Page 88 - JSOM Winter 2024

Quality of Vision and Patient Satisfaction After Refractive Surgery

A Comparative Analysis of LASIK, SMILE, and PRK

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Denise S. Ryan, MS ; Rose K. Sia, MD *; Hind Beydoun, PhD, MPH ; Katelyn E. Earls, MD ;
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Samantha B. Rodgers, MD ; Zachary P. Skurski, MD ; Bruce A. Rivers, MD 7
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ABSTRACT
Background: This study assessed patient-reported outcomes hyperopia, and astigmatism. The role of the Special Operations
(PRO) of active-duty U.S. Military Servicemembers following community in the initiation and ongoing mission of the War-
refractive surgery. Methods: We retrospectively reviewed the fighter Refractive Eye Surgery Program (WRESP) cannot be un-
medical records of 375 U.S. Servicemembers who underwent derstated. Historically, the WRESP was initiated after a group
LASIK (118 eyes), photorefractive keratectomy (PRK, 550 from the Special Operations Community underwent PRK. The
eyes), or small incision lenticule extraction (SMILE, 82 eyes). success of this small pilot group catapulted the Department of
Surgeries occurred at the former Walter Reed Army Medical Defense to establish the WRESP, which now boasts at least 20
Center’s Center for Refractive Surgery or the current FBCH’s centers with the readiness mission to enhance the Warfighter.
Warfighter Refractive Eye Surgery Program and Research
Center (WRESP-RC) from 2004 to 2019. Preoperative and The WRESP’s designed goal is to improve the Armed Forces’
6-month postoperative data included “Quality of Vision and refractive safety and efficacy. Approximately 750,000 vision
Patient Satisfaction Before and After Refractive Surgery” ques- corrective procedures have been performed in the U.S. mili-
tionnaire. Outcome measures included uncorrected distance tary by the WRESP since 2000. The procedures available to
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visual acuity (UDVA). Results: In this study, 95% LASIK, 94% the U.S. military include laser in situ keratomileusis (LASIK),
PRK, and 94% SMILE achieved UDVA 20/20 or better with photo refractive keratectomy (PRK), and more recently, small
no between-group differences (P=.308). There were no differ- incision lenticule extraction (SMILE) and implantable colla-
ences between groups in efficacy (P=.204) or the safety index mer lenses (ICL). Individual refractive needs drive surgical
(P=.066). Postoperative QOV was comparable between groups selection criteria, but additional variables aid the final deter-
for ‘far vision’ (P=.292) and ‘night vision’ (P=.505). From be- mination; these include surgeon knowledge, physiological con-
fore to after the operation, far vision significantly improved in straints, the technology available, and patient preference.
LASIK (P=.009) and PRK (P<.001) but not SMILE (P=.384).
Postoperative glare was comparable (P=.258). Driving diffi- Ongoing research of clinical outcomes, performance outcomes,
culty was significantly different between treatments (P=.025), and patient-reported outcomes (PRO) drive technology up-
with significant improvements in PRK and LASIK. There were grades and surgical recommendations and guidelines. U.S.
no significant differences between groups for activity limita- military studies of PROs often explore factors affecting patient
tions (P=.093) or being bothered by glare, halos, or lack of selection and potential quality of vision. Stanley et al. (2008)
sharpness of vision (P=.131). Conclusion: This study found reported laser vision correction’s impact on various Navy
comparable or improved PRO six months after LASIK, PRK, occupations. Bower et al. (2006) reported improved night
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and SMILE. All three yielded excellent visual outcomes with weapon firing performance after LASIK and PRK. Quality of
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minimal visual symptoms, allowing the performance of daily Vision (QOV) complaints, such as glare and halos after LASIK,
activities with less difficulty and limitation. are also critically relevant to military communities. Sia et al.
reported uncorrected visual acuity of 20/20 in over 96% of
Keywords: quality of vision; patient satisfaction; laser refractive treated eyes, with minimal subjective visual complaints on a
surgery; SMILE; small incision lenticule extraction; LASIK; laser military refractive surgery questionnaire. 5
in-situ keratomileusis; PRK; photorefractive keratectomy;
patient-reported outcomes Active duty Servicemembers, particularly those in Special Op-
erations units, experience difficulties wearing standard optical
devices when performing extraordinary tasks like diving or
parachuting in wide-ranging and challenging environments.
Introduction
Glasses scratch easily and may be incompatible with vision
Laser refractive surgery is one of the most-performed eye sur- augmentation devices and equipment. Contact lenses are
geries worldwide. It continues to evolve in the precision reshap- prohibited by Department of Defense policy in deployed or
ing of the cornea to correct refractive errors such as myopia, training environments. Medical issues experienced by service
*Correspondence to Rose Kristine C. Sia, Warfighter Refractive Eye Surgery Program and Research Center at Fort Belvoir, Fort Belvoir Commu-
nity Hospital, 9300 DeWitt Loop, Fort Belvoir, Virginia 22060 or dha.belvoir.fbch.mbx.wresp-research@health.mil
1 Denise S. Ryan, Dr. Rose K. Sia, and MAJ Zachary P. Skurski are affiliated with the Warfighter Refractive Eye Surgery Program and Research
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Center, Fort Belvoir Community Hospital (known as Alexander T. Augusta Military Medical Center since 2023), Fort Belvoir, VA. Denise S.
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Ryan and Dr. Rose K. Sia are affiliated with the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD.
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1 Denise S. Ryan and COL (Ret.) Bruce A. Rivers are affiliated with the Envue Eye & Laser Center, Oxon Hill, MD. Dr. Hind Beydoun is affil-
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iated with the Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, VA. LTC Katelyn E. Earls is affiliated with
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the Womack Army Medical Center, Fort Bragg (known as Fort Liberty since 2023), NC. LTC Samantha B. Rodgers is affiliated with the Brooke
Army Medical Center, Fort Sam Houston, TX.
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