Effects of two different femtosecond laser surgeries for the treatment of thin corneal myopic astigmatism
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摘要:目的
探讨飞秒激光制瓣的准分子激光原位角膜磨镶术(FS-LASIK)与飞秒激光小切口角膜基质透镜取出术(SMILE)治疗薄角膜近视散光的效果。
方法选取2022年9月—2023年9月本院收治的薄角膜近视散光患者128例为研究对象，随机分为FS-LASIK组(64例, 128眼，接受FS-LASIK治疗)和SMILE组(64例, 124眼，接受SMILE治疗)。比较2组患者术前及术后1年视力水平[未矫正视力(UCVA)、最佳矫正视力(BCVA)]，术后3、6、12个月的屈光参数等效球镜(SE)水平，术前及术后1年角膜表面形态[角膜平均曲率值(KAve)、角膜表面规则指数(SRI)、角膜表面不对称指数(SAI)], 以及角膜生物力学参数[角膜扩张综合偏差分析指数(BAD-D)、角膜生物力学指数(CBI)、综合分析指数(TBI)]、角膜损伤程度[角膜内皮细胞计数、角膜内皮细胞大小变异系数(CV)]、术后散光矫正矢量指标[误差幅度(ME)、误差角度(AE)、矫正指数(CI)和成功指数(IOS)]的差异，并记录术后残余基质床厚度及并发症发生情况。
结果术后1年, 2组UCVA和BCVA均较术前升高，差异有统计学意义(P < 0.05), 但组间比较差异无统计学意义(P>0.05)。术后3、6、12个月, 2组SE水平均高于术前，差异有统计学意义(P < 0.05), 但组间以上时点的SE水平比较，差异无统计学意义(P>0.05)。术后1年, 2组角膜表面形态KAve、SRI、SAI水平均较术前降低，且SMILE组低于FS-LASIK组，差异有统计学意义(P < 0.05)。术后1年, 2组BAD-D和TBI均较术前升高, CBI均较术前降低，但SMILE组BAD-D和TBI低于FS-LASIK组, CBI高于FS-LASIK组，差异有统计学意义(P < 0.05)。术后1年, 2组角膜内皮细胞计数均较术前降低，角膜内皮细胞大小CV较术前升高，但SMILE组角膜内皮细胞计数高于FS-LASIK组，角膜内皮细胞大小CV低于FS-LASIK组，差异有统计学意义(P < 0.05)。2组术后ME、AE、CI和IOS比较，差异无统计学意义(P>0.05)。术后FS-LASIK组残余基质床厚度为(302.01±55.03) μm, SMILE组为(310.23±46.03) μm, 差异无统计学意义(t=1.284, P=0.200); 术后1年, FS-LASIK组发生干眼症5例, SMILE组2例, 2组干眼症发生率比较，差异无统计学意义(χ2=1.227, P=0.268)。
结论对于薄角膜的近视散光患者, 应用FS-LASIK和SMILE治疗均能取得满意的视力提升和屈光改善效果，但后者对角膜结构完整性、生物力学稳定性以及手术损伤程度的影响相对更小。
Abstract:ObjectiveTo explore the effect of femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and small incision lenticule extraction (SMILE) femtosecond laser in the treatment of myopic astigmatism with thin cornea.
MethodsFrom September 2022 to September 2023, 128 patients with thin cornea myopic astigmatism in the hospital were selected and randomly divided into FS-LASIK group (64 cases, 128 eyes, receiving FS-LASIK) and SMILE group (64 cases, 124 eyes, receiving SMILE). The visual acuity [uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA)] before surgery and at 1 year after surgery, refractive parameter spherical equivalent (SE) at 3, 6 and 12 months after surgery, corneal surface morphology [average corneal curvature (KAve), surface regularity index (SRI), surface asymmetry index (SAI)] before surgery and at 1 year after surgery, corneal biomechanic indicators[corneal expansion comprehensive deviation analysis index (BAD-D), corneal biomechanical index (CBI), total biomechanical index (TBI)] and corneal injury degree [corneal endothelial cell count, corneal endothelial cell size, coefficient of variation (CV)] and differences in postoperative astigmatism correction vector indicators [magnitude of error (ME), angle of error (AE), correction index (CI), and index of success (IOS)] were compared. Residual stromal bed thickness and the incidence of complications after surgery were recorded.
