Hindawi Publishing Corporation

Journal of Ophthalmology
Volume 2016, Article ID 2507973, 9 pages
http://dx.doi.org/10.1155/2016/2507973

Clinical Study
Comparison of the Optical Quality between Small Incision
Lenticule Extraction and Femtosecond Laser LASIK

Ying Jin, Yan Wang, Lulu Xu, Tong Zuo, Hua Li, Rui Dou, and Jiamei Zhang
Tianjin Eye Hospital, Tianjin Eye Institute, Tianjin Key Lab of Ophthalmology and Visual Science,
Tianjin Medical University and Nankai University, Tianjin 300020, China

Correspondence should be addressed to Yan Wang; [email protected]

Received 27 June 2016; Accepted 31 August 2016

Academic Editor: Vasilios F. Diakonis

Copyright © 2016 Ying Jin et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. To investigate the visual quality after SMILE and Femto-LASIK. Methods. About 123 eyes from 63 patients were enrolled
in this study. The parameters were measured preoperatively and 1 week, 1 month, and 3 months postoperatively using Sirius System.
Results. The MTF curve increase slightly from low to high frequency at 3 mm and 6 mm pupil diameter after SMILE surgery (𝑃 <
0.05) during the follow-up time comparing with the preoperative values. And the SR has a significant increase at various pupil
diameters as well (𝑃 < 0.05). However, there was little increase for MTF at intermediate to high frequency at 3 mm pupil diameter
after Femto-LASIK procedure (𝑃 < 0.05). And the SR had only significant increase at 3 mm pupil diameter. Between SMILE and
Femto-LASIK, there was no statistic difference both in MTF and SR (𝑃 > 0.05) at 3 mm pupil diameter at vertical and horizontal
meridian. However, significant difference was found in MTF at low to mediate frequency at 6 mm pupil diameter at vertical meridian
at 1 week postoperatively (𝑃 < 0.05). Conclusions. Both SMILE and Femto-LASIK show a great improvement in optical quality at
small diameter. It was found that SMILE shows better optical quality than Femto-LASIK at larger pupil diameter, which might be
good for the night vision.

1. Introduction takes into account diffraction effect and is usually evaluated as

Strehl ratio (SR). Therefore, this study was conducted to eval-
Small incision lenticule extraction (SMILE), without lifting uate the optical quality after SMILE procedure using these
a flap, has been proposed as an alternative to conventional two objective parameters, MTF and SR. And the results were
LASIK for the refractive correction. Interestingly, the recov- also compared with those after Femto-LASIK procedure in
ery of the visual acuity after this novel technique has been order to evaluate them objectively and comprehensively.
found to be slightly slower than that after other techniques
in the early postoperative period [1, 2]. Whether the optical 2. Participants and Methods
quality of the early stage after surgery is affected by this
phenomenon is not clear. In this prospective clinical comparative study, 63 eyes of 32
Modulation transfer function (MTF) and point spread patients who underwent SMILE and 61 eyes of 31 patients who
function (PSF) are two parameters to evaluate optical quality. underwent Femto-LASIK for the correction of myopia and
MTF indicates the ability of cornea to transfer various levels myopic astigmatism were included. Informed consent was
of detail from the object to the image. As a function of spatial obtained from each patient and the tenets of the Declaration
frequency, its units are the ratio of image contrast over the of Helsinki were followed. This study was approved by the
object contrast. Physical optics theory demonstrated that any Institutional Review Board and Ethics Committee of Tianjin
object is composed of an infinite array of point sources, each Eye Hospital, Tianjin, Chinese. The treatment eligibility crite-
with its respective intensity, position, and color. Convolution ria were identical for both groups: spherical myopia up to −10
operation gives each point of the PSF shape. Thus, PSF is the diopters (D) and myopic astigmatism up to −4D cylinders.
image that an optical system forms of a point source which is Other criteria were a minimum age of 21 years, corrected
the fundamental object and forms for any complex object. It distance visual acuity (CDVA) ≥ 0.8 (20/25) and no other
2 Journal of Ophthalmology

