Du et al.

BMC Ophthalmology (2023) 23:291 BMC Ophthalmology

https://doi.org/10.1186/s12886-023-03045-6

RESEARCH Open Access

Quality of vision after myopic refractive

surgeries: SMILE, FS-LASIK, and ICL
Huiyi Du1, Bo Zhang1, Zheng Wang1 and Lu Xiong1*

Abstract
Background To characterize the quality of vision after SMILE, FS-LASIK, and ICL implantation and evaluate the related
factors.
Methods 131 eyes of 131 myopic patients (90 female, 41 male) who underwent refractive surgeries including
SMILE (35 patients), FS-LASIK (73 patients), and ICL implantation (23 patients) were analyzed. The Quality of Vision
questionnaires were completed 3 months after surgery, and the results were characterized and analyzed with baseline
characteristics, treatment parameters, and postoperative refractive outcomes using logistic regression analysis to find
out predicted factors.
Results Mean age was 26.5 ± 4.6 years (range: 18 to 39 years) and mean preoperative spherical equivalent was
− 4.95 ± 2.04 diopters (D) (range: -1.5 to -13.5). Safety and efficacy index was comparable between different
techniques: the safety index was 1.21 ± 0.18, 1.22 ± 0.18, and 1.22 ± 0.16 and the efficacy index were 1.18 ± 0.20,
1.15 ± 0.17, 1.17 ± 0.15 for SMILE, FS-LASIK and ICL respectively. The mean overall QoV score was 13.40 ± 9.11, with
mean frequency, severity, and bothersome score of 5.40 ± 3.29, 4.53 ± 3.04, and 3.48 ± 3.18 respectively, and there
was no significant difference between different techniques. Overall, the symptom with the highest scores was
glare, following fluctuation in vision and halos. Only the scores of halos were significantly different among different
techniques (P < 0.000). Using ordinal regression analysis, mesopic pupil size was identified as a risk factor (OR = 1.63,
P = 0.037), while postoperative UDVA was a protective factor (OR = 0.036, P = 0.037) for overall QoV scores. Using binary
logistic regression analysis, we found that patients with larger mesopic pupil size had an increased risk to experience
glare postoperatively; compared to ICL, patients who underwent SMILE or FS-LASIK tended to report fewer halos;
patients with better postoperative UDVA were less likely to report blurred vision and focusing difficulty; with larger
residual myopic sphere postoperatively, patients experienced focusing difficulties and difficulty judging distance or
depth perception more frequently.
Conclusions SMILE, FS-LASIK, and ICL had comparable visual outcomes. Overall, glare, fluctuation in vision, and
halos were the most frequently experienced visual symptoms 3 months postoperatively. Patients with ICL implanted
tended to report halos more frequently compared with SMILE and FS-LASIK. Mesopic pupil size, postoperative UDVA,
and postoperative residual myopic sphere were predicted factors for reported visual symptoms.
Keywords SMILE, FS-LASIK, ICL, Quality of Vision

*Correspondence:
Lu Xiong
[email protected]
1
Department of Refractive Surgery, Guangzhou Aier Eye Hospital,
Guangzhou, China

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.
Du et al. BMC Ophthalmology (2023) 23:291 Page 2 of 10

