Topography-guided excimer laser ablation

Comparing femtosecond LASIK and small-incision lenticule extraction (SMILE)

PURPOSE OF REVIEW

This review compares two refractive surgery modalities, femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and small-incision lenticule extraction (SMILE), focusing on their efficacy, safety, postoperative recovery, and patient-reported outcomes. The aim is to provide an updated review of recent findings and identify areas for additional research to further optimize surgical outcomes and patient selection.

RECENT FINDINGS

FS-LASIK and SMILE show excellent, comparable visual outcomes for the correction of myopia and astigmatism. SMILE may have a lower risk of dry eye and has no flap-related complications, while FS-LASIK provides quicker visual recovery. SMILE may offer superior long-term visual outcomes, particularly for high myopia. However, customized FS-LASIK (wavefront- and topography-guided) outperform SMILE in some visual metrics, including uncorrected visual acuity and reduction in higher-order aberrations.

SUMMARY

FS-LASIK remains the gold standard refractive procedure due to its rapid recovery and predictable results, but SMILE offers advantages in preserving corneal biomechanical stability and potentially minimizing dry eye symptoms. SMILE may also offer improved long-term stability for patients at risk of myopic regression. However, a growing body of evidence suggests that wavefront- and topography-guided LASIK yield superior visual outcomes compared to SMILE. Additional long-term comparative studies are needed for different refractive treatment requirements.

Patient-Reported Outcomes and Higher Order Aberrations Following Topography-Guided Femtosecond Laser-Assisted In Situ Keratomileusis

PURPOSE

To examine patient-reported outcomes and higher order aberrations following topography-guided laser-assisted in situ keratomileusis (LASIK).

METHODS

This was a prospective, nonrandomized observational study at a single academic center. Sixty eyes from 30 patients underwent bilateral topography-guided femtosecond LASIK for correction of myopia using the VisuMax 500 femtosecond laser (Zeiss; Oberkochen, Germany) and Allegretto Wave Eye-Q 400 Hz Excimer Laser (Alcon/Wavelight; Erlangen, Germany) with the Contoura topography system (Alcon; Geneva, Switzerland) for topography-modified refraction. The main outcomes of this study were higher order aberrations (HOAs) and results from the Patient-Reported Outcomes with LASIK questionnaire.

RESULTS

There was a small, significant increase in HOA root mean square, spherical aberration, and coma at 1, 3, 6, and 12 months following topography-guided LASIK (all P < 0.05), but no change in trefoil. In addition, self-reported worry related to vision ( P < 0.001) and ability to perform activities ( P < 0.001) significantly improved after surgery. The prevalence of double images, glare, halos, or starbursts decreased from 73% preoperatively to 56%, and no participants reported "very" or "extremely" bothersome visual symptoms after 12 months. Dry eye symptoms per Ocular Surface Disease Index score decreased significantly at 6 ( P = 0.01) and 12 ( P = 0.002) months after surgery. There was a 100% satisfaction rate with visual outcomes and duration of time to improvement in vision following the procedure.

CONCLUSIONS

Although there was an increase in HOAs following topography-guided LASIK, there were significant improvements in the presence of double images, glare, halos, and starbursts and vision-related quality-of-life metrics. Overall satisfaction rates in this study were high.

Laser in Situ Keratomileusis Outcomes and Complications: 2016 to 2023

PURPOSE

To review current clinical outcomes, complications, and patient satisfaction of laser in situ keratomileusis (LASIK) from studies published between 2016 and 2023, with a specific focus on refractive outcomes and topography-guided LASIK (TG-LASIK).

METHODS

A literature review was conducted using PubMed and Scopus, identifying studies reporting LASIK outcomes, complications, and patient satisfaction. Inclusion criteria required studies to report aggregate clinical data, using validated metrics for subjective outcomes. Studies on re-treatment, specific corneal/systemic disorders, or follow-up shorter than 1 month were excluded. Separate analyses were performed for TG-LASIK and other LASIK treatments.

RESULTS

Ninety-five studies met the final inclusion criteria. Myopic treatment achieved better outcomes than hyperopic treatment, with 88.3% and 69.2% reaching an uncorrected distance visual acuity (UDVA) of 20/20, respectively. TG-LASIK demonstrated superior refractive outcomes to LASIK myopic treatment, with 91.8% having 20/20 or better UDVA, and 95% and 100% of eyes achieving refractive accuracy within ±0.50 and ±1.00 diopters, respectively. Complication rates were low, with the most common being flap folds (0.73%). Sight-threatening complications occurred in 0.07% of the eyes. Patient satisfaction remained high, with 92.6% reporting satisfaction with surgery, and 99% would recommend the procedure to a friend.

CONCLUSIONS

LASIK remains a safe, effective, and highly satisfying refractive surgery, with TG-LASIK demonstrating superior outcomes compared to other LASIK treatments. Complications were infrequent, and subjective visual symptoms generally improved postoperatively. Future research should use standardized methods for assessing and reporting subjective outcomes, including preoperative and postoperative comparisons, to provide a more comprehensive understanding of LASIK outcomes. [J Refract Surg. 2025;41(4):e391-e403.].

Application of Surgical Protocols for the Treatment of Highly Irregular Astigmatism with Topographic Guided Ablation in a Case of Post-LASIK Ectasia

Purpose

To compare the outcomes of two different surgical planning strategies for topography-guided repair of post-LASIK ectasia.

Methods

This is a case report of a patient presenting with post-LASIK ectasia. A retrospective chart review was used to collect details of the ophthalmic exam, as well as ocular imaging such as anterior segment optical coherence tomography and Scheimpflug corneal tomography. Treatment planning was performed initially with the Phorcides analytical engine, and then an enhancement was performed with the LYRA/San Diego Protocol. Epithelium-off corneal cross-linking was performed at 3.0 mW/cm for 30 minutes.

