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Leccisotti A, Fields SV, De Bartolo G. Refractive Corneal Lenticule Extraction With the CLEAR Femtosecond Laser Application. Cornea 2023; 42:1247-1256. [PMID: 36156507 DOI: 10.1097/ico.0000000000003123] [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: 06/02/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate a new femtosecond laser application for refractive corneal lenticule extraction with suction control and computerized regulation of centration and alignment (Ziemer CLEAR). METHODS This was a retrospective, consecutive, noncomparative case series study. Patients undergoing CLEAR for spherical equivalent (SE) between -3 and -10 D, evaluating SE, defocus equivalent, refractive astigmatism, visual acuity, and centration at 10 months were evaluated in the study. RESULTS Fifty-three eyes of 42 patients (mean age 40.4 ± 8.6 years) were included, with preoperative SE -5.99 ± 1.49 D and mean corrected distance visual acuity (CDVA) of 0.05 ± 0.07 logMAR. With no suction losses, an intact lenticule was extracted in all eyes. In 6 eyes, peripheral adhesion was resolved by lenticulerrhexis, and in 1 eye, the incision was opened by a crescent blade. Moderate interface inflammation occurred in 3 eyes. At day 1, in the 42 eyes with uneventful surgery, the mean CDVA was 20/27, whereas in the 11 eyes with extra surgical manipulations, it was 20/36 ( P = 0.04). At 10 months, for the 53 eyes, the mean uncorrected distance visual acuity was 0.05 ± 0.09 logMAR; in 37 eyes (70%), it was 20/25 or better; and the mean CDVA was 0.04 ± 0.06 logMAR. Eight eyes (15%) lost 1 logMAR line. The mean SE was -0.13 ± 0.15 D. The mean defocus equivalent was 0.33 ± 0.32 D, with 46 eyes (87%) ≤0.50 D and 52 eyes (98%) ≤1 D. Refractive astigmatism was ≤0.50 D in 48 eyes (90%). The efficacy index was 1.00, and the safety index was 0.98. The mean decentration from the corneal vertex was 0.28 ± 0.07 mm. CONCLUSIONS The application yielded good predictability, efficacy, and safety. Slower visual recovery was observed after extra surgical manipulations.
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Affiliation(s)
- Antonio Leccisotti
- Siena Eye Laser, Poggibonsi, Siena, Italy
- Scuola di Specializzazione in Oftalmologia, Università di Siena, Siena, Italy; and
- School of Biomedical Sciences, Ulster University, Coleraine, UK
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Modified Technique for Small-Incision Lenticule Extraction: Ye's Swing Technique. Ophthalmol Ther 2023; 12:365-376. [PMID: 36402902 PMCID: PMC9834450 DOI: 10.1007/s40123-022-00612-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION This study aimed to evaluate the lenticule integrity and refractive outcomes of a new technique, Ye's swing technique, during small-incision lenticule extraction (SMILE). METHODS This prospective study enrolled patients who underwent the SMILE procedure using a modified technique for lenticule dissection. Per the standard SMILE procedure, the cap cut was opened using a hook, and an anterior dissection was performed with a counterclockwise swing, from 8 to 12 o'clock. A posterior dissection was then performed by swinging counterclockwise, leaving a thin band of the peripheral rim undissected, from 8 to 4 o'clock. The counterclockwise swing was continued to separate the edges of the rim from 4 to 12 o'clock, after which microforceps were used to extract the lenticules. The primary outcome measures were safety and lenticule integrity at the end of the surgery, and the secondary outcome measure was efficacy. Changes in the ocular parameters from the preoperative visit to 1 month postoperative, including uncorrected and corrected distance visual acuity, manifest refraction, lenticule quality, and lenticule residual, were assessed using optical coherence tomography. RESULTS A total of 246 patients (490 eyes) with myopia and myopic astigmatism were included in the present study. The dissected lenticules ranged in size from 52 to 148 µm. Postoperatively, the lenticule was completely and successfully extracted in all cases. There was no incisional edge tearing during lenticule separation. CONCLUSIONS Ye's swing technique is a safe and effective procedure for lenticule dissection and refractive outcomes. We have now adopted this technique as our routine method for performing the SMILE procedure.
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Zhao Y, Lin X, Chen Z, Zhou X. Five-year stability of posterior corneal surface after small incision lenticule extraction for high myopia. BMC Ophthalmol 2022; 22:239. [PMID: 35643458 PMCID: PMC9145076 DOI: 10.1186/s12886-022-02463-2] [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: 02/14/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To study the 5-year changes in the posterior corneal surface after small incision lenticule extraction (SMILE) for high myopia.