Background the last 2 years (< 0.50 D increase per year of sphere or
The demand for refractive surgery are increasing yearly cylinder), IOP ≤ 21, anterior chamber depth > 2.6 mm,
and globally during the last decade. Nowadays, the 3 endothelial cell density ≥ 2000 cells/mm2. The exclusion
most commonly performed refractive procedures are criteria included severe dry eye, obvious corneal scaring,
small incision lenticule extraction (SMILE), femtosec- corneal ectasia, remaining stromal thickness after laser
ond assisted laser in situ keratomileusis (FS-LASIK), and ablation < 250 μm, active ocular or systemic diseases,
implantable collamer lens (ICL; STAAR Surgical, Nidau, glaucoma or retina diseases, severe systematic diseases,
Switzerland) implantation. The safety, efficacy, and pre- history of ocular surgery, pregnancy or lactation.
dictability of these procedures have been widely proven All patients completed the regular 3 months follow-up
and compared [1–4]; however, less has been reported visits postoperatively, and the QoV questionnaires were
about comparing the quality of vision postoperatively. assessed at that time. The dominant eye was used for
The quality of vision has raised attention in refractive analysis.
surgeries in recent years. Generally, it is divided into
objective and subjective quality of vision. The objective Surgical techniques
quality of vision is usually assessed through higher-order Two surgeons performed all of the procedures (ZW and
aberrations, modulation transfer function (MTF), objec- LX). Each surgeon had a similar experience with the oper-
tive scatter index (OSI) value and et al. Several studies ations. Levofloxacin 5 mg/mL was instilled into the eyes
[5–7] have investigated the objective quality of vision 4 times a day for 3 days before surgery. SMILE was per-
after SMILE, FS-LASIK, and ICL implantation. For high formed on VisuMax femtosecond laser (Carl Zeiss Med-
myopic correction, ICL was shown to be superior com- itec AG, Jena, Germany). The cap thickness was 110 μm,
pared to LASIK and SMILE regarding objective visual the cap diameter was 7.5 mm and the incision was set at
outcomes. However, few have studied and compared the 135° with a width of 2.00 mm. The optical zone ranged
subjective quality of vision. As the subjective quality of from 6.0 to 6.5 mm. The flaps of FS-LASIK were created
vision is a subjective perception consisting of both visual either on WaveLight FS200 (Alcon, Fort Worth, TX) or
and psychological factors, the way to assess it is usually VisuMax femtosecond laser. Flap thickness ranged from
through questionnaires. One instrument, developed by 100 to 110 μm with a diameter from 8.1 to 8.5 mm. The
Colm McAlinden [8], called the Quality of Vision (QoV) flaps were roundly shaped with superior hinges. All the
questionnaire, is a validated and standard measurement excimer laser treatments of FS-LASIK were done with
for assessing subjective visual symptoms. the WaveLight EX500 (Alcon, Fort Worth, TX). During
The purpose of the current study was to characterize the ICL implantation procedure, a 2.8 mm temporal clear
and compare the subjective visual symptoms after differ- corneal incision was performed through which a loaded
ent refractive surgeries through the QoV questionnaire V4c ICL or TICL was injected and positioned to the pos-
and assess the factors that might predict postoperative terior chamber with the footplates situated posterior to
visual symptoms. the iris plane. Emmetropia was the goal in all the inves-
tigated eyes. After all the procedures, steroids and anti-
Methods biotics were administered 4 times daily for 7 days, and
Subjects lubricating eye drops were used for 3 months.
After obtaining informed consent, 131 patients who
underwent refractive surgeries for the correction of myo- Preoperative and postoperative parameters
pia with or without myopic astigmatism from 30th April The preoperative and 3-month postoperative routine
to 11th December 2022 at Guangzhou Aier Eye Hospi- examinations consisted of measuring uncorrected visual
tal were included. Refractive surgical techniques include acuity (UCVA), best corrected visual acuity (BCVA) in
SMILE, FS-LASIK, and ICL; the procedure was chosen decimal, manifest refraction, IOP (intraocular pressure),
according to the patient’s preferences after discussion and corneal topography. The IOP was measured with
with the surgeons. a noncontact tonometer (NCT, Topcon Computerized
The inclusion criterion for corneal laser procedures Tonometer, CT-1). The pupil size was measured under
(SMILE and FS-LASIK) included: no more than 10.00 low light conditions (< 5 lx) using the autorefractor (Top-
diopter (D) spherical myopia, no more than 5.00 D astig- con KR-800). The original Quality of Vision (QoV) Ques-
matism, manifest refraction stable for the last 2 years tionnaire was translated into Chinese, and completed by
(< 0.50 D increase per year of sphere or cylinder), age patients 3 months after surgery. The QoV questionnaire
18 to 40 years old, IOP ≤ 21; the inclusion criterion for [8] was developed by consisting of 10 subjective visual
ICL implantation included: age 18 to 40 years old, no symptoms, including glare, halos, starburst, hazy vision,
more than 18.00 diopter (D) spherical myopia, no more blurred vision, distortion, double or multiple images,
than 5.00 D astigmatism, manifest refraction stable for fluctuation in vision, focusing difficulty, and difficulty
Du et al. BMC Ophthalmology (2023) 23:291 Page 3 of 10

