Purpose: To evaluate the intraexaminer repeatability and the interobserver reproducibility of manifest refraction. Setting: Tertiary referral center. Design: Retrospective study. Methods: Patients attending at least 2 preoperative refractions before undergoing subsequent refractive surgery were included. All manifest refractions were performed by 1 of 4 experienced optometrists using an automated phoropter according to a standard protocol. The first manifest refraction was performed after obtaining automated refraction and measuring the spectacles of the patient. The second refraction was typically refined from the first also considering wavefront refraction and tomography/topography. Results: The latest 2 manifest refractions of 1000 eyes obtained at 2 separate visits showed a mean pairwise absolute difference of 0.16 ± 0.19 diopter (D) (range 0 to 1.38 D) in spherical equivalent (SE). This SD was better than 0.25 D (the minimum measurement increment of refraction itself). The 95% limit of agreement (LoA) was within 0.50 D for sphere, cylinder, and SE. The SD of the astigmatism axis was approximately 10 degrees, and the 95% LoA was within 22 degrees (the difference in axis decreasing significantly with the measured cylinder magnitude). The SD for corrected distance visual acuity (CDVA) was half a Snellen line and the 95% LoA was within 1.5 lines (with increasing deviation with worse vision). There were no clinically meaningful differences in reproducibility (2 optometrists) compared with repeatability (same optometrist) in sphere, axis, and CDVA. Conclusions: Reproducibility was 0.16 D irrespective whether refractions were performed by 1 or 2 different optometrists. Obtaining multiple refractions preoperatively might increase the predictability of surgery and decrease the enhancement rate.
This report illustrates that the currently used prophylactic CXL protocol in combination with LASIK may not be effectively preventing corneal ectasia in every case. [J Refract Surg. 2017;33(1):50-52.].
Purpose:Excimer laser-based refractive procedures can have less predictable results when used for correcting high myopia than when used for moderate myopia. Small incision lenticule extraction might overcome this weakness. However, small incision lenticule extraction is only Food and Drug Administration approved for use in myopic eyes up to −8 D with astigmatism of −3 D or less. We report outcomes of small incision lenticule extraction in highly and moderately myopic eyes and compare these to modern laser-assisted in situ keratomileusis.Methods:Retrospective, observational consecutive case series. Inclusion criteria: attempted myopic spherical correction ⩾−8 or−3 to −7.75 D with astigmatism ⩽−3 D, and corrected distance visual acuity of 1.0 (decimal scale) or better.Results:A total of 62 highly myopic and 407 moderately myopic eyes were included. At 3 months postoperatively, the highly myopic eyes had a mean spherical equivalent refraction of −0.28 ± 0.41 D (range: −1.13 to +0.75 D). Mean uncorrected distance visual acuity was 1.0. Mean efficacy index was 0.84. Mean safety index was 1.03. Uncorrected distance visual acuity same or better than corrected distance visual acuity: 61%. Astigmatism was ⩽0.5 D in 90% and ⩽1 D in 100%. The results in the moderately myopic eyes were comparable.Conclusion:We found equally good visual and refractive outcomes after small incision lenticule extraction for the correction of high and of moderate myopia combined with an astigmatic correction of up to 3 D, respectively.
Small Incision Lenticule Extraction (SMILE) is a relatively new surgical method to correct myopia and myopic astigmatism. Although considered to be safe and effective, it is not yet popular. Potential reasons for its limited use could be that surgeons fear inferior results and a higher complication rate in the learning phase. Therefore we present our experiences with the treatment of our first 200 eyes, with special attention to refraction results, complications, and learning curve. 200 myopic or myopic astigmatic eyes of 102 patients were treated with SMILE. The analysis was separated into two phases: Phase I (first 100 treatments) with large variation of laser parameters and surgical technique, phase II (second 100 treatments) with mostly constant laser parameters and identical surgical technique. Phase I showed the following 3-month results after a mean attempted correction of - 5.70 ± 2.54 D (range: - 1.25 to - 10.00 D): spherical equivalent - 0.03 ± 0.46 D, astigmatism - 0.34 ± 0.35 D, uncorrected distance visual acuity 1.02, corrected distance visual acuity (CDVA) 1.22. Postoperative and preoperative CDVA did not differ (p = 0.71). Mean refraction reached the targeted value after 5 days. Efficacy index was 0.55 ± 0.19 at day 1, 0.67 ± 0.22 at day 5, and 0.87 ± 0.23 at 3 months. In Phase II, the efficacy index improved to 0.63 ± 0.25 (p = 0.039) at day 1 and to 0.75 ± 0.26 (p = 0,02) at day 5. The most frequent complications were intraoperative abrasions and epithelial cells in the interface. Almost all complications occurred less frequently in Phase II. Our first SMILE treatments showed very good refractive predictability, very good safety and rapid visual recovery. Results after high myopic corrections were equivalent to or better than our first Femto-LASIK treatments. We had a much higher complication rate than with our LASIK treatments - that have been established over several years. All complications could be managed without loss of visual acuity. Visual recovery was faster and complications less frequent with experience gained. SMILE has replaced LASIK as our preferred treatment modality for the correction of myopic astigmatic eyes.
