{"paper_id":"1fe8f7f3-dbe3-47ff-b040-22970d2524f4","body_text":"Impact of Densitometry-Detected Subtle Residual Lenticule on Post-SMILE Corneal Higher-Order Aberrations: A Contralateral Eye Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Densitometry-Detected Subtle Residual Lenticule on Post-SMILE Corneal Higher-Order Aberrations: A Contralateral Eye Study Fu Gui, Mengdan He, Fei Huang, Haizhou Miao, Mengyun Zhou, Chong Ai, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7862892/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background To investigate the impact of subtle residual lenticule (SRL) on corneal higher-order aberrations (HOAs) after small incision lenticule extraction (SMILE). Methods This prospective, contralateral eye study included 33 myopic patients with unilateral SRL identified 3 months postoperatively. SRL was defined as retained fragments spanning fewer than two quadrants, identified via a novel protocol using corneal densitometry and anterior elevation maps, and confirmed with anterior segment optical coherence tomography (AS-OCT). Postoperative changes (Δ) in corneal HOAs (6.0/8.0 mm zones) were compared between SRL and control eyes. Multiple linear regression explored factors associated with Δ8.0mm spherical aberration (SA) and horizontal coma (HC). Results Compared to controls, SRL eyes showed significantly greater changes in 6.0 mm/8.0 mm total HOA root mean square (ΔRMS: P = 0.006 / P < 0.001) and ΔSA (P = 0.026 / P = 0.001), and a negative shift in HC (8.0 mm zone; P = 0.001). Regression analysis identified only SRL presence associated with negative Δ8.0mm HC (P = 0.004). Conversely, increased Δ8.0mm SA was associated with higher preoperative myopia and a smaller postoperative effective optical zone (all P < 0.001), not directly with SRL (P = 0.990). Conclusions The presence of SRL after SMILE is associated with statistically significant increases in postoperative HOAs, notably a negative shift in horizontal coma. Furthermore, the densitometry-guided protocol offers a practical tool for screening these subtle fragments. Complete lenticule removal remains the ideal goal for optimizing postoperative optical quality. Subtle Residual Lenticule Higher-Order Aberrations Small incision lenticule extraction Corneal Densitometry Figures Figure 1 Figure 2 Figure 3 Background Small incision lenticule extraction (SMILE) is a widely performed procedure for correcting refractive errors, offering predictability, biomechanical stability, and favorable visual outcomes. 1 – 3 Intraoperative complications such as residual lenticule fragments can arise during lenticule dissection or extraction, 4 with central or large fragments routinely removed to preserve vision. 1 , 5 However, the precise impact of minimal peripheral fragments, which are often observed clinically, 1 on visual quality beyond Snellen acuity, particularly concerning higher-order aberrations (HOAs), remains unclear. A significant challenge in this field has been the lack of a standardized method to identify and analyze these subtle findings. Current guidelines acknowledge that retained tissue might compromise visual quality despite normal acuity, 1 yet evidence-driven protocols for managing such subtle findings remain undefined, perpetuating therapeutic ambiguity. Corneal HOAs provide an objective metric for optical quality following lamellar corneal refractive surgery. Changes in corneal asphericity primarily induce spherical aberration (SA, Z₄⁰), whereas interface irregularities may induce asymmetric aberrations like coma (Z₃¹ vertical, Z₃⁻¹ horizontal) and trefoil (Z₃³ oblique, Z₃⁻³ vertical), often associated with night vision disturbances. 6 , 7 As HOA magnitude increases with pupil diameter and analysis zone size, 8 evaluating HOAs over both 6.0 mm (representing photopic conditions) and 8.0 mm diameters (reflecting mesopic conditions) centered on the corneal apex is critical for a comprehensive assessment, especially when considering peripherally located SRLs. 6 – 8 Therefore, this contralateral eye study aimed to quantify the impact of SRL on 3-month postoperative changes in key corneal HOAs (total RMS, SA, coma, and trefoil) within 6.0 mm and 8.0 mm analysis zones following SMILE. Additionally, this study employed a specific corneal densitometry protocol to define SRL, facilitating clinical identification and research consistency. Patients and methods Study Design and Patient Selection This prospective, observational, contralateral eye study was conducted at the Second Affiliated Hospital of Nanchang University. The study cohort was drawn from a continuously maintained database (registration number: NCT06204926), which was established under prior institutional ethics approval (Approval No: [2023] No. (96)). For this analysis, we included consecutive patients treated between October 2024 and January 2025 who had a complete 3-month postoperative follow-up. This specific retrospective study adhered to the tenets of the Declaration of Helsinki, received separate approval from the Institutional Ethics Committee of the Second Affiliated Hospital of Nanchang University ([2024] NO. (138)), and was independently registered at ClinicalTrials.gov (NCT06806085). Patient eligibility for this analysis was determined by the following inclusion criteria: (1) age 18–45 years; (2) bilateral myopia with spherical refraction of -0.50 to -10.00 diopters (D) and myopic astigmatism < 3.00 D; (3) corrected distance visual acuity (CDVA) of ≥ 20/25 before SMILE surgery; (4) refractive errors stable for at least 1 year (≤ 0.50 D change per year); (5) central corneal thickness (CCT) ≥ 480 µm and calculated residual stromal thickness (RST) ≥ 280 µm; and (6) at the 3-month follow-up, effective optic zone (EOZ) decentration within 0.2 mm of the corneal apex. 1 Exclusion criteria were: (1) history of ocular trauma or surgery; (2) pre-existing or significant postoperative corneal abnormalities (e.g., keratoconus, clinically significant interface haze or stromal scarring) or clinically significant ocular surface disease (e.g., severe dry eye); (3) relevant uncontrolled systemic diseases (e.g., autoimmune disorders, diabetes mellitus) or central neurological conditions; and (4) pregnancy or lactation. Subtle residual lenticule screening, identification, and confirmation Protocol Patients with confirmed unilateral SRL, identified by applying a standardized multi-step screening protocol to 3-month postoperative imaging data, were allocated to the study group. The protocol began with a detailed slit-lamp examination to exclude confounding pathologies such as significant interface haze or scarring. Subsequently, a systematic review of Pentacam HR (OCULUS, Wetzlar, Germany) scans was performed for every eye by two independent observers (J. Xiong, F. Gui). An eye was flagged as suspicious for an SRL if it met both of the following criteria: (1) a localized area of low corneal optical density (COD) value consistent with normal untreated stroma, in the expected lenticule extraction area (high COD value) of the densitometry map (120 ± 5 µm layer), and (2) a subtle, spatially correlated elevation on the corresponding anterior elevation map. All suspicious cases then underwent confirmatory anterior segment optical coherence tomography (AS-OCT; Cirrus 5000, Carl Zeiss Meditec, Jena, Germany). An SRL was considered confirmed only if the AS-OCT scan showed a distinct lamellar separation at the surgical interface, 5 with compensatory thinning of the overlying tissue relative to adjacent areas ( Figure S1 ). For final classification, the confirmed fragment also had to occupy less than two quadrants relative to the corneal apex in densitometry map. This quadrant-based threshold was chosen to operationally distinguish the 'subtle' fragments under investigation, from larger retained lenticules that typically necessitate surgical intervention. Densitometry map screenshots from the \"Corneal Densito\" display were imported into ImageJ software (v2.14.0/1.54f; NIH, USA) for spatial calibration (130px: 3mm). The scale was set by drawing a line from the corneal apex to the 3.0-mm diameter concentric ring and defining this distance as 1.5 mm. This analysis served to quantitatively measure the area and the precise number of quadrants occupied, as well as to qualitatively characterize the morphology (e.g., vermiculate, crescentic, or boxy) consistent with lenticular fragments ( Figure S2 ). Ophthalmic examinations and measurements All participants underwent comprehensive baseline ophthalmic evaluations, including uncorrected distance visual acuity (UDVA) and CDVA, manifest and cycloplegic refraction (Auto Refractometer, ARK-510A; NIDEK, Aichi, Japan), intraocular pressure measurement (CT-80A; Topcon, Tokyo, Japan), slit-lamp biomicroscopy, and fundus examination. In addition, AS-OCT was performed for all cases where SRL was suspected based on the screening protocol. Corneal imaging and aberrometry were performed preoperatively and 3 months postoperatively using a corneal topographer (Pentacam HR). Standard outputs, including horizontal corneal diameter, CCT, central flat keratometry (K1) and steep keratometry (K2), were obtained from the \"4 Maps Refractive\" display. Corneal HOAs were evaluated using the \"Zernike Analysis\" mode, centered on the corneal apex. Root mean square (RMS) of total HOAs, and Zernike coefficients (reported in µm according to OSA standards) for vertical trefoil (Z₃⁻³), horizontal trefoil (Z₃³), vertical coma (Z₃⁻¹), horizontal coma (Z₃¹), and spherical aberration (Z₄⁰) were recorded for 6.0 mm and 8.0 mm analysis diameters. EOZ analysis used the \"Compare 