Ophthalmic & Physiological Optics ISSN 0275-5408

Aberration compensation between anterior and posterior

corneal surfaces after Small incision lenticule extraction and
Femtosecond laser-assisted laser in-situ keratomileusis
Xiaojing Li, Yan Wang and Rui Dou
Refractive Surgery Center, Tianjin Eye Hospital, Tianjin, China

Citation information: Li X, Wang Y & Dou R. Aberration compensation between anterior and posterior corneal surfaces after Small incision lenticule
extraction (SMILE) and Femtosecond laser-assisted laser in-situ keratomileusis (FS-LASIK). Ophthalmic Physiol Opt 2015; 35: 540–551. doi: 10.1111/
opo.12226

Keywords: compensation, corneal Abstract

aberrations, laser in-situ keratomileusis,
posterior corneal surface, small incision
lenticule extraction
Correspondence: Yan Wang
E-mail address: wangyan7143@vip.sina.com
Received: 6 March 2015; Accepted: 3 June
2015; Published Online: 18 June 2015
Purpose: To investigate the aberration compensation between anterior and pos-
terior corneal surfaces after SMILE and FS-LASIK.
Methods: Fifty-five subjects (55 eyes) undergoing SMILE and 51 subjects (51
eyes) undergoing FS-LASIK were enrolled in this study. Wavefront aberrations of
anterior and posterior corneal surfaces and the whole cornea at 6 mm in diameter
were measured using a Scheimpflug Camera preoperatively and one, three and
6 months postoperatively. The compensation factor (CF), where CF = 1
(aber-
ration of the whole cornea/aberration of anterior corneal surface), was calculated.
Results: Spherical aberration of the posterior surface and the whole cornea
remained stable after SMILE. However, spherical aberration of posterior surface
increased significantly at 6 months in the FS-LASIK group. The total higher-order
aberration (tHOA) of the anterior surface and the whole cornea was lower at
6 months than at one and 3 months (p = 0.001 and 0.001, respectively) in the
FS-LASIK group. Meanwhile, in the SMILE group, no significant difference in
tHOA was found between various postoperative time points. There were signifi-
cant decreases in the CF of tHOA compared with preoperative values in both
groups. The CF of spherical aberration reduced significantly in both groups at 3
and 6 mm in diameter one, three and 6 months postoperatively. Significant
decreases in the CF of vertical coma were found at three and 6 months postopera-
tively in the FS-LASIK group compared with preoperative values at 6 mm in
diameter (p = 0.021 and 0.008, respectively). The change in CF (DCF) of spheri-
cal aberration was smaller in the SMILE group than in the FS-LASIK group at one
and 3 months postoperatively (p = 0.003 and p < 0.0001, respectively). The DCF
of spherical aberration was significantly lower in moderately myopic subjects than
in subjects with high myopia at 1 month in the SMILE group (p = 0.041) and at
one, three and 6 months in the FS-LASIK group (p = 0.014, 0.020, and 0.004,
respectively).
Conclusions: The posterior corneal surface plays an important role in compensat-
ing for spherical aberration of the anterior corneal surface. The compensation
mechanisms of spherical aberration and higher-order aberration between anterior
and posterior corneal surfaces were disrupted by the SMILE and the FS-LASIK
procedures. The change in the CF of spherical aberration was smaller in the
SMILE group compared with the FS-LASIK group, especially in subjects with high
myopia.