Table 1: Preoperative patients characteristics. separated bluntly and removed with a forceps through the
side-cut incision.
Mean ± SD a
Group 𝐹 𝑃
SMILE FS-LASIK 2.4. Femto-LASIK Procedure. The same femtosecond laser
Age, years 22.7 ± 5.6 23.30 ± 4.14 0.463 0.499 system was used in the Femto-LASIK group. Eyes had flap
SD, D −5.13 ± 1.25 −5.90 ± 1.85 8.605 0.058 creation performed with a 110 𝜇m flap thickness and pro-
MRSE, D −5.55 ± 1.23 −5.84 ± 1.90 9.787 0.055 grammed flap diameters of 7.9∼8.0 mm. standard 90∘ hinges
CCT, 𝜇m 551.78 ± 24.10 540.48 ± 31.55 3.076 0.089 and 90∘ side-cut angles. Stromal tissue ablation was per-
Mean K, D 43.32 ± 1.24 41.96 ± 1.26 0.347 0.547 formed with excimer laser system (Allegretto; WaveLight
Laser Technologie AG, Erlangen, Germany) whose repetition
ANOVA test.
SDa : standard deviation; SD: spherical degree; MRSE: manifest refraction
frequency was 400 kHz. The pulse energy was 150 nJ and the
spherical equivalent; K: Pentacam keratometry; CCT: central corneal thick- ablation diameter of the Gaussian spot profile was 1.0 mm.
ness. Eyes had ablations using an optical zone diameter of 6.0∼
6.5 mm surrounded by a transition zone of 1.0∼1.2 mm.
Both in the ReLEx SMILE group and in Femto-LASIK
ocular diseases except myopia and astigmatism. The central group, topical ofloxacin 0.3% (Tarivid; Santen, Inc., Osaka,
corneal thickness had to be more than 480 𝜇m, and the calcu- Japan) was applied 4 times daily for 2 days postoperatively.
lated residual stromal bed after treatment should more than 0.1% fluorometholone (Flumetholon; Santen, Inc., Osaka,
280 𝜇m. The patients were matched for similar age, refractive Japan) was applied 4 times per day for 2 weeks and then
error, and other preoperative parameters as shown later in tapered over 2 months.
Table 1. A regular corneal topographic shape was verified
by SIRIUS topography and values at 3 mm and 6 mm pupil 2.5. Statistical Analysis. All statistical analyses were per-
diameter of cornea were included in consideration of the formed by SPSS (20.0 USA). Repeat one-way analysis of vari-
pupil diameters’ effect on MTF and SR before the procedures. ance (ANOVA) was used for the analysis of the time course
All patients had a bilateral simultaneous procedure. Our of changes after surgery. The normality of all data samples
routine follow-up times were 1 week, 1 month, and 3 months. was first checked by the Kolmogorov–Smirnov test. The
Wilcoxon signed rank test was used for statistical analysis to
2.1. Examination Instruments. 3D Sirius-Complete Anterior compare the uncorrected distance visual acuity (UDVA) and
Segment Imaging System (Italy CSO, SIRIUS, software ver- manifest spherical equivalent between the two groups. The
sion: phoenis 1.2), which includes Scheimpflug tomographic difference change of MTF values, Strehl ratio, and RMS values
mapping of the cornea for shape, was used to measure the between SMILE and Femto-LASIK groups were tested by
MTF curves at various spatial frequencies (10, 20, 30, 40, 50, repeat one-way analysis of variance (ANOVA). The results are
and 60 cpd) and SR values at 3 mm and 6 mm pupil diameter expressed as mean ± SD. P value less than 0.05 was considered
of cornea. All examinations were operated by the same expert statistically significant.
technician. The examination was conducted immediately
after blink eyes under natural light. The patients were told 3. Results
to stare at the blue fixation light of the corneal topography.
Three eligible measurements were taken and the subjects were The preoperative characteristics of these two groups were
excluded if the three scans were of poor quality. The one of shown in Table 1. There was no significant difference in the
highest quality was chosen for analysis. The repeatability and preoperative parameters between the two groups.
reliability of SIRIUS for measuring segment parameters have
been demonstrated [3–5]. 3.1. Visual Acuity and Refraction. The preoperative Log MAR
UDVA was 1.10 ± 0.23 (0.50 to 1.54) in SMILE group and
2.2. Surgical Techniques. SMILE and Femto-LASIK proce- 1.08 ± 0.29 (0.50 to 1.52) in Femto-LASIK group. There was
dure were performed under topical anesthesia (Benoxil, no significant difference in Log MAR UDVA between two
Santen, Inc., Osaka, Japan) and all eyes were performed by groups. Three months postoperatively, the Log MAR UDVA
the same surgeon (Y. W.). was −0.17 ± 0.10 (range 0.00 to −0.30) in SMILE group and
in Femto-LASIK group the Log MAR UDVA was −0.14 ±
2.3. ReLEx SMILE Procedure. In ReLEx SMILE procedure, a 0.10 (range 0.10 to −0.30). The manifest spherical equivalent
femtosecond laser system (Carl Zeiss Meditec AG VisuMax) in SMILE group was −0.05 ± 0.26 (range: −0.50 to +1.25)
with a repetition rate of 500 kHz was used to perform the and −0.15 ± 0.26 (range: −0.75 to +1.25) for Femto-LASIK
whole surgical. The cap thickness set at 110 𝜇m and the diam- group. Wilcoxon signed rank test showed that there were no
eter was set 7.0∼7.5 mm. The lenticule size was 6.2 ± 0.2 mm significant differences in terms of Log MAR UDVA (𝑃 =
(range 6.0∼6.5 mm) with no transition zone for spherical 0.42) and manifest spherical equivalent (𝑃 = 0.58).
aberration and an 0.1 mm transition zone for astigmatism
correction. A side-cut incision angle was set 90∘ and the 3.2. Changes of MTF after SMILE. The MTF curve of the
side-cut incision was set at 2∼4 mm. the ablation energy was corneal surface at vertical and horizontal meridian increase
110∼175 nJ. The ablation order was as follows: the posterior significantly from low to high frequency at 3 mm pupil
surface of the lenticule; the anterior surface of the lenticule; diameter after SMILE procedure (𝑃 < 0.05 for all) during
the side cut and the side-cut incision. The lenticule was then the follow-up time (Figures 1(a) and 1(b)). However, the MTF
Journal of Ophthalmology 3