judging distance or depth perception. The frequency this study. 35, 73, and 23 patients underwent SMILE, FS-
(never [0], occasionally [1], quite often [2], very often LASIK, and ICL implantation respectively. The follow-
[3]), severity(not at all [0], mild [1], moderate [2], severe up period was 3 months (± 15days). Baseline parameters
[3]) and bothersome(not at all [0], a little [1], quite [2], were shown in Table 1. One-way ANOVA analysis and
very [3]) of each symptom were asked on a scale of 0 to posthoc test (S-N-K) revealed that patients who under-
3 points. went ICL implantation had a significantly higher myopic
sphere, thinner central corneal thickness, steeper mean
Analysis corneal K, larger corneal astigmatism compared with
Pre and postoperative parameters were examined by patients who underwent SMILE and FS-LASIK; patients
types of refractive surgeries using an analysis of vari- underwent FS-LASIK had higher myopic sphere com-
ance (one-way ANOVA) and the S-N-K test was used pared with SMILE. However, the postoperative visual
for posthoc analysis. A comparison of mean QoV scores outcomes didn’t differ significantly between different
among different surgical techniques was conducted using procedures (Table 2). The safety index was 1.21 ± 0.18,
the Kruskal-Wallis test. Chi-squared test was used to 1.22 ± 0.18, and 1.22 ± 0.16 and the efficacy index were
compare the frequency, severity, and bothersome rates 1.18 ± 0.20, 1.15 ± 0.17, 1.17 ± 0.15 for SMILE, FS-LASIK
of visual symptoms for SMILE, FS-LASIK, and ICL. Pre- and ICL respectively (All P > 0.05) (Table 2).
dictors of overall QoV scores were examined using ordi-
nal logistic regression analysis while a score of 0–9 was Quality of vision questionnaires
defined as mild, 10–19 as moderate, 20–29 as severe, The overall mean score of QoV was 13.40 ± 9.11. The
and ≥ 30 as very severe. Logistic regression was used for mean frequency, severity, and bothersome scores were
examining predictors for the occurrence of each visual 5.40 ± 3.29, 4.53 ± 3.04, and 3.48 ± 3.18 respectively. There
symptom. Data analysis was performed using SPSS for was no significant difference among different procedures
Windows (Version 22.0, SPSS, Inc.,). A p-value less than regarding the overall QoV scores as well as the overall
0.05 was considered to be statistically significant. frequency, severity, and bothersome scores (Kruskal-
Wallis Test, P = 0.714, 0.156, 0.806, 0.428). The glare
Results was the most frequent, bothersome, and severest symp-
Baseline characteristics and visual outcomes tom, which was experienced by 74.8% of patients, 69.5%
A total of 131 eyes of 131 patients, 90 females (68.7%) and of patients reported at least mild severity, and 56.5%
41 males (31.3%), age 26.5 ± 4.6 years, were included in of patients reported it bothersome (Figs. 1, 2 and 3).

Table 1 Baseline Parameters

Parameter Total (131) SMILE(35) FS-LASIK (73) ICL(23) P
Sex (female) 90 (68.7%) 20(57.1%) 53(72.6%) 17(73.9%) 0.225
Age (years) 26.46 ± 4.64 25.80 ± 4.98 27.11 ± 4.85 25.39 ± 2.95 0.187
(18, 39) (18,37) (19, 39) (19, 31)
Pupil size (mm) 6.21 ± 0.82 6.14 ± 0.76 6.29 ± 0.86 6.05 ± 0.74 0.415
(3.75, 7.75) (4.00, 7.25) (3.75, 7.75) (4.50, 7.25)
Sphere(D) -4.95 ± 2.04 -3.82 ± 1.20 -4.67 ± 1.44 -7.54 ± 2.49 0.000
(-13.50, -1.50) (-6.25, -1.50) (-8.00, -1.50) (-13.50, -2.75)
Cylinder(D) -0.64 ± 0.55 -0.54 ± 0.37 -0. 64 ± 0.54 -0.78 ± 0.78 0.241
(-3.50, 0) (-1.50, 0) (-3.50, 0) (-2.75, 0)
Pre-op CDVA 1.02 ± 0.08 1.03 ± 0.09 1.03 ± 0.08 1.00 ± 0.06 0.139
(0.9, 1.2) (0.9, 1.2) (0.9, 1.2) (0.9, 1.2)
IOP (mmHg) 17.28 ± 2.08 17.46 ± 2.11 17.33 ± 1.95 16.87 ± 2.46 0.555
(12, 21) (14, 21) (13, 21) (12, 21)
CCT (µm) 535.41 ± 29.14 547.71 ± 22.90 535.62 ± 24.00 516.04 ± 41.10 0.000
(439, 606) (509, 605) (495, 598) (439, 606)
Km (D) 43.43 ± 1.31 43.17 ± 1.20 43.37 ± 1.36 44.05 ± 1.16 0.032
(40.3, 47.0) (40.3, 45.9) (41.0, 47.0) (42.2, 46.2)
ACA (D) 1.14 ± 0.54 1.07 ± 0.36 1.09 ± 0.59 1.41 ± 0.51 0.026
(0.1, 3.3) (0.3, 1.9) (0.1, 3.3) (0.7, 2.7)
Chord µ (mm) 0.18 ± 0.11 0.17 ± 0.10 0.17 ± 0.11 0.23 ± 0.11 0.092
(0.01, 0.51) (0.02, 0.43) (0.01, 0.49) (0.08. 0.51)
The data are presented as means ± standard deviation (SD) and range. Bold data are significant at P < 0.05 (One-way ANOVA and Pearson Chi-Square). D = diopters,
Pre-op = preoperative, IOP = intraocular pressure, UDVA = uncorrected distance visual acuity, CDVA = corrected distance visual acuity, Km = mean keratometry,
ACA = anterior corneal astigmatism, Chord µ = the two-dimensional distance between the center of the pupil and the subject-fixated coaxially sighted corneal light
reflex
Du et al. BMC Ophthalmology (2023) 23:291 Page 4 of 10

