Purpose: To compare corrected distance visual acuity (CDVA) outcomes of hyperopic laser in situ keratomileusis (LASIK) with a postoperative corneal steepness above vs below 49 diopters (D). Setting: Care-Vision Laser Centers, Tel-Aviv, Israel. Design: Retrospective study. Methods: This study included consecutive patients who underwent hyperopic LASIK between January 2013 and December 2019. Hyperopic patients were divided into 2 groups based on postoperative corneal steepness with steep corneas defined >49.0 D and the control group ≤49.0 D. Adjustments were performed to account for differences in baseline and intraoperative parameters. Results: Overall, 1703 eyes of 1703 patients were included. Mean age was 48.3 ± 10.0 years, and 45.3% were male. Preoperatively, the steep group (2.4%, n = 41/1703) had steeper mean (44.6 D vs 43.1 D, P < .001) and steep (45.1 D vs 43.5 D, P < .001) keratometry, worse logMAR CDVA (0.07 vs 0.04, P = .02), and higher sphere (4.9 D vs 2.9 D, P < .001). Intraoperatively, they had a higher spherical treatment (4.6 D vs 2.8 D, P < .001). After hyperopic LASIK, the steep group had worse logMAR CDVA (0.10 vs 0.06, P = .01). However, after accounting for differences in baseline and spherical treatment, no significant differences were found in postoperative logMAR CDVA (0.06 vs 0.06, P = .99). The factors that remained associated with worse postoperative CDVA were higher spherical treatment (0.01 logMAR per 1 D, P < .001) and preoperative CDVA (0.60 logMAR per 1.00 logMAR, P < .001). Conclusions: Postoperative corneal steepness greater than 49 D is not associated with worse visual outcomes after hyperopic LASIK. However, lower preoperative visual potential and higher spherical treatment applied are associated with worse outcomes. The 49 D cutoff should be revisited.

Background/Objectives: To compare the visual and refractive outcomes of myopic patients undergoing high astigmatic photorefractive keratectomy (PRK) surgery with and without pupillary decentration of treatment. Methods: In this retrospective study, we reviewed the medical records of myopic patients who underwent PRK surgery for high astigmatism (>3 diopters [D]) between January 2013 and December 2023. The patients were divided into two groups based on whether the surgeon applied pupillary decentration during surgery. Preoperative, intraoperative, and postoperative parameters were compared between the groups. Adjustments were made to account for differences in baseline characteristics and intraoperative parameters. Results: Overall, the study included 575 eyes from 414 patients, of which 79 eyes were treated with pupil decentration. The pupil-decentered group exhibited significantly preoperative higher myopia (subjective spherical equivalent (SEQ) of −5.30 ± 3.12 D vs. −4.26 ± 2.45 D, p < 0.001) and subjective sphere (−3.40 ± 3.13 D vs. −2.31 ± 2.49 D, p < 0.001). Visual and refractive outcomes, including uncorrected visual acuity (UCVA) of logMAR 0.11 ± 0.77 vs. 0.09 ± 0.72 (p = 0.302), best-corrected visual acuity (BCVA) of 0.07 ± 0.92 vs. 0.07 ± 0.82 (p = 0.982), SEQ (−0.33 ± 0.93 vs. −0.19 ± 0.60D, p = 0.094), sphere (0.02 ± 0.98 vs. 0.15 ± 0.67 D, p = 0.142), cylinder (−0.71 ± 0.48 vs. −0.70 ± 0.55 D, p = 0.894), safety index (1.07 ± 0.27 vs. 1.12 ± 0.31, p = 0.236), and efficacy index (0.99 ± 0.31 vs. 1.07 ± 0.35, p = 0.065), showed no significant differences between the two groups. Postoperative outcomes remained comparable after adjusting for baseline and intraoperative parameters. Conclusions: Our findings suggest that, in myopic patients undergoing high-astigmatic PRK surgery, pupil decentration does not lead to superior postoperative visual and refractive outcomes. This highlights that, in this scenario, surgeons can preserve the efficacy and safety of the procedure even without applying pupil decentration.