ResultsOne year after surgery, both UCVA and BCVA in both groups were improved compared with preoperation (P < 0.05), but there were no significant between-group differences (P>0.05). At 3, 6, and 12 months postoperatively, the SE levels in both groups were higher than preoperation (P < 0.05); however, there were no statistically significant differences in SE levels between the groups at above time points (P>0.05). One year after surgery, KAve, SRI, and SAI in both groups were lower than preoperative levels, and the SMILE group was lower than those in the FS-LASIK group (P < 0.05). One year after operation, BAD-D and TBI in both groups were higher than preoperative levels, while CBI was lower than preoperative levels; however, BAD-D and TBI in the SMILE group were lower than those in the FS-LASIK group, and CBI was higher than that in the FS-LASIK group (P < 0.05). One year after surgery, corneal endothelial cell counts in both groups were lower than preoperative levels, and CV of corneal endothelial cell size was higher than preoperative levels; however, corneal endothelial cell count in the SMILE group were higher than those in the FS-LASIK group, and the CV of corneal endothelial cell size was lower than that in the FS-LASIK group (P < 0.05). There were no statistically significant differences in ME, AE, CI, and IOS between the two groups (P>0.05). The residual stromal bed thickness was (302.01±55.03) μm in the FS-LASIK group and (310.23±46.03) μm in the SMILE group after surgery, with no statistically significant between-group difference (t=1.284, P=0.200). One year after surgery, there were 5 cases of dry eye in the FS-LASIK group and 2 cases in the SMILE group, with no statistically significant difference in incidence of dry eye between the two groups (χ2=1.227, P=0.268).
ConclusionFor patients with myopic astigmatism with thin cornea, both FS-LASIK and SMILE can achieve satisfactory improvement in visual acuity and refractive state, and the latter one has a relatively small impact on the integrity of corneal structure, biomechanical stability and surgical injury.
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表 1 2组一般资料比较(x ±s)
组别 男/例 女/例 男眼数/眼 女眼数/眼 年龄/岁 球镜度/D 散光度/D 散光轴位/° 最薄角膜基质床厚度/μm FS-LASIK组 27 37 55 73 27.11±2.15 -5.27±0.83 1.24±0.54 100.11±15.65 476.12±5.33 SMILE组 29 35 56 68 28.02±4.36 -5.41±0.35 1.33±0.49 101.34±20.11 477.45±5.11 
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表 2 2组视力水平比较(x ±s)
组别 眼数 UCVA BCVA 术前 术后1年 术前 术后1年 FS-LASIK组 128 0.42±0.12 0.92±0.15* 0.71±0.11 1.06±0.23* SMILE组 124 0.40±0.13 0.94±0.22* 0.73±0.22 1.08±0.21* UCVA: 未矫正视力; BCVA: 最佳矫正视力。与术前比较, * P < 0.05。
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表 3 2组SE水平比较(x ±s)
组别 眼数 术前 术后3个月 术后6个月 术后12个月 FS-LASIK组 128 -4.25±1.02 -0.41±0.31* -0.24±0.21* -0.13±0.12* SMILE组 124 -4.45±1.15 -0.39±0.28* -0.20±0.25* -0.12±0.16* SE: 等效球镜。与术前比较, * P < 0.05。
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表 4 2组角膜表面形态比较(x ±s)
组别 眼数 KAve/D SRI SAI 术前 术后1年 术前 术后1年 术前 术后1年 FS-LASIK组 128 45.20±1.46 38.39±1.26* 1.24±0.52 0.56±0.22* 2.10±0.48 0.76±0.25* SMILE组 124 45.05±1.35 38.01±1.14*# 1.30±0.40 0.48±0.18*# 2.12±0.55 0.69±0.20*# KAve: 角膜平均曲率值; SRI: 角膜表面规则指数; SAI: 角膜表面不对称指数。与术前比较, * P < 0.05。
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表 5 2组角膜生物力学参数比较(x ±s)
组别 眼数 BAD-D CBI TBI 术前 术后1年 术前 术后1年 术前 术后1年 FS-LASIK组 128 1.41±0.57 1.58±0.32* 0.46±0.20 0.35±0.12* 0.66±0.25 0.87±0.25* SMILE组 124 1.40±0.54 1.50±0.18*# 0.45±0.21 0.39±0.14*# 0.65±0.23 0.77±0.24*# BAD-D: 角膜扩张综合偏差分析指数; TBI: 综合分析指数; CBI: 角膜生物力学指数。
与术前比较, * P < 0.05; 与FS-LASIK组比较, #P < 0.05。
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表 6 2组角膜内皮损伤程度比较(x ±s)
组别 眼数 角膜内皮细胞计数/(个/mm2) 角膜内皮细胞大小CV/% 术前 术后1年 术前 术后1年 FS-LASIK组 128 2 652.05±212.28 2 312.44±190.75* 33.75±4.25 37.12±3.65* SMILE组 124 2 695.15±200.17 2 367.87±194.42*# 34.05±4.15 35.95±3.82*# CV: 变异系数。与术前比较, * P < 0.05; 与FS-LASIK组比较, #P < 0.05。
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表 7 2组术后散光矫正矢量指标比较(x ±s)
组别 眼数 ME/D AE/° CI IOS FS-LASIK组 128 -0.03±0.12 2.78±1.12 1.05±0.89 0.42±0.13 SMILE组 124 -0.04±0.22 2.66±1.03 1.15±0.65 0.39±0.22 ME: 误差幅度; AE: 误差角度; CI: 矫正指数; IOS: 成功指数。
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