2 Exams\" function to generate tangential curvature difference maps (preoperative vs. 3 months postoperative). Screenshots were processed using ImageJ2 software (version 2.14.0/1.54f; National Institutes of Health, USA) to calculate the EOZ area (mm²) and diameter, and quantify decentration relative to the corneal apex. 9 , 10 Surgical technique All SMILE procedures were performed by two experienced surgeons (J. Xiong, F. Gui) using the VisuMax 500-kHz femtosecond laser system (Carl Zeiss Meditec, Jena, Germany) under standardized environmental conditions. Laser settings included a planned optical zone of 6.5 mm, cap thickness of 120 µm, pulse energy of 130 nJ, and 4.5 µm spot/track distance. A superiorly located incision (width of 2 mm, angle of 30°) was created with an incision position of 90° or 120°. Postoperative management included topical 0.5% levofloxacin (Santen Pharmaceutical, Ikoma, Nara, Japan) and 0.1% fluorometholone (Fluorometholone; Santen, Osaka, Japan) eye drops, each administered four times daily for one week. Statistical analysis Statistical analysis was conducted using R software (version 4.4.1; R Foundation for Statistical Computing, Vienna, Austria). Normality was assessed using the Kolmogorov-Smirnov test. Data are presented as mean ± standard deviation (SD). Paired t-tests (normally distributed) or Wilcoxon signed-rank tests (non-normally distributed) compared contralateral eyes for preoperative parameters and postoperative HOAs changes (ΔHOAs = Postop HOAs - Preop HOAs). Multiple linear regression analysis identified factors independently associated with ΔHOA outcomes (specifically Δ8.0mm SA and Δ8.0mm HC). Given the paired design, which inherently controls for inter-individual differences such as age, gender, and eye laterality, the models included only ocular parameters as independent variables, focusing on factors directly influencing HOA changes. These variables comprised preoperative factors (corneal diameter, sphere, cylinder, flat and steep keratometry), surgery-related factors (central corneal thickness, lenticule thickness), and postoperative factors (SRL presence/absence, effective optical zone area, sphere, cylinder). Statistical significance was defined as P < 0.05. Results From a retrospectively screened cohort of 577 consecutive patients (1085 eyes), a final study group of 33 patients (mean age 22.21 ± 0.59 years; 18 (54.5%) male) of 66 eyes was identified for analysis. These patients met all eligibility criteria for the study and were confirmed to have unilateral SRL through our multi-modal screening protocol. Among the 33 eyes with confirmed SRL, 17 (51.5%) were right eyes, while among the contralateral non-SRL eyes, 16 (48.5%) were right eyes. Preoperative parameters for SRL and contralateral non-SRL eyes are compared in Table 1 . Groups were well-matched preoperatively for mean corneal diameter, sphere, K1, and K2 (all P > 0.05), while preoperative cylinder magnitude was slightly lower in the SRL group (P = 0.046). Mean CCT was also slightly lower (553.12 ± 28.91 µm vs. 555.91 ± 29.20 µm, P = 0.002), while planned lenticule thickness and calculated RST were comparable (P > 0.05). Table 1 Comparison of ocular clinicopathological parameters Subtle Residual Lenticule Parameter Present Absent P Preoperative Corneal diameter (mm) 11.60 ± 0.47 11.57 ± 0.52 0.726 Sphere (D) -3.29 ± 1.49 -3.09 ± 1.59 0.050 Cylinder (D) -0.43 ± 0.45 -0.60 ± 0.45 0.046* Flat Keratometry (D) 42.81 ± 1.58 42.72 ± 1.58 0.113 Steep Keratometry (D) 43.68 ± 1.63 43.81 ± 1.67 0.236 Surgery-related CCT (µm) 553.12 ± 28.91 555.91 ± 29.20 0.002* Lenticule thickness (µm) 83.64 ± 22.13 85.64 ± 22.75 0.187 RST (µm) 349.79 ± 27.65 350.58 ± 27.27 0.634 Postoperative at 3 months EOZ area (mm 2 ) 25.74 ± 2.70 27.84 ± 3.15 < 0.001* EOZ diameter (mm) 6.08 ± 0.42 6.24 ± 0.40 0.024* Sphere (D) 0.21 ± 0.46 0.14 ± 0.40 0.324 Cylinder (D) -0.26 ± 0.25 -0.24 ± 0.30 0.741 Data were presented as means ± SDs or numbers. The paired t-test and Wilcoxon signed-rank test were performed for SRL and non-SRL variables. Abbreviations: CCT = central corneal thickness; D = diopter; EOZ = effective optical zone; K = keratometric value; RST = residual stromal thickness; SD = standard deviation; SRL = subtle residual lenticule. * p < 0.05, statistically significant. Characteristics of subtle residual lenticule Details of the 33 SRLs are provided in Table 2 . The mean area of the SRLs was 0.875 ± 0.406 mm², and they occupied an average of 0.73 ± 0.26 quadrants, confirming their subtle nature. The most frequent location for SRL was the 6–12 o'clock sector [corresponding to the temporal cornea in right eyes (RE) and nasal cornea in left eyes (LE); n = 22, 66.7%], followed by the 6–9 o'clock sector (inferior-temporal RE / inferior-nasal LE; n = 6, 18.2%) and the 9–12 o'clock sector (superior-temporal RE / superior-nasal LE; n = 5, 15.2%). Predominant morphologies were vermiculate (39.4%), crescentic (36.4%), or boxy (24.2%) shapes. Table 2 Characteristics of subtle residual lenticule n Area (mm 2 ) Quadrants Occupied Total 33 0.875 ± 0.406 0.73 ± 0.26 Vermiculate 13 0.704 ± 0.377 0.71 ± 0.29 Crescentic 12 0.979 ± 0.367 0.86 ± 0.24 Boxy 8 0.995 ± 0.457 0.59 ± 0.12 Data were presented as means ± SDs or numbers. The \"Quadrants Occupied\" value represents the mean number of corneal quadrants (out of four) that the subtle residual lenticules extended into. Visual and refractive outcomes At 3 months postoperatively, standard visual and refractive outcomes were comparable between SRL and contralateral control eyes (Fig. 1 ). There were no statistically significant differences in postoperative uncorrected or corrected distance visual acuity, refractive predictability, accuracy, or stability (all P > 0.05). However, SRL eyes exhibited a significantly smaller mean EOZ area (P < 0.001) and EOZ diameter (P = 0.024) compared to contralateral controls (Table 1 ). Corneal higher-order aberrations Corneal HOA analysis revealed statistically significant differences related to SRL presence (Table 3 ) . SRL eyes showed a significantly greater increase in total HOA RMS from baseline compared to controls in both the 6.0 mm (P = 0.006) and 8.0 mm zones (P < 0.001). Specifically, ΔSA showed a greater positive shift in the SRL group for both 6.0 mm (P = 0.026) and 8.0 mm zones (P = 0.001). ΔHC demonstrated a significant negative shift exclusively within the 8.0 mm zone in SRL eyes compared to controls (P = 0.001). Table 3 Comparison of higher-order aberration Subtle Residual Lenticule Parameter Present Absent P HOAs at 6-mm zone centered around the corneal vertex Total HOA RMS Pre 0.43 ± 0.12 0.44 ± 0.16 0.317 Post 0.59 ± 0.19 0.52 ± 0.17 0.004* Change 0.16 ± 0.21 0.07 ± 0.20 0.006* Spherical aberration Pre 0.22 ± 0.09 0.21 ± 0.11 0.586 Post 0.31 ± 0.14 0.24 ± 0.16 0.005 Change 0.08 ± 0.14 0.03 ± 0.13 0.026* Horizontal coma Pre -0.02 ± 0.11 0.01 ± 0.12 0.325 Post -0.08 ± 0.24 0.05 ± 0.18 0.057 Change -0.06 ± 0.21 0.04 ± 0.18 0.104 Vertical coma Pre -0.00 ± 0.24 0.04 ± 0.22 0.101 Post -0.17 ± 0.26 -0.11 ± 0.26 0.086 Change -0.16 ± 0.19 -0.14 ± 0.19 0.463 Oblique trefoil Pre -0.06 ± 0.13 -0.09 ± 0.17 0.037 Post -0.07 ± 0.17 -0.06 ± 0.16 0.611 Change -0.01 ± 0.13 0.03 ± 0.13 0.225 Horizontal trefoil Pre 0.01 ± 0.09 -0.01 ± 0.08 0.922 Post -0.01 ± 0.10 -0.03 ± 0.09 0.244 Change 0.00 ± 0.09 -0.02 ± 0.10 0.375 HOAs at 8-mm zone centered around the corneal vertex Total HOA RMS Pre 1.03 ± 0.17 1.06 ± 0.24 0.758 Post 2.18 ± 0.69 1.88 ± 0.53 0.001* Change 1.15 ± 0.71 0.82 ± 0.64 < 0.001* Spherical aberration Pre 0.63 ± 0.25 0.60 ± 0.27 0.120 Post 1.71 ± 0.55 1.48 ± 0.53 0.001* Change 1.08 ± 0.51 0.88 ± 0.49 0.001* Horizontal coma Pre -0.07 ± 0.38 0.10 ± 0.37 0.206 Post -0.53 ± 0.77 0.11 ± 0.57 0.008 Change -0.46 ± 0.60 0.02 ± 0.53 0.001* Vertical coma Pre -0.00 ± 0.40 0.02 ± 0.41 0.390 Post -0.05 ± 0.68 -0.01 ± 0.60 0.728 Change -0.04 ± 0.56 -0.03 ± 0.51 0.900 Oblique trefoil Pre -0.10 ± 0.24 -0.15 ± 0.32 0.025* Post -0.16 ± 0.37 -0.14 ± 0.35 0.729 Change -0.06 ± 0.31 0.01 ± 0.29 0.207 Horizontal trefoil Pre -0.04 ± 0.19 0.01 ± 0.22 0.378 Post -0.05 ± 0.21 -0.01 ± 0.23 0.486 Change -0.01 ± 0.16 -0.02 ± 0.20 0.828 Data were presented as means ± SDs or numbers. The paired t-test and Wilcoxon signed-rank test were performed for SRL and non-SRL variables. Abbreviations: HOA = higher-order aberration; Pre = preoperatively; Post = postoperatively; RMS = root mean square; SD = standard deviation; SRL = subtle residual lenticule. * p < 0.05, statistically significant. Risk factor analyses of changes in key HOAs Multiple linear regression analysis explored factors independently associated with changes in key HOAs (Fig. 2 ). No significant independent influencing factors were identified for Δ6.0mm SA (all P > 0.05). For Δ8.0mm SA, higher preoperative spherical error (P < 0.001) and smaller postoperative EOZ area (P < 0.001) were significant independent factors, but SRL presence was not independently associated (P = 0.990). Conversely, for Δ8.0mm HC, SRL presence was the sole significant independent factor associated with the negative shift (P = 0.004). Discussion This retrospective contralateral study demonstrates that SRL after SMILE significantly impacts postoperative corneal HOAs at 3 months, particularly within the 8.0 mm analysis zone. The findings suggest potential mechanisms by which SRL influences HC and SA. A key strength of this study is the implementation of a systematic, multi-modal protocol for identifying and confirming SRLs. We defined SRLs as fragments spanning less than two quadrants, an operational threshold to distinguish these subtle findings from large retained