540 © 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists
Ophthalmic & Physiological Optics 35 (2015) 540–551
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X Li et al.
Introduction
Wavefront aberrations in human eyes are one of the most
important factors that degrade retinal image quality1–3 so
that the various components of the wavefront aberrations,
and their interactions, should be carefully analysed. Previ-
ous studies have found partial compensation between the
cornea and the internal optics.4–8 In 1998, Pablo Artal
et al.4 studied optical aberrations of the cornea and the
crystalline lens contribution to the retinal image quality of
the human eye. They found that spherical aberration and
coma were significantly greater for the cornea than for the
complete eye, which indicated that the lens compensated
for the corneal aberrations in a significant way. Another
study6 found strong evidence for compensation of horizon-
tal/vertical astigmatism, lateral coma and spherical aberra-
tion between the cornea and the internal optics. Although
aberrations of the cornea typically occur on anterior cor-
neal surface, the aberrations of the posterior corneal surface
cannot be ignored. One study9 analysed the contribution of
the aberrations of the posterior corneal surface of the
human eye and showed that the posterior surface compen-
sated for 3.5% of the coma of the anterior surface. If the
posterior surface wavefront was not taken into account and
a one-surface model was used to calculate the spherical
aberration (SA) of the whole cornea, the error of the ratio
SAposterior/SAanterior would vary from
8% to 27%.10 How-
ever, Barbero et al.11 reported that the posterior cor-
neal surface contributed at most 2% to the aberrations of
the normal cornea. The difference between anterior corneal
aberrations and total aberrations of the aphakic eye was not
significant and was within the error of measurement. This
raises the question of whether compensation arises from
the posterior corneal surface, and how much compensation
is present in post-surgical eyes. Therefore, we investigate
the aberrations on both the anterior and the posterior cor-
neal surfaces to elucidate the possible contribution of the
posterior corneal surface in compensating for the aberra-
tions of the anterior corneal surface.
Refractive lenticule extraction (ReLEx) with a single fem-
tosecond laser has been recently introduced12–18 and rap-
idly expanded. SMILE, the improved form of FLEx, is
flapless and keeps the epithelium and Bowman’s membrane
intact. The safety, efficacy, stability and predictability of
SMILE have been reported.14,15 The aberrations induced by
SMILE are much smaller than those induced by traditional
LASIK, leading to a better quality of vision.16–18 However,
studies of the aberrations of SMILE focus on either ocular
or corneal aberrations, and the relationship between differ-
ent parts of the aberrations are unknown.
In the current study, we measured the aberrations of the
anterior and posterior corneal surfaces before and after
SMILE and FS-LASIK. The possible compensation mecha-
© 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists
Ophthalmic & Physiological Optics 35 (2015) 540–551
Aberration compensation after SMILE
nism of aberrations between these corneal surfaces and
their changes after refractive surgery are investigated. To
the best of our knowledge, a comparison of aberration
compensation of anterior and posterior corneal surfaces
between SMILE and FS-LASIK is not available to date.
Methods
Subjects
One hundred and six eyes from 106 myopia and myopic
astigmatism patients who sought corneal refractive surgery
were recruited at the Tianjin Eye Hospital, China, from
January 2011 to November 2013. Fifty-five of these patients
were scheduled for SMILE and the other 51 for FS-LASIK.
Inclusion criteria were as follows: age from 18 to 30 years,
no ocular or systemic disease such as diabetes or connective
tissue disease, no history of ocular surgery, a stable refrac-
tion (a change of 0.50 D or less) in the past two years, soft
contact lens discontinuation for at least 2 weeks and rigid
gas permeable lens discontinuation for at least 4 weeks.
An overall ophthalmic examination was performed as
part of the patients’ preoperative assessment. This included
uncorrected visual acuity (UCVA) and best-corrected visual
acuity (BCVA), slit lamp microscopy, intraocular pressure
(IOP), and dilated indirect fundoscopy. A Snellen chart
was used for the measurement of visual acuity and both
objective (retinoscopy and autorefractor) and subjective
refraction (manifest and cycloplegic) was performed before
surgeries. The aberrations of the anterior corneal surface,
the posterior corneal surface and the whole cornea were
measured using the rotating Scheimpflug tomography sys-
tem (Pentacam; Oculus GmbH, Wetzlar, Germany; http://
www.pentacam.com/sites/index.php). The postoperative
follow-up took place at one, three and 6 months. The aber-
rations were measured at each follow-up visit. Slit lamp
examination and tonometry were also performed. Moder-
ate and high myopia were stratified according to the spheri-
cal power in each group. Patients who had a sphere
between
3.00 D to
6.00 D were placed in the moderate
myopia group, and those whose sphere exceeded
6.00D
were placed in the high myopia group.
The protocol adhered to the tenets of the Declaration of
Helsinki and was approved by the Institutional Review
Board of Tianjin Eye Hospital. Informed consent was
obtained from all participants after a thorough understand-
ing of the nature and possible consequences of the proce-
dures were acquired.
Surgical technique
All procedures were performed by the same surgeon (YW).