Methods
Eighty eyes received SMILE was included in this prospective study. They were allocated into two groups based on the spherical equivalent: high myopia (40eyes, -7.49 ± 0.70D) and moderate myopia (40eyes, -4.43 ± 0.87D). Certain points of posterior corneal elevation (the central point (PCE), thinnest point (PTE), maximal point (PME), and in various corneal areas) were evaluated using a Scheimpflug camera (Pentacam; Oculus GmbH, Germany) preoperatively and at 6 months and 5 years after surgery.
Results
All surgeries were completed uneventfully and no ectasia was developed throng the observation. The safety index and efficacy index were 1.14 and 1.03 in the high myopia group, and 1.16 and 1.06 in the moderate myopia group, respectively. Most of the calculated values in the high myopia group showed a slight increase at 6 months but decreased at 5 years. At 5 years postoperatively, the value of the PTE was significantly lower than at baseline in both groups (P ≤ 0.047); a statistical difference was also revealed in the PME in the moderate group with slight changes (10.15 ± 3.01 μm vs. 11.60 ± 4.33 μm, P = 0.002); no statistical significance was observed in other calculated values (P ≥ 0.067). Similarly, no significant linear correlation was noted between changes in all values and the residual bed thickness either (P ≥ 0.057).
Conclusions
SMILE causes no protrusion in posterior corneal surface for correction of high myopia at the follow-up visit of 5 years.
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Ma J, Wang Y, Jhanji V. Bilateral Lenticule Creation Followed by Bilateral Lenticule Separation Improves Visual Outcomes After SMILE. J Refract Surg 2021; 37:726-733. [PMID: 34756141 DOI: 10.3928/1081597x-20210809-01] [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 explore the impact of different surgical sequences on the visual and refractive outcomes of bilateral small incision lenticule extraction (SMILE) surgery using propensity score matching (PSM) analysis. METHODS Participants who underwent uneventful SMILE between March 2018 and September 2019 were retrospectively analyzed and were divided into two groups: Sequence A (laser scanning [LS] of the right eye, manual separation lenticule [MSL] of the right eye, and LS and MSL of the left eye) and Sequence B (LS of the right eye, LS of the left eye, MSL of the left eye, and MSL of the right eye). PSM was conducted to minimize the effect of confounding factors on postoperative visual outcomes at days 1 and 7 and months 1, 3, and 6. Safety, efficacy, predictability, and stability were compared between groups. RESULTS Overall, 1,854 eyes of 927 participants were included (Sequence A, n = 280; Sequence B, n = 647). After PSM, there were no significant differences in baseline characteristics, and 534 eyes (267 patients) in the Sequence A group were matched (1:1) to the Sequence B group. The postoperative corrected distance visual acuity significantly differed between groups at 3 months (adjusted P = .007). The uncorrected distance visual acuity significantly differed between groups at all follow-up visits (adjusted P < .01). The safety index (1.341 ± 0.265 and 1.413 ± 0.294) and efficacy index (1.173 ± 0.191 and 1.251 ± 0.269) were different in the Sequence A and Sequence B groups, respectively, at 3 months (adjusted P < .01). No difference in visual outcomes was found between right and left eyes. CONCLUSIONS Patients who had bilateral lenticule creation followed by bilateral lenticule separation had better postoperative visual outcomes than those who underwent complete SMILE surgery in each eye separately. Regardless of the surgical sequence chosen for the SMILE procedure, there was no impact on outcomes between the right and left eyes. Adjusting the sequence of the surgical procedure may be a way to improve the visual results. [J Refract Surg. 2021;37(11):726-733.].
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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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Agarwal R, Puri P, Bafna RK, Chetan C, Sharma N. Inverse centripetal dissection: A rescue technique for mis-dissected lenticule during SMILE. Eur J Ophthalmol 2021; 31:3537-3541. [PMID: 34030503 DOI: 10.1177/11206721211018347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Management of mis-dissected lenticule during Small-incision lenticule extraction (SMILE) is technically challenging and might be experienced more by novice surgeons especially in eyes with low refractive errors and thin lenticules. Presently, we describe a rescue method of inverse centripetal dissection (ICD) to manage mis-dissected lenticules. In this technique, after inadvertent dissection of posterior plane prior to anterior plane, the double-ended SMILE dissector is rotated along its shaft axis clockwise from the left upper margin of the mis-dissected lenticule to form an inversely folded lenticule which is then subsequently dissected centripetally till midline. This is then extracted by performing lenticulorrhexis with a pair of microforceps. We performed this technique in 10 eyes of 10 patients and the lenticule extraction was accomplished successfully in all eyes. At six months follow-up, the uncorrected visual acuity was 20/20 with a clear interface in all eyes. The ICD approach might serve as a useful rescue technique for managing mis-dissected lenticules.