lenticules that likely induce complex aberrations and significant astigmatic effects, whereas our definition focuses on the more regular impact of smaller fragments. While AS-OCT provided definitive structural confirmation,1 this study highlights the potential of corneal densitometry as a sensitive primary screening tool. Our protocol was based on identifying focal areas of relatively low COD on 3-month postoperative scans, which stood out against the generally high COD background of the lenticule extraction area at the 120 µm depth.11,12 We hypothesize that these hypodense \"islands\" represent undisturbed tissue where incomplete lenticule separation occurred, thus retaining a near-normal COD compared to the surrounding stroma. This optical signal may be more sensitive than structural changes alone, potentially identifying SRLs too thin to create a discernible interface elevation on AS-OCT. Our key finding was the independent association between SRL and negative HC induction in the 8.0 mm zone, with a predisposition in the 6–12 o'clock sector. This locational preference may be explained by surgical technique, as a small peripheral area is often intentionally left attached to provide counter-traction during dissection. In the ergonomically challenging infero-temporal (RE) or infero-nasal (LE) quadrants for a right-handed surgeon, this attached area is at higher risk of being incompletely separated or torn, resulting in a retained fragment. Optically, such fragments in the 6–12 o'clock sector can cause localized corneal steepening, causing light rays passing through this area (e.g., the negative x-axis corresponds temporal side of RE or nasal side of LE, Fig. 3 B) to propagate faster than the corresponding opposite side, resulting in a differential wavefront advancement along the horizontal meridian manifests directly as negative HC.8,13,14 This effect was restricted to the 8.0 mm zone, consistent with the peripheral nature of SRLs, which have a greater impact on the larger analysis zone but a diluted, statistically insignificant effect on the central 6.0 mm zone.15,16 Given that coma significantly impacts vision in larger pupil conditions,7,8,17 this provides an objective correlate for potential night vision symptoms like halos,18 although definitive clinical significance requires correlation with patient-reported outcomes. Conversely, the link between SRL and increased positive ΔSA is indirect. Instead, higher preoperative myopia and a smaller EOZ were the primary drivers of increased Δ8.0mm SA. Critically, we found that SRL eyes had significantly smaller EOZs, which itself may be a consequence of localized epithelial or stromal remodeling triggered by the interface irregularity of the SRL. A smaller EOZ, known to increase positive SA after refractive surgery,1,16,19 results from a steeper peripheral cornea relative to the flattened central cornea, particularly in higher myopia corrections,14,16 causing peripheral light rays to pass through a more abrupt transition and elevate Δ8.0mm SA (Fig. 3 A). The lack of significant influencing factors for Δ6.0mm SA, suggests the effect within this smaller zone is multifactorial or below the detection threshold of this analysis. While our analysis revealed statistically significant HOA changes, the clinical relevance of these modest effect sizes warrants careful consideration. The subtle and peripheral nature of the SRLs, coupled with the absence of significant effect on standard photopic visual outcomes (usually assessed central vision in pupil diameters of ≤ 4.0 mm) like UDVA and CDVA, 1,15–17,20 relying on the correction of low-order aberrations (sphere and cylinder) which are determined by the removal of the main lenticule body. However, the altered HOAs in SMILE,16,21,22 particularly the HC increase in the 8.0 mm zone, serve as an objective marker of incomplete surgery and may contribute to subjective visual disturbances in visually sensitive individuals under demanding conditions.23,24 Although epithelial remodeling can compensate for stromal irregularities, it may also induce its own aberrations, creating a complex optical interplay.25 Therefore, persistent aberration-related visual symptoms should prompt careful multi-modal evaluation of both the stromal interface and epithelial profile. The current data suggest that intervention for asymptomatic SRL, even when objectively confirmed, may not be warranted, and management should likely be guided by patient symptoms. Complete lenticule extraction remains the ideal goal for optimizing postoperative optical quality. This study has several limitations. Firstly, the modest sample size (n = 33 pairs) and specific cohort characteristics may limit statistical power and generalizability. Although the paired design controls for age, sex, and laterality, and the bilateral symmetry of HOAs is well-documented,26 exploration of these demographic-related factors in larger, more diverse cohorts is still warranted. Secondly, our multi-modal definition of SRL, while robust, is novel and requires further validation. Future studies could directly compare the diagnostic sensitivity and specificity of densitometry against other high-resolution modalities like AS-OCT for identifying SRLs. Thirdly, the three-month follow-up may not fully capture long-term corneal remodeling. Fourthly, correlating objective HOA changes with validated patient-reported outcomes is a crucial next step in the future. Fifthly, future studies could explore the relationship between specific SRL characteristics, such as area and location, and the precise magnitude of induced aberrations. Finally, the observational design limits definitive causal inference, despite associations strengthened by the contralateral comparison; confirming causality would require higher-level evidence, such as intervention trials or large prospective cohort studies. Conclusion In conclusion, SRL after SMILE directly induces negative HC within the 8.0 mm zone, likely impacting mesopic vision, while its association with increased SA appears indirect. Meticulous surgical technique aimed at complete lenticule removal remains the ideal goal for optimizing postoperative optical quality. Abbreviations SRL Subtle residual lenticule HOAs Higher-order aberrations SMILE Small incision lenticule extraction AS-OCT Anterior segment optical coherence tomography SA Spherical aberration HC Horizontal coma CDVA Corrected distance visual acuity CCT Central corneal thickness EOZ Effective optic zone COD Corneal optical density UDVA Uncorrected distance visual acuity RE Right eye LE Left eye Declarations Ethics approval and consent to participate : This specific retrospective study adhered to the tenets of the Declaration of Helsinki, received separate approval from the Institutional Ethics Committee of the Second Affiliated Hospital of Nanchang University ([2024] NO. (138)), and was independently registered at ClinicalTrials.gov (NCT06806085). Informed consent to participate was obtained from all participants. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests in this section. Funding: This study was supported by the National Natural Science Foundation of China (82260214), the Science and Technology Program of Jiangxi Provincial Health Commission (202210631). Author Contribution Study concept and design (JX, WW); data collection (FG, MH, FH, HM, MZ, CA, YL); analysis and interpretation of data ((FG, MH, FH, HM); writing the manuscript (FG, MH, FH, HM); critical revision of the manuscript (JX, WW); statistical expertise (JX, FH, HM); supervision (JX, WW). Acknowledgement: We thank all the patients involved for supporting this study Data Availability The data can be provided upon request. All data associated with this study have been published. Requests for data should be directed to the corresponding author and are subject to ethical approval. References Wang Y, Xie L, Yao K, et al. Evidence-Based Guidelines for Keratorefractive Lenticule Extraction Surgery. Ophthalmology. 2025;132(4):397–419. Han T, Xu Y, Han X, et al. 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Supplementary Files FigureS1.tif Figure S1 Multi-modal imaging examples of a normal cornea and three distinct morphologies of subtle residual lenticule. Each row represents a single case at the three-month postoperative follow-up: (A) a normal contralateral eye for comparison, (B) a vermiculate SRL, (C) a crescentic SRL, and (D) a boxy SRL. The three images presented for each case are, from left to right: the corneal densitometry map (120 µm layer), in which yellow lines delineate the approximate lenticule extraction edge and outline the SRL region; the anterior elevation map; and the AS-OCT B-scan. In cases B-D, key diagnostic features are highlighted: a low COD area of SRL (red arrow) in the densitometry map, a corresponding subtle elevation (red arrow) in the elevation map, and definitive lamellar separation (red arrow) in the AS-OCT scan. Yellow lines delineate the approximate lenticule extraction edge and outline the SRL region. Abbreviations: AS-OCT = anterior segment optical coherence tomography; COD = corneal optical density; SRL = subtle residual lenticule. FigureS2.tif Figure S2 Measurement of subtle residual lenticule area using ImageJ software. Steps shown: (A) Capturing a corneal densitometry map (120 µm layer) from the Pentacam HR (\"Corneal Densito\" mode); (B) Defining the lenticule boundary in ImageJ; (C) Setting spatial scale calibration (130:3px/mm); (D) Outlining the SRL fragment via polygon selection for automated area measurement. (E) Automatically calculating the area of the SRL region using ImageJ. Abbreviations: SRL = subtle residual lenticule. 