Table 2 Postoperative Visual Outcomes

Visual outcomes Total (131) SMILE(35) FS-LASIK (73) ICL(23) P
Post-op 1.19 ± 0.17 1.21 ± 0.20 1.18 ± 0.16 1.17 ± 0.14 0.601
UDVA (0.9, 1.5) (0.9, 1.5) (0.9, 1.5) (0.9, 1.5)
Post-op 1.24 ± 0.17 1.25 ± 0.18 1.25 ± 0.17 1.21 ± 0.13 0.606
CDVA (0.9, 1.5) (0.9, 1.5) (1.0, 1.5) (1.0, 1.5)
Post-op -0.006 ± 0.227 0.029 ± 0.199 -0.007 ± 0.253 -0.054 ± 0.168 0.398
sphere (D) (-0.75, + 1.00) (-0.25, + 0.50) (-0.75, + 1.00) (-0.50, + 0.25)
Post-op -0.10 ± 0.21 -0.07 ± 0.18 -0.11 ± 0.20 -0.14 ± 0.29 0.467
cylinder (D) (-1.00, 0) (-0.75, 0) (-0.75, 0) (-1.00. 0)
Safety index 1.22 ± 0.18 1.21 ± 0.18 1.22 ± 0.18 1.22 ± 0.16 0.996
Efficacy index 1.16 ± 0.17 1.18 ± 0.20 1.15 ± 0.17 1.17 ± 0.15 0.752
The data are presented as means ± standard deviation (SD) and range. Bold data are significant at P < 0.05 (One-way ANOVA and Pearson Chi-Square). Post-
op = postoperative, UDVA = uncorrected distance visual acuity, CDVA = corrected distance visual acuity, D = diopters

Fig. 1 The frequency of different visual symptoms experienced by patients

Followed by glare, fluctuation in vision and halos were scores of halos were found to be significantly different
among the top 3 most frequent and severe visual symp- (Kruskal-Wallis Test, P < 0.000). The frequency of halos
toms 3 months postoperatively with a frequency of 71.8% after ICL was 87.0%, while that after SMILE and FS-
and 59.5%, while 64.1% and 52.7% of patients reported LASIK were 42.9% and 58.9% respectively (Chi-squared
at least mild severity for fluctuation in vision and halos test, P = 0.016)(Fig. 4); 82.6% of patients who underwent
respectively. Regarding different procedures, only the ICL reported at least mild severity of halos, compared
Du et al. BMC Ophthalmology (2023) 23:291 Page 5 of 10

