Comparison of corneal sensitivity, tear function and corneal staining following laser in situ keratomileusis with two femtosecond laser platforms

Femtosecond Small Incision Lenticular Extraction in comparison to Femtosecond Laser In situ Keratomileusis Regarding Dry Eye Disease

 Abstract Objective: Comparison of femtosecond small incision lenticule extraction (FS-SMILE) versus Femtosecond laser Insitu keratomileusis (FS-LASIK) regarding dry eye disease (DED) and corneal sensitivity (CS) after those refractive surgeries. Methods: A comparative prospective study conducted for a period of 2 years; from March 2017 until February, 2019. Enrolled patients were diagnosed with myopia. Fifty patients (100 eyes) were scheduled for bilateral FS-SMILE and the other 50 patients (100 eyes) had been scheduled for bilateral FS-LASIK. Both groups were followed for six months after surgery. The age, gender, and preoperative refraction for both groups were matched. Complete evaluation of dry eye disease had been performed for the intervals of one week pre-operatively, one and six months postoperatively. The evaluation included history of symptoms according to scoring systems, investigations and clinical examination. Results: One month postoperatively and in both groups, there was significant DED (P < .01), although the incidence was lower in femtosecond SMILE group, overall severity score (0-4): 0.3 ± 0.3 (FS-SMILE) vs. 1.4 ± 0.9 (LASIK). One month postoperatively, CS was lower in FS- LASIK more than FS-SMILE eyes (2.3 ± 2.2 vs 3.6 ± 1.8, respectively, P < .01) and then return to not statistically significant sensitivities at six-month duration. DED was negatively correlated with CS (P < 0.01). Conclusions: The FS-LASIK surgery had a more pronounced effect on the CS and DED compared with FS-SMILE, with higher incidence of DED postrefractive surgery.

Lipidomics Analysis of the Tears in the Patients Receiving LASIK, FS-LASIK, or SBK Surgery

Purpose: Tear film lipid layer (TFLL) plays a vital role in maintaining the tear film stability and, thus, the lipid composition of the tears could greatly affect the physiological function and biophysical integrity of the tear film. The objective of this study is to assess the tear lipid composition of the patients receiving laser-assisted in situ keratomileusis (LASIK), femtosecond LASIK (FS-LASIK), or sub-Bowman's keratomileusis (SBK) surgery preoperatively and postoperatively.

Methods: Tear samples were collected from the left eye of the patient who receiving LASIK (n = 10), FS-LASIK (n = 10), or SBK (n = 10) surgery in week 0, week 1, week 4, and week 52. A rapid direct injection shotgun lipidomics workflow, MS/MS^ALL (<2 min/sample), was applied to examine the tear lipidome.

Results: In week 52, the SBK group demonstrated a similar lipidome profile compared to week 0, while the FS-LASIK and LASIK groups shifted away from week 0. Two lipids, ganglioside (GD3) 27:4 and triacylglycerol (TAG) 59:3, were found to be associated with the lipidome changes preoperatively and postoperatively. No statistical significance was found in the overall lipid classes from the FS-LASIK group. The LASIK group showed significant alteration in the phospholipid and sphingolipid over time, while the SBK group demonstrated a significant difference in the (O-acyl)-ω-hydroxy fatty acid (OAHFA) and phospholipid.

Conclusion: LASIK showed the greatest impact on the tear lipidome changes over time, while SBK demonstrated minimal impact among the three types of refractive surgeries after 1 year.

Clinical outcomes after small-incision lenticule extraction versus femtosecond laser-assisted LASIK for high myopia: A meta-analysis

AIM

To compare postoperative clinical outcomes of high myopia after small-incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK).

METHODS

From March 2018 to July 2020, PubMed, MEDLINE, Embase, the Cochrane Library, and several Chinese databases were comprehensively searched. The studies meeting the criteria were selected and included; the data were extracted by 2 independent authors. The clinical outcome parameters were analyzed with RevMan 5.3.

