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      Research Progress on Morphological Changes and Surgery-Related Parameters of Corneal Cap in Small-Incision Lenticule Extraction


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          Small-incision lenticule extraction (SMILE) is an “all-in-one” surgical method for refractive correction. An advantage of the SMILE over traditional surgery is that it depends on the corneal cap’s design. This review discusses the morphological evaluation of the corneal cap, selection of the corneal cap with different thicknesses and diameters, influence of the corneal cap design on re-treatment, and management of corneal cap-related complications. The following points should be recognized to define the correct morphology and design of the operation-related parameters of the corneal cap during SMILE: (1) the thickness and diameter of the corneal cap are predictable and influence postoperative visual quality, (2) the change in the anterior surface curvature of the corneal cap should be considered in the design of the nomogram value, (3) for patients with moderate myopic correction, early visual quality is better with a 6.9-mm than with a 7.5-mm-diameter corneal cap, (4) there is no significant difference in visual quality or biomechanics among corneal caps with different thicknesses, (5) the primary corneal cap thickness plays an important role in the SMILE re-treatment, (6) a 7.78-mm diameter corneal cap has a greater risk of suction loss than a 7.60-mm diameter corneal cap, (7) if suction loss occurs when lenticular scanning exceeds 10%, then SMILE can be continued by changing the corneal cap thickness, (8) preventive collagen cross-linking with SMILE caps are 90–120 μm thick and 7–7.8 mm in diameter, and (9) properly treating SMILE-related complications ensures better postoperative results. The data presented herein shall deepen the understanding of the importance of the corneal cap during SMILE and provide diversified analysis for personalized operational design of corneal cap parameters.

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          Most cited references86

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          Refractive surgery

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            Safety and complications of more than 1500 small-incision lenticule extraction procedures.

            To evaluate the safety and complications of small-incision lenticule extraction (SMILE). Clinical control cohort study. A total of 922 healthy patients (1800 eyes) who were treated for myopia or myopic astigmatism between January 2011 and March 2013 at the Department of Ophthalmology, Aarhus, Denmark. Patients received a full preoperative examination and were treated with SMILE in both eyes and followed for 3 months (1574 eyes). Patients with complications, including loss of corrected distance visual acuity (CDVA) or dissatisfaction, were offered a late reexamination. Surgical complications and CDVA. Mean preoperative spherical equivalent refraction was -7.25±1.84 diopters (D). Average postoperative refraction was -0.28±0.52 D, and mean error of treatment was -0.15±0.50 D. By 3 months, 86% (1346 eyes) had unchanged or improved CDVA. A loss of 2 or more lines was observed in 1.5% of eyes; however, at a late follow-up visit (average, 18 months), CDVA was within 1 line of the preoperative level in all eyes. Perioperative complications included epithelial abrasions (6%), small tears at the incision (1.8%), and difficult lenticule extraction (1.9%). The cap was perforated in 4 eyes, and a major tear occurred in 1 eye; however, none of these patients had late visual symptoms. In 0.8% (14 eyes), suction was lost during surgery. Re-treatment was successful in 13 eyes, whereas 1 eye had ghost images and was re-treated with topography-guided photorefractive keratectomy (PRK). Postoperative complications included trace haze (8%), epithelial dryness on day 1 (5%), interface inflammation secondary to central abrasion (0.3%), and minor interface infiltrates (0.3%); these complications had an impact on CDVA at 3 months in only 1 case. Irregular corneal topography occurred in 1.0% of eyes, resulting in reduced 3-month CDVA (12 eyes) or ghost images (6 eyes). Topography-guided PRK was performed in 4 eyes, with improvement in 3 cases. Satisfaction was high, with only 2 patients dissatisfied at their latest visit because of blurred vision or residual astigmatism. Overall, SMILE had acceptable safety. Although 1.5% of eyes had reduced CDVA by 3 months, visual acuity was restored in the long term. Likewise, patient satisfaction was high. Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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              Mathematical model to compare the relative tensile strength of the cornea after PRK, LASIK, and small incision lenticule extraction.

              To develop a mathematical model to estimate the relative differences in postoperative stromal tensile strength following photorefractive keratectomy (PRK), LASIK, and small incision lenticule extraction (SMILE). Using previously published data where in vitro corneal stromal tensile strength was determined as a function of depth, a mathematical model was built to calculate the relative remaining tensile strength by fitting the data with a fourth order polynomial function yielding a high correlation coefficient (R(2) = 0.930). Calculating the area under this function provided a measure of total stromal tensile strength (TTS), based only on the residual stromal layer for PRK or LASIK and the residual stromal layers above and below the lenticule interface for SMILE. Postoperative TTS was greatest after SMILE, followed by PRK, then LASIK; for example, in a 550-μm cornea after 100-μm tissue removal, postoperative TTS was 75% for SMILE (130-μm cap), 68% for PRK, and 54% for LASIK (110-μm flap). The postoperative TTS decreased for thinner corneal pachymetry for all treatment types. In LASIK, the postoperative TTS decreased with increasing flap thickness by 0.22%/μm, but increased by 0.08%/μm for greater cap thickness in SMILE. The model predicted that SMILE lenticule thickness could be approximately 100 μm greater than the LASIK ablation depth and still have equivalent corneal strength (equivalent to approximately 7.75 diopters). This mathematical model predicts that the postoperative TTS is considerably higher after SMILE than both PRK and LASIK, as expected given that the strongest anterior lamellae remain intact. Consequently, SMILE should be able to correct higher levels of myopia. Copyright 2013, SLACK Incorporated.

                Author and article information

                Ophthalmic Res
                Ophthalmic Research
                S. Karger AG
                February 2022
                20 October 2021
                : 65
                : 1
                : 4-13
                Corneal Refraction Department, The Second Hospital of Jilin University, Changchun, China
                Author notes
                *Shurong Wang, srwang@jlu.edu.cn
                520241 Ophthalmic Res 2022;65:4–13
                © 2021 The Author(s) Published by S. Karger AG, Basel

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                : 11 June 2021
                : 10 October 2021
                Page count
                Figures: 1, Tables: 1, Pages: 10
                Review Article

                Vision sciences,Ophthalmology & Optometry,Pathology
                Corneal cap,Re-treatment,Surgical parameters,Complication,Small-incision lenticule extraction


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