Oxybuprocaine eye drops (Benoxil; Santen, Inc., Osaka,
Japan; http://www.santen.com/en/) were used for topical
541
Aberration compensation after SMILE
anaesthesia two or 3 minutes before surgery. The same
femtosecond laser system (VisuMax; Carl Zeiss Meditec
AG, Germany; http://gc_yp9879417799.en.gongchang.com/)
platform with a 500 kHz repetition rate was applied to all
patients. The femtosecond laser system was utilised during
the whole procedure in the SMILE group and only for the
creation of the flap in the FS-LASIK group.
In all patients of both groups, 0.3% levofloxacin and Pra-
noprofen eye drops were used preoperatively, four times
per day for 3 days. After the surgery, use of 0.3% levofloxa-
cin eye drops continued for 3 days. The 0.1% fluorometho-
lone (Flumetholon; Santen, Inc.) was applied four times
daily for 2 weeks and tapered over 2 months postopera-
tively, which meant one less drop every 2 weeks. In addi-
tion, artificial tears (Hypromellose 2910, Dextran 70 and
Glycerol Eye Drops; Alcon Laboratories, Inc., Fort Worth,
TX, USA; http://www.infectioncontroltoday.com/buyers-
guide.aspx?li=46880) were applied four times per day.
SMILE procedure
In the SMILE group, the femtosecond laser energy was
between 110 and 120 nJ. Track distance and spot distance
were 3.0 lm for the anterior surface and the posterior sur-
face. The track and spot distance of the lenticule border and
the single small incision were 2.5 and 2.0 lm, respectively.
Four sections were created by the femtosecond laser with
definite orders: the posterior surface of the refractive lenti-
cule, the lenticule border, the anterior surface of the refrac-
tive lenticule, which extended as a cap, and the side-cutting
of the incision. The diameter of the lenticule was 6.0 mm.
A transition zone of 0.1 mm was necessary for the correc-
tion of astigmatism. The cap diameter was 7.0 mm and the
thickness of the cap was set to 110 lm. The incision was
made at the 12 o’clock position with a circumferential
length of 2.0–5.0 mm and a side-cut angle of 90°. The pos-
terior surface of the lenticule was created by laser scanning
in decreasing spirals from the periphery to the centre of the
optical zone, while the anterior surface of the lenticule was
created in expanding spirals from the centre of the pupil to
the edge of the cap. After scanning, dissection of the lenti-
cule was performed from the anterior surface to the poster-
ior surface. The lenticule was then extracted through the
small incision using a spatula. Balanced salt solution (BSS;
Alcon) was utilised for irrigating the stromal bed.
FS-LASIK procedure
In the FS-LASIK group, the femtosecond laser energy was
between 165 and 175 nJ. Track distance and spot distance
were 3.0 lm during flap creation and 1.5 lm during
side-cutting of the flap. The flap diameter was 8.0 mm, and
the flap thickness was the same as the cap thickness in the
542 © 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists
X Li et al.
SMILE group. The side-cut angle of the flap was 90°. The
hinge of the flap was positioned nasally. A spiral scanning
pattern of the femtosecond laser from the periphery to the
centre of the pupil was used for flap creation. Ablation of
the stromal bed was performed by an excimer laser system
(Allegretto; WaveLight Laser Technologie AG, Erlangen,
Germany; http://www.wavelight-laser.net/) after lifting the
flap. The optical zone was set to 6.0 mm surrounded by a
transition zone of 1.0 mm. The flap was repositioned in a
similar fashion as in routine LASIK immediately after the
excimer ablation was completed.
Pentacam scheimpflug images
The aberrations of the anterior and posterior surfaces
and the whole cornea were measured with Pentacam
corneal topography. The rotating Scheimpflug camera
identified 25 000 true elevation points with which to
compute the aberrations. All of the measurements were
centred on the vertex and performed just after a blink-
ing to minimise the impact of tear film on the data.
Previous studies have shown the excellent repeatability,
reproducibility and precision of Pentacam in measuring
corneal wavefront errors.19,20 All patients were imaged
preoperatively and one, three and 6 months postopera-
tively. Two images with quality specification (QS)
showing OK were acquired. The averages of the coeffi-
cients were calculated for analysis.
Statistical analysis
Higher-order aberrations, which were decomposed into
Zernike polynomials (Znm) of the anterior and posterior
corneal surfaces and the whole cornea, were obtained. The
magnitudes of the aberrations of the anterior and posterior
surfaces and the whole cornea were provided independently
by topography. In addition, the Root-Mean-Square (RMS)
of the total higher-order aberration (tHOA) of the whole
cornea was calculated from the whole corneal Zernike aber-
rations. All measurements of wavefront aberrations were
reported for both 3 and 6 mm diameters centred on the
vertex. The coefficients of the vertical coma (Z3
1), the
horizontal coma (Z31) and the spherical aberration (Z40)
were recorded, and the RMS of tHOA, which is the combi-
nation of the aberrations from 3-order to 7-order, was
computed. Although all of the surgeries were performed
bilaterally, only the right eye was selected for wavefront
aberration analysis. The Compensation Factor (CF), which
was defined by Artal and Guirao,21 was calculated as a rela-
tive efficiency of the aberration compensation mechanism.
In this study, the compensation factor between the anterior
and the posterior corneal surfaces was calculated using the
following equation:
Ophthalmic & Physiological Optics 35 (2015) 540–551
X Li et al. Aberration compensation after SMILE