RESULTS

This meta-analysis included twelve studies involving 766 patients (1400 eyes: 748 receiving SMILE and 652 receiving FS-LASIK). Pooled results revealed no significant differences in the following outcomes: the logarithm of the mean angle of resolution (logMAR) of postoperative uncorrected distance visual acuity (weighted mean difference (WMD) = -0.01, 95% confidence interval (CI): -0.02 to 0.00, I2 = 0%, P = 0.07 at 1 mo; WMD = -0.00, 95% CI: -0.01 to 0.01, I2 = 0%, P = 0.83 at 3 mo; WMD = -0.00, 95% CI: -0.01 to 0.00, I2 = 32%, P = 0.33 in the long term), and the postoperative mean refractive spherical equivalent (WMD = -0.03, 95% CI: -0.09 to 0.03, I2 = 13%, P = 0.30). However, the SMILE group had significantly better postoperative corrected distance visual acuity (CDVA) than the FS-LASIK group (WMD = -0.04, 95% CI, -0.05 to -0.02, I2 = 0%, P<0.00001). In the long term, postoperative total higher-order aberration (WMD = -0.09, 95% CI: -0.10 to -0.07, I2 = 7%, P<0.00001) and postoperative spherical aberration (WMD = -0.15, 95% CI: -0.19 to -0.11, I2 = 29%, P<0.00001) were lower in the SMILE group than in the FS-LASIK group; a significant difference was also found in postoperative coma (WMD = -0.05, 95% CI: -0.06 to -0.03, I2 = 30%, P<0.00001).

CONCLUSION

For patients with high myopia, both SMILE and FS-LASIK are safe, efficacious and predictable. However, the SMILE group demonstrated advantages over the FS-LASIK group in terms of postoperative CDVA, while SMILE induced less aberration than FS-LASIK. It remains to be seen whether SMILE can provide better visual quality than FS-LASIK; further comparative studies focused on high myopia are necessary.

[LenSx® femto-LASIK, FEMTO LDV Z4® femto-LASIK, and PRK : Comparison of refractive results and an analysis of complications]

BACKGROUND

The aim of this study is to evaluate three refractive procedures: LenSx® (Alcon, Fort Worth, TX, USA) femto-laser in situ keratomileusis (LASIK), FEMTO LDV Z4® (Ziemer, Port, Switzerland) femto-LASIK, and photorefractive keratectomy (PRK) in terms of refractive outcome, perioperative complications, pain, and patient satisfaction.

MATERIALS AND METHODS

Data of 168 eyes (myopic n = 84) were included in this retrospective study. Of these, 54 eyes (n = 27, 33.85 ± 7.64 years) were treated with LenSx® femto-LASIK, 60 eyes (n = 30, 35.03 ± 7.46 years) with FEMTO LDV Z4® femto-LASIK, and 54 eyes (n = 27, 33.24 ± 8.52 years) with PRK. Photoablation was induced by a MEL80 Excimerlaser (Zeiss, Oberkochen, Germany). The corrected (V_sc) and uncorrected (V_cc) distance subjective visual acuity, corneal topography (Pentacam® HR; Wetzlar, Germany), and objective astigmatism (ARK-760A Refractometer ; Nidek, Fremont, CA, USA) were measured preoperatively, and 1 day, 1 week, 1 month, and 3 months postoperatively. Subjective pain (verbal rating scale) and patient satisfaction were also recorded.

RESULTS

Subjective V_sc showed significantly better results in both femto-LASIK cohorts compared to PRK (p < 0.05) 1 day and 1 week postoperatively. There was no significant difference between the groups in terms of spherical equivalent and astigmatism 3 months postoperatively. The LenSx® femto-LASIK caused flap complications. The highest patient satisfaction results were shown in the LDV Z4® group, followed by the LenSx® and PRK cohorts (p = 0.072). LDV Z4® femto-LASIK showed the lowest pain score 1 day postoperatively (p < 0.001). There was no significant correlation between target refraction and preoperative corneal thickness and astigmatism.

DISCUSSION

Femtosecond laser-assisted LASIK is an effective procedure enabling rapid rehabilitation of visual acuity with low postoperative pain compared to PRK. There is no difference between the three techniques regarding refractive outcome after 3 months follow-up. LDV Z4® femto-LASIK can be recommended, if available, due to its low intraoperative complication rate and higher patient satisfaction compared to LenSx® femto-LASIK.

Recent advances in laser in situ keratomileusis-associated dry eye

Dry eye is the most common complication after laser in situ keratomileusis (LASIK). The major cause of LASIK-associated dry eye is corneal nerve damage. Early identification and treatment of post-operative dry eye are essential to prevent further ocular surface damage. This article reviews the recent studies of LASIK-associated dry eye, including clinical features, aetiology, risk factors, evaluations and treatment. The applications of novel technologies in LASIK-associated dry eye evaluation like anterior segment spectral-domain optical coherence tomography (SD-OCT) and corneal confocal microscopy are also introduced in this review.

