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A Modified Small-Incision Lenticule Intrastromal Keratoplasty (sLIKE) for the Correction of High Hyperopia: A Description of a New Surgical Technique and Comparison to Lenticule Intrastromal Keratoplasty (LIKE)

Majid Moshirfar, Tirth J. Shah, Maliha Masud, Trey Fanning, Steven H Linn, Yasmyne Ronquillo, Phillip C. Hoopes, Sr.


Patients with high hyperopia are generally confined to either spectacle wear or contact lenses as a primary means of refractive correction. For this patient population, the surgical corrective methods, such as hyperopic laser assisted in-situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) are imperfect options due to induction of higher-order aberrations, optical regression, and loss of best corrected distance visual acuity. Recently, there has been growing interest in lenticule implantation underneath a flap via lenticule intrastromal keratoplasty (LIKE) for high hyperopia correction (+3 diopters to +10 diopters). We instead propose a modified surgical technique (small-incision lenticule intrastromal keratoplasty, sLIKE), in which the lenticule is implanted inside an intrastromal pocket thereby causing less injury to the subbasal nerve plexus injury, less postoperative dry eye symptoms, less reduction in biomechanical strength, and lower chances for epithelial ingrowth. We provide an overview of these novel surgical techniques to treat high hyperopia, and compare the associated advantages and disadvantages. In addition, we will discuss the enhancement options and methods of optimization for both surgical techniques.



Vitale S. Prevalence of Refractive Error in the United States, 1999-2004. Archives of Ophthalmology. 2008;126:1111. doi: 10.1001/archopht.126.8.1111

Suarez E, Torres F, Duplessie M. LASIK for correction of hyperopia and hyperopia with astigmatism. Int Ophthalmol Clin. 1996;36:65-72. pmid: 9072516

Varley GA, Huang D, Rapuano CJ, Schallhorn S, Boxer Wachler BS, Sugar A, et al. LASIK for hyperopia, hyperopic astigmatism, and mixed astigmatism: a report by the American Academy of Ophthalmology. Ophthalmology. 2004;111:1604-17. doi: 10.1016/j.ophtha.2004.05.016 pmid: 15288995

Ditzen K, Huschka H, Pieger S. Laser in situ keratomileusis for hyperopia. J Cataract Refract Surg. 1998;24:42-7. pmid: 9494898

Llorente L, Barbero S, Merayo J, Marcos S. Total and corneal optical aberrations induced by laser in situ keratomileusis for hyperopia. J Refract Surg. 2004;20:203-16. pmid: 15188896

Ma L, Atchison DA, Albietz JM, Lenton LM, McLennan SG. Wavefront aberrations following laser in situ keratomileusis and refractive lens exchange for hypermetropia. J Refract Surg. 2004;20:307-16. pmid: 15307391

Moshirfar M, J DD, B DW, M SM, O CB, C. Hoopes P S. Mechanisms of Optical Regression Following Corneal Laser Refractive Surgery: Epithelial and Stromal Responses. Med Hypothesis Discov Innov Ophthalmol. 2018;7:1-9. pmid: 29644238

Alio JL, El Aswad A, Vega-Estrada A, Javaloy J. Laser in situ keratomileusis for high hyperopia (>5.0 diopters) using optimized aspheric profiles: efficacy and safety. J Cataract Refract Surg. 2013;39:519-27. doi: 10.1016/j.jcrs.2012.10.045 pmid: 23375692

Damgaard IB, Ivarsen A, Hjortdal J. Biological Lenticule Implantation for Correction of Hyperopia: An Ex Vivo Study in Human Corneas. J Refract Surg. 2018;34:245-52. doi: 10.3928/1081597X-20180206-01 pmid: 29634839

Williams GP, Wu B, Liu YC, Teo E, Nyein CL, Peh G, et al. Hyperopic refractive correction by LASIK, SMILE or lenticule reimplantation in a non-human primate model. PLoS One. 2018;13:e0194209. doi: 10.1371/journal.pone.0194209 pmid: 29590157

The tool for additive hyperopia surgery - creating refractive lenticules for LIKE surgery. [cited 2018 June 10]. Available from:

Pradhan KR, Reinstein DZ, Carp GI, Archer TJ, Gobbe M, Gurung R. Femtosecond laser-assisted keyhole endokeratophakia: correction of hyperopia by implantation of an allogeneic lenticule obtained by SMILE from a myopic donor. J Refract Surg. 2013;29:777-82. doi: 10.3928/1081597X-20131021-07 pmid: 24203809

Guilbert E, Laroche L, Borderie V. Le rejet d’allogreffe de cornée. Journal Français d'Ophtalmologie. 2011;34:331-48. doi: 10.1016/j.jfo.2011.02.001

Jankov M, Mrochen M, Seiler T. Laser intrastromal keratoplasty-Case report. Journal of Refractive Surgery. 2004;20:79-84.