Fig. 2 The severity of different visual symptoms experienced by patients

to 40% and 49.3% of patients underwent SMILE and FS- risk to have glare postoperatively (OR = 1.666, P = 0.038).
LASIK respectively(P = 0.011), but no one reported severe The other predictor was the procedure used. Compared
halos in all procedures(Fig. 5); 60.9%, 34.3% and 34.2% to ICL, patients who underwent SMILE or FS-LASIK
of ICL, SMILE and FS-LASIK patients reported a little tend to report fewer halos (OR = 0.113, 0.215, P = 0.002,
bothersome for halos(P = 0.059), while no one reported it 0.020 respectively).
quite or very bothersome (Fig. 6).
Visual outcomes and QoV
Baseline characteristics and QoV Using ordinal regression analysis, the postoperative
Using ordinal analysis, the mesopic pupil was found to UDVA was found to be a protective factor for the over-
be a risk factor for the overall QoV scores (OR = 1.627, all QoV scores (OR = 0.037, P = 0.031) (Table 3). 2 visual
P = 0.037). Patients with a larger mesopic pupil size symptoms --- blurred vision and focusing difficulties
tended to have more visual symptoms postoperatively. were found to be related to postoperative UDVA as
2 baseline parameters that could be used to predict well (Table 3). Patients with better UDVA postopera-
the occurrence of visual symptoms of glare and halos tively tended to report fewer blurred vision (OR = 0.086,
were identified using logistic regression analysis and P = 0.024) and fewer focusing difficulties (OR = 0.058
were demonstrated in Table 3. The mesopic pupil size P = 0.011). The postoperative myopic sphere was found to
was found to be related to the visual symptom of glare. be a risk factor for both focusing difficulties (OR = 1.277,
Patients with a larger mesopic pupil size had an increased P = 0.012) and difficulty judging distance or depth
Du et al. BMC Ophthalmology (2023) 23:291 Page 6 of 10

Fig. 3 The bothersome of different visual symptoms experienced by patients

perception (OR = 1.549, P = 0.008) --- with larger residual The report of symptoms related to visual quality was
myopic sphere, patients were more likely to experience thought to be increased after corneal refractive surgeries
the 2 visual symptoms. and after ICL implantation. Steven C et al [10] found an
increased report of glare, haze, and halos at night dur-
Discussion ing the first and third month after LASIK, and decreased
Several instruments have been developed to assess to preoperative level by 6 months. Reinstein DZ et al.
patient-report outcomes after refractive surgery. The [11] found an increase in QoV symptoms, mainly glare
most frequently used validated questionnaires include and starbursts after SMILE. In theory, ICL implanta-
Quality of Life Impact of Refractive Correction(QIRC), tion might have a better quality of vision compared with
Quality of Vision(QoV), and Patient-Reported Outcomes LASIK or SMILE at an early postoperative time point, as
with LASIK(PROWL), among which the QoV question- it has less disturbance on the cornea and there was some
naire was found to be the most appropriate questionnaire evidence proving this [1].
for assessing visual symptoms [9]. The QoV question- In the present study, we chose the 3 months postop-
naire [8] is based on item response theory(IRT) using eratively time point for evaluation and found out that
Rasch analysis and consists of 30 items measuring 10 glare, fluctuation in vision, and halos were the most fre-
visual symptoms, each on three scales in terms of symp- quently reported visual symptoms. For the 10 visual
tom frequency, severity, and bothersome. symptoms evaluated, only halos were found to be signifi-
cantly different among different procedures --- patients
Du et al. BMC Ophthalmology (2023) 23:291 Page 7 of 10

Fig. 4 The frequency of halos after SMILE, FS-LASIK, and ICL. Person Chi-squared test, P = 0.016

Fig. 5 The severity of halos after SMILE, FS-LASIK, and ICL. Person Chi-squared test, P = 0.011

who underwent ICL reported more halos compared after ICL and FS-LASIK. One case report by Nikolaos
to SMILE or FS-LASIK. This is consistent with previ- ST et al [12] illustrated the patients had one eye under-
ous reports as halos were reported to be a major visual went LASIK and the fellow eye had phakic intraocular
complaint following ICL implantation in several studies. lens implantation reporting fewer night vision problems
Our result is consistent with Ruouyan Wei et al. [7] and including glare and halos in the eye with the ICL com-
Aruma A et al [6], both reporting a significantly higher pared to the LASIK eye, which was contrary to our
incidence of postoperative halos after ICL compared with results. However, it was one case report and the follow-
SMILE. One meta-analysis conducted by Kai C et al [4] up time was 9 years postoperatively, which is much lon-
also showed that ICL implantation had a higher risk of ger than ours. Although most of the studies showed a
halos compared with SMILE (RR = 1.79, 95%: 1.48 to high frequency of halos after ICL, it didn’t seem to affect
2.16). Nevertheless, less was investigated comparing QoV patients’ satisfaction and daily activities [13]. Similarly,
Du et al. BMC Ophthalmology (2023) 23:291 Page 8 of 10

Fig. 6 The bothersome of halos after SMILE, FS-LASIK, and ICL. Person Chi-squared test, P = 0.059