1 1
0.9 0.9
0.8 0.8
0.7 0.7
0.6 0.6 ∗
0.5 ∗ 0.5
0.4 0.4
0.3 0.3 ∗
∗
0.2 ∗ 0.2 ∗
∗ ∗ ∗
0.1 ∗ ∗ 0.1 ∗
0 0
0 10 cpd 20 cpd 30 cpd 40 cpd 50 cpd 60 cpd 0 10 cpd 20 cpd 30 cpd 40 cpd 50 cpd 60 cpd

Pre-op Post-op 1 month Pre-op Post-op 1 month

Post-op 1 week Post-op 3 months Post-op 1 week Post-op 3 months
(a) (b)
1 1
0.9 0.9
0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 ∗ 0.3
0.2 0.2
∗
0.1 ∗ ∗ 0.1
∗ ∗
0 0
0 10 cpd 20 cpd 30 cpd 40 cpd 50 cpd 60 cpd 0 10 cpd 20 cpd 30 cpd 40 cpd 50 cpd 60 cpd

Pre-op Post-op 1 month Pre-op Post-op 1 month

Post-op 1 week Post-op 3 months Post-op 1 week Post-op 3 months
(c) (d)

Figure 1: The changes of MTF values before and 1 week, 1 month, and 3 months after SMILE procedure. (a) The change of MTF curve at
vertical meridian at 3 mm pupil diameters; (b) the change of MTF curve at horizontal meridian at 3 mm pupil diameters; (c) the change
of MTF curve at vertical meridian at 6 mm pupil diameters; (d) the change of MTF curve at horizontal meridian at 6 mm pupil diameters.
∗
Significant difference among different follow-up times.

