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In the 1990s, the excimer laser revolutionized the field of corneal refractive surgery with <jats:styled-content style=\"fixed-case\">PRK<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">LASIK<\/jats:styled-content>, and lately refractive lenticule extraction (<jats:styled-content style=\"fixed-case\">R<\/jats:styled-content>e<jats:styled-content style=\"fixed-case\">LE<\/jats:styled-content>x) of intracorneal tissue, using only a femtosecond laser, has become possible. Two new procedures were developed, <jats:styled-content style=\"fixed-case\">R<\/jats:styled-content>e<jats:styled-content style=\"fixed-case\">LE<\/jats:styled-content>x flex (<jats:styled-content style=\"fixed-case\">FLEX<\/jats:styled-content>) and <jats:styled-content style=\"fixed-case\">R<\/jats:styled-content>e<jats:styled-content style=\"fixed-case\">LE<\/jats:styled-content>x smile (<jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content>).<\/jats:p><\/jats:sec><jats:sec><jats:label\/><jats:p>Until this thesis, only a few long\u2010term studies of <jats:styled-content style=\"fixed-case\">PRK<\/jats:styled-content> with a relatively limited number of patients had been published; therefore, this thesis intended to retrospectively evaluate long\u2010term outcomes after <jats:styled-content style=\"fixed-case\">PRK<\/jats:styled-content> for all degrees of myopia for a large number of patients. Furthermore, a prospective contralateral eye study comparing <jats:styled-content style=\"fixed-case\">FLEX<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content>, when treating high to moderate degrees of myopia, had not been performed prior to this study. This was the second aim of this thesis.<\/jats:p><\/jats:sec><jats:sec><jats:label\/><jats:p>In the first study, results from 160 <jats:styled-content style=\"fixed-case\">PRK<\/jats:styled-content> patients (289 eyes) were presented. Preoperative spherical equivalent ranged from \u22121.25 to \u221220.25\u00a0D, with 78% having low myopia (&lt;\u22126\u00a0D). Average follow\u2010up time was 16\u00a0years (range 13\u201319\u00a0years), making this the longest published follow\u2010up study on <jats:styled-content style=\"fixed-case\">PRK<\/jats:styled-content> patients. Outcomes from eyes with low myopia were generally superior to outcomes from eyes with high myopia, at final follow\u2010up. Seventy\u2010two percent were within \u00b11.00\u00a0D of target refraction, as compared to 47% of eyes with high myopia. However, results from a subgroup of unilateral treated <jats:styled-content style=\"fixed-case\">PRK<\/jats:styled-content> patients indicated that refraction at final follow\u2010up was affected by myopic progression. Fifty percent of eyes with low myopia had uncorrected 20\/20 distance visual acuity or better, as compared to 22% of eyes with high myopia. Haze did not occur if attempted corrections were &lt;\u22124\u00a0D, and only eyes with high myopia lost two lines or more of <jats:styled-content style=\"fixed-case\">CDVA<\/jats:styled-content> (corrected distance visual acuity). Eighty\u2010one per cent were satisfied or very satisfied with their surgery.<\/jats:p><\/jats:sec><jats:sec><jats:label\/><jats:p>Conclusion: The results support the continued use of the excimer laser for corneal surface ablation as a treatment option for correction of low degrees of myopia, and as the treatment of choice for subgroups of refractive patients (thin corneas, etc.). The results also highlight that treatment of higher degrees of myopia with standard <jats:styled-content style=\"fixed-case\">PRK<\/jats:styled-content> should only be done today under special circumstances, due to low refractive predictability, and high risk of corneal haze. Technological advances since then should be taken into account when comparing these results with contemporary techniques.<\/jats:p><\/jats:sec><jats:sec><jats:label\/><jats:p>In the second study, 35 patients were randomized to receive <jats:styled-content style=\"fixed-case\">FLEX<\/jats:styled-content> in one eye and <jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content> in the other. Preoperative spherical equivalent refraction ranged from \u22126 to \u221210\u00a0D with low degrees of astigmatism. A total of 34 patients completed the 6\u00a0month follow\u2010up period. Refractive and visual outcomes were very similar for the two methods, as well as tear film measurements and changes in corneal biomechanics. Ninety\u2010seven percent were within \u00b11.00\u00a0D of target refraction, no eyes lost two lines or more of <jats:styled-content style=\"fixed-case\">CDVA<\/jats:styled-content>, and contrast sensitivity was unaffected after both procedures. The changes in higher\u2010order aberrations were also very similar. There were also no differences in tear film parameters 6\u00a0months after surgery, although less postoperative foreign body sensation was reported within the first week after surgery in <jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content> eyes. Corneal sublayer pachymetry measurements demonstrated equally increased epithelial thickness 6\u00a0months after surgery. Contrary to expectations, it was not possible to measure the theoretical biomechanical advantages of a small corneal incision in <jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content> as compared to a corneal flap in <jats:styled-content style=\"fixed-case\">FLEX<\/jats:styled-content>. The main differences between <jats:styled-content style=\"fixed-case\">FLEX<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content> were found when the corneal nerves and intraoperative complications were evaluated. Thus, corneal sensitivity was better preserved and corneal nerve morphology was less affected after <jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content>, but intraoperative complications occurred more frequently, although without visual sequela. Finally, 97% were satisfied or very satisfied with both their surgeries.<\/jats:p><\/jats:sec><jats:sec><jats:label\/><jats:p>Conclusion: The results support the continued use of both <jats:styled-content style=\"fixed-case\">FLEX<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content> for treatment of up to high degrees of myopia. Overall, refractive and visual results for both procedures were good and similar, but from a biological point of view, the less invasive <jats:styled-content style=\"fixed-case\">SMILE<\/jats:styled-content> technique is more attractive, as demonstrated in this study, despite being slightly more surgically demanding than <jats:styled-content style=\"fixed-case\">FLEX<\/jats:styled-content>.<\/jats:p><\/jats:sec>","DOI":"10.1111\/aos.12385","type":"journal-article","created":{"date-parts":[[2014,3,18]],"date-time":"2014-03-18T09:27:51Z","timestamp":1395134871000},"page":"1-21","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":42,"title":["Past and present of corneal refractive surgery"],"prefix":"10.1111","volume":"92","author":[{"given":"Anders H\u00f8jslet","family":"Vestergaard","sequence":"first","affiliation":[{"name":"Faculty of Health Science University of Southern Denmark Odense Denmark"},{"name":"Department of 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