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01:12:32\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":317606,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eStandard graphs for reporting refractive surgery outcomes at 3 months postoperatively.\\u003c/p\\u003e\\n\\u003cp\\u003eComparison between eyes with Subtle Residual Lenticule (SRL group, A1-F1) and contralateral eyes without SRL (non-SRL group, A2-F2). (A1, A2) Cumulative postoperative uncorrected distance visual acuity (UDVA) and preoperative corrected distance visual acuity (CDVA); (B1, B2) Difference between postoperative UDVA and preoperative CDVA (Efficacy); (C1, C2) Change in Snellen lines of postoperative CDVA (Safety); (D1, D2) Attempted versus achieved spherical equivalent refraction (Predictability); (E1, E2) Spherical equivalent refractive accuracy relative to target; (F1, F2) Stability of spherical equivalent refraction between 1 and 3 months postoperatively.\\u003c/p\\u003e\\n\\u003cp\\u003eAbbreviations: CDVA = corrected distance visual acuity; D = diopters; SRL = subtle residual lenticule; UDVA = uncorrected distance visual acuity.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"OnlineFigure1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7862892/v1/a863e1df6dd929a96f540489.png\"},{\"id\":96422668,\"identity\":\"ef5ecd00-8308-48a4-9d16-70032f399e83\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 01:12:32\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":750640,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMultivariate analysis of factors affecting corneal higher-order aberration changes over the 3-month postoperative period.\\u003c/p\\u003e\\n\\u003cp\\u003e(A) Influencing factors for Δ6.0mm SA; (B) Influencing factors for Δ8.0mm SA; (C) Influencing factors for Δ8.0mm HC. Dots represent the estimated regression coefficient (β), and horizontal lines represent the 95% CI. Variables assessed include preoperative parameters (Corneal diameter, Sphere, Cylinder, Flat Keratometry, Steep Keratometry), surgery-related parameters (Central corneal thickness, Lenticule thickness), and postoperative parameters (Subtle Residual Lenticule presence/absence, Effective Optical Zone area, Postoperative Sphere, Postoperative Cylinder).\\u003c/p\\u003e\\n\\u003cp\\u003eAbbreviations: CI = confidence interval; D = diopters; HC = horizontal coma; SA = spherical aberration; Δ = change from preoperative to 3 months postoperative.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"OnlineFigure2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7862892/v1/23161d209bc05e01d75b0570.png\"},{\"id\":96454594,\"identity\":\"76f697f2-19b0-4977-b162-69aeb49c2e9c\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 10:02:57\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":277413,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe proposed mechanism for subtle residual lenticule-induced changes in 8.0mm corneal higher-order aberrations.\\u003c/p\\u003e\\n\\u003cp\\u003eThe green plane indicates the ideal aberration-free wavefront, while the red plane depicts the actual wavefront; the difference illustrates the aberrations.\\u003c/p\\u003e\\n\\u003cp\\u003e(A) Induction of positive SA after standard SMILE. Parallel central (yellow solid lines) and representative peripheral (blue dashed lines) light rays focus, resulting in a typical post-myopic ablation corneal positive Δ8.0mm SA shown in the associated wavefront map (indicated by black arrow).\\u003c/p\\u003e\\n\\u003cp\\u003e(B) Induction of negative HC by an SRL. Cornea with an SRL located temporally (T). Light rays passing through the SRL region (purple solid lines) focus differently relative to central and nasal rays (yellow solid lines), while representative peripheral rays are shown by blue dashed lines. This differential focusing induces a negative Δ8.0mm HC and positive SA shown in the combined wavefront map (indicated by black arrow) and the isolated negative HC component.\\u003c/p\\u003e\\n\\u003cp\\u003eAbbreviations: HC = horizontal coma; SMILE = small incision lenticule extraction; N = nasal; SA = spherical aberration; SRL = subtle residual lenticule; T = temporal; Δ = change from preoperative to 3 months postoperative.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"OnlineFigure3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7862892/v1/f0981d5feeecd20aec2fd0bb.png\"},{\"id\":96456922,\"identity\":\"6367c2fc-59c2-4fad-b744-17d377fbb0de\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 10:08:24\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":2783116,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7862892/v1/ba6339cf-899a-43b2-93e9-5e1f93a26bb3.pdf\"},{\"id\":96422666,\"identity\":\"2ae0f2d7-30f8-4319-b99c-20749370fa7a\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 01:12:32\",\"extension\":\"tif\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":2293376,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eFigure S1\\u003c/strong\\u003e Multi-modal imaging examples of a normal cornea and three distinct morphologies of subtle residual lenticule.\\u003c/p\\u003e\\n\\u003cp\\u003eEach row represents a single case at the three-month postoperative follow-up: (A) a normal contralateral eye for comparison, (B) a vermiculate SRL, (C) a crescentic SRL, and (D) a boxy SRL. The three images presented for each case are, from left to right: the corneal densitometry map (120 µm layer), in which yellow lines delineate the approximate lenticule extraction edge and outline the SRL region; the anterior elevation map; and the AS-OCT B-scan. In cases B-D, key diagnostic features are highlighted: a low COD area of SRL (red arrow) in the densitometry map, a corresponding subtle elevation (red arrow) in the elevation map, and definitive lamellar separation (red arrow) in the AS-OCT scan. Yellow lines delineate the approximate lenticule extraction edge and outline the SRL region.\\u003c/p\\u003e\\n\\u003cp\\u003eAbbreviations: AS-OCT = anterior segment optical coherence tomography; COD = corneal optical density; SRL = subtle residual lenticule.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"FigureS1.tif\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7862892/v1/ea8c923559972850d517f1fa.tif\"},{\"id\":96454782,\"identity\":\"73f776a0-4a1a-4ffe-a15a-3ad33f668c1f\",\"added_by\":\"auto\",\"created_at\":\"2025-11-21 10:03:08\",\"extension\":\"tif\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":5842473,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eFigure S2 \\u003c/strong\\u003eMeasurement of subtle residual lenticule area using ImageJ software.\\u003c/p\\u003e\\n\\u003cp\\u003eSteps shown: (A) Capturing a corneal densitometry map (120 µm layer) from the Pentacam HR (\\\"Corneal Densito\\\" mode); (B) Defining the lenticule boundary in ImageJ; (C) Setting spatial scale calibration (130:3px/mm); (D) Outlining the SRL fragment via polygon selection for automated area measurement. (E) Automatically calculating the area of the SRL region using ImageJ.\\u003c/p\\u003e\\n\\u003cp\\u003eAbbreviations: SRL = subtle residual lenticule.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"FigureS2.tif\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7862892/v1/bb710cb40696e819b3e63cdd.tif\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Impact of Densitometry-Detected Subtle Residual Lenticule on Post-SMILE Corneal Higher-Order Aberrations: A Contralateral Eye Study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eSmall incision lenticule extraction (SMILE) is a widely performed procedure for correcting refractive errors, offering predictability, biomechanical stability, and favorable visual outcomes.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR2\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e Intraoperative complications such as residual lenticule fragments can arise during lenticule dissection or extraction,\\u003csup\\u003e4\\u003c/sup\\u003e with central or large fragments routinely removed to preserve vision.\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e However, the precise impact of minimal peripheral fragments, which are often observed clinically,\\u003csup\\u003e1\\u003c/sup\\u003e on visual quality beyond Snellen acuity, particularly concerning higher-order aberrations (HOAs), remains unclear. A significant challenge in this field has been the lack of a standardized method to identify and analyze these subtle findings. Current guidelines acknowledge that retained tissue might compromise visual quality despite normal acuity,\\u003csup\\u003e1\\u003c/sup\\u003e yet evidence-driven protocols for managing such subtle findings remain undefined, perpetuating therapeutic ambiguity.\\u003c/p\\u003e\\u003cp\\u003eCorneal HOAs provide an objective metric for optical quality following lamellar corneal refractive surgery. Changes in corneal asphericity primarily induce spherical aberration (SA, Z₄⁰), whereas interface irregularities may induce asymmetric aberrations like coma (Z₃\\u0026sup1; vertical, Z₃⁻\\u0026sup1; horizontal) and trefoil (Z₃\\u0026sup3; oblique, Z₃⁻\\u0026sup3; vertical), often associated with night vision disturbances.\\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e As HOA magnitude increases with pupil diameter and analysis zone size,\\u003csup\\u003e8\\u003c/sup\\u003e evaluating HOAs over both 6.0 mm (representing photopic conditions) and 8.0 mm diameters (reflecting mesopic conditions) centered on the corneal apex is critical for a comprehensive assessment, especially when considering peripherally located SRLs.