values only showed significant increase at vertical meridian high frequency at 6 mm pupil diameter during the follow-up
from low to high frequency at 6 mm pupil diameter before time (Figures 2(c) and 2(d)).
and after SMILE procedure (𝑃 < 0.05 for all) (Figures 1(c)
and 1(d)). 3.4. Changes in ΔMTF Values (Postoperative-Preoperative
MTF Value) between SMILE and Femto-LASIK Procedures.
3.3. Changes of MTF Values after Femto-LASIK. There was As shown in Figure 3, it can be seen that the MTF values
significant increase in the MTF values of anterior corneal sur- decrease following the increase of the frequency for both two
face at vertical meridian in low and mediate frequency (10, 20, groups. And the values in SMILE group were almost all higher
and 30 cpd) at 3 mm pupil diameter before and after Femto- than those in Femto-LASIK group. There was no significant
LASIK procedure (𝑃 < 0.05 for all) 1 week, 1 month, and difference in ΔMTF values from low to high frequency at
3 months postoperatively. However, there was no significant vertical and horizontal meridian of 3 mm pupil diameter
difference in the MTF values at horizontal meridian from between SMILE and Femto-LASIK procedures at 1 week,
low to high frequency at 3 mm optical zone before and after 1 month, and 3 months (𝑃 > 0.05 for all) (Figures 3(a)
Femto-LASIK procedure (𝑃 < 0.05 for all) (Figures 2(a) and and 3(b)). However, significant differences in ΔMTF values
2(b)). And there was also no significant difference in the MTF were shown at low frequency of vertical meridian at 6 mm
values at both vertical and horizontal meridian from low to pupil diameter during all the follow-up time (𝑃 < 0.05 for
4 Journal of Ophthalmology

1 1
0.9 0.9
0.8 0.8
0.7 0.7
0.6 0.6
0.5 ∗ 0.5
0.4 0.4
0.3 0.3
∗
0.2 ∗ 0.2
0.1 0.1
0 0
0 10 cpd 20 cpd 30 cpd 40 cpd 50 cpd 60 cpd 0 10 cpd 20 cpd 30 cpd 40 cpd 50 cpd 60 cpd

Pre-op Post-op 1 month Pre-op Post-op 1 month

Post-op 1 week Post-op 3 months Post-op 1 week Post-op 3 months
(a) (b)
1 1
0.9 0.9
0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 10 cpd 20 cpd 30 cpd 40 cpd 50 cpd 60 cpd 0 10 cpd 20 cpd 30 cpd 40 cpd 50 cpd 60 cpd

Pre-op Post-op 1 month Pre-op Post-op 1 month

Post-op 1 week Post-op 3 months Post-op 1 week Post-op 3 months
(c) (d)

Figure 2: The changes of MTF values before and 1 week, 1 month, and 3 months after Femto-LASIK procedure. (a) The change of MTF curve
at vertical meridian at 3 mm pupil diameters; (b) the change of MTF curve at horizontal meridian at 3 mm pupil diameters; (c) the change
of MTF curve at vertical meridian at 6 mm pupil diameters; (d) the change of MTF curve at horizontal meridian at 6 mm pupil diameters.
∗
Significant difference among different follow-up time.

all) (Figures 4(a), 4(b), and 4(c)). This showed a significant 3.6. Changes in ΔRMS Values between SMILE and Femto-
difference from low to high frequency of horizontal meridian LASIK Procedures. Significant differences in ΔRMS values of
3 months postoperatively (𝑃 < 0.05 for all) (Figure 4(f)). 3 mm pupil diameter were found between SMILE and Femto-
From the three-dimensional images of MTF values, it can be LASIK procedures at 1 month and 3 months postoperatively
found that SMILE showed an improvement in optical quality (𝑃 < 0.05). However, there was no significant difference in
(Figure 5). ΔRMS of 6 mm pupil diameter during the follow-up time
(𝑃 > 0.05 for all) (Table 2).
3.5. Changes in ΔStrehl Ratio Values between SMILE and
Femto-LASIK Procedures. Significant differences in ΔStrehl 4. Discussion
ratio values of 6 mm pupil diameter between SMILE and
Femto-LASIK procedures were shown between SMILE and Small incision lenticule extraction (SMILE), as a novel tech-
Femto-LASIK procedures at 1 week, 1 month, and 3 months nique of refractive correction, has been widely used in the
postoperatively (𝑃 = 0.038, 0.039, and 0.023, resp.). How- correction of myopia and myopic astigmatism. The clinical
ever, significant difference in ΔStrehl ratio values of 3 mm outcomes of SMILE used to correct refractive error have been
pupil diameter was only found at 1 month postoperatively demonstrated generally [6–8]. Visual acuity and high-order
(𝑃 < 0.05) between SMILE and Femto-LASIK procedures aberration after SMILE procedure have also been studied [8].
(Figure 6). However, to our knowledge, there are less studies on optical
Journal of Ophthalmology 5