aberration of the total cornea
CF ¼ 1

aberration of the anterior corneal surface
The change in CF (DCF), with DCF = CFpost-op
CFpre-
op, was calculated in both groups. Complete compensation
was expected when CF = 1, which meant that the aberration
of the whole cornea was equal to zero, which represents per-
fect condition. Under-compensation is observed when CF
ranges from 0 to 1. Normally, the aberrations of the anterior
corneal surface are partially compensated for by the aberra-
tions of the posterior corneal surface but not completely.
Overcompensation is observed when CF is larger than 1.
This means that the sign of the whole cornea is opposite
from the sign of the anterior corneal surface, and it is due to
excessive compensation of the posterior corneal surface. In
addition, a negative value for CF indicates augmentation.
The aberrations of the whole cornea are enlarged compared
with the aberrations of the anterior corneal surface.
Statistical analysis was performed using SPSS 20.0
software (http://www.ibm.com/us/en/). The normality of
all data samples was examined by the Kolmogorov–
Smirnov test. An independent sample t-test was used
for the comparison of the baseline characteristics and
preoperative aberrations between the SMILE and the
FS-LASIK groups. Repeated ANOVA was used for the
comparison of preoperative aberrations and at one,
three and 6 months postoperatively in each group. Fur-
ther comparison between the different time points was
performed by the LSD test. Any significant difference
in the CF in each group was compared by the Fried-
man test. The Mann–Whitney U test was utilised to
compare the DCF and refractive characteristics between
groups at 1, 3 and 6 months postoperatively. p < 0.05
was considered statistically significant.
Results
Table 1 shows the baseline characteristics of the partici-
pants by group. There was no statistically significant differ-
ence between the SMILE and the FS-LASIK groups in
moderate and high myopia patients. The postoperative
refractive characteristics are shown in Table 2.
Wavefront Aberrations after SMILE and FS-LASIK
Figure 1 shows the wavefront aberrations of the anterior
and the posterior corneal surfaces and the whole cornea at
3 mm in diameter preoperatively and one, three and
6 months postoperatively. The wavefront aberrations mea-
sured at 6 mm in diameter are shown in Figure 2.
For 3 mm in diameter, aberrations of the posterior sur-
face remained stable after both surgeries except for vertical
coma in the SMILE group (F = 3.81, p = 0.018) and hori-
zontal coma in the FS-LASIK group (F = 2.74, p = 0.045).
The RMS of the tHOA of the anterior corneal surface and
the whole cornea increased significantly after both surger-
ies. There were significant improvements in the tHOA of
the whole cornea at three and 6 months compared with
1 month postoperatively in the SMILE group (p = 0.047
and 0.041, respectively). However, there was no significant

Table 1. Baseline characteristics in the SMILE and FS-LASIK groups

Parameters SMILE FS-LASIK t p Value

Number 55 51
Age (Y)a 22.22  3.04 (18 to 30) 22.90  3.18 (18 to 30) 1.13 0.26
Sphere (D)a
5.74  1.39 (
3.00 to
9.00)
6.18  1.61 (
2.25 to
10.75)
1.52 0.13
Cylinder (D)a
0.66  0.70 (0 to
3.25)
0.83  0.66 (0 to
3.00)
1.30 0.20
UCVA (logMAR)b 1.00 (2.00 to 0.54) 1.10 (1.60 to 0.30)
1.28 0.18
BCVA (logMAR)b 0.00 (0.10 to
0.20) 0.00 (0.10 to
0.20)
1.54 0.28

logMAR, logarithm of minimum angle of resolution; UCVA, uncorrected visual acuity; BCVA, best corrected visual acuity.
a
Mean  S.D. (full range).
b
Median (full range).

Table 2. Refractive characteristics of the SMILE and FS-LASIK groups at 6 months postoperatively

Parameters SMILE FS-LASIK t p Value

Sphere (D)a 0.00 (
0.75 to 0.75) 0.00 (
0.75 to 1.00) 1.61 0.11
Cylinder (D)a
0.25 (
1.5 to 0.00)
0.25 (
1.00 to 0.00)
1.17 0.24
UCVAa 0.00 (0.18 to
0.20)
0.10 (0.10 to
0.20)
1.18 0.18
BCVAa
0.10 (0.00 to
0.20)
0.10 (0.10 to
0.20) 1.22 0.21

UCVA, uncorrected visual acuity; BCVA, best corrected visual acuity.

a
Median (full range).

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Ophthalmic & Physiological Optics 35 (2015) 540–551
Aberration compensation after SMILE X Li et al.

(a) (b)

Figure 1. The mean of wavefront aberrations of the anterior corneal surface (circle), the posterior corneal surface (rhombus), and the whole cornea
(triangle) in both the SMILE (a) and FS-LASIK (b) groups at a diameter of 3 mm, and their changes over time (preoperatively, and one, three and
6 months postoperatively). The S.D. is shown by the error bar. (*p < 0.05 compared with the values at 1 month postoperatively, **p < 0.05 com-
pared with the values at 3 months postoperatively)

544 © 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists
Ophthalmic & Physiological Optics 35 (2015) 540–551
X Li et al. Aberration compensation after SMILE

(a) (b)

Figure 2. The mean of wavefront aberrations of the anterior corneal surface (circle), the posterior corneal surface (rhombus), and the whole cornea
(triangle) in both the SMILE (a) and FS-LASIK (b) groups at a diameter of 6 mm and their changes over time (preoperatively, and one, three and
6 months postoperatively). The S.D. is shown by the error bar. (*p < 0.05 compared with the values at 1 month postoperatively, **p < 0.05 com-
pared with the values at 3 months postoperatively)