\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR7\\\" citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eTherefore, this contralateral eye study aimed to quantify the impact of SRL on 3-month postoperative changes in key corneal HOAs (total RMS, SA, coma, and trefoil) within 6.0 mm and 8.0 mm analysis zones following SMILE. Additionally, this study employed a specific corneal densitometry protocol to define SRL, facilitating clinical identification and research consistency.\\u003c/p\\u003e\"},{\"header\":\"Patients and methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStudy Design and Patient Selection\\u003c/h2\\u003e\\u003cp\\u003eThis prospective, observational, contralateral eye study was conducted at the Second Affiliated Hospital of Nanchang University. The study cohort was drawn from a continuously maintained database (registration number: NCT06204926), which was established under prior institutional ethics approval (Approval No: [2023] No. (96)). For this analysis, we included consecutive patients treated between October 2024 and January 2025 who had a complete 3-month postoperative follow-up. This specific retrospective study adhered to the tenets of the Declaration of Helsinki, received separate approval from the Institutional Ethics Committee of the Second Affiliated Hospital of Nanchang University ([2024] NO. (138)), and was independently registered at ClinicalTrials.gov (NCT06806085).\\u003c/p\\u003e\\u003cp\\u003ePatient eligibility for this analysis was determined by the following inclusion criteria: (1) age 18\\u0026ndash;45 years; (2) bilateral myopia with spherical refraction of -0.50 to -10.00 diopters (D) and myopic astigmatism\\u0026thinsp;\\u0026lt;\\u0026thinsp;3.00 D; (3) corrected distance visual acuity (CDVA) of \\u0026ge;\\u0026thinsp;20/25 before SMILE surgery; (4) refractive errors stable for at least 1 year (\\u0026le;\\u0026thinsp;0.50 D change per year); (5) central corneal thickness (CCT)\\u0026thinsp;\\u0026ge;\\u0026thinsp;480 \\u0026micro;m and calculated residual stromal thickness (RST)\\u0026thinsp;\\u0026ge;\\u0026thinsp;280 \\u0026micro;m; and (6) at the 3-month follow-up, effective optic zone (EOZ) decentration within 0.2 mm of the corneal apex.\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\u003cp\\u003eExclusion criteria were: (1) history of ocular trauma or surgery; (2) pre-existing or significant postoperative corneal abnormalities (e.g., keratoconus, clinically significant interface haze or stromal scarring) or clinically significant ocular surface disease (e.g., severe dry eye); (3) relevant uncontrolled systemic diseases (e.g., autoimmune disorders, diabetes mellitus) or central neurological conditions; and (4) pregnancy or lactation.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003eSubtle residual lenticule screening, identification, and confirmation Protocol\\u003c/h3\\u003e\\n\\u003cp\\u003ePatients with confirmed unilateral SRL, identified by applying a standardized multi-step screening protocol to 3-month postoperative imaging data, were allocated to the study group. The protocol began with a detailed slit-lamp examination to exclude confounding pathologies such as significant interface haze or scarring. Subsequently, a systematic review of Pentacam HR (OCULUS, Wetzlar, Germany) scans was performed for every eye by two independent observers (J. Xiong, F. Gui). An eye was flagged as suspicious for an SRL if it met both of the following criteria: (1) a localized area of low corneal optical density (COD) value consistent with normal untreated stroma, in the expected lenticule extraction area (high COD value) of the densitometry map (120\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5 \\u0026micro;m layer), and (2) a subtle, spatially correlated elevation on the corresponding anterior elevation map. All suspicious cases then underwent confirmatory anterior segment optical coherence tomography (AS-OCT; Cirrus 5000, Carl Zeiss Meditec, Jena, Germany). An SRL was considered confirmed only if the AS-OCT scan showed a distinct lamellar separation at the surgical interface,\\u003csup\\u003e5\\u003c/sup\\u003e with compensatory thinning of the overlying tissue relative to adjacent areas (\\u003cb\\u003eFigure S1\\u003c/b\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eFor final classification, the confirmed fragment also had to occupy less than two quadrants relative to the corneal apex in densitometry map. This quadrant-based threshold was chosen to operationally distinguish the 'subtle' fragments under investigation, from larger retained lenticules that typically necessitate surgical intervention. Densitometry map screenshots from the \\\"Corneal Densito\\\" display were imported into ImageJ software (v2.14.0/1.54f; NIH, USA) for spatial calibration (130px: 3mm). The scale was set by drawing a line from the corneal apex to the 3.0-mm diameter concentric ring and defining this distance as 1.5 mm. This analysis served to quantitatively measure the area and the precise number of quadrants occupied, as well as to qualitatively characterize the morphology (e.g., vermiculate, crescentic, or boxy) consistent with lenticular fragments (\\u003cb\\u003eFigure S2\\u003c/b\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eOphthalmic examinations and measurements\\u003c/h3\\u003e\\n\\u003cp\\u003eAll participants underwent comprehensive baseline ophthalmic evaluations, including uncorrected distance visual acuity (UDVA) and CDVA, manifest and cycloplegic refraction (Auto Refractometer, ARK-510A; NIDEK, Aichi, Japan), intraocular pressure measurement (CT-80A; Topcon, Tokyo, Japan), slit-lamp biomicroscopy, and fundus examination. In addition, AS-OCT was performed for all cases where SRL was suspected based on the screening protocol.\\u003c/p\\u003e\\u003cp\\u003eCorneal imaging and aberrometry were performed preoperatively and 3 months postoperatively using a corneal topographer (Pentacam HR). Standard outputs, including horizontal corneal diameter, CCT, central flat keratometry (K1) and steep keratometry (K2), were obtained from the \\\"4 Maps Refractive\\\" display. Corneal HOAs were evaluated using the \\\"Zernike Analysis\\\" mode, centered on the corneal apex. Root mean square (RMS) of total HOAs, and Zernike coefficients (reported in \\u0026micro;m according to OSA standards) for vertical trefoil (Z₃⁻\\u0026sup3;), horizontal trefoil (Z₃\\u0026sup3;), vertical coma (Z₃⁻\\u0026sup1;), horizontal coma (Z₃\\u0026sup1;), and spherical aberration (Z₄⁰) were recorded for 6.0 mm and 8.0 mm analysis diameters.\\u003c/p\\u003e\\u003cp\\u003eEOZ analysis used the \\\"Compare 2 Exams\\\" function to generate tangential curvature difference maps (preoperative vs. 3 months postoperative). Screenshots were processed using ImageJ2 software (version 2.14.0/1.54f; National Institutes of Health, USA) to calculate the EOZ area (mm\\u0026sup2;) and diameter, and quantify decentration relative to the corneal apex.\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eSurgical technique\\u003c/h3\\u003e\\n\\u003cp\\u003eAll SMILE procedures were performed by two experienced surgeons (J. Xiong, F. Gui) using the VisuMax 500-kHz femtosecond laser system (Carl Zeiss Meditec, Jena, Germany) under standardized environmental conditions. Laser settings included a planned optical zone of 6.5 mm, cap thickness of 120 \\u0026micro;m, pulse energy of 130 nJ, and 4.5 \\u0026micro;m spot/track distance. A superiorly located incision (width of 2 mm, angle of 30\\u0026deg;) was created with an incision position of 90\\u0026deg; or 120\\u0026deg;. Postoperative management included topical 0.5% levofloxacin (Santen Pharmaceutical, Ikoma, Nara, Japan) and 0.1% fluorometholone (Fluorometholone; Santen, Osaka, Japan) eye drops, each administered four times daily for one week.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e\\u003cp\\u003eStatistical analysis was conducted using R software (version 4.4.1; R Foundation for Statistical Computing, Vienna, Austria). Normality was assessed using the Kolmogorov-Smirnov test. Data are presented as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;standard deviation (SD). Paired t-tests (normally distributed) or Wilcoxon signed-rank tests (non-normally distributed) compared contralateral eyes for preoperative parameters and postoperative HOAs changes (ΔHOAs\\u0026thinsp;=\\u0026thinsp;Postop HOAs - Preop HOAs). Multiple linear regression analysis identified factors independently associated with ΔHOA outcomes (specifically Δ8.0mm SA and Δ8.0mm HC). Given the paired design, which inherently controls for inter-individual differences such as age, gender, and eye laterality, the models included only ocular parameters as independent variables, focusing on factors directly influencing HOA changes. These variables comprised preoperative factors (corneal diameter, sphere, cylinder, flat and steep keratometry), surgery-related factors (central corneal thickness, lenticule thickness), and postoperative factors (SRL presence/absence, effective optical zone area, sphere, cylinder). Statistical significance was defined as P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eFrom a retrospectively screened cohort of 577 consecutive patients (1085 eyes), a final study group of 33 patients (mean age 22.21\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.59 years; 18 (54.5%) male) of 66 eyes was identified for analysis. These patients met all eligibility criteria for the study and were confirmed to have unilateral SRL through our multi-modal screening protocol. Among the 33 eyes with confirmed SRL, 17 (51.5%) were right eyes, while among the contralateral non-SRL eyes, 16 (48.5%) were right eyes. Preoperative parameters for SRL and contralateral non-SRL eyes are compared in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. Groups were well-matched preoperatively for mean corneal diameter, sphere, K1, and K2 (all P\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05), while preoperative cylinder magnitude was slightly lower in the SRL group (P\\u0026thinsp;=\\u0026thinsp;0.046). Mean CCT was also slightly lower (553.12\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;28.91 \\u0026micro;m vs. 555.91\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;29.20 \\u0026micro;m, P\\u0026thinsp;=\\u0026thinsp;0.002), while planned lenticule thickness and calculated RST were comparable (P\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05).