loss in the Verisyse group and 3.9% loss in the Veriflex group, p=0.670). At 5 years, the mean cumulative ECD losses in the Verisyse and Veriflex groups were 7.42% and 7.64%, respectively (p=0.709). Cataracts developed in 2.1% of the eyes in the Verisyse group and in 2.0% of those in the Veriflex group. No sight-threatening complications were observed.

Conclusion

Verisyse and Veriflex pIOLs are highly effective for treating high myopia up to 5 years after surgery. Longitudinal studies with longer follow-up periods are necessary to determine the endothelial safety profile.

Visual and Refractive Outcomes of Small-Incision Lenticule Extraction in High Myopia: 5-Year Results

Purpose

To report long-term visual and refractive results of small-incision lenticule extraction (SMILE) in treatment of high myopia.

Materials and Methods

Medical records of patients who underwent SMILE for surgical correction of myopia or myopic astigmatism were retrospectively reviewed. Only patients with a preoperative spherical equivalent of subjective manifest refraction (SE) ≥ 6 D and a postoperative follow-up of 5 years were included in the study. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and SE were analyzed preoperatively and at 1-, 3-, and 5-year postoperative periods.

Results

Thirty-seven eyes of 37 patients were included in the study. The mean attempted SE was −7.47 ± 1.10 D (range −6.00 to −10.00 D). At the 5-year visit, the mean difference between achieved and attempted SE was −0.43 ± 0.47 (0.50 to −1.25 D). Mean postoperative UDVA and CDVA were 0.20 ± 0.18 and 0.06 ± 0.08 logMAR, respectively. At the 1-year visit, 70% and 97% of the eyes were within ±0.50 D and ±1.00 D of the intended correction. At the 5-year follow-up, 59% and 92% percent of the eyes were within ±0.50 D and ±1.00 D of the intended SE, respectively. At the 5-year visit, the efficacy index was 0.89 ± 0.26 and the safety index was 1.16 ± 0.20. Fifty-four percent of the eyes gained one or more lines of CDVA.

Conclusion

SMILE with an intended correction of up to a spherical equivalent of 10 D is safe and effective. However, there is regression of the refractive effect over extended follow-up.

Initial Single-Site Surgical Experience with SMILE: A Comparison of Results to FDA SMILE, and the Earliest and Latest Generation of LASIK

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.