比较角膜断层地形图引导与像差优化飞秒激光辅助准分子激光原位角膜磨镶术(FS-LASIK)治疗近视眼散光术后1年高阶像差(HOA)及客观视觉质量。

选取2022年1月至2023年12月在石家庄市人民医院行FS-LASIK治疗近视眼散光患者98例(196只眼)。其中，男性65例(130只眼)，女性33例(66只眼)；年龄18~41岁，平均年龄20(18，25.25)岁。按照手术方式不同，分为地形图组和像差优化组，前者行角膜断层地形图引导FS-LASIK(TG-FS-LASIK)，后者行像差优化FS-LASIK(WO-FS-LASIK)。患者球镜屈光度、柱镜屈光度、等效球镜屈光度、角膜曲率、HOA、总彗差、总三叶草、总球差(TSA)、调制传递函数截止空间频率(MTF cutoff)以及斯特列尔比值(SR)值符合正态分布，采用±s表示，年龄、视力及客观散射指数(OSI)经Kolmogorov-Smirnov检验不符合正态分布，采用中位数和四分位数间距M(Q1，Q3)表示。本研究纳入双眼数据，考虑同一患者双眼之间可能存在相关性，基线资料的组间和组内比较采用广义线性混合模型进行分析。不同时间点HOA、总彗差、总三叶草、TSA、OSI、MTF cutoff以及SR值比较采用两因素重复测量的方差分析。

地形图组54例(108只眼)，像差优化组44例(88只眼)。术前，地形图组患者年龄、球镜屈光度、柱镜屈光度、等效球镜屈光度、平坦曲率值及陡峭曲率值分别为20(18，25)岁、(5.06±1.54)D、(1.07±0.79)D、(5.60±1.68)D、(42.7±1.16)D、(44.2±1.18)D；像差优化组分别为20(18，28.5)岁、(5.04±1.51)D、(1.08±0.69)D、(5.58±1.58)D、(42.6±1.24)D及(44.1±1.23)D。两组年龄球镜屈光度、柱镜屈光度、等效球镜屈光度、平坦曲率值及陡峭曲率值比较差异无统计学意义(Z＝1.691，F＝0.045，0.052，0.023，2.833，0.029；P>0.05)。地形图组与像差优化组患者术前和术后12个月裸眼视力分别为0.9(0.80，1.07)最小分辨视角的对数(logMAR)、0.0(0.08，0.00)logMAR、1.0(0.80，1.00)logMAR及0.0(0.06，0.00)logMAR，组间比较差异无统计学意义(Z＝0.766，0.894；P>0.05)，组内比较差异有统计学意义(Z＝9.050，8.209；P<0.05)。地形图组与像差优化组患者术后12个月球镜屈光度、柱镜屈光度及等效球镜屈光度分别为(0.08±0.38)D、(0.24±0.33)D、(0.21±0.40)D、(0.07±0.36)D、(0.25±0.35)D及(0.05±0.43)D，组间比较差异无统计学意义(t＝1.938，0.163，1.658；P>0.05)；组内比较差异有统计学意义(t＝19.561，6.258，20.694，22.841，6.875，23.209；P<0.05)。地形图组患者总HOA、总彗差、总三叶草以及总球差值，在术前、术后3个月、术后6个月以及术后12个月分别为(0.33±0.10)、(0.58±0.18)、(0.56±0.19)、(0.61±0.19)、(0.15±0.08)、(0.31±0.12)、(0.31±0.12)、(0.30±0.12)、(0.20±0.09)、(0.19±0.08)、(0.19±0.09)、(0.19±0.06)、(0.09±0.04)、(0.22±0.09)、(0.19±0.08)及(0.21±0.09)；像差优化组分别为(0.33±0.12)、(0.60±0.21)、(0.60±0.22)、(0.63±0.23)、(0.17±0.07)、(0.40±0.16)、(0.39±0.22)、(0.34±0.13)、(0.20±0.08)、(0.26±0.07)、(0.25±0.08)、(0.27±0.09)、(0.10±0.04)、(0.39±0.12)、(0.32±0.09)及(0.31±0.09)。术后总彗差、总三叶草以及总球差值的组间比较，差异均有统计学意义(t＝4.241，3.814，2.595，6.236，5.504，8.035，11.914，9.554，7.237；P<0.05)，地形图组患者总HOA、总彗差及总球差在不同时间点比较，差异均有统计学意义(F＝72.501，61.390，53.259；P<0.05)；像差优化组患者总HOA、总彗差、总三叶草及总球差，在不同时间点比较，差异均有统计学意义(F＝165.185，55.345，14.853，174.245；P<0.05)。地形图组患者OSI、MTF cutoff以及SR值，在术前、术后3个月、术后6个月以及术后12个月分别为0.66(0.54，0.80)、0.68(0.54，0.82)、0.69(0.53，0.82)、0.68(0.54，0.82)、(35.86±0.51)、(36.40±2.05)、(36.63±2.41)、(36.63±2.61)、(0.202±0.06)、(0.214±0.04)、(0.214±0.05)及(0.212±0.04)；像差优化组分别为0.67(0.58，0.77)、0.66(0.59，0.76)、0.66(0.59，0.75)、0.66(0.58，0.76)、(35.70±1.90)、(35.65±1.88)、(35.60±1.88)、(35.71±2.03)、(0.201±0.09)、(0.201±0.03)、(0.203±0.03)及(0.196±0.03)。组间MTF cutoff值在术后比较，差异均有统计学意义(t＝2.661，3.278，2.611；P<0.05)，SR值在术后3个月和术后12个月时比较，差异均有统计学意义(t＝2.304，2.611；P<0.05)。地形图组患者MTF cutoff和SR值在不同时间点比较，差异均有统计学意义(F＝14.836，5.766；P<0.05)；像差优化组患者OSI、MTF cutoff以及SR值，在不同时间点比较，差异均无统计学意义(F＝0.124，1.920，2.581；P>0.05)。