\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eComparison of ocular clinicopathological parameters\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e\\u003cp\\u003eSubtle Residual Lenticule\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eParameter\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePresent\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eAbsent\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eP\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003ePreoperative\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCorneal diameter (mm)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e11.60\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.47\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e11.57\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.52\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.726\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSphere (D)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-3.29\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.49\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-3.09\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.59\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.050\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCylinder (D)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.43\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.45\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.60\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.45\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.046*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFlat Keratometry (D)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e42.81\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.58\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e42.72\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.58\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.113\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSteep Keratometry (D)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e43.68\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.63\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e43.81\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.67\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.236\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eSurgery-related\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCCT (\\u0026micro;m)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e553.12\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;28.91\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e555.91\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;29.20\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.002*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eLenticule thickness (\\u0026micro;m)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e83.64\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;22.13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e85.64\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;22.75\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.187\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eRST (\\u0026micro;m)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e349.79\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;27.65\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e350.58\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;27.27\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.634\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003ePostoperative at 3 months\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEOZ area (mm\\u003csup\\u003e2\\u003c/sup\\u003e)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e25.74\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.70\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e27.84\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.15\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEOZ diameter (mm)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e6.08\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.42\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e6.24\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.40\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.024*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSphere (D)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.21\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.46\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.14\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.40\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.324\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCylinder (D)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.26\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.25\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.24\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.30\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.741\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eData were presented as means\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SDs or numbers. The paired t-test and Wilcoxon signed-rank test were performed for SRL and non-SRL variables. Abbreviations: CCT\\u0026thinsp;=\\u0026thinsp;central corneal thickness; D\\u0026thinsp;=\\u0026thinsp;diopter; EOZ\\u0026thinsp;=\\u0026thinsp;effective optical zone; K\\u0026thinsp;=\\u0026thinsp;keratometric value; RST\\u0026thinsp;=\\u0026thinsp;residual stromal thickness; SD\\u0026thinsp;=\\u0026thinsp;standard deviation; SRL\\u0026thinsp;=\\u0026thinsp;subtle residual lenticule.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e* p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05, statistically significant.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eCharacteristics of subtle residual lenticule\\u003c/h3\\u003e\\n\\u003cp\\u003eDetails of the 33 SRLs are provided in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. The mean area of the SRLs was 0.875\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.406 mm\\u0026sup2;, and they occupied an average of 0.73\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.26 quadrants, confirming their subtle nature. The most frequent location for SRL was the 6\\u0026ndash;12 o'clock sector [corresponding to the temporal cornea in right eyes (RE) and nasal cornea in left eyes (LE); n\\u0026thinsp;=\\u0026thinsp;22, 66.7%], followed by the 6\\u0026ndash;9 o'clock sector (inferior-temporal RE / inferior-nasal LE; n\\u0026thinsp;=\\u0026thinsp;6, 18.2%) and the 9\\u0026ndash;12 o'clock sector (superior-temporal RE / superior-nasal LE; n\\u0026thinsp;=\\u0026thinsp;5, 15.2%). Predominant morphologies were vermiculate (39.4%), crescentic (36.4%), or boxy (24.2%) shapes.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eCharacteristics of subtle residual lenticule\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003en\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eArea (mm\\u003csup\\u003e2\\u003c/sup\\u003e)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eQuadrants Occupied\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e33\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.875\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.406\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.73\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.26\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eVermiculate\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.704\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.377\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.71\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.29\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCrescentic\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e12\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.979\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.367\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.86\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.24\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBoxy\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.995\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.457\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\"\\u0026plusmn;\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.59\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.12\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eData were presented as means\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SDs or numbers. The \\\"Quadrants Occupied\\\" value represents the mean number of corneal quadrants (out of four) that the subtle residual lenticules extended into.