Small Incision Lenticule Extraction for Correction of Pediatric Unilateral Anisometropic Myopia

Pediatric refractive surgery: Review article

Refractive surgery is one of the most commonly performed elective procedures in ophthalmology; it is mostly performed in patients who are older than 18 years of age. This routine procedure has been time-tested and is proven to be both safe and effective in adults. However, little is known about the safety and efficacy of refractive surgery in pediatric patients. Granted, refractive surgery should not be used in kids merely for the purpose of avoiding spectacles wear, but it can be of valuable help is preserving vision in patients with amblyopia and accommodative esotropia who otherwise couldn't comply with traditional management options. Refractive surgery in pediatric patients is a complex and challenging field due to the unique characteristics of their developing eyes. This review article aims to provide an overview of the current literature on refractive surgery in pediatric patients, focusing on the different surgical options, the advantages and disadvantages of each procedure.

Refractive Surgery in Myopic Children

In this paper, we summarize the current knowledge on refractive surgery performed in the myopic pediatric population. We describe the main concerns about refractive surgery in myopic children and the indications for refractive surgery in this age group. We present a range of surgical procedures that are being used for the management of unilateral/bilateral myopia in children: corneal refractive surgery (PRK, LASEK, LASIK, FS-LASIK and SMILE) and intraocular refractive surgery (phakic intraocular lens implantation, refractive lens exchange or clear lens extraction), with both their advantages and drawbacks. We also describe the various complications and measures to prevent them.

Refractive surgeries in children: Debunking the controversy and assessing the safety and efficacy

New innovations in adults' refractive surgeries have revolutionized the field, offering improved outcomes and enhanced patient experiences. While traditionally considered contraindicated in pediatric populations, emerging research suggests that this notion may not always hold true. Challenges, indications, safety, and other topics will be addressed in this review article.

Accuracy of the FY-L formula in calculating intraocular lens power after small-incision lenticule extraction

Purpose

The study aimed to assess the accuracy of the FY-L formula in calculating intraocular lens (IOL) power after small-incision lenticule extraction (SMILE).

Methods

For the post-SMILE IOL calculation of the same eye, the IOL power targeting the pre-SMILE eyes' lowest myopic refractive error was used. The FY-L formula, the Emmetropia Verifying Optical Formula (EVO-L), the Barrett True-K no history, and the Shammas-L, respectively, were used to calculate the predicted refractive error of target IOL power. A comparison was made between the change in spherical equivalent induced by SMILE (SMILE-Dif) and the variance between IOL-Dif (IOL-Induced Refractive Error) before and after SMILE. The prediction error (PE) was defined as SMILE-Dif minus IOL-Dif. The proportion of eyes with PEs within ±0.25 D, ±0.50 D, ±0.75 D, and ±1.00 D, the numerical and absolute prediction errors (PEs and AEs), and the median absolute error (MedAE) were compared.

Results

In total, 80 eyes from 42 patients who underwent SMILE were included in the study. The FY-L formula generated the sample's lowest mean PE (0.06 ± 0.76 D), MAE (0.58 ± 0.50 D), and MedAE (0.47 D), respectively. The PEs in ±0.25 D, ±0.50 D, ±0.75 D, and ±1.00 D comprised 28.8%, 46.3%, 70.0%, and 87.5%, respectively, for the FY-L formula. Compared to other formulas, the FY-L formula produced the highest value with PEs for the percentage of eyes in ±0.50 D, ±0.75 D, and ±1.00 D.

Conclusion

This study demonstrates that the FY-L formula provides satisfactory outcomes in estimating the IOL power in the eyes after SMILE.

Effectiveness of Laser Refractive Surgery to Address Anisometropic Amblyogenic Refractive Error in Children: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature assessing the safety and effectiveness of laser refractive surgery to treat anisometropic amblyogenic refractive error in children aged ≤ 18 years.

METHODS

A literature search of the PubMed database was conducted in October 2021 with no date limitations and restricted to publications in English. The search yielded 137 articles, 69 of which were reviewed in full text. Eleven articles met the criteria for inclusion and were assigned a level of evidence rating.

RESULTS

The 11 included articles were all level III evidence and consisted of 1 case-control study and 10 case series. Six studies used laser-assisted in situ keratomileusis (LASIK), 1 used photorefractive keratectomy (PRK), 1 used refractive lenticule extraction/small incision lenticule extraction, and the rest used a combination of LASIK, PRK, laser epithelial keratomileusis (LASEK), or refractive lenticule extraction/small incision lenticule extraction. Five studies enrolled patients with anisometropic myopia, 2 studies enrolled patients with anisometropic hyperopia, and the remainder were mixed. Although all studies demonstrated an improvement in best-corrected visual acuity (BCVA), the magnitude of improvement varied widely. As study parameters varied, a successful outcome was defined as residual refractive error of 1 diopter (D) or less of the target refraction because this was the most commonly used metric. Successful outcomes ranged between 38% and 87%, with a mean follow-up ranging from 4 months to 7 years. Despite this wide range, all studies demonstrated an improvement in the magnitude of anisometropia. Regression in refractive error occurred more frequently and to a greater degree in myopic eyes and eyes with longer follow-up, and in younger patients. Although one study reported 2 free flaps, most studies reported no serious adverse events. The most common complications were corneal haze and striae.

CONCLUSIONS

Findings from included studies suggest that laser refractive surgery may address amblyogenic refractive error in children and that it appears to decrease anisometropia. However, the evidence for improvement in amblyopia is unclear and long-term safety data are lacking. Long-term data and well-designed clinical studies that use newer refractive technologies in standardized patient populations would help address the role of refractive surgery in children and its potential impact on amblyopia.

Corneal morphological changes after small incision lenticule extraction for myopic anisometropia

Purpose

This research aims to study the corneal morphological changes in adult patients with myopic anisometropia after small incision lenticule extraction (SMILE) and the safety, efficacy, and predictability of clinical outcomes.

Methods

This was a prospective cohort study. Patients with myopic anisometropia [refractive difference >2.0 diopters (D)] were included in this study who underwent SMILE at our hospital from September 2019 to March 2021. For the two eyes of each patient, the one with higher myopia was defined as group A, and the fellow eye was group B. The follow-up time points were set as 1 week, 1 month, 3 months, and 6 months after the surgery. The data collected were uncorrected and best-corrected distance visual acuity (UDVA and CDVA), spherical equivalent (SE), efficacy and safety indexes, posterior corneal elevation (PCE), anterior and posterior corneal radius of curvature in the 3 mm area at the center of the thinnest point of the cornea (ARC and PRC), and higher-order aberrations (HOAs).

Results

The study included 36 patients (72 eyes), and the mean age was 25.2 ± 6.4 years. The preoperative SEs were −6.45 ± 1.25 D in group A and −3.76 ± 1.29 D in group B. Six months after surgery, the SEs in groups A and B were −0.09 ± 0.50 D and 0.07 ± 0.47 (P = 0.059), respectively. The efficacy indexes were 1.06 ± 0.16 in group A and 1.07 ± 0.14 in group B (P = 0.750). The safety indexes were 1.08 ± 0.14 in group A and 1.12 ± 0.15 in group B (P = 0.173). The PCE was significantly reduced at 6 months after surgery in pagebreak both groups (P < 0.05). The ARC was significantly higher than before the surgery (P < 0.05) in the two groups. The two groups showed significant increases in total HOAs, coma 90°, and spherical aberrations (P < 0.05).

Conclusion

SMILE is predictable, effective, and safe in correcting myopic anisometropia. The postoperative changes in HOAs are characteristic.