Purpose:To compare the visual and refractive outcomes of small incision lenticule extraction and advanced surface ablation for low myopia or myopic astigmatism.Methods:Retrospective, observational case series of our first 50 consecutive small incision lenticule extraction patients compared to refraction-matched 50 advanced surface ablation treatments with attempted spherical equivalent correction ⩽−3.5 D, astigmatism ⩽−1.5 D, and corrected distance visual acuity of 1.0 (decimal scale) or better. Only one eye per patient was included.Results:Small incision lenticule extraction: mean attempted spherical equivalent correction was −2.80 ± 0.63 D. Uncorrected distance visual acuity was 0.85 and 1.0 at days 1 and 5, respectively. At 3 months, mean spherical equivalent refraction was 0.02 ± 0.32 D (range: −0.5 to +0.75 D), mean cylinder was −0.24 ± 0.21 D (range: 0 to −0.75 D), mean uncorrected distance visual acuity was 1.27, mean efficacy index was 0.96, and mean safety index was 1.05. Uncorrected distance visual acuity was same or better than corrected distance visual acuity in 96%, astigmatism ⩽0.5 D in 98% and ⩽1 D in 100% of eyes, respectively. Advanced surface ablation: mean attempted spherical equivalent correction was −2.75 ± 0.5 D. Uncorrected distance visual acuity was 0.72 and 0.61 at days 1 and 5, respectively. At 3 months, mean spherical equivalent refraction was 0.22 ± 0.32 D, mean cylinder was −0.27 ± 0.27 D, mean uncorrected distance visual acuity was 1.21, mean efficacy index was 1.03, and mean safety index was 1.08.Conclusion:Small incision lenticule extraction for low myopia was found to be safe and effective with outcomes at 3 months similar to those obtained with advanced surface ablation while offering a quicker visual recovery.
PURPOSE: To compare varifocal (SupraCor; Technolas Perfect Vision GmbH, Munich, Germany) to monofocal (Zyoptix TissueSaving; Bausch & Lomb, Rochester, NY) LASIK in patients with hyperopic presbyopia. METHODS: In this prospective, non-randomized, comparative case series, consecutive patients with hyperopia, presbyopia, and emmetropia as target refraction were bilaterally treated with varifocal (8 patients) or monofocal (7 patients) LASIK. The study was designed for 35 patients, but was terminated early after interim analysis. Outcomes (preoperative and 1 day, 1 week, 1 month, and 3 months postoperative) were: monocular and binocular uncorrected near visual acuity (UNVA), distance-corrected near visual acuity (DCNVA), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), low-contrast UDVA and CDVA, efficacy, and safety. RESULTS: Preoperative data were similar in both groups. Monocular and binocular UNVA were not significantly different between both groups at any follow-up visit. At 3 months, mean monocular UNVA was 0.40 logMAR in both groups. Monocular DCNVA and binocular CDVA were not significantly different between groups. Monocular mean CDVA was 0.00 ± 0.06 logMAR after varifocal LASIK and −0.06 ± 0.04 logMAR after monofocal LASIK. The efficacy index was 0.9 after vari-focal LASIK and 0.88 after monofocal LASIK (not significant). The safety index was 1.08 after varifocal LASIK and 1.125 after monofocal LASIK (not significant). CONCLUSIONS: With emmetropia as target refraction, varifocal ablations yielded no additional benefit compared to monofocal ablations in hyperopic presbyopic LASIK. The authors speculate that epithelial remodeling masks the impact of a varifocal ablation pattern and that a myopic postoperative refraction (modified monovision) may be necessary to further improve near and intermediate vision. These results demonstrate the value of a control group in studies evaluating presbyopia corrections. [ J Refract Surg. 2019;35(7):459–466.]
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