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\n\\u003ch3\\u003eVisual and refractive outcomes\\u003c/h3\\u003e\\n\\u003cp\\u003eAt 3 months postoperatively, standard visual and refractive outcomes were comparable between SRL and contralateral control eyes (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). There were no statistically significant differences in postoperative uncorrected or corrected distance visual acuity, refractive predictability, accuracy, or stability (all P\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05). However, SRL eyes exhibited a significantly smaller mean EOZ area (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and EOZ diameter (P\\u0026thinsp;=\\u0026thinsp;0.024) compared to contralateral controls (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eCorneal higher-order aberrations\\u003c/h2\\u003e\\u003cp\\u003eCorneal HOA analysis revealed statistically significant differences related to SRL presence (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e\\u003cb\\u003e)\\u003c/b\\u003e. SRL eyes showed a significantly greater increase in total HOA RMS from baseline compared to controls in both the 6.0 mm (P\\u0026thinsp;=\\u0026thinsp;0.006) and 8.0 mm zones (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Specifically, ΔSA showed a greater positive shift in the SRL group for both 6.0 mm (P\\u0026thinsp;=\\u0026thinsp;0.026) and 8.0 mm zones (P\\u0026thinsp;=\\u0026thinsp;0.001). ΔHC demonstrated a significant negative shift exclusively within the 8.0 mm zone in SRL eyes compared to controls (P\\u0026thinsp;=\\u0026thinsp;0.001).\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eComparison of higher-order aberration\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"4\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e\\u003cp\\u003eSubtle Residual Lenticule\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eParameter\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePresent\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eAbsent\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eP\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eHOAs at 6-mm zone centered around the corneal vertex\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal HOA RMS\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.43\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.12\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.44\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.16\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.317\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.59\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.19\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.52\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.17\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.004*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.16\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.21\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.07\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.20\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.006*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eSpherical aberration\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.22\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.09\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.21\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.11\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.586\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.31\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.14\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.24\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.16\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.005\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.08\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.14\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.03\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.026*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eHorizontal coma\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.02\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.11\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.12\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.325\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.08\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.24\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.05\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.18\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.057\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.06\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.21\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.04\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.18\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.104\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eVertical coma\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.00\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.24\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.04\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.22\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.101\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.17\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.26\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.11\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.26\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.086\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.16\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.19\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.14\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.19\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.463\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eOblique trefoil\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.06\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.09\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.17\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.037\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.07\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.17\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.06\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.16\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.611\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.03\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.225\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eHorizontal trefoil\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.09\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.08\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.922\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.10\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.03\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.09\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.244\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.00\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.09\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.02\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.10\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.375\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eHOAs at 8-mm zone centered around the corneal vertex\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal HOA RMS\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1.03\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.17\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1.06\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.24\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.758\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e2.18\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.69\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1.88\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.53\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.001*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1.15\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.71\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.82\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.64\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eSpherical aberration\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.63\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.25\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.60\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.27\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.120\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1.71\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.55\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1.48\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.53\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.001*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1.08\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.51\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.88\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.49\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.001*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eHorizontal coma\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.07\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.38\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.10\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.37\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.206\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.53\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.77\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.11\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.57\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.008\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.46\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.60\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.02\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.53\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.001*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eVertical