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Affiliation(s)
- Rinky Agarwal
- Department of Ophthalmology, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences New Delhi, India
| | - Prabhav Puri
- 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
| | - Chetan Chetan
- Department of Optometry, 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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Sachdev GS, Ramamurthy S, Dandapani R. Stop sign for correct tissue plane identification in small incision lenticule extraction. Indian J Ophthalmol 2021; 68:895-896. [PMID: 32317474 PMCID: PMC7350430 DOI: 10.4103/ijo.ijo_1264_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We describe the “stop sign“ which allows correct anterior and posterior lenticular plane delineation in Small Incision Lenticule Extraction (SMILE). This sign describes the resistance noted at the junction between the dissected and undissected halves of both the planes, interfering with subsequent lateral movement of the instrument. The resistance is demonstrated at both the anterior and posterior lenticular plane. This allows ideal dissection of the lenticule from the overlying cap and underlying stroma, thereby reducing the complications arising from incorrect tissue dissection.
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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
| | - Ramamurthy Dandapani
- Refractive Services, The Eye Foundation, RS Puram, Coimbatore, Tamil Nadu, India
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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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Nagaraja H, Mehta JS, Zhou X, Yam JC, Lam DS. Will SMILE Become the New Benchmark of Corneal Laser Refractive Surgery? Asia Pac J Ophthalmol (Phila) 2019; 8:351-354. [PMID: 31567435 PMCID: PMC6784770 DOI: 10.1097/01.apo.0000579956.14784.91] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/06/2019] [Indexed: 12/02/2022] Open
Affiliation(s)
- Harsha Nagaraja
- International Eye Research Institute of the Chinese University of Hong Kong (Shenzhen), Shenzhen, P.R. China
- C-MER (Shenzhen) Dennis Lam Eye Hospital, 1 Tairan 9th Rd, Futian, Shenzhen, China
| | - Jodhbir S. Mehta
- Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Fudan University, Shanghai, China
| | | | - Jason C. Yam
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Kowloon, Hong Kong
| | - Dennis S.C. Lam
- International Eye Research Institute of the Chinese University of Hong Kong (Shenzhen), Shenzhen, P.R. China
- C-MER (Shenzhen) Dennis Lam Eye Hospital, 1 Tairan 9th Rd, Futian, Shenzhen, China
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Qin B, Zhao J, Li M, Yao P, Zhou X. The comparison of visual outcomes, aberrations, and Bowman's layer micro-distortions after femtosecond laser small-incision lenticule extraction (SMILE) for the correction of high and moderate myopia and myopic astigmatism. BMC Ophthalmol 2019; 19:138. [PMID: 31248387 PMCID: PMC6598346 DOI: 10.1186/s12886-019-1135-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 05/27/2019] [Indexed: 12/02/2022] Open
Abstract
Background This study compares the clinical outcomes of femtosecond laser small-incision lenticule extraction (SMILE) for the correction of myopia and myopic astigmatism greater than − 10 D, and − 10 D or less respectively. Methods 60 eyes/patients were equally selected into group 1 (myopia and myopic astigmatism of − 10 D or less) and group 2 (myopia and myopic astigmatism of over − 10 D), both of which were treated with SMILE. Visual and refractive outcomes, corneal higher-order aberrations, and Bowman’s layer micro-distortions were evaluated preoperatively, 3 months, and 6 months postoperatively. Results LogMAR corrected distance visual acuity (CDVA) of group 1 and group 2 was − 0.069 ± 0.047 and − 0.053 ± 0.073 6 months postoperatively (P = 0.48). 100% eyes in group 1 and 97% in group 2 were within 1 D of targeted correction (P = 0.45). Meanwhile, 100% eyes in group 1 and 97% in group 2 had an uncorrected distance visual acuity of 20/25 or better (P = 0.20). Changes in corneal higher-order aberrations root mean square, coma, and trefoil were similar between the two groups but spherical aberration was higher in group 2 (P < 0.01). Micro-distortions were observed in 53% in group 1 and 77% in group 2. More micro-distortions were observed in group 2 (3.40 ± 2.66) than in group 1 (2.07 ± 2.29) (P = 0.041). The total number of micro-distortions was not correlated with postoperative CDVA (P = 0.77). Conclusions Visual outcomes showed similar results of SMILE for myopic correction of > − 10 D and ≤ − 10 D. Refractive outcomes showed slightly under-correction in higher myopic eyes. Higher myopic treatment tends to induce more spherical aberrations. Micro-distortions had no impact in visual and refractive outcomes.