Results

The patient initially presented with a remote history of LASIK and progressive left eye blurring. His uncorrected distance visual acuity (UDVA) was 20/40, with a corrected distance visual acuity (CDVA) of 20/25 with a manifest refraction of -1.25 +1.75 × 180. His central corneal thickness was 529 μm, and corneal topography/tomography demonstrated inferior steepening of the left eye consistent with post-LASIK ectasia. He underwent simultaneous PRK and epithelium-off corneal cross-linking with a treatment plan by Phorcides of -0.14 -0.87 × 001. His vision stabilized at post-operative month 7 to a UDVA 20/40, CDVA 20/20, and manifest refraction of -2.75 +3.50 × 005. He underwent PRK enhancement with a treatment plan by the San Diego Protocol of +0.00 -1.15 × 094, with an outcome of UDVA 20/20, CDVA 20/20, and manifest refraction of -1.00 +0.75 × 174.

Conclusion

The LYRA/San Diego Protocol outperformed Phorcides in a case of corneal ectasia. With appropriate planning, patients with irregular corneas can achieve excellent refractive outcomes.

Optimization of Ray-Tracing-Guided LASIK Outcomes: A Prospective Comparative Study of ZZ InnovEyes Strategy versus Automated Strategy

Purpose

To evaluate the effectiveness of Zhang and Zheng's InnovEyes (ZZ InnovEyes) strategy for optimizing outcomes of ray-tracing-guided laser in situ keratomileusis (LASIK) compared to the standard automated strategy.

Methods

A total of 38 patients (71 eyes) undergoing therapeutic refractive surgery at Hangzhou MSK Eye Hospital were randomly assigned to the ZZ InnovEyes and automated groups using double-masked randomization. The study assessed visual acuity, refractive outcomes, and higher-order aberrations preoperatively and at 1-day, 2-week, 1-month, and 3-month follow-ups. Statistical analysis was done with Microsoft Excel and SPSS 19.0.

Results

The exposure and control groups comprised 36 and 35 eyes, respectively. The ZZ InnovEyes group demonstrated significant advantages in manifest refraction spherical equivalent (MRSE) correction compared to the automated approach group (0.13 ± 0.30 D vs 0.62 ± 0.40 D, p < 0.001), achieving 97.22% uncorrected distance visual acuity (UDVA) of 20/16 or better compared to 85.71% in the automated group at the 3-month follow-up (p = 0.08), and achieving 50.00% UDVA of 20/12.5 or better compared to 28.57% in the automated group at the 3-month follow-up (p = 0.06). Loss lines from preoperative corrected distance visual acuity to postoperative UDVA were lower in the ZZ InnovEyes group (0.00%) than the automated group (8.57%; p = 0.07). Both groups exhibited similar astigmatism corrections and higher-order aberrations.

Conclusion

The ZZ InnovEyes strategy, which incorporates manifest and wavefront refraction for ray-tracing-guided LASIK, demonstrated superior MRSE correction and potential advantages in visual acuity outcomes compared to the standard automated strategy. This study highlights the need for ongoing optimization and research in refractive surgery.

Clinical Trial Registration Number

ChiCTR2300078709.

Application of sentiment and word frequency analysis of physician review sites to evaluate refractive surgery care

Background

Online physician reviews increase transparency in health care, helping patients make informed decisions about their provider. Language processing techniques can quantify this data and allow providers to better understand patients' experiences, perspectives, and priorities. The objective of this study was to assess patient satisfaction and understand the aspects of care that are valued by patients seeking refractive care using sentiment and word frequency analysis.

Methods

Written reviews and Star ratings for members of the Refractive Surgery Alliance Society practicing in the United States were collected from Healthgrades, a popular physician rating website. Surgeons with at least one written review were included in the study. Reviews were scored from -1 (most negative) to +1 (most positive) using Valence Aware Dictionary sEntiment Reasoner (VADER). Reviews were stratified by demographic characteristics, namely gender, region, and years in practice. Word frequency analysis was applied to find the most common words and phrases.

Results

A total of 254 specialists and 3104 reviews were analyzed, with an average of 4.4/5 stars and mean 48 ratings each. Most physicians had positive reviews (96%, average VADER ​= ​0.69). Younger physicians (<20 years since residency) had significantly higher Stars rating than senior peers (>20 years) (P ​< ​0.001). A similar trend was observed in VADER score (0.71 vs 0.69), although not statistically significant (P ​= ​0.06). No statistical differences were observed between Stars rating and VADER score by gender (P ​= ​0.66, P ​= ​0.83) or by geographical region (P ​= ​0.74, P ​= ​0.07). "Staff" (n ​= ​1269), "professional" (n ​= ​631), "office" (n ​= ​523), "questions" (n ​= ​424), and "friendly" (n ​= ​386) were frequently used in reviews, along with phrases such as "the staff" (n ​= ​273) and "my questions" (n ​= ​174). "Surgery" (n ​= ​719), "staff" (n ​= ​576), "procedure" (n ​= ​251), "experience" (n ​= ​243), and "professional" (n ​= ​240) were the most common words in positive reviews, while "surgery" (n ​= ​147), "office" (n ​= ​86), "staff" (n ​= ​54), "time" (n ​= ​47), and "insurance" (n ​= ​28) were the most commonly used in negative reviews.

Conclusions

Both the average Stars and VADER sentiment score suggest a high satisfaction among refractive patients. Word frequency analysis revealed that patients value non-clinical aspects of care, including interactions with staff, insurance coverage, and wait-times, suggesting that improving non-clinical factors could enhance patient satisfaction with refractive surgery.