coma\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.00\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.40\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.02\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.41\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.390\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.05\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.68\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.60\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.728\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.04\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.56\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.03\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.51\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.900\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eOblique trefoil\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.10\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.24\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.15\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.32\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.025*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.16\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.37\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.14\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.35\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.729\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.06\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.31\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.29\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.207\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colspan=\\\"4\\\" nameend=\\\"c4\\\" namest=\\\"c1\\\"\\u003e\\u003cp\\u003eHorizontal trefoil\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePre\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.04\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.19\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.22\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.378\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003ePost\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.05\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.21\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.23\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.486\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eChange\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e-0.01\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.16\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e-0.02\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.20\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.828\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eData were presented as means\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SDs or numbers. The paired t-test and Wilcoxon signed-rank test were performed for SRL and non-SRL variables. Abbreviations: HOA\\u0026thinsp;=\\u0026thinsp;higher-order aberration; Pre\\u0026thinsp;=\\u0026thinsp;preoperatively; Post\\u0026thinsp;=\\u0026thinsp;postoperatively; RMS\\u0026thinsp;=\\u0026thinsp;root mean square; SD\\u0026thinsp;=\\u0026thinsp;standard deviation; SRL\\u0026thinsp;=\\u0026thinsp;subtle residual lenticule.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e* p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05, statistically significant.\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eRisk factor analyses of changes in key HOAs\\u003c/h2\\u003e\\u003cp\\u003eMultiple linear regression analysis explored factors independently associated with changes in key HOAs (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). No significant independent influencing factors were identified for Δ6.0mm SA (all P\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05). For Δ8.0mm SA, higher preoperative spherical error (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and smaller postoperative EOZ area (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) were significant independent factors, but SRL presence was not independently associated (P\\u0026thinsp;=\\u0026thinsp;0.990). Conversely, for Δ8.0mm HC, SRL presence was the sole significant independent factor associated with the negative shift (P\\u0026thinsp;=\\u0026thinsp;0.004).\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis retrospective contralateral study demonstrates that SRL after SMILE significantly impacts postoperative corneal HOAs at 3 months, particularly within the 8.0 mm analysis zone. The findings suggest potential mechanisms by which SRL influences HC and SA.\\u003c/p\\u003e\\u003cp\\u003eA key strength of this study is the implementation of a systematic, multi-modal protocol for identifying and confirming SRLs. We defined SRLs as fragments spanning less than two quadrants, an operational threshold to distinguish these subtle findings from large retained lenticules that likely induce complex aberrations and significant astigmatic effects, whereas our definition focuses on the more regular impact of smaller fragments. While AS-OCT provided definitive structural confirmation,1 this study highlights the potential of corneal densitometry as a sensitive primary screening tool. Our protocol was based on identifying focal areas of relatively low COD on 3-month postoperative scans, which stood out against the generally high COD background of the lenticule extraction area at the 120 \\u0026micro;m depth.11,12 We hypothesize that these hypodense \\\"islands\\\" represent undisturbed tissue where incomplete lenticule separation occurred, thus retaining a near-normal COD compared to the surrounding stroma. This optical signal may be more sensitive than structural changes alone, potentially identifying SRLs too thin to create a discernible interface elevation on AS-OCT.\\u003c/p\\u003e\\u003cp\\u003eOur key finding was the independent association between SRL and negative HC induction in the 8.0 mm zone, with a predisposition in the 6\\u0026ndash;12 o'clock sector. This locational preference may be explained by surgical technique, as a small peripheral area is often intentionally left attached to provide counter-traction during dissection. In the ergonomically challenging infero-temporal (RE) or infero-nasal (LE) quadrants for a right-handed surgeon, this attached area is at higher risk of being incompletely separated or torn, resulting in a retained fragment. Optically, such fragments in the 6\\u0026ndash;12 o'clock sector can cause localized corneal steepening, causing light rays passing through this area (e.g., the negative x-axis corresponds temporal side of RE or nasal side of LE, Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig5\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eB) to propagate faster than the corresponding opposite side, resulting in a differential wavefront advancement along the horizontal meridian manifests directly as negative HC.8,13,14 This effect was restricted to the 8.0 mm zone, consistent with the peripheral nature of SRLs, which have a greater impact on the larger analysis zone but a diluted, statistically insignificant effect on the central 6.0 mm zone.15,16 Given that coma significantly impacts vision in larger pupil conditions,7,8,17 this provides an objective correlate for potential night vision symptoms like halos,18 although definitive clinical significance requires correlation with patient-reported outcomes.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003eConversely, the link between SRL and increased positive ΔSA is indirect. Instead, higher preoperative myopia and a smaller EOZ were the primary drivers of increased Δ8.0mm SA. Critically, we found that SRL eyes had significantly smaller EOZs, which itself may be a consequence of localized epithelial or stromal remodeling triggered by the interface irregularity of the SRL. A smaller EOZ, known to increase positive SA after refractive surgery,1,16,19 results from a steeper peripheral cornea relative to the flattened central cornea, particularly in higher myopia corrections,14,16 causing peripheral light rays to pass through a more abrupt transition and elevate Δ8.0mm SA (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig5\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eA). The lack of significant influencing factors for Δ6.0mm SA, suggests the effect within this smaller zone is multifactorial or below the detection threshold of this analysis.\\u003c/p\\u003e\\u003cp\\u003eWhile our analysis revealed statistically significant HOA changes, the clinical relevance of these modest effect sizes warrants careful consideration. The subtle and peripheral nature of the SRLs, coupled with the absence of significant effect on standard photopic visual outcomes (usually assessed central vision in pupil diameters of \\u0026le;\\u0026thinsp;4.0 mm) like UDVA and CDVA, 1,15\\u0026ndash;17,20 relying on the correction of low-order aberrations (sphere and cylinder) which are determined by the removal of the main lenticule body. However, the altered HOAs in SMILE,16,21,22 particularly the HC increase in the 8.0 mm zone, serve as an objective marker of incomplete surgery and may contribute to subjective visual disturbances in visually sensitive individuals under demanding conditions