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Ophthalmic & Physiological Optics 35 (2015) 540–551
Aberration compensation after SMILE X Li et al.

difference among any postoperative time points in the FS-
LASIK group. A significant increase of vertical coma and
horizontal coma of both the anterior surface and the whole
cornea were noted at three and 6 months compared with
1 month postoperatively in the SMILE and FS-LASIK
groups. Spherical aberration of the anterior surface were
positive at 1 and 3 months in the SMILE group with no
significant difference between them (p = 0.47), and they
were significantly different at 6 months (p = 0.002 and
0.003, respectively) with the sign reversed to negative in the
SMILE group. Nevertheless, during the follow-up period,
no significant deviation was detected regarding spherical
aberration of the anterior corneal surface with negative val-
ues in the FS-LASIK group. Spherical aberration of the
whole cornea increased significantly at 6 months compared
with the values at 1 month in the FS-LASIK group
(p = 0.032) and the SMILE group (p = 0.002).
In analysing an area of 6 mm in diameter, all of the
wavefront aberrations of the anterior and posterior surfaces
and the whole cornea showed statistically significant
improvements at one, three and 6 months over baseline
values (Tables 3 and 4). In the FS-LASIK group, the tHOA
of the anterior surface and the whole cornea at 6 months
were lower than the values at one and 3 months
(p = 0.001, 0.001, respectively). Meanwhile, in the SMILE
group, there was no significant difference between the vari-
ous postoperative time points. For vertical coma of the
anterior surface at 6 months, we found a significant
increase in the SMILE group (p = 0.037), and a significant
reduction in the FS-LASIK group (p = 0.041) compared
with the values at 3 months. Vertical coma of the whole
cornea remained stable in both groups. There was a signifi-
cant difference in vertical coma of the posterior surface
between 1 and 3 months postoperatively (p = 0.007) in the
SMILE group. Significant differences were observed in hor-
izontal coma between one and 3 months for the anterior
surface (p = 0.002) and three and 6 months for the poster-
ior surface in the SMILE group (p = 0.020) and between
one and 3 months for the posterior surface in the FS-
LASIK group (p = 0.023). Spherical aberration of the pos-
terior surface and the whole cornea remained stable after
SMILE surgery. A significant difference was found in spher-
ical aberration of the anterior surface between 3 and
6 months (p < 0.0001). Significant differences in spherical
aberration of the anterior surface and the whole cornea at
various postoperative time points were evident in the FS-
LASIK group. However, spherical aberration of the poster-
ior surface increased significantly at 6 months compared
with the values at 6 months in the FS-LASIK group
(p = 0.005).
We found that most aberrations of the anterior surface
and the whole cornea in the FS-LASIK group were higher
than the values in the SMILE group. However, there was no
statistically significant difference between these groups in
tHOA and spherical aberration of the anterior and the pos-
terior corneal surfaces at 6 months postoperatively at a
diameter of 6 mm. Furthermore, the difference in horizon-
tal coma at a diameter of 3 mm and vertical coma at both
analysed areas (3 and 6 mm) was not significant at various
follow-up visits. Horizontal coma of the posterior corneal
surface in the FS-LASIK group was higher than those in the
SMILE group at and one, three and 6 months postopera-
tively (t = 3.12, 2.06, and 2.89, respectively, and p = 0.002,
0.042, and 0.005, respectively).
Compensation factor (CF) in the SMILE and FS-LASIK
groups
Figure 3a shows the differences in compensation factor (CF)
in the SMILE group at a diameter of 6 mm. Compared to

Table 3. Significant pre- and postoperative differences at 6 mm in diameter in the SMILE groups

Pre-op 1 month 3 month 6 month F p

Anterior corneal surface

tHOA 0.371  0.111 0.890  0.220 0.891  0.192 0.911  0.180 159.1 <0.0001
Vertical coma
0.041  0.133
0.502  0.310
0.490  0.291
0.529  0.308 82.5 <0.0001
Horizontal coma
0.062  0.077
0.200  0.161
0.217  0.190
0.210  0.183 27.2 <0.0001
Spherical aberration 0.274  0.070 0.509  0.093 0.518  0.070 0.480  0.087 79.1 <0.0001
Posterior corneal surface
tHOA 0.190  0.011 0.188  0.010 0.180  0.010 0.190  0.021 4.1 0.032
Vertical coma
0.021  0.020 0.022  0.012
0.010  0.020 0.031  0.013 25.0 <0.0001
Horizontal coma
0.022  0.010
0.005  0.001 0.001  0.010 0.000  0.011 3.9 0.016
Spherical aberration
0.151  0.010
0.159  0.001
0.172  0.023
0.171  0.025 5.5 0.004
Whole cornea
tHOA 0.333  0.120 0.921  0.243 0.939  0.231 0.952  0.230 158.7 <0.0001
Vertical coma
0.081  0.100
0.553  0.321
0.537  0.312
0.609  0.391 76.2 <0.0001
Horizontal coma
0.111  0.103
0.255  0.180
0.260  0.181
0.244  0.190 24.6 <0.0001
Spherical aberration 0.194  0.090 0.483  0.133 0.492  0.121 0.411  0.180 47.8 <0.0001