Moshirfar M, Jehangir N, Fenzl CR, McCaughey M. LASIK Enhancement: Clinical and Surgical Management. J Refract Surg. 2017;33:116-27. doi: 10.3928/1081597X-20161202-01 pmid: 28192591

Riau AK, Liu YC, Lim CHL, Lwin NC, Teo EP, Yam GH, et al. Retreatment strategies following Small Incision Lenticule Extraction (SMILE): In vivo tissue responses. PLoS One. 2017;12:e0180941. doi: 10.1371/journal.pone.0180941 pmid: 28708898

Riau AK, Ang HP, Lwin NC, Chaurasia SS, Tan DT, Mehta JS. Comparison of four different VisuMax circle patterns for flap creation after small incision lenticule extraction. J Refract Surg. 2013;29:236-44. doi: 10.3928/1081597X-20130318-02 pmid: 23557221

Siedlecki J, Luft N, Mayer WJ, Siedlecki M, Kook D, Meyer B, et al. CIRCLE Enhancement After Myopic SMILE. J Refract Surg. 2018;34:304-9. doi: 10.3928/1081597X-20180308-02 pmid: 29738585

Ganesh S, Brar S, Rao PA. Cryopreservation of extracted corneal lenticules after small incision lenticule extraction for potential use in human subjects. Cornea. 2014;33:1355-62. doi: 10.1097/ICO.0000000000000276 pmid: 25343698

Swinger CA, Barraquer JI. Keratophakia and keratomileusis--clinical results. Ophthalmology. 1981;88:709-15. pmid: 7033859

Moshirfar M, McCaughey MV, Reinstein DZ, Shah R, Santiago-Caban L, Fenzl CR. Small-incision lenticule extraction. Journal of Cataract & Refractive Surgery. 2015;41:652-65.

Osman IM, Helaly HA, Abdalla M, Shousha MA. Corneal biomechanical changes in eyes with small incision lenticule extraction and laser assisted in situ keratomileusis. BMC Ophthalmol. 2016;16:123. doi: 10.1186/s12886-016-0304-3 pmid: 27457241

Wang D, Liu M, Chen Y, Zhang X, Xu Y, Wang J, et al. Differences in the corneal biomechanical changes after SMILE and LASIK. J Refract Surg. 2014;30:702-7. doi: 10.3928/1081597X-20140903-09 pmid: 25291754

Denoyer A, Landman E, Trinh L, Faure JF, Auclin F, Baudouin C. Dry eye disease after refractive surgery: comparative outcomes of small incision lenticule extraction versus LASIK. Ophthalmology. 2015;122:669-76. doi: 10.1016/j.ophtha.2014.10.004 pmid: 25458707

Moshirfar M, Walker BD, Linn SH, Birdsong OC, Hoopes PC, Jr. Optimal Pocket Depth for Corneal Inlays. J Refract Surg. 2018;34:288. doi: 10.3928/1081597X-20180209-01 pmid: 29634846

Kohlhaas M, Spoerl E, Schilde T, Unger G, Wittig C, Pillunat LE. Biomechanical evidence of the distribution of cross-links in corneas treated with riboflavin and ultraviolet A light. J Cataract Refract Surg. 2006;32:279-83. doi: 10.1016/j.jcrs.2005.12.092 pmid: 16565005

Scarcelli G, Pineda R, Yun SH. Brillouin optical microscopy for corneal biomechanics. Invest Ophthalmol Vis Sci. 2012;53:185-90. doi: 10.1167/iovs.11-8281 pmid: 22159012

Chansue E, Tanehsakdi M, Swasdibutra S, McAlinden C. Safety and efficacy of VisuMax(R) circle patterns for flap creation and enhancement following small incision lenticule extraction. Eye Vis (Lond). 2015;2:21. doi: 10.1186/s40662-015-0031-5 pmid: 26709375

Ting DSJ, Srinivasan S, Danjoux JP. Epithelial ingrowth following laser in situ keratomileusis (LASIK): prevalence, risk factors, management and visual outcomes. BMJ Open Ophthalmol. 2018;3:e000133. doi: 10.1136/bmjophth-2017-000133 pmid: 29657982

Mohamed TA, Hoffman RS, Fine IH, Packer M. Post-laser assisted in situ keratomileusis epithelial ingrowth and its relation to pretreatment refractive error. Cornea. 2011;30:550-2. pmid: 21598428

Caster AI, Friess DW, Schwendeman FJ. Incidence of epithelial ingrowth in primary and retreatment laser in situ keratomileusis. J Cataract Refract Surg. 2010;36:97-101. doi: 10.1016/j.jcrs.2009.07.039 pmid: 20117711

Rapuano CJ. Management of epithelial ingrowth after laser in situ keratomileusis on a tertiary care cornea service. Cornea. 2010;29:307-13. doi: 10.1097/ICO.0b013e3181b7f3c5 pmid: 20098302

Chen LY, Kung JS, Manche EE. Management of Complex Epithelial Ingrowth After Laser In Situ Keratomileusis Using Fibrin Tissue Glue. Eye Contact Lens. 2017. doi: 10.1097/ICL.0000000000000447 pmid: 29219897

Mastropasqua L, Nubile M, Salgari N, Mastropasqua R. Femtosecond Laser-Assisted Stromal Lenticule Addition Keratoplasty for the Treatment of Advanced Keratoconus: A Preliminary Study. J Refract Surg. 2018;34:36-44. doi: 10.3928/1081597X-20171004-04 pmid: 29315440

Kanellopoulos AJ, Asimellis G. Epithelial remodeling after femtosecond laser-assisted high myopic LASIK: comparison of stand-alone with LASIK combined with prophylactic high-fluence cross-linking. Cornea. 2014;33:463-9. doi: 10.1097/ICO.0000000000000087 pmid: 24622298

Jacob S, Kumar DA, Agarwal A, Agarwal A, Aravind R, Saijimol AI. Preliminary Evidence of Successful Near Vision Enhancement With a New Technique: PrEsbyopic Allogenic Refractive Lenticule (PEARL) Corneal Inlay Using a SMILE Lenticule. J Refract Surg. 2017;33:224-9. doi: 10.3928/1081597X-20170111-03 pmid: 28407161

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