高度近视SMILE和FS-LASIK术后早期局部调节和中枢视感知觉功能变化

目的：探讨高度近视患者行飞秒激光小切口角膜基质透镜取出术（SMILE）和飞秒激光制瓣准分子激光原位角膜磨镶术（FS-LASIK）术后早期双眼调节功能和视感知觉功能的变化及差异。方法：前瞻性临床研究。选取2019年11月至2020年7月在中南大学湘雅医院眼科中心行SMILE和FS-LASIK手术的患者60例（120眼），其中SMILE组35例（70眼），FS-LASIK组25例（50眼）。测量术前术后1周、 1个月、3个月的调节功能（正/负相对调节、调节幅度、调节反应、调节灵活度）和视感知觉功能（知觉眼位、注视稳定性、精细立体视）。用t检验、Wilcoxon检验或λ2 检验进行组间数据比较，用重复测量方差分析、LSD-t检验、Kruskal-Wallis H或λ2检验进行组内不同时间点间比较。结果：SMILE组正相对调节术后1、3个月较术前提高（P<0.05），单、双眼调节幅度和调节灵活度术后1、3个月均较术后1周提高（P<0.05），术后3个月单眼调节幅度高于术前（P=0.028）。垂直眼位、5 m精细立体视术后1、 3个月较术前提高（P<0.05）。FS-LASIK组正相对调节术后1个月较术后1周提高（P=0.02），术后3个 月较术前、术后1周提高（P<0.05），单、双眼调节幅度术后3个月较术前，术后1周、1个月提高（P<0.05）， 单、双眼调节灵活度术后1周低于术前（P<0.05），术后1、3个月较术后1周提高（P<0.05），且在术后 3个月恢复到术前水平。5 m精细立体视术后3个月较术后1周提高（P<0.05）。组间比较：FS-LASIK 组术前双眼调节幅度（t=-2.067，P=0.043），术后1个月负相对调节（t=-3.181，P=0.03）及术后3个月单眼调节幅度（t=-2.126，P=0.036）高于SMILE组，而术后1周正相对调节（t=-2.249，P=0.028）、单眼调节灵活度（t=3.013，P=0.003），术后1个月双眼调节幅度差值（t=3.031，P=0.004）小于SMILE组。 FS-LASIK组术后1周、1个月2.5 m精细立体视和5 m精细立体视，术后3个月5 m精细立体视等级总体低于SMILE组（P<0.05）。结论：SMILE与FS-LASIK不仅能改善高度近视双眼局部调节功能，还能改善大脑知觉层面的高级视功能。且SMILE术后早期视感知觉功能恢复快于FS-LASIK。

Local Accommodative and Central Visual Perceptual Changes in the Early Stages after SMILE and FS-LASIK for High Myopia

Objective: To compare the changes and differences of accommodative and visual perceptual functions after small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomiluesis (FS-LASIK) for the correction of high myopia. Methods: This prospective, comparative clinical studyincluded 60 patients (SMILE: n=35, FS-LASIK: n=25) who underwent SMILE or FS-LASIK surgery at the Eye Center of Xiangya Hospital, Central South University between November 2019 and July 2020. Accommodation (including negative/positive relative accommodation, amplitude of accommodation, accommodative response and facility of accommodation) and visual perceptual functions (including perceptual eye positon, fixation stability and fine stereopsis) were measured preoperatively and at week 1, month 1 and month 3 postoperatively. Using a t test, Wilcoxon test or λ2 test for comparison between the two groups, comparisons between the pre- and all three postoperative time-points were performed using repeated measures analysis of variance, LSD-t test, Kruskal-Wallis H or λ2 test. Results: In the SMILE group, the positive relative accommodations at month 1 and month 3 were higher than before surgery (all P<0.05). The monocular and binocular amplitudes of accommodation and facility of accommodation improved at month 1 and month 3 compared to week 1 (all P<0.05). The monocular amplitude of accommodation at month 3 was larger than the preoperative amplitude (P=0.028). The vertical eye position and 5 meters fine stereopsis at month 1 and month 3 were improved compared to preoperative levels (all P<0.05). In the FS-LASIK group, the positive relative accommodation at month 1 was larger than accommodation at week 1 (P=0.02), and improved at month 3 compared to preoperative and week 1 levels (P<0.05). The monocular and binocular amplitudes of accommodation at month 3 were improved compared to the earlier measurements (all P<0.05). The monocular and binocular facility of accommodation at week 1 was less than preoperative levels, but increased at month 1 and month 3 (all P<0.05), and at month 3 after surgery returned to the preoperative level. The 5 meters fine stereopsis was increased at month 3 compared to week 1 (P<0.05). When comparing the two groups, the preoperative binocular amplitude of accommodation (t=-2.067, P=0.043), the negative relative accommodation at month 1 (t=-3.181, P=0.03) and the monocular amplitude of accommodation at month 3 (t=-2.126, P=0.036) in the FS-LASIK group were higher than in the SMILE group. However, the positive relative accommodation (t=-2.249, P=0.028) and monocular facility of accommodation (t=3.013, P=0.003) at week 1 and binocular amplitude of accommodation at month 1 (t=3.031, P=0.004) in the FS-LASIK group were lower than in the SMILE group. The grades of 2.5 meters fine stereopsis in week 1 and month 1, and the 5 meters fine stereopsis in the three follow-ups after surgery in the FS-LASIK group were generally less than in the SMILE group (all P<0.05). Conclusions: Both SMILE and FS-LASIK have good results for correcting high myopia. The two operations cannot only improve the local accommodation functions of the eyes, but also improve the high-level visual perceptual function of the brain. The early postoperative visual perception function in the SMILE group recovers faster than that in the FS-LASIK group.