546 © 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists
Ophthalmic & Physiological Optics 35 (2015) 540–551
X Li et al. Aberration compensation after SMILE

Table 4. Significant pre- and postoperative differences at 6 mm in diameter in the FS-LASIK groups

Pre-operative 1 month 3 month 6 month F p

Anterior corneal surface

tHOA 0.370  0.121 1.122  0.320 1.110  0.302 1.071  0.240 167.2 <0.0001
Vertical coma
0.071  0.110
0.522  0.400
0.561  0.409
0.466  0.317 38.1 <0.0001
Horizontal coma
0.044  0.110
0.343  0.268
0.388  0.191
0.404  0.173 32.0 <0.0001
Spherical aberration 0.260  0.088 0.689  0.185 0.623  0.140 0.564  0.177 84.5 <0.0001
Posterior corneal surface
tHOA 0.201  0.030 0.278  0.022 0.200  0.031 0.222  0.022 5.7 0.001
Vertical coma
0.011  0.020 0.022  0.020 0.014  0.030 0.000  0.016 5.9 0.009
Horizontal coma
0.015  0.013 0.005  0.002 0.011  0.023 0.020  0.011 21.4 <0.0001
Spherical aberration
0.122  0.010
0.181  0.015
0.180  0.011
0.178  0.013 9.6 <0.0001
Whole cornea
tHOA 0.310  0.144 1.161  0.369 1.189  0.342 1.111  0.220 175.8 <0.0001
Vertical coma
0.110  0.091
0.541  0.420
0.592  0.503
0.507  0.431 26.7 <0.0001
Horizontal coma
0.072  0.090
0.431  0.251
0.430  0.221 0.431  0.209 54.4 <0.0001
Spherical aberration 0.183  0.081 0.641  0.192 0.602  0.174 0.522  0.190 97.7 <0.0001

0.30 p < 0.0001 and p < 0.0001, respectively). However, there

(a) Vertical coma
was no difference in the CFs of both spherical aberration
Compensation factor (CF)

Horizontal coma
Spherical aberration
0.20 and tHOA between various follow-up visits. Compensation
tHOA

factors in the FS-LASIK group at 6 mm in diameter are pre-

0.10 sented in Figure 3b. In the FS-LASIK group, the CFs of
* * *
spherical aberration reduced significantly at one, three and
0.00
* * 6 months postoperatively compared with the preoperative
*
values (all p < 0.0001). However, the differences were not
–0.10
significant between various follow-up visits after the surgery.
The same rules were found in the CFs of tHOA at 6 mm in
–0.20
Pre-op 1 month 3 month 6 month diameter at one, three and 6 months postoperatively
Time (p = 0.002, p < 0.0001 and p < 0.0001, respectively). Other
changes in CFs were noted in vertical coma at 6 mm in
0.30 Vertical coma diameter in the FS-LASIK group. A significant reduction of
(b)
Compensation factor (CF)

Horizontal coma
Spherical aberration
vertical coma CF was observed at 3 months (p = 0.021) and
0.20
tHOA 6 months (p = 0.008) postoperatively compared with the
0.10
preoperative values.
* *
*
0.00
* Change in CF (DCF) between the SMILE and FS-LASIK
* *
groups
–0.10
* * Significant differences inDCF of spherical aberration
–0.20 between the SMILE and FS-LASIK groups were found at
Pre-op 1 month 3 month 6 month
Time 1 month (p = 0.003) and 3 months (p < 0.0001) with
6 mm in diameter. The changes were smaller in the SMILE
Figure 3. Compensation factors decreased at all postoperative time group than in the FS-LASIK group (Figure 4). There was
points in the SMILE group (a) and in the FS-LASIK group (b) at 6 mm in no statistically significant difference inDCF at a diameter of
diameter (* significant difference compared with the preoperative val-
3 mm.
ues)
Figure 5 shows the change in compensation factors of
spherical aberration. In patients with high myopia, the DCF
the preoperative values preoperatively, significant decreases of spherical aberration were smaller in the SMILE group
in the CF of spherical aberration (Z40) were found at a diam- than in the FS-LASIK group at one and 3 months postop-
eter of 6 mm (all p < 0.0001) postoperatively. The CFs of eratively (p = 0.009 and 0.003, respectively). A significant
tHOA diminished in statistical significance compared with difference in the DCF of tHOA was observed in patients
the preoperative values at a diameter of 6 mm (p = 0.001, with moderate myopia between the SMILE and FS-LASIK

© 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists 547
Ophthalmic & Physiological Optics 35 (2015) 540–551
Aberration compensation after SMILE X Li et al.