Table 3 Predicted factors of QoV more glare than SMILE 3 years postoperatively via QIRC
Factor P Exp(B) 95% C.I for questionnaire [18].
EXP(B) In the present study, we demonstrated mean QoV
Total QoV Mesopic pupil 0.037 1.627 (1.031, 2.570) scores of 13.00 ± 9.02, with overall mean frequency, sever-
size ity, and bothersome scores of 5.26 ± 3.27, 4.39 ± 3.02,
Post-op UDVA 0.037 0.036 (0.0016,0.816) 3.35 ± 3.12 respectively. Previous studies reported much
Glare Mesopic pupil 0.038 1.666 (1.028,2.700) higher scores. In the study of Mohr [19] which evalu-
size
ated the postoperative QoV after ICL, they demonstrated
Halos SMILE 0.002 0.113 (0.028,0.450)
mean QoV scores of 35.5 ± 11.3. Reinstein DZ et al [11]
FS-LASIK 0.020 0.215 (0.059,0.789)
investing the subjective and objective quality of vision
Blurred Vision Post-op UDVA 0.024 0.086 (0.010,0.726)
12 months after SMILE, the mean QoV score was 41 ± 18
Focusing Post-op UDVA 0.011 0.058 (0.006,0.553)
difficulties and the main visual symptoms were glare and starbursts;
Post-op sphere 0.012 1.277 (1.055,1.545)
(-) however, the population in their study were high myo-
Difficulty judging Post-op sphere 0.008 1.549 (1.119,2.145) pic patients between − 9.00 and − 13.00 diopters, which
distance or depth (-) were different from ours. Schmelter V et al’ study [20]
perception also demonstrated a higher QoV score for symptom fre-
QoV = Quality of Vision, UDVA = uncorrected distance visual acuity, quency, severity, and bothersome compared with ours
Post-op = postoperative
after the SMILE procedure (34.63 ± 13.69, 29.60 ± 12.38,
and 24.56 ± 16.00, respectively), and found that patients
in our study, we showed that although the frequency and older than 40 years reported worse QoV scores. The dif-
severity of halos after ICL implantation were significantly ference in the mean QoV scores between ours and the
higher than that after SMILE and FS-LASIK, the bother- previous studies might due to differences in laser equip-
some of halos didn’t differ significantly. ment used, surgeons’ techniques, patients’ expectation
As for the comparison of SMILE and FS-LASIK, one management, culture, environment, and different popu-
contralateral eye study by He SY et al. reported no sig- lations in the studies.
nificant difference was found in QoV scores between the The predictors for visual symptoms were investigated
two, which is consistent with our results [14]. Via other in previous studies. Theoretically, pupil size is an impor-
instruments such as QIRC and PROWL [15–17], most tant predictor for the quality of vision after refractive
studies showed a comparable visual quality between surgery as suggested by optical models such as the point
SMILE and LASIK at different time points; only Tian H spread function. The relationship between night vision
et al’s study reported that patients after FS-LASIK had problems and mesopic pupil size has been investigated
in many studies. However, the results were controversial:
Du et al. BMC Ophthalmology (2023) 23:291 Page 9 of 10