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Affiliation(s)
- Bing Qin
- Department of Ophthalmology and Optometry, Eye and ENT Hospital, Fudan University, Shanghai, China Shanghai Research Center of Ophthalmology and Optometry, NHC Key Laboratory of Myopia, Shanghai, People's Republic of China
| | - Jing Zhao
- Department of Ophthalmology and Optometry, Eye and ENT Hospital, Fudan University, Shanghai, China Shanghai Research Center of Ophthalmology and Optometry, NHC Key Laboratory of Myopia, Shanghai, People's Republic of China
| | - Meiyan Li
- Department of Ophthalmology and Optometry, Eye and ENT Hospital, Fudan University, Shanghai, China Shanghai Research Center of Ophthalmology and Optometry, NHC Key Laboratory of Myopia, Shanghai, People's Republic of China
| | - Peijun Yao
- Department of Ophthalmology and Optometry, Eye and ENT Hospital, Fudan University, Shanghai, China Shanghai Research Center of Ophthalmology and Optometry, NHC Key Laboratory of Myopia, Shanghai, People's Republic of China
| | - Xingtao Zhou
- Department of Ophthalmology and Optometry, Eye and ENT Hospital, Fudan University, Shanghai, China Shanghai Research Center of Ophthalmology and Optometry, NHC Key Laboratory of Myopia, Shanghai, People's Republic of China.
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Titiyal JS, Kaur M, Shaikh F, Gagrani M, Brar AS, Rathi A. Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives. Clin Ophthalmol 2018; 12:1685-1699. [PMID: 30233132 PMCID: PMC6134409 DOI: 10.2147/opth.s157172] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Refractive lenticule extraction is becoming the procedure of choice for the management of myopia and myopic astigmatism owing to its precision, biomechanical stability, and better ocular surface. It has similar safety, efficacy, and predictability as femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and is associated with better patient satisfaction. The conventional technique of small incision lenticule extraction (SMILE) involves docking, femtosecond laser application, lenticule dissection from the surrounding stroma, and extraction. It has a steep learning curve compared to conventional flap-based corneal ablative procedures, and the surgical technique may be challenging especially for a novice surgeon. As SMILE is gaining worldwide acceptance among refractive surgeons, different modifications of the surgical technique have been described to ease the process of lenticule extraction and minimize complications. Good patient selection is essential to ensure optimal patient satisfaction, and novice surgeons should avoid cases with low myopia (thin refractive lenticules), difficult orbital anatomy, high astigmatism, or uncooperative, anxious patients to minimize complications. A comprehensive MEDLINE search was performed using “small incision lenticule extraction,” “SMILE,” and “refractive lenticule extraction” as keywords, and we herein review the patient selection for SMILE and various surgical techniques of SMILE with their pros and cons. With increasing surgeon experience, a standard technique is expected to evolve that may be performed in all types of cases with optimal outcomes and minimal adverse effects.
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Affiliation(s)
- Jeewan S Titiyal
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Manpreet Kaur
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Farin Shaikh
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Meghal Gagrani
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Anand Singh Brar
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
| | - Anubha Rathi
- Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India,
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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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Miao H, Liu X, Tian M, Zhao J, Fang X, Zhou X. Short-term Observation of Intraocular Scattering and Bowman's Layer Microdistortions After SMILE-CCL. J Refract Surg 2018; 34:387-392. [PMID: 29889291 DOI: 10.3928/1081597x-20180426-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/20/2018] [Indexed: 01/24/2023]
Abstract
PURPOSE To investigate changes in intraocular scattering and Bowman's layer microdistortions after femtosecond laser small incision lenticule extraction using the continuous curvilinear lenticulerhexis technique (SMILE-CCL). METHODS In this prospective study, 93 eyes of 93 patients (44 women, 49 men) were treated with SMILE-CCL. Mean age was 26.09 ± 4.39 years and mean spherical equivalent was -6.31 ± 2.16 diopters. The Objective Scatter Index (OSI) was examined with an objective optical quality analysis system. Bowman's layer microdistortions in the central 4-mm optical zone were measured using Fourier-domain optical coherence tomography. RESULTS The mean OSI value increased from 0.67 preoperatively to 1.09 at 20 days, and then decreased to 0.84 at 3 months (P < .05). Microdistortions were observed in 62.37% of the eyes at 20 days and 48.39% at 3 months postoperatively (P < .05). The width of the microdistortions per meridian was 283.18 ± 197.19 μm at 20 days; this decreased to 156.00 ± 159.86 μm at 3 months (P < 0.05). Regression analysis models revealed that older age (b = 0.02, P = .03) and higher preoperative spherical equivalent (b = -0.09, P < .05) resulted in higher postoperative OSI values; no significant association was found between postoperative OSI values and microdistortion-related parameters (P > .05). Higher preoperative spherical equivalent (b = -0.28, P = .01) and thinner preoperative corneal thickness (b = -0.02, P = .01) were associated with more microdistortions. CONCLUSIONS SMILE induced a temporary increase in OSI values and Bowman's layer microdistortions. The microdistortions did not influence intraocular scattering. [J Refract Surg. 2018;34(6):387-392.].