Small Incision Lenticule Extraction (SMILE) versus Femtosecond Laser-Assisted In Situ Keratomileusis (FS-LASIK) for Myopia: A Systematic Review and Meta-Analysis

PURPOSE

The goal of this study was to compare small incision lenticule extraction (SMILE) with femtosecond laser-assisted in situ keratomileusis (FS-LASIK) for treating myopia.

METHODS

The CENTRAL, EMBASE, PubMed databases and a Chinese database (SinoMed) were searched in May of 2016. Twelve studies with 1,076 eyes, which included three randomized controlled trials (RCTs) and nine cohorts, met our inclusion criteria. The overall quality of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group framework. Data were extracted and analysed at three to six months postoperatively. Primary outcome measures included a loss of one or more lines of best spectacle corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA) of 20/20 or better, mean logMAR UCVA, postoperative mean spherical equivalent (SE) and postoperative refraction within ±1.0 D of the target refraction. Secondary outcome measures included ocular surface disease index (OSDI), tear breakup time (TBUT) and Schirmer's 1 test (S1T) as dry eye parameters, along with corneal sensitivity.

RESULTS

The overall quality of evidence was considered to be low to very low. Pooled results revealed no significant differences between the two groups with regard to a loss of one or more lines in the BSCVA (OR 1.71; 95% CI: 0.81, 3.63; P = 0.16), UCVA of 20/20 or better (OR 0.71; 95% CI: 0.44, 1.15; P = 0.16), logMAR UCVA (MD 0.00; 95% CI: -0.03, 0.04; P = 0.87), postoperative refractive SE (MD -0.00; 95% CI: -0.05, 0.05; P = 0.97) or postoperative refraction within ±1.0 D of the target refraction (OR 0.78; 95% CI: 0.22, 2.77; P = 0.70) within six months postoperatively. The pooled analysis also indicated that the FS-LASIK group suffered more severely from dry eye symptoms (OSDI; MD -6.68; 95% CI: -11.76, -2.00; P = 0.006) and lower corneal sensitivity (MD 12.40; 95% CI: 10.23, 14.56; P < 0.00001) at six months postoperatively.

CONCLUSIONS

In conclusion, both FS-LASIK and SMILE are safe, effective and predictable surgical options for treating myopia. However, dry eye symptoms and loss of corneal sensitivity may occur less frequently after SMILE than after FS-LASIK.

Dry eye disease after refractive surgery: comparative outcomes of small incision lenticule extraction versus LASIK

PURPOSE

To compare small incision lenticule extraction (SMILE) versus LASIK for post-refractive dry eye disease.

DESIGN

Prospective, comparative, nonrandomized clinical study.

PARTICIPANTS

Thirty patients scheduled for bilateral myopic SMILE and 30 age-, sex-, and refraction-matched patients scheduled for bilateral myopic LASIK were enrolled and followed for 6 months after the surgery.

METHODS

Complete evaluation of dry eye disease was performed at 1 and 6 months postoperatively, which included vision-related quality of life (Ocular Surface Disease Index [OSDI]), clinical examinations (tear film breakup time [TBUT], Schirmer I test, corneal staining), and tear osmolarity measurements, together with an overall severity score. Function and morphology of the corneal innervation were evaluated by corneal esthesiometry and subbasal nerve imaging using in vivo confocal microscopy (IVCM).

MAIN OUTCOME MEASURES

Overall analysis of dry eye disease and corneal innervation.

RESULTS

High incidence of mild to moderate dry eye disease was observed in both groups 1 month postoperatively, which remained significantly higher in the LASIK group than in the SMILE group 6 months after surgery (overall severity score [0-4]: 1.2±1.1 vs. 0.2±0.4, respectively, P < 0.01), leading to more frequent use of tear substitutes over the long term. Corneal sensitivity was better in SMILE than in LASIK eyes 1 month postoperatively (3.5±1.79 vs. 2.45±2.48, respectively, P < 0.01) and then recovered to statistically similar values at 6 months. Corneal nerve density, number of long fibers, and branchings as assessed by IVCM were significantly higher in the SMILE group compared with the LASIK group 1 and 6 months after surgery. Corneal sensitivity was negatively correlated with dry eye-related corneal damage (R² = 0.48, P < 0.01), and the long fiber nerve density was independently correlated with the OSDI score (R² = 0.50, P < 0.01) and the Schirmer test (R² = 0.21, P < 0.01) 6 months postoperatively.

CONCLUSIONS

The SMILE procedure has a less pronounced impact on the ocular surface and corneal innervation compared with LASIK, further reducing the incidence of dry eye disease and subsequent degradation in quality of life after refractive surgery.