Changes of compensation factor (ΔCF) groups at 3 months postoperatively (p = 0.033). In the

–0.25 SMILE group, the decrease in CF of spherical aberration
SMILE
was smaller in moderate myopia patients than in high myo-
–0.2 * * FS-LASIK
pia patients at 1 month after the surgery (p = 0.041).
Meanwhile, in the FS-LASIK group, there were significant
–0.15
differences of DCF in one, three and 6 months between
–0.1 high myopia and moderate myopia groups (p = 0.014,
0.020, and 0.004, respectively).
–0.05

0 Discussion
1 month
Figure 4. Change in compensation factor (DCF) of spherical aberration
in both the SMILE and FS-LASIK groups at one, three and 6 months
postoperatively. There were significant differences between these
groups at one and 3 months (*p < 0.05).
Changes of compensation factor (ΔCF)
3 month 6 month
Time In this study, wavefront aberrations increased after
refractive surgeries, while the compensation factors of
aberrations decreased. Previous studies focused on the
refractive outcomes and the magnitude of the aberra-
tions after SMILE surgery. Neither aberration compen-
sation after SMILE, nor aberration compensation
between the anterior and the posterior corneal surfaces
was reported previously. Compensation of aberrations

–0.4
SMILE after LASIK was discussed in previous studies.22–24 The
(a)
FS-LASIk differences of the compensation mechanism and the
–0.3 magnitude of the compensation between SMILE and
FS-LASIK have not been investigated. In the current
study, different compensation mechanism was revealed
–0.2
in the SMILE and FS-LASIK groups. The compensation
factors were reduced at one, three and 6 months post-
–0.1 operatively compared with the preoperative values.
Because there was some controversy about age, we
0 monitored the corneal aberrations of young subjects
Pre-op 1 month 3 month 6 month (18–30 years old) to mitigate the influence of age.25–27
Time A significant increase in spherical aberration after SMILE
and FS-LASIK was found in our results. It was in good
Changes of compensation factor (ΔCF)

–0.4 agreement with former studies.28–31 However, fewer studies

(b)
–0.3
* ranged from 0 to 1 at 6 mm in diameter after both surger-
–0.2
–0.1
0 posterior corneal surface indicated that the oblate shape of
Pre-op 1 month
Time
Figure 5. Change in compensation factor (DCF) of spherical aberration
in moderate myopia patients (a) and high myopia patients (b). A signifi-
cant difference between the SMILE and FS-LASIK groups was noted in
patients with high myopia at one and 3 months postoperatively
(p < 0.05). TheDCF was lower in moderate myopia patients than in high
myopia patients at 1 month in the SMILE group (p = 0.041) and at vari-
ous postoperative time points in the FS-LASIK group (p = 0.014, 0.020
and 0.004, respectively) (* significant difference between the SMILE
group and FS-LASIK groups).
SMILE of the aberration compensation between the anterior and
FS-LASIK posterior corneal surfaces have been reported. In the cur-
* rent study, the compensation factors of spherical aberration
ies, suggesting that the posterior corneal surface plays a
compensatory role in the balance of spherical aberrations
of the whole cornea. The association between the increase
in positive spherical aberration of the anterior corneal sur-
face and the increase in negative spherical aberration of the
3 month 6 month
the anterior corneal surface is compensated for by the steep
posterior surface. Nevertheless, a significant decrease in the
CFs of spherical aberration, ranging from 0 to 1, was
noticed after the surgeries. Because the ablation of the laser
was performed on the anterior surface of the cornea, the
increase of the spherical aberration on the anterior cornea
surface was much more remarkable than that on the poster-
ior surface. Therefore, the weak aberration of the posterior
surface cannot compensate enough for the much stronger
aberration of the anterior surface. Spherical aberration of