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Urkude J, Titiyal JS, Sharma N. Intraoperative Optical Coherence Tomography-Guided Management of Cap-Lenticule Adhesion During SMILE. J Refract Surg 2018; 33:783-786. [PMID: 29117420 DOI: 10.3928/1081597x-20170920-01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/18/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE To report successful lenticule extraction using intraoperative optical coherence tomography (OCT) in a case of cap-lenticule adhesion during small incision lenticule extraction (SMILE). METHODS Case report. RESULTS A 22-year-old patient with a refractive error of -5.00 -0.50 × 120° and -5.00 -0.75 × 60° in the right and left eyes, respectively, was scheduled for SMILE. The lenticule was created using the VisuMax femtosecond laser system (Carl Zeiss Meditec, Jena, Germany). The surgeon experienced difficulty while extracting the lenticule in the right eye. The patient was immediately shifted under the surgical microscope integrated with intraoperative OCT. The lenticule was found to be adherent to the anterior stromal cap, which was seen as hyperreflective spikes in the posterior plane, in contrast to the anterior plane, which showed minimal reflectivity, suggesting an inadvertent posterior plane entry. The peripheral edge of the lenticule was lifted from the anterior stromal cap under direct visualization of intraoperative feedback images provided by intraoperative OCT. The edge of the lenticule, which was freed, was then grasped with microforceps and extracted in toto using the continuous curvilinear lenticulerrhexis technique. At the end of surgery, the intrastromal pocket was screened under intraoperative OCT for any lenticule remnants. One week after surgery, the uncorrected distance visual acuity was 20/20 with smooth, regular interface on anterior segment optical coherence tomography. CONCLUSIONS Intraoperative OCT is useful in cases of difficult lenticule extraction during SMILE because it provides real-time visualization of the lenticule and helps in discerning its relation with the anterior stromal cap and the underlying stromal bed. By using intraoperative OCT and the continuous curvilinear lenticulerrhexis technique, satisfactory anatomical and visual outcomes were obtained. [J Refract Surg. 2017;33(11):783-786.].
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Qin B, Li M, Chen X, Sekundo W, Zhou X. Early visual outcomes and optical quality after femtosecond laser small-incision lenticule extraction for myopia and myopic astigmatism correction of over -10 dioptres. Acta Ophthalmol 2018; 96:e341-e346. [PMID: 29251814 DOI: 10.1111/aos.13609] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 09/02/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate early visual and refractive outcomes, corneal stability and optical quality after femtosecond laser small-incision lenticule extraction (SMILE) for treating myopia and myopic astigmatism over -10 D. METHODS Thirty eyes (30 patients) with myopia and myopic astigmatism of over -10 D were treated with VisuMax® femtosecond laser (version 3.0; Carl Zeiss Meditec AG, Jena, Germany). Six months postoperative safety, efficacy and predictability were evaluated. Corneal Scheimpflug topography was measured preoperatively, 1 day, 3 months and 6 months postoperatively. Wavefront aberrations were measured preoperatively, 3 months and 6 months postoperatively. RESULTS Six months postoperatively, LogMAR uncorrected and corrected distance visual acuity (CDVA) were -0.013 ± 0.086 and -0.073 ± 0.069, respectively. 73% (97%) of eyes were within 0.5 (1) D of target refraction. No eyes lost CDVA, 43% (13 eyes) gained one line and 7% (two eyes) gained two lines. Mean corneal back curvature (KMB) and posterior central elevation (PCE) did not change significantly comparing preoperative and 6 months postoperative data (p = 0.91 and 0.77, respectively). Comparing 1 day with 6 months postoperative data, central corneal thickness (CCT), mean corneal front curvature (KMF), KMB and PCE did not change significantly (p = 0.27, 0.07, 0.52, 0.71, respectively). Total higher-order aberration (HOA), spherical aberration and coma increased significantly (p < 0.01) but trefoil remained stable (p = 0.49). CONCLUSION Our results indicate that SMILE can correct myopia and myopic astigmatism of over -10 D predictably. No early ectasia was observed. Long-term changes in visual quality and corneal stability require further investigation.