0.12 0.14

Postoperative-preoperative MTF value

Postoperative-preoperative MTF value

0.12
0.10
0.10
0.08
(ΔMTF values)

(ΔMTF values)
0.08
0.06 0.06
0.04
0.04
0.02
0.02
0.00
0.00 −0.02
10 20 30 40 50 60 10 20 30 40 50 60
Frequency (cpd) Frequency (cpd)
Post-op 1 week Post-op 1 week
Post-op 1 month Post-op 1 month
Post-op 3 months Post-op 3 months
(a) (b)
0.12 0.12
Postoperative-preoperative MTF value

0.10 Postoperative-preoperative MTF value 0.10

0.08 (ΔMTF values) 0.08
(ΔMTF values)

0.06 0.06
0.04 0.04
0.02 0.02
0.00 0.00
−0.02 −0.02
−0.04 −0.04
10 20 30 40 50 60 10 20 30 40 50 60
Frequency (cpd) Frequency (cpd)
Post-op 1 week Post-op 1 week
Post-op 1 month Post-op 1 month
Post-op 3 months Post-op 3 months
(c) (d)

Figure 3: The changes in ΔMTF values (postoperative-preoperative MTF value) between SMILE and Femto-LASIK procedures at 1 week,
1 month, and 3 months postoperatively (up broken lines: Changes of MTF values at 1 week, 1 month, and 3 months after SMILE procedure
at different spatial frequency; lower broken lines: changes of MTF values at 1 week, 1 month, and 3 months after Femto-LASIK procedure
at different spatial frequency). (a) The change of MTF at vertical meridian at 3 mm pupil diameters; (b) the change of MTF at horizontal
meridian at 3 mm pupil diameters; (c) the change of MTF at vertical meridian at 6 mm pupil diameters; (d) the change of MTF at horizontal
meridian at 6 mm pupil diameters.

Table 2: ΔRMS at different pupil diameter between SMILE and Femto-LASIK procedure.

Group (mean ± SD)

Pupil diameter (𝜇m) Time 𝑡 𝑃
SMILE Femto-LASIK
Post-op 1 week 0.070 ± 0.208 0.010 ± −0.255 −1.886 0.062
3 mm Post-op 1 month 0.103 ± −0.182 0.053 ± 0.473 −2.561 0.012∗
Post-op 3 month 0.119 ± 0.172 0.054 ± 0.131 −2.325 0.022∗
Post-op 1 week 0.123 ± 1.005 0.459 ± 1.507 −1.433 0.152
6 mm Post-op 1 month −0.085 ± 0.693 0.364 ± 1.389 −1.628 0.089
Post-op 3 month −0.106 ± 0.128 0.593 ± 0.770 −1.875 0.063
Mann–Whitney 𝑈 nonparametric test.
SD: standard deviation; Pre-op: preoperation; Postop: postoperative.
∗
Significant differences (𝑃 < 0.05) in ΔRMS between SMILE and Femto-LASIK procedure.
6 Journal of Ophthalmology

