Clinical Scorecard: Clinical Outcomes of SMILE, Femtosecond LASIK, and Transepithelial PRK: A Multicenter Study in Iraq

At a Glance

Key Highlights

• SMILE demonstrated superior refractive predictability, long-term stability, and visual quality compared to FS-LASIK and Trans-PRK.
• Trans-PRK was associated with greater residual myopia, increased refractive regression, higher induced corneal higher-order aberrations, and worse ocular surface symptoms.
• All three procedures showed high safety profiles with low rates of corrected distance visual acuity loss and infrequent enhancement procedures.

Guideline-Based Recommendations

Diagnosis

• Assess degree of myopia and corneal parameters to determine suitability for SMILE, FS-LASIK, or Trans-PRK.

Management

• Consider SMILE as first-line for myopia correction due to superior refractive outcomes and ocular surface preservation.
• FS-LASIK remains an effective and safe alternative with intermediate outcomes.
• Reserve Trans-PRK for patients with thin corneas, borderline topography, or higher ectasia risk despite slower visual recovery and higher enhancement rates.

Monitoring & Follow-up

• Evaluate refractive predictability and stability at 6 months, 1 year, and 1.5 years postoperatively.
• Monitor ocular surface symptoms using Ocular Surface Disease Index (OSDI) scores.
• Assess for induced corneal higher-order aberrations and need for enhancement procedures.

Risks

• FS-LASIK carries risks of flap-related complications and postoperative dry eye symptoms.
• Trans-PRK may cause greater early postoperative discomfort, slower visual recovery, and risk of corneal haze, especially in high myopia.
• SMILE may have delayed early visual recovery and more technically demanding enhancement procedures.

Patient & Prescribing Data

919 myopic patients undergoing refractive surgery (388 SMILE, 344 FS-LASIK, 187 Trans-PRK)

SMILE patients had the closest postoperative spherical equivalent to emmetropia and lowest residual refractive error; FS-LASIK showed intermediate results; Trans-PRK had greater residual myopia and regression.

Clinical Best Practices

• Select refractive procedure based on individual corneal anatomy, myopia degree, and risk factors to optimize outcomes.
• Use SMILE preferentially to maximize refractive predictability and minimize ocular surface disturbance.
• Monitor patients longitudinally for refractive stability and ocular surface health.
• Counsel patients on differences in visual recovery speed and potential need for enhancements depending on procedure.

References

• Global myopia prevalence and projections
• Femtosecond laser-assisted LASIK outcomes
• SMILE technique and outcomes
• Transepithelial PRK advantages and limitations