Postoperative Efficacy, Predictability, Safety, and Visual Quality of Laser Corneal Refractive Surgery: A Network Meta-analysis

Am J Ophthalmol. 2017 Jun:178:65-78. doi: 10.1016/j.ajo.2017.03.013. Epub 2017 Mar 20.


Purpose: To compare the postoperative efficacy, predictability, safety, and visual quality of all major forms of laser corneal refractive surgeries for correcting myopia.

Design: Systematic review and network meta-analysis.

Methods: Search of MEDLINE, EMBASE, Cochrane Library, and the US trial registry was conducted up to November 2015. Randomized controlled trials (RCT) reporting in accordance with the eligibility criteria were included in this review. We performed a Bayesian random-effects network meta-analysis.

Results: Forty-eight RCTs were identified. For efficacy (uncorrected visual acuity [UCVA]), there were no statistically significant differences between any pair of treatments analyzed. The SUCRA (surface under the cumulative ranking curve) ranking (from best to worst) was femtosecond-based laser in situ keratomileusis (FS-LASIK), LASIK, small-incision lenticule extraction, femtosecond lenticule extraction (FLEx), photorefractive keratectomy (PRK), laser epithelial keratomileusis (LASEK), epipolis (Epi)-LASIK, transepithelial PRK (T-PRK). For predictability (refractive spherical equivalent [SE]), a statistically significant difference was found when FS-LASIK was compared with LASIK (odds ratio [OR] 2.29, 95% credible interval [CrI] 1.20-4.14), PRK (OR 2.16, 95% CrI 1.15-4.03), LASEK (OR 2.09, 95% CrI 1.08-4.55), and Epi-LASIK (OR 2.74, 95% CrI 1.11-6.20). The SUCRA ranking (from best to worst) was FS-LASIK, T-PRK, LASEK, PRK, LASIK, Epi-LASIK. There were no statistically significant differences in the safety (best spectacle-corrected visual acuity) comparisons. For both postoperative higher-order aberrations (HOAs) and contrast sensitivity (CS), there were no statistically significant differences between any pair of treatments analyzed. The SUCRA ranking results show that some corneal surface ablation techniques (PRK and LASEK) rank highest.

Conclusions: This network meta-analysis shows that there were no statistically significant differences in either visual outcomes (efficacy and safety) or visual quality (HOAs and CS). FS-LASIK behaved better in predictability than any other type of surgeries.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Cornea / surgery
  • Humans
  • Lasers, Excimer / therapeutic use*
  • Myopia / physiopathology
  • Myopia / surgery*
  • Network Meta-Analysis
  • Photorefractive Keratectomy*
  • Postoperative Period
  • Refraction, Ocular / physiology*
  • Visual Acuity*