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Background:  Modern preoperative diagnostics as well as current surgical techniques allow cataract and refractive surgery to deliver precise refractive results.Occasionally, unsatisfactory refractive and visual results occur despite all the care taken. In these cases, subsequent improvement is required to achieve the best final visual outcome. This article shows the therapeutic options for the treatment of residual refractive errors after lens and corneal refractive surgery., Key Messages:  The causes of postoperative refractive errors after refractive laser- or lens-based procedures are very diverse and require extensive workup of the cause as well as an individual solution to achieve the desired result. Before any further surgical intervention, specific complications of the primary procedure as well as concomitant ocular diseases must be excluded or treated. The appropriate enhancement after keratorefractive surgery depends primarily on the type of primary surgery, residual stromal thickness, possible complications from the initial surgery, and the patient's personal preference. For enhancements using surface treatments, such as PRK, the use of mitomycin C is recommended for prophylaxis of haze formation. After lens surgery, for low-grade postoperative refractive errors (spherical and astigmatic), keratorefractive enhancements provide the most accurate results. For higher refractive errors, lens-based procedures can be used, with add-on IOLs being safer and more precise compared with one IOL exchange. Low astigmatisms can be successfully treated with LRI or keratorefractive surgery, but higher astigmatisms should be corrected with an IOL exchange in the early postoperative period and with an add-on IOL in the later postoperative period. IOL explantations should be performed very cautiously, especially in cases of pronounced capsular fibrosis, previous posterior capsulotomy, and existing weakness of the zonular apparatus., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an im Bereich der Medizin aktiven Firma: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an zu Sponsoren dieser Fortbildung bzw. durch die Fortbildung in ihren Geschäftsinteressen berührten Firma: nein. Erklärung zu nichtfinanziellen Interessen Lukas Feldhaus: keine finanziellen Interessenkonflikte.Nikolaus Luft: Consultant & Speaker für Carl Zeiss Meditec.Wolfgang Mayer: Alcon (F/C/R); Zeiss (F/C/R); Ziemer (F/C/R); DORC (F/R); Allergan (F/R); Teleon Surgical (F/R); Novartis (F/R); Bausch & Lomb (F/R); Heidelberg Engineering (R); Örtli (R); Staar Surgical (R); CSO (R); Humanoptics (R); Ophtec (R) [F: Financial Support; C: Consultant; R: Recipient], (Thieme. All rights reserved.)

With an estimated incidence of 0.011%, the SMILE procedure seems to have the lowest risk of postoperative keratectasia among contemporary keratorefractive procedures. Nevertheless, due to the novelty of the procedure as well as the lack of data, no clear superiority over femto-LASIK or PRK can be stated at this time. In this respect, application of the identical tomographic screening criteria previously developed for excimer-based procedures is of paramount importance to minimize the risk of corneal ectasia. As an adjunct to conventional corneal tomography, newer imaging modalities such as OCT-based epithelial mapping should be used for preoperative screening before keratorefractive surgery. Corneal crosslinking is an established treatment modality for post-SMILE keratectasia, which promises high success rates especially in early stages. The present case report illustrates these diagnostic and therapeutic considerations., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht./The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: To characterize patient-reported long-term quality of vision (QoV) after small-incision lenticule extraction (SMILE), and to identify potential clinical parameters that might predispose to experiencing deteriorated visual quality., Setting: University Eye Hospital, Ludwig-Maximilians-University, Munich, Germany., Design: Prospective cross-sectional study., Methods: For the assessment and scoring of visual symptoms, the Quality of Vision questionnaire was employed, which constitutes a clinically validated, linear-scaled 30-item instrument providing a QoV score on three scales (symptom frequency, severity, and bothersome). Subgroup analyses were performed for patient subgroups stratified by baseline characteristics (eg, age) and treatment parameters (eg, surgical refractive correction) as well as refractive outcomes (eg, residual refraction) and visual outcomes (eg, uncorrected distance visual acuity [UDVA])., Results: The study comprised 394 eyes of 197 patients (117 women [59.4%], 80 men [40.6%]) were included with a mean postoperative follow-up of 24.4 months ± 14.1 (SD). The QoV scores for symptom frequency, severity, and bothersome were 34.63 ± 13.69, 29.60 ± 12.38, and 24.56 ± 16.00, respectively. Patients with a preoperative binocular corrected distance visual acuity (CDVA) of 20/12.5 or better, patients who lost 1 or more lines of UDVA as compared with preoperative CDVA, patients older than the age of 40, and patients with inadvertent anisometropia more than 0.375 diopters reported worse QoV scores., Conclusion: The relationship between objective clinical parameters and patient-reported subjective QoV after SMILE seems complex. Defined prognostic factors that convey a higher risk for experiencing visual disturbances were identifiable and should be discussed with patients seeking SMILE treatment during preoperative counseling., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the feasibility and outcomes of surface ablation after small incision lenticule extraction (SMILE)., Methods: In this retrospective evaluation of 1,963 SMILE procedures, 43 eyes (2.2%) were re-treated at three separate clinics. Of these, 40 eyes of 28 patients with a follow-up of at least 3 months were included in the analysis. During surface ablation, mitomycin C was applied for haze prevention., Results: Spherical equivalent was -6.35 ± 1.31 diopters (D) before SMILE and -0.86 ± 0.43 D before surface ablation. Surface ablation was performed after a mean of 9.82 ± 5.27 months and resulted in a spherical equivalent of 0.03 ± 0.57 D at 3 months (P < .0001). The number of patients within ±0.50 and ±1.00 D of target refraction increased from 22.5% to 80% and from 72.5% to 92.5%, respectively. Mean uncorrected distance visual acuity (UDVA) improved from 0.23 ± 0.20 to 0.08 ± 0.15 logMAR (P < .0001); 65% of patients gained at least one line. Corrected distance visual acuity (CDVA) remained unchanged with 0.01 ± 0.07 logMAR before versus -0.01 ± 0.05 logMAR after re-treatment (P = .99). Six eyes (15.0%) lost one line of CDVA, but final CDVA was 0.00 logMAR in four and 0.10 logMAR in two of these cases. The safety and efficacy indices were 1.06 and 0.90 at 3 months, respectively. Three of the four surface ablation profiles (Triple-A, tissue-saving algorithm, and topography-guided) resulted in equally good results, whereas enhancement with the aspherically optimized profile (ASA), used in two eyes, resulted in overcorrection (+1.38 and +1.75 D)., Conclusions: Combined with the intraoperative application of mitomycin C, surface ablation seems to be a safe and effective method of secondary enhancement after SMILE. Due to the usually low residual myopia, the ASA profile is not recommended in these cases. [J Refract Surg. 2017;33(8):513-518.]., (Copyright 2017, SLACK Incorporated.)

Purpose: To assess the reactive changes of the corneal epithelial thickness (ET) profile induced by small incision lenticule extraction (SMILE) for treatment of myopia., Methods: This prospective observational study included 46 eyes of 23 patients that were scheduled for myopic SMILE. High-resolution spectral-domain optical coherence tomography (SD-OCT) and a custom image segmentation algorithm were applied to measure corneal ET at multiple time points within the central 5-mm zone. Postoperative ET alterations were correlated with treatment parameters and refractive outcomes., Results: Mean age was 33 ± 6 years and mean spherical equivalent of surgical refractive correction was -4.78 ± 1.75 diopters. The average ET (averaged over the central 5-mm zone) increased from 52.3 ± 3.6 μm preoperatively to 57.7 ± 5.1 μm 6 months postoperatively (P < 0.01). Average ET was 101.9% of the preoperative thickness at 24 hours postoperatively, 103.2% at 1 week, 106.7% at 6 weeks, 109.3% at 3 months, and 110.4% at 6 months postoperatively. The epithelial thickening response could be modeled by an exponential recovery function and stabilized after 3 months. The extent of epithelial hyperplasia was highly dependent on the magnitude of the induced refractive correction (P = 0.002)., Conclusions: In this initial study of corneal ET remodeling after myopic SMILE, significant epithelial thickening was detected as a function of the extent of surgical refractive correction. Moreover, the epithelial remodeling response to the corneal refractive change appeared to decrease with higher age. In our hands, the observed epithelial changes did not appear to affect the refractive outcome of SMILE. (ClinicalTrials.gov number, NCT02614625).