角膜断层地形图引导FS-LASIK较波前像差优化FS-LASIK术后总彗差、总三叶草及总球差值更低，MTF cutoff和SR值更高，可为近视眼散光患者提供更优的视觉质量。

The aim of this study is to compare higher-order aberrations(HOA)and objective visual quality at 1 year after tomography-guided femtosecond assisted laser in situ keratomileusis (FS-LASIK) versus wavefront-optimized FS-LASIK for the treatment of myopic astigmatism.

98 patients(196 eyes) with myopic astigmatism who underwent FS-LASIK in Shijiazhuang People′s Hospital from January 2022 to December 2023.There were 65 males(130 eyes)and 33 females(66 eyes)with the average age of 20(18.00, 25.25) years(ranging from 18 to 41 years). Patients were divided into the tomography-guided group and the wavefront-optimized group. Uncorrected distance visual acuity, spherical error, cylindrical error, spherical equivalent, keratometry, total HOA, total coma, total trefoil, total spherical aberration, objective scattering index (OSI), modulation transfer function cutoff (MTF cutoff), and Strehl ratio (SR) were evaluated preoperatively and at 3, 6, and 12 months postoperatively. Normally distributed continuous variables were presented as ±s and were compared using t-tests; non-normally distributed variables were presented by median with interquartile range M(Q1, Q3) and were compared using nonparametric tests. Longitudinal changes across time points were assessed using two-way repeated-measures analysis of variance. Considering the non-independence of bilateral-eye data, baseline intergroup and intragroup comparisons were performed using a generalized linear mixed model.