Haw and Manche [21] reported no relationship between 3 months postoperatively. Therefore, we did not report
pupil size and postoperative visual symptoms in patients on changes in the QoV scores pre- and postoperatively
who underwent PRK; other studies [22, 23] also found over time. Lastly, although the QoV questionnaire used in
no significant correlation between pupil size and post- this study was a standardized and evaluated one, and was
operative visual symptoms and patient satisfaction; while widely used; the Chinese version of it had not been evalu-
Schallhorn et al [10] found that large pupils had more ated yet. However, since the questions in it were relatively
symptoms in the early postoperative period after LASIK. easy with illustrated pictures on it, we didn’t find patients
In our study, the preoperative pupil size was found to having any difficulties answering them. In the future, a
be a risk factor for the overall QoV scores (OR = 1.627) randomized controlled study including a more objec-
and the visual symptom of glare (OR = 1.666) 3 months tive quality of vision analysis is expected to provide more
postoperatively; however, other visual symptoms such evidence, and a validated Chinese version of the Qual-
as halos and starburst were not related to mesopic pupil ity of Vision questionnaire could be developed. Further-
size. Therefore, the mesopic pupil size might not be as more, more parameters like pre- and postoperative tear
important a factor in postoperative visual symptoms as breakup time (TBUT) and et al. could be investigated for
we use to think. their relationships with QoV.
Meanwhile, objective quality of vision, such as ocular
or corneal higher-order aberrations (HOAs), are also Conclusion
thought to be related to subjective QoV. However, Jakob SMILE, FS-LASIK, and ICL had comparable visual out-
S et al’s study [24] demonstrated no correlation between comes and quality of vision except for the visual symptom
postoperative HOA and QoV scores after SMILE; of halos. Overall, glare, fluctuation in vision, and halos
Gyldenkerne A et al [25] also showed that scatter and were the most frequently experienced visual symptoms
corneal HOAs were not correlated with visual symptoms. 3 months postoperatively. Patients with ICL implanted
Haw and Schallhorn’s studies [10, 21] reported the reported halos more frequently compared with SMILE
attempted correction was related to visual symptoms and FS-LASIK. Mesopic pupil size and residual myopic
after refractive surgery. However, in the present study, sphere were found to be risk factors, while postoperative
we haven’t found a correlation between the preop- UDVA was a protective factor for the investigated visual
erative spherical equivalent and the investigated visual symptoms. Through improved efficacy and precision of
symptoms. refractive surgeries, the subjective quality of vision could
Previous studies [22, 23] have shown that postopera- be improved as well.
tive residual refractive error and uncorrected visual acu-
Abbreviations
ity was important factor in visual disturbance and patient BCVA Best corrected visual acuity
dissatisfaction. In our study, we found that postoperative FS-LASIK Femtosecond assisted laser in situ keratomileusis
UVDA was a protective factor for the overall QoV scores ICL Implantable collamer lens
IOP Intraocular pressure
and also related to the visual symptoms of blurred vision MTF Modulation transfer function
and focusing difficulties; postoperative residual myopic NCT Noncontact tonometer
sphere was found to be a risk factor for focusing difficul- OSI Objective scatter index
Pre-op Preoperative
ties and difficulty judging distance and depth perception. Post-op Postoperative
That is to say, by improving the precision and efficacy QoV Quality of vision
of refractive surgeries, postoperative visual complaints SMILE Small incision lenticule extraction
UCVA Uncorrected visual acuity
could be reduced.
Overall, our studies demonstrated that the visual symp-
toms after SMILE, FS-LASIK, and ICL implantation 3 Supplementary Information
months postoperatively were relatively mild and compa- The online version contains supplementary material available at https://doi.
org/10.1186/s12886-023-03045-6.
rable except for halos. To our knowledge, our study is the
first to characterize and compare the QoV after SMILE, Supplementary Material 1
FS-LASIK, and ICL 3 months postoperatively.
Our studies have several limitations. First, it was a Acknowledgements
retrospective study. Since the selection of procedures Not Applicable.
for patients was partly based on the patient’s baseline
Author contributions
parameters, some of the parameters were not compa- H.D. and B.Z. collected the data. H.D. performed the analyses and statistics
rable among the 3 procedures. However, we used regres- and drafted the initial manuscript. B.Z., L.X., and Z.W. were also contributing
sion analysis to control variables. Second, the objective to the writing and reviewing of the manuscript. All authors approved the final
manuscript.
quality of vision was not assessed and analyzed in this
study. Third, the QoV questionnaire was assessed only at
Du et al. BMC Ophthalmology (2023) 23:291 Page 10 of 10

Funding 8. McAlinden C, Pesudovs K, Moore JE. The development of an instrument to