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Affiliation(s)
- Bing Qin
- Department of Ophthalmology; Myopia Key Laboratory of the Health Ministry; Eye and ENT Hospital of Fudan University; Shanghai China
| | - Meiyan Li
- Department of Ophthalmology; Myopia Key Laboratory of the Health Ministry; Eye and ENT Hospital of Fudan University; Shanghai China
| | - Xun Chen
- Department of Ophthalmology; Myopia Key Laboratory of the Health Ministry; Eye and ENT Hospital of Fudan University; Shanghai China
| | - Walter Sekundo
- Department of Ophthalmology; Philipps University of Marburg; Marburg Germany
| | - Xingtao Zhou
- Department of Ophthalmology; Myopia Key Laboratory of the Health Ministry; Eye and ENT Hospital of Fudan University; Shanghai China
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Ganesh S, Brar S. Lenticuloschisis: A "No Dissection" Technique for Lenticule Extraction in Small Incision Lenticule Extraction. J Refract Surg 2018; 33:563-566. [PMID: 28787523 DOI: 10.3928/1081597x-20170504-09] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 04/28/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe a "no dissection" technique of lenticule removal in small incision lenticule extraction (SMILE). METHODS After docking and laser delivery, a microforceps is used to grasp and gently peel off the lenticule from the underlying stromal bed, without performing any dissection of the upper and lower planes of the lenticule. Prerequisites are a surgeon experienced in the conventional SMILE technique, optimized laser energy settings, and a minimum peripheral lenticule thickness of 25 to 30 µm. RESULTS The interface as assessed in postoperative dilated clinical photographs was seen to be clearer with less roughness compared to the conventional dissection technique. This may potentially result in better first postoperative visual acuity and quality of vision due to less corneal tissue trauma and minimal tissue handling, thus potentially resulting in faster visual recovery. CONCLUSIONS No dissection lenticule removal is a feasible and reproducible technique that may result in better immediate visual quality compared to the conventional SMILE technique. [J Refract Surg. 2017;33(8):563-566.].
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Zhao Y, Jian W, Chen Y, Knorz MC, Zhou X. Three-Year Stability of Posterior Corneal Elevation After Small Incision Lenticule Extraction (SMILE) for Moderate and High Myopia. J Refract Surg 2017; 33:84-88. [PMID: 28192586 DOI: 10.3928/1081597x-20161117-01] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 10/31/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To investigate long-term changes in posterior corneal elevation after small incision lenticule extraction (SMILE). METHODS Thirty-six eyes of 20 patients (7 male, 13 female) who underwent SMILE were recruited for this prospective consecutive study. The mean preoperative manifest spherical equivalent was -6.24 ± 1.47 diopters (D) (range: -3.88 to -8.75 D). Posterior corneal surfaces were measured by a Scheimpflug camera (Pentacam; Oculus Optikgeräte GmbH, Wetzlar, Germany) preoperatively and at 1 month, 6 months, 12 months, 2 years, and 3 years after surgery. Posterior central elevation (PCE), posterior maximal elevation (PME), and posterior elevation at the thinnest corneal point (PTE) in the central 4-mm area above the best-fit sphere (BFS) were analyzed. The BFS was the same across all follow-up periods and determined by the preoperative data. A P value of less than .05 was considered statistically significant. RESULTS All surgeries were executed without complications and no case of keratectasia was observed during the follow-up. An uncorrected distance visual acuity of 20/20 or better was achieved in 100% of eyes at the last visit. The mean change of PCE, PME, and PTE at 3 years after the operation was -2.39 ± 2.85, 0.50 ± 3.33, and -2.33 ± 2.90 µm, respectively. There were significant differences in the measurements of PCE and PTE before surgery and 3 years after surgery (P ≤ .009); however, there was no significant difference in PME before surgery and 3 years after surgery (P = 1.000). No correlation was found between changes in posterior corneal elevation and residual bed thickness, ablation depth, and preoperative thinnest corneal thickness. CONCLUSIONS The posterior corneal surface, measured using the Pentacam, was stable after SMILE in the long-term follow-up. The cause of the slight backward change of PCE and PTE needs further study. [J Refract Surg. 2017;33(2):84-88.].