Purpose: To evaluate the long-term visual, refractive, and patient-reported satisfaction of epithelial photorefractive keratectomy (ePRK) combined with corneal cross-linking (CXL) - the Tel-Aviv Protocol - in patients with progressive keratoconus. Setting: Care-Vision Laser Center, Tel Aviv, Israel. Design: Retrospective, single-center case series. Methods: Consecutive patients with progressive keratoconus who underwent ePRK-CXL were included. Preoperative and last-available postoperative pachymetry, keratometry (K _mean , K _min , K _max ), spherical equivalent (SEQ), manifest refraction, uncorrected distance visual acuity (UDVA), and corrected distance visual acuity (CDVA) were recorded; safety and efficacy indices were calculated. Patient-reported outcomes regarding spectacle/contact lens dependence, satisfaction, and visual symptoms were assessed with a structured questionnaire. Results: Fifty eyes of 38 patients (mean age 25.9±6.8 years) were followed for a mean of 2,910±605 days (∼8 years; range 5–12). UDVA improved from 1.04±0.70 to 0.36±0.37 logMAR and CDVA from 0.23±0.16 to 0.11±0.10 logMAR (both P < 0.001); safety and efficacy indices were 1.42±0.55 and 0.93±0.51. K-max decreased from 47.51±2.96 to 45.95±2.99 D and SEQ from −2.42±2.29 to −0.82±1.57 D (both P < 0.001). Pachymetry decreased from 448.65±38.95 to 418.93±55.77 μm. Overall satisfaction was high (81.6% satisfied/very satisfied), 76.3% reported subjective visual improvement, 52.6% achieved spectacle independence, and 92.1% required no contact lenses. No progression was observed in the examined eyes. Conclusions: At a mean follow-up of ∼8 years, the Tel-Aviv Protocol provided durable visual and refractive improvement, stabilized keratometry without progression, and yielded high patient satisfaction with low symptom burden. These results support ePRK-CXL as a tissue-sparing option for progressive keratoconus.

Purpose: To characterize vertical gas breakthrough (VGB) during femtosecond LASIK (FS-LASIK) by frequency, location, management, and early visual outcomes. Setting: Care-Vision Laser Center, Tel Aviv, Israel. Design: Retrospective consecutive case series. Methods: All FS-LASIK procedures (June 2020–January 2023) were reviewed. Cases with an uncut area during flap creation were identified; VGB was confirmed on intraoperative video as gas breaching the lamellar plane with subepithelial accumulation. Management was classified as proceed, manual completion (crescent/keratome), conversion to PRK, or procedure abortion. Primary outcomes were UDVA and CDVA at the last postoperative refraction visit; postoperative day (POD) was summarized, and complications recorded. Results: Among 7,746 eyes, uncut areas occurred in 79 (1.0%) and VGB in 23 (0.3%). Mean age was 36±12 years; 14/23 (60.9%) were female. VGB was located near the hinge in all eyes, with central extension in 3/23 eyes (13.0%). Management included proceeding as planned in 10/23 (43.5%), manual completion in 4/23 (17.4%), same-day conversion to PRK in 7/23 (30.4%; three were primary, four after attempted flap elevation), and procedure abortion in 2/23 (8.7%). Endpoint timing was POD 70±44 (median 62 [58–78]; range 7–184). Postoperative acuity was available in 21/21 eyes for both UDVA and CDVA; mean decimal UDVA was 0.96±0.21 and CDVA 1.03±0.09. Accuracy was high: 81.0% and 90.5% were within ±0.50 D and ±1.00 D of target. Complications were infrequent: buttonholes occurred in 2/21 treated eyes (9.5%) and grade 1 haze after PRK occurred in 2/21 treated eyes (9.5%). Conclusions: VGB was uncommon, usually peripheral, and manageable with surgeon-directed adjustments. Early postoperative visual outcomes at the last refraction visit were favorable and similar across management strategies.

Purpose: To identify risk factors for retreatment after laser-assisted in situ keratomileusis (LASIK) in eyes with high myopia. Setting: Care Vision Laser Center, Tel Aviv, Israel. Design: Retrospective comparative study. Methods: Data from eyes with myopia ≥6 diopters (D) treated between 2000 and 2022 were analyzed. Eyes were grouped according to retreatment status. Preoperative and intraoperative parameters were compared using t tests and chi-square tests. Generalized estimating equations (GEE) logistic regression accounting for intereye correlation, including variables with P < .1, was performed to identify independent predictors of retreatment. Results: The study included 2100 eyes (2020 controls and 80 retreatments). Retreatment eyes had shorter contact lens-free intervals ( P = .029) and a higher proportion of baseline cylinder <−1.0 D (32.5% vs 21.9%, P = .025). Significant differences were observed in uncorrected distance visual acuity ( P = .026) and corrected distance visual acuity ( P = .034). Intraoperatively, retreatment cases had higher treated cylinder ( P = .043), greater ablation depth (104.7 ± 14.8 vs 100.6 ± 12.5 μm, P = .004), and the optical-zone distribution differed between groups, with more 6.0 mm treatments and no 7.0 mm treatments in retreatment eyes ( P < .001). Retreatment was also associated with earlier surgical years ( P < .001) and use of the EX200 laser ( P = .01). GEE logistic regression identified 2 independent predictors: baseline cylinder <−1.0 D (odds ratio [OR] 2.208, 95% CI 1.126-4.330, P = .021) and EX200 laser use (OR 4.776, 95% CI 2.496-9.140, P < .001). Conclusions: LASIK retreatment in high myopia is independently associated with higher baseline refractive cylinder and older laser technology (EX200). Optimizing patient selection and adopting modern laser platforms may reduce the likelihood of additional procedures.