0.14 0.14 0.14

0.12 0.12 0.12
0.1 0.1 0.1
0.08 0.08 0.08
∗ ∗
0.06 ∗ 0.06 0.06 ∗
0.04 ∗ ∗ 0.04 0.04
0.02 0.02 0.02
0 0 0
10 20 30 40 50 60 10 20 30 40 50 60 10 20 30 40 50 60
−0.02 −0.02 −0.02
(cpd) (cpd) (cpd)
−0.04 −0.04 −0.04
SMILE SMILE SMILE
FS-LASIK FS-LASIK FS-LASIK
(a) (b) (c)
0.14 0.14 0.14
0.12 0.12 0.12
0.1 0.1 0.1
0.08 0.08 0.08
0.06 0.06 0.06
∗
0.04 0.04 0.04 ∗
∗ ∗ ∗
0.02 0.02 0.02
0 0 0
10 20 30 40 50 60 10 20 30 40 50 60 10 20 30 40 50 60
−0.02 −0.02 −0.02
(cpd) (cpd) (cpd)
−0.04 −0.04 −0.04
SMILE SMILE SMILE
FS-LASIK FS-LASIK FS-LASIK
(d) (e) (f)

Figure 4: The changes in ΔMTF values at 6 mm pupil diameter (postoperative-preoperative MTF value) between SMILE and Femto-LASIK
procedures at 1 week, 1 month, and 3 months postoperatively. (a) The change of ΔMTF at vertical meridian at 1 week postoperatively; (b) the
change of ΔMTF at vertical meridian at 1 month postoperatively; (c) the change of ΔMTF at vertical meridian at 3 months postoperatively;
(d) the change of ΔMTF at horizontal meridian at 1 week postoperatively; (e) the change of ΔMTF at horizontal meridian at 1 month
postoperatively; (f) the change of ΔMTF at horizontal meridian at 3 months postoperatively. ∗ Significant differences (𝑃 < 0.05) in ΔMTF
between SMILE and Femto-LASIK group.

quality after SMILE procedure. This study was conducted to visual outcomes, our results suggest that both two groups
compare the MTF and PSF values changes between SMILE experienced highly effective myopia correction. Therefore,
and Femto-LASIK surgery in order to evaluate the optical both groups showed significant improvement in low and high
quality of the early stage postoperatively. frequency at 3 mm pupil diameter during the follow-up time.
The result showed that the MTF curve of the corneal Secondly, the optical quality of human eyes can be
surface at vertical and horizontal meridian increases signif- affected mainly by defocus while the effect of high-order
icantly from low to high frequency at 3 mm pupil diameter aberrations only takes 10%∼20%. After surgery, the defocus
before and after SMILE procedure during the follow-up time. was corrected. And the MTF values would be improved.
And it only showed significant increase at vertical meridian However, for Femto-LASIK group, there was no signif-
of low and high frequency (10, 20, and 30 cpd) at 3 mm icant difference in MTF values of high frequency at 3 mm
pupil diameter after Femto-LASIK procedure. Some reasons pupil diameter after surgery comparing to preoperative.
may contribute to this difference in MTF values after SMILE Many previous studies have shown that small irregularities
and Femto-LASIK surgery. Firstly, MTF analyzes the image in the stromal surface, such as tissue bridges and interface
contrast as a function of frequency. The low frequency reflects debris, can lead to light scatter and elevated straylight values
the capability to identify an object’s contour. The mediate [10, 11]. Our previous study shows that straylight increased
frequency reflects the transfer capability of the objects’ layers, significantly in the early stages after Femto-LASIK [12] and
and it can indicate the outcomes of visual acuity and contrast there was more increase in straylight than those after SMILE
sensitivity. The high frequency of the curve reflects the [13]. Therefore, we speculate that increased straylight may
transfer capability of the objects’ details [9]. Regarding the affect the results of MTF after Femto-LASIK.
Journal of Ophthalmology 7

1.0 1.0

0.5 0.5

0.0 0.0
60 60 60 60

0 0 0 0
(a) (b)
1.0 1.0

0.5 0.5

0.0 0.0
60 60 60 60

0 0 0 0
(c) (d)

Figure 5: The three-dimensional images of MTF values ((a) before procedure; (b) 1 week after procedure; (c) 1 month after procedure; (d) 3
months after SMILE procedure).