A total of 98 patients (196 eyes) were included, with 54 patients (108 eyes) in the tomography-guided group and 44 patients (88 eyes) in the wavefront-optimized group. In the tomography-guided group, the age, spherical error, cylindrical error, spherical equivalent, flat keratometry, and steep keratometry were 20 (18, 25) years, (5.06±1.54) D, (1.07±0.79) D, (5.60±1.68) D, (42.7±1.16) D, and (44.2±1.18) D, respectively. The corresponding values in the wavefront-optimized group were 20 (18, 28.5) years, (5.04±1.51) D, (1.08±0.69) D, (5.58±1.58) D, (42.6±1.24) D, and (44.1±1.23) D. There were no statistically significant differences between the two groups in baseline characteristics (Z=1.691; F=0.045, 0.052, 0.023, 2.833, 0.029; P>0.05). The logarithm of the minimum angle of resolution(logMAR) of uncorrected distance visual acuity in the tomography-guided and wavefront-optimized groups was 0.9 (0.80, 1.07) logMAR and 1.0 (0.80, 1.00) logMAR preoperatively, and improved to 0.0 (0.08, 0.00) logMAR and 0.0 (0.06, 0.00) logMAR at 12 months postoperatively, respectively. There were no significant differences between the two groups (Z= 0.766, 0.894; P>0.05), whereas significant improvements were observed within each group (Z= 9.050, 8.209; P<0.05). At 12 months postoperatively, the spherical error, cylindrical error, and spherical equivalent were (0.08±0.38)D, (0.24±0.33)D, and (0.21±0.40)D in the tomography-guided group, and (0.07±0.36)D, (0.25±0.35)D, and (0.05±0.43)D in the wavefront-optimized group, respectively. No significant differences were found between the two groups (t= 1.938, 0.163, 1.658; P>0.05). However, significant improvements were observed within both groups compared with preoperative values (t= 19.561, 6.258, 20.694, 22.841, 6.875, 23.209; P<0.05). In the tomography-guided group, the values for total HOA, total coma, total trefoil, and total spherical aberration preoperatively and at 3, 6, and 12 months were (0.33±0.10), (0.58±0.18), (0.56±0.19), (0.61±0.19), (0.15±0.08), (0.31±0.12), (0.31±0.12), (0.30±0.12), (0.20±0.09), (0.19±0.08), (0.19±0.09), (0.19±0.06), (0.09±0.04), (0.22±0.09), (0.19±0.08), (0.21±0.09), respectively. Corresponding values for the wavefront-optimized group were (0.33±0.12), (0.60±0.21), (0.60±0.22), (0.63±0.23), (0.17±0.07), (0.40±0.16), (0.39±0.22), (0.34±0.13), (0.20±0.08), (0.26±0.07), (0.25±0.08), (0.27±0.09), (0.10±0.04), (0.39±0.12), (0.32±0.09), and (0.31±0.09), respectively. There was statistically significant difference between the groups at postoperative time points in total coma, total trefoil, and total spherical aberration (t=4.241, 3.814, 2.595, 6.236, 5.504, 8.035, 11.914, 9.554, 7.237; P<0.05). In the tomography-guided group, total HOA, total coma, and total spherical aberration showed statistically significant difference over time (F=72.501, 61.390, 53.259; P<0.05). In the wavefront-optimized group, total HOA, total coma, total trefoil, and total spherical aberration all showed statistically significant difference over time (F=165.185, 55.345, 14.853, 174.245; P<0.05). The OSI, MTF cutoff, and SR values in the tomography-guided group preoperatively and at 3, 6, and 12 months postoperatively were 0.66(0.54, 0.80), 0.68(0.54, 0.82), 0.69(0.53, 0.82), 0.68(0.54, 0.82), (35.86±0.51), (36.40±2.05), (36.63±2.41), (36.63±2.61), (0.202±0.06), (0.214±0.04), (0.214±0.05), (0.212±0.04), respectively. Corresponding values for the wavefront-optimized group were 0.67(0.58, 0.77), 0.66(0.59, 0.76), 0.66(0.59, 0.75), 0.66(0.58, 0.76), (35.70±1.90), (35.65±1.88), (35.60±1.88), (35.71±2.03), (0.201±0.09), (0.201±0.03), (0.203±0.03), and (0.196±0.03), respectively. There was statistically significant difference in MTF cutoff at all postoperative time points (t=2.661, 3.278, 2.611; P<0.05)and in SR at 3 and 12 months postoperatively (t=2.304, 2.611; P<0.05). In the tomography-guided group, MTF cutoff and SR showed statistically significant variations over time(F=14.836, 5.766; P<0.05). In the wavefront-optimized group, OSI, MTF cutoff, and SR showed no statistically significant variations over time (F=0.124, 1.920, 2.581; P>0.05).

Tomography-guided FS-LASIK yields lower postoperative total coma, total trefoil and total spherical aberration values, along with higher MTF cutoff and SR, compared with wavefront-optimized FS-LASIK, thereby providing superior visual quality for patients with myopic astigmatism.