PURPOSE: To compare the outcomes of enhancement after small incision lenticule extraction (SMILE) using surface ablation versus the VisuMax CIRCLE option (Carl Zeiss Meditec AG, Jena, Germany), which converts the SMILE cap into a femtosecond laser–assisted laser in situ keratomileusis flap. METHODS: The databases of the SMILE Eyes centers in Munich, Marburg, and Cologne, Germany, and Linz, Austria, were screened for eyes that had undergone enhancement using surface ablation with mitomycin C or CIRCLE. Eyes from both enhancement methods suitable for a retrospective matched analysis were identified based on pre-SMILE and pre-enhancement mean refractive spherical equivalent (MRSE), astigmatism, age, and corrected and uncorrected distance visual acuity (CDVA/UDVA). Refractive and functional outcomes were compared after a follow-up of 3 months. RESULTS: After the application of the matching criteria on 2,803 SMILE procedures, 24 eyes (12 in each group) with a follow-up of 3 months or longer were available for analysis. Enhancement was performed after a mean 9.7 ± 7.2 (surface ablation) and 11.0 ± 4.4 (CIRCLE) months for a residual MRSE of −0.91 ± 0.55 (surface ablation) and −0.90 ± 0.61 (CIRCLE) diopters. At 3 months, residual MRSE showed comparable accuracy with −0.07 ± 0.19 (surface ablation) and 0.04 ± 0.22 (CIRCLE) diopters ( P = .18). UDVA improvement was similar to a final value of 0.02 ± 0.10 (surface ablation) versus 0.03 ± 0.07 (CIRCLE) logMAR ( P = .78). Only one eye in the surface ablation group and no eye in the CIRCLE group lost one line of CDVA. At 3 months, the safety (surface ablation: 1.00, CIRCLE: 1.06; P = .36) and efficacy (surface ablation: 0.95, CIRCLE: 1.03; P = .36) indices were equivalent. In terms of speed of visual recovery, at week 1 UDVA and CDVA were significantly better after CIRCLE than surface ablation ( P = .008 and .002, respectively). CONCLUSIONS: In this first study directly comparing surface ablation versus CIRCLE enhancement after SMILE, both methods yielded comparable results at 3 months. However, CIRCLE re-treated eyes showed a markedly increased speed of recovery concerning UDVA and CDVA compared to surface ablation. [ J Refract Surg . 2019;35(5):294–300.]

The CIRCLE procedure represents an effective re-treatment option after SMILE. Compared to surface ablation re-treatment after SMILE, CIRCLE seems to offer advantages in respect to speed of visual recovery, safety, and predictability, but at the price of flap creation. [J Refract Surg. 2018;34(5):304-309.].

PurposeA retrospective comparison of refractive outcomes of a new, aspherically optimized profile with an enhanced energy correction feature (Triple-A) and the conventionally used aspherically optimized profile (ASA, or aberration smart ablation) for correction of low-to-high myopia.SettingAugen-OP-Centrum, Cologne, GermanyDesignRetrospective nonrandomized comparative studyMethodsA central database at the Augen-OP-Centrum was used to gather retrospective data for low-to-high myopia (up to −10 D). One hundred and seven eyes (56 patients) were treated with the ASA profile, and 79 eyes (46 patients) were treated with the Triple-A profile. Postoperative outcomes were evaluated at 1 month, 3 months, 6 months, and 1 year follow-up time points.ResultsThe Triple-A profile showed better predictability indicated by a significantly lower standard deviation of residuals (0.32–0.34 vs 0.36–0.44, Triple-A vs ASA) in the 6-month to 1-year period. The Triple-A group had better stability across all time intervals and achieved better postoperative astigmatism improvements with significantly lower scatter. This group achieved better safety at 1 year, with 100% of eyes showing no change or gain in Snellen lines, compared with 97% in the ASA group. A better safety index was observed for the Triple-A group at later time points. The Triple-A group had a better efficacy index and a higher percentage of eyes with an uncorrected Snellen visual acuity of 20/20 or greater at all investigated follow-up time points.ConclusionThe new aspherically optimized Triple-A profile can safely and effectively correct low-to-high myopia. It has demonstrated superiority over the ASA profile in most refractive outcomes.

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