∗
0.14
0.14

0.12
0.12

0.1 0.1

0.08 0.08
∗
0.06 0.06
∗ ∗

0.04 0.04

0.02 0.02

0 0
Post-op 1 week Post-op 1 month Post-op 3 months Post-op 1 week Post-op 1 month Post-op 3 months
−0.02 −0.02
SMILE SMILE
Femto-LASIK Femto-LASIK
(a) (b)

Figure 6: Changes in ΔStrehl ratio values between SMILE and Femto-LASIK procedures ((a) 3 mm pupil diameter, (b) 6 mm pupil diameter).
∗
Significant differences (𝑃 < 0.05) in ΔStrehl ratio values between SMILE and Femto-LASIK procedures.
8 Journal of Ophthalmology

We also found that there was no significant difference during the flap creating. Therefore, patients are more likely
in the MTF values at horizontal meridian from low to high to suffer dry eye after Femto-LASIK than SMILE procedure.
frequency at 3 mm pupil diameter before and after Femto- It was presumed that the MTF values after Femto-LASIK
LASIK procedure. That might be related to the direction of are more likely affected by tear film quality than those after
the flap. The pedicle of the flap is located on the nasal SMILE surgery. A study shows that ocular forward light
side. Thus, the transverse wound healing may decrease the scattering from the anterior cornea was greater in dry eyes
MTF value. For the SMILE surgery, one study [14] has than in normal eyes [18]. Thus, in this study, we can find that
demonstrated that the early inflammatory and wound healing the ΔStrehl ratio in Femto-LASIK shows less change than in
response were minimal. This might be another reason why SMILE group during the follow-up time.
the MTF improved after SMILE surgery. In conclusion, SMILE shows a great improvement in opti-
Our previous study [15] found that average optical quality cal quality both under small and lager pupil diameter at early
in those eyes after correction of sphere and cylinder was stage postoperatively. Femto-LASIK has shown improvement
dependent on pupil size. Over a large range of spatial in optical quality at small pupil diameter. SMILE shows better
frequencies, the average ΔMTF in the 3 mm pupils diameter optical quality than Femto-LASIK at lager pupil diameter. It
were almost identical between SMILE and Femto-LASIK means that better night vision might be shown after SMILE
eyes, while for 6 mm pupil diameter the MTF was much lower procedure. However, further investigations on the optical
than those for the 3 mm pupil diameter across all spatial quality may be needed due to the complex nature of visual
frequencies. It also can be seen that, with a 6 mm pupil system.
diameter, SMILE was higher than that for Femto-LASIK at
spatial frequencies less than 60 cpd during the follow-up Competing Interests
time. The ΔMTF also shows that much more changes in low
frequency at vertical meridian of 6 mm pupil diameter were None of the authors has a financial interest related to this
found in SMILE group than Femto-LASIK group at 1 week, study.
1 month, and 3 months postoperatively. At horizontal merid-
ian, significant differences were found in MTF values from Acknowledgments
low to high frequency at 3 months after surgery. The ΔStrehl
ratio also shows a significant difference between SMILE and This work was supported by the National Natural Science
Femto-LASIK group at 1 month at 3 mm pupil diameter and Foundation of China (Grant no. 81470658).
at 1 week, 1 month, and 3 months postoperatively at 6 mm
pupil diameter. Thus, from these, it can be seen that the References
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Higher-order RMS and MTF were both used to evaluate refractive surgery using the small incision lenticule extraction
image quality, although the exact relationship between the (SMILE) procedure for the correction of myopia and myopic
astigmatism: results of a 6 month prospective study,” British
two metrics was dependent on the relationships between
Journal of Ophthalmology, vol. 95, no. 3, pp. 335–339, 2011.
Zernike coefficients [15]. One of our previous studies showed
that, for an equal increase of pupil size, not all Zernike poly- [2] R. Shah, S. Shah, and S. Sengupta, “Results of small incision
lenticule extraction: all-in-one femtosecond laser refractive
nomial coefficients induced equivalent increase of values.
surgery,” Journal of Cataract and Refractive Surgery, vol. 37, no.
Coma-like aberrations had less increase following the pupil 1, pp. 127–137, 2011.
dilation. Spherical-like aberration and other higher-order
[3] H. A. Bayhan, S. Aslan Bayhan, E. Muhafiz, and I. Can, “Repeat-
aberrations also showed slight increase following the pupil
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