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Sequential segmental terminal lenticular side-cut dissection for safe and effective small-incision lenticule extraction in thin lenticules. J Cataract Refract Surg 2017; 43:443-448. [DOI: 10.1016/j.jcrs.2017.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/24/2016] [Accepted: 12/19/2016] [Indexed: 11/23/2022]
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Shroff R, Francis M, Pahuja N, Veeboy L, Shetty R, Sinha Roy A. Quantitative Evaluation of Microdistortions in Bowman's Layer and Corneal Deformation after Small Incision Lenticule Extraction. Transl Vis Sci Technol 2016; 5:12. [PMID: 27777827 PMCID: PMC5072544 DOI: 10.1167/tvst.5.5.12] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/31/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose To quantitatively evaluate microdistortions in Bowman's layer and change in corneal stiffness after small incision lenticule extraction (SMILE). Methods This was a prospective, longitudinal, and interventional study. Thirty eyes of 30 patients were screened preoperatively and underwent SMILE for treatment of myopia with astigmatism. Visual acuity, refraction, optical coherence tomography (OCT; Bioptigen, Inc., Morrisville, NC) imaging of the layer and air-puff applanation (Corvis-ST, OCULUS Optikgeräte Gmbh, Germany) was performed before and after surgery (1 day, 1 week, and 1 month). The Bowman's Roughness Index (BRI) was defined as the enclosed area between the actual and an ideal smooth layer to quantify the microdistortions. A viscoelastic model was used to quantify the change in corneal stiffness using applanation. Results Uncorrected distance visual acuity improved (P < 0.001) and refractive error decreased (P < 0.0001) after SMILE. BRI increased from preoperative levels (1.81 × 10−3 mm2) to 1 week (3.14 × 10−3 mm2) after SMILE (P < 0.05) and then decreased up to a month (2.43 × 10−3 mm2; P < 0.05). Increase in the magnitude of the index correlated positively with refractive error (P = 0.02). However, corneal stiffness reduced after SMILE (105.86 ± 1.4 N/m versus 97.97 ± 1.21 N/m at 1 month, P = 0.001). The decrease in corneal stiffness did not correlate with refractive error (P = 0.61). Conclusions BRI correlated positively the magnitude of refractive error. However, decrease in corneal stiffness, assessed by air-puff applanation, may not be related to microdistortions after SMILE. Translational Relevance An objective method of quantification of Bowman's layer microdistortions using OCT was developed to monitor corneal wound healing and improve lenticule extraction methods.
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Affiliation(s)
- Rushad Shroff
- Cornea and Refractive Surgery Division, Narayana Nethralaya, Bangalore, India
| | - Mathew Francis
- Imaging, Biomechanics and Mathematical Modeling Solutions, Narayana Nethralaya Foundation, Bangalore, India
| | - Natasha Pahuja
- Cornea and Refractive Surgery Division, Narayana Nethralaya, Bangalore, India
| | - Leio Veeboy
- Imaging, Biomechanics and Mathematical Modeling Solutions, Narayana Nethralaya Foundation, Bangalore, India
| | - Rohit Shetty
- Cornea and Refractive Surgery Division, Narayana Nethralaya, Bangalore, India ; Vice-Chairman, Narayana Nethralaya, Bangalore, India
| | - Abhijit Sinha Roy
- Chief Scientist, Imaging, Biomechanics and Mathematical Modeling Solutions, Narayana Nethralaya Foundation, Bangalore, India
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Zheng K, Han T, Zhou X. Accommodative changes after SMILE for moderate to high myopia correction. BMC Ophthalmol 2016; 16:173. [PMID: 27716112 PMCID: PMC5050588 DOI: 10.1186/s12886-016-0352-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 09/23/2016] [Indexed: 11/12/2022] Open
Abstract
Background To investigate accommodative response and accommodative lag changes after femtosecond laser small incision lenticule extraction (SMILE) for moderate to high myopia correction. Methods A total of 32 eyes of 32 patients with no strabismus who underwent SMILE were enrolled in this prospective clinical study. The accommodative response was obtained viewing monocularly with spherical equivalent refractive error corrected, using an open-field autorefractor at different stimulus levels (2.00D, 2.50D, 3.00D, 4.00D and 5.00D) for the right eye before a standard SMILE surgery and at 1-month follow-up after surgery. Results The mean age of the patients were 23.34 ± 2.90 years and the mean preoperative manifest refraction spherical equivalent was −5.74 ± 1.98 diopters. Significant differences were detected in both preoperative and postoperative accommodative responses to different stimulus levels (P < 0.001). Multiple linear regression model analysis revealed preoperative manifest refractive spherical equivalent (P = 0.006) and preoperative accommodative lag (P = 0.04) showed a significant impact on postoperative accommodative lag. Conclusions This is the first report of accommodative changes after SMILE. Our preliminary results showed that a decrease in postoperative accommodative lag that might be related to the relief of the visual discomfort symptom.