548 © 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists
Ophthalmic & Physiological Optics 35 (2015) 540–551
X Li et al.
the human cornea is one of the most important factors that
limit the optical quality of the retinal image and the spatial
resolution capabilities of the visual system.6 The favourable
compensation of spherical aberration at 6 mm in diameter
might contribute to the visual acuity in mesopic circum-
stances.
In the current study, we observed that the CF of vertical
coma changed significantly at three and 6 months postop-
eratively compared with the preoperative values in the FS-
LASIK group, with no significant difference at 1 month
postoperatively. This might have been caused by oedema in
the early stages of the wound healing response. Although
there were no significant differences in vertical coma
between the SMILE and FS-LASIK groups at various post-
operative time points, changes in vertical coma of diverse
corneal surfaces had occurred in each group. It has been
reported that SMILE induces less keratocyte apoptosis, pro-
liferation and inflammation compared with femtosecond
laser LASIK in rabbit eyes.32 With regard to vertical coma,
the asymmetry in the vertical direction will be influenced
much more dramatically by the wound healing response at
the superior incision. We suppose that the weaker wound
healing response at the small incision contributed to the
stability of the compensation factor of vertical coma in the
SMILE group.
Higher-order aberration is the combination of all of the
Zernike terms ranging from third-order to seventh-order
aberrations and will be influenced by any coefficients.
There were significant decreases in the CFs of HOA after
both SMILE and FS-LASIK, except for the CFs in the
SMILE group with a 3 mm diameter. Juhasz et al.33 mea-
sured the RMS-HOA of the posterior corneal surface with a
6 mm in diameter. They concluded that the aberrations on
the posterior corneal surface compensated for the wave-
front aberrations of the anterior cornea in myopia patients
and remained stable after PRK. This is identical to our
results. The ablation depth should be considered in assess-
ing the difference in results between PRK and lamellar sur-
geries.
The results of this study showed that the change in CF
(DCF) of spherical aberration at 1 and 3 months was signif-
icantly smaller in the SMILE group than in the FS-LASIK
group with 6 mm in diameter. When we stratified the pop-
ulation into high myopia and moderate myopia groups,
similar results of spherical aberration were observed in the
high myopia group. The difference in DCF between the
SMILE and FS-LASIK groups can also be found in HOA in
patients with moderate myopia. Benito et al.22 noted that
myopia LASIK increased the average aberration compensa-
tion, mainly because of SA. Hyperopic LASIK disrupts the
compensation mechanism with a reduction of the CF.
Another study by Artal et al.7 investigated the compensa-
tion between aberrations of cornea and internal ocular
© 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists
Ophthalmic & Physiological Optics 35 (2015) 540–551
Aberration compensation after SMILE
optics in the human eye. They found that the compensation
was greater in hyperopic eyes and could not be found in
highly myopic eyes. This was identical to our study. How-
ever, the changes in the CFs were not shown in their study.
We speculate that SMILE can prevent the disruption of the
compensation of spherical aberration compared with FS-
LASIK, especially in patients with high myopia.
One study34 evaluated the detailed optical properties of
the cornea after three representative types of keratoplasty
(PK, DALK, and DSAEK, respectively) and found that in
DSAEK eyes, in which the posterior surface of the cornea
was replaced, the posterior surface increased HOAs of the
whole corneal. They demonstrated that the disruption of
the posterior surface causes a loss in the ability to compen-
sate for the aberrations of the anterior surface. Antonio
Benito et al.22 found some patients with differences
between preoperative and postoperative internal ocular
aberrations. The average difference for the measured popu-
lation was <0.1 lm. However, they did not support the
idea that systematic changes in the aberrations induced by
the posterior corneal surface resulted from LASIK. In our
study, significant differences in aberrations of the anterior
and posterior corneal surfaces and the whole cornea were
found between preoperative and postoperative time points
at 6 mm in diameter. The compensation of the aberrations
of the posterior corneal surface changed simultaneously.
The combination of wavefront aberrations between the
anterior and posterior corneal surfaces is a complicated
relationship.
The SD’s in the FS-LASIK group were larger than those
in the SMILE group. This indicated that the extent of the
aberration fluctuation in the FS-LASIK group was more
remarkable. This might have been caused by the flap cre-
ated in the FS-LASIK group. The stability of the values of
aberrations and CFs in the SMILE group might be attrib-
uted to the lack of a flap.
Limitations exist in the current study. Although atten-
tion instruction was given before each capturing, measure-
ment errors such as ocular movements and slight blinking
during the examination could not be completely prevented.
Because the tear film is one of the most important optical
mediums, the measurement was performed immediately
after blinking; however, the deformation and breaking up
of the tear film while collecting the images still impacted
the measurement. We did our best to minimise these
errors, though they were inevitable. Higher speed equip-
ment is expected to solve these problems in the future.
In conclusion, the posterior corneal surface plays a com-
pensatory role, to a certain extent, in the balance of corneal
aberrations after refractive surgery. The results of the cur-
rent study indicate that the changes in aberration compen-
sation in the SMILE group were smaller and closer to the
original condition than those in the FS-LASIK group. These
549
Aberration compensation after SMILE
results were especially evident in spherical aberrations and
in patients with high myopia. The compensation mecha-
nism of corneal aberrations may contribute to the visual
quality under mesopic conditions. Further studies are nec-
essary to investigate and define the relationship between
aberration compensation and visual quality.
Acknowledgements
This work was supported by the National Key Natural Sci-
ence Program Grant (No. 81470658). We thank Larry N.
Thibos and Tao Liu (School of Optometry, Indiana Univer-
sity, Bloomington, Indiana, USA) for providing generous
assistance and attentive editing of the text.
Disclosure
The authors report no conflicts of interest and have no proprie-
tary interest in any of the materials mentioned in this article.
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