No grants and/or other financial support were received for the presented measure quality of vision: the quality of Vision (QoV) questionnaire. Invest
study. Ophthalmol Vis Sci. 2010;51(11):5537–45.
9. Kandel H, et al. Questionnaires for measuring refractive surgery outcomes. J
Data availability Refract Surg. 2017;33(6):416–24.
All data generated or analyzed during the current study are included in this 10. Schallhorn SC, et al. Pupil size and quality of vision after LASIK. Ophthalmol-
published article (supplementary file). ogy. 2003;110(8):1606–14.
11. Reinstein DZ, et al. Objective and subjective quality of Vision after SMILE for
high myopia and astigmatism. J Refract Surg. 2022;38(7):404–13.
Declarations 12. Tsiklis NS, et al. Nine-year follow-up of a posterior chamber phakic IOL in
one eye and LASIK in the fellow eye of the same patient. J Refract Surg.
Competing interests 2007;23(9):935–7.
The authors declare no competing interests. 13. Liu T et al. Effects of V4c-ICL Implantation on Myopic Patients’ Vision-Related
Daily Activities J Ophthalmol, 2016. 2016: p. 5717932.
Financial support 14. He S, et al. Prospective, randomized, Contralateral Eye comparison of
No grants and/or other financial support were received for the presented functional Optical Zone, and visual quality after SMILE and FS-LASIK for high
study. myopia. Transl Vis Sci Technol. 2022;11(2):13.
15. Ma KK, Manche EE. Patient-reported quality of Vision in a prospective
Conflict of interest disclosure Randomized Contralateral-Eye Trial comparing LASIK and SMILE. J Cataract
The authors report there are no competing interests to declare. Refract Surg; 2022.
16. Ang M, et al. Vision-related quality of life and visual outcomes after small-
Ethics approval and consent to participate incision lenticule extraction and laser in situ keratomileusis. J Cataract Refract
This study was approved by the Ethics Review Board of Guangzhou Aier Eye Surg. 2015;41(10):2136–44.
Hospital. Written informed consent was received from all patients. All methods 17. Damgaard IB, et al. Intraoperative patient experience and postoperative
were carried out in accordance with relevant guidelines and regulations. visual quality after SMILE and LASIK in a Randomized, Paired-Eye, controlled
study. J Refract Surg. 2018;34(2):92–9.
Consent for publication 18. Han T, et al. Quality of life impact of refractive correction (QIRC) results three
Not Applicable. years after SMILE and FS-LASIK. Health Qual Life Outcomes. 2020;18(1):107.
19. Mohr N, et al. Determinants of subjective quality of Vision after phakic intra-
Received: 11 April 2023 / Accepted: 14 June 2023 ocular Lens Implantation. J Refract Surg. 2022;38(5):280–7.
20. Schmelter V, et al. Determinants of subjective patient-reported quality
of vision after small-incision lenticule extraction. J Cataract Refract Surg.
2019;45(11):1575–83.
21. Haw WW, Manche EE. Effect of preoperative pupil measurements on glare,
halos, and visual function after photoastigmatic refractive keratectomy. J
References Cataract Refract Surg. 2001;27(6):907–16.
1. Goes S, Delbeke H. Posterior chamber toric implantable collamer lenses vs 22. Tahzib NG, et al. Functional outcomes and patient satisfaction after laser
LASIK for myopia and astigmatism: systematic review. J Cataract Refract Surg. in situ keratomileusis for correction of myopia. J Cataract Refract Surg.
2022;48(10):1204–10. 2005;31(10):1943–51.
2. Chen D, et al. Comparison of visual outcomes and Optical Quality of Femto- 23. Schmidt GW, et al. Evaluation of the relationship between ablation diameter,
second Laser-Assisted SMILE and Visian Implantable Collamer Lens (ICL V4c) pupil size, and visual function with vision-specific quality-of-life measures
implantation for moderate to high myopia: a Meta-analysis. J Refract Surg. after laser in situ keratomileusis. Arch Ophthalmol. 2007;125(8):1037–42.
2022;38(6):332–8. 24. Siedlecki J, et al. Corneal wavefront aberrations and subjective qual-
3. Lin F, Xu Y, Yang Y. Comparison of the visual results after SMILE and femtosec- ity of vision after small incision lenticule extraction. Acta Ophthalmol.
ond laser-assisted LASIK for myopia. J Refract Surg. 2014;30(4):248–54. 2020;98(7):e907–13.
4. Cao K, et al. Implantable collamer lens versus small incision lenticule extrac- 25. Gyldenkerne A, Ivarsen A, Hjortdal J. Optical and visual quality after small-
tion for high myopia correction: a systematic review and meta-analysis. BMC incision lenticule extraction. J Cataract Refract Surg. 2019;45(1):54–61.
Ophthalmol. 2021;21(1):450.
5. Igarashi A et al. Visual performance after implantable collamer lens implanta- Publisher’s Note
tion and wavefront-guided laser in situ keratomileusis for high myopia. Am J Springer Nature remains neutral with regard to jurisdictional claims in
Ophthalmol, 2009. 148(1): p. 164 – 70 e1. published maps and institutional affiliations.
6. Chen X, et al. Contralateral eye comparison of the long-term visual quality
and stability between implantable collamer lens and laser refractive surgery
for myopia. Acta Ophthalmol. 2019;97(3):e471–8.
7. Qin Q, et al. Comparison of visual quality after EVO-ICL implantation and
SMILE to select the appropriate surgical method for high myopia. BMC
Ophthalmol. 2019;19(1):21.