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Affiliation(s)
- Ke Zheng
- Key Lab of Myopia, Ministry of Health, Department of Ophthalmology, Eye & ENT Hospital of Fudan University, 19 Baoqing Road, Shanghai, 200031, China
| | - Tian Han
- Key Lab of Myopia, Ministry of Health, Department of Ophthalmology, Eye & ENT Hospital of Fudan University, 19 Baoqing Road, Shanghai, 200031, China
| | - Xingtao Zhou
- Key Lab of Myopia, Ministry of Health, Department of Ophthalmology, Eye & ENT Hospital of Fudan University, 19 Baoqing Road, Shanghai, 200031, China.
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Kim BK, Mun SJ, Lee DG, Choi HT, Chung YT. Chung's swing technique: a new technique for small-incision lenticule extraction. BMC Ophthalmol 2016; 16:154. [PMID: 27580699 PMCID: PMC5007688 DOI: 10.1186/s12886-016-0321-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/01/2016] [Indexed: 11/15/2022] Open
Abstract
Background To introduce the Chung’s swing technique for small-incision lenticule extraction (SMILE). Methods A total of 112 eyes of 56 patients were included in this study. Patients were divided into two groups: 52 eyes of 26 patients were treated with SMILE using a traditional method (traditional group) and 60 eyes of 30 patients were treated with SMILE using the Chung’s swing technique (swing group). Results At 1 month postoperatively, all eyes in both groups had an uncorrected distance visual acuity of 20/20 or better. The efficacy indices were 1.09 ± 0.17 and 1.02 ± 0.11 (p = 0.492), and the safety indices were 1.12 ± 0.14 and 1.09 ± 0.15 (p = 0.537), for the traditional and swing group, respectively. All eyes in both groups underwent successful lenticule extraction; all lenticules were intact and complete. The mean lenticule extraction times were 48.67 ± 4.9 and 39.8 ± 5.53 s, for the traditional and swing group, respectively (p < 0.001). Conclusions The Chung’s swing technique is efficient for lenticule separation and extraction. Our study results showed good clinical outcomes. Trial registration Trial registration number: KCT0001978. Registered 22 July 2016. Retrospectively registered. Electronic supplementary material The online version of this article (doi:10.1186/s12886-016-0321-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bu Ki Kim
- Onnuri Smile Eye Clinic, Hyobong building 9F 1, Gangnam-daero 65 gil, Seocho-gu, Seoul, Korea
| | - Su Joung Mun
- Onnuri Smile Eye Clinic, Hyobong building 9F 1, Gangnam-daero 65 gil, Seocho-gu, Seoul, Korea
| | - Dae Gyu Lee
- Onnuri Smile Eye Clinic, Hyobong building 9F 1, Gangnam-daero 65 gil, Seocho-gu, Seoul, Korea
| | - Hyun Tae Choi
- Onnuri Smile Eye Clinic, Hyobong building 9F 1, Gangnam-daero 65 gil, Seocho-gu, Seoul, Korea
| | - Young Taek Chung
- Onnuri Smile Eye Clinic, Hyobong building 9F 1, Gangnam-daero 65 gil, Seocho-gu, Seoul, Korea.
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Clinical Outcomes After SMILE and Femtosecond Laser-Assisted LASIK for Myopia and Myopic Astigmatism. Cornea 2016; 35:210-6. [DOI: 10.1097/ico.0000000000000707] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhao Y, Li M, Sun L, Zhao J, Chen Y, Zhou X. Lenticule Quality After Continuous Curvilinear Lenticulerrhexis in SMILE Evaluated With Scanning Electron Microscopy. J Refract Surg 2015; 31:732-5. [DOI: 10.3928/1081597x-20151029-01] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 08/18/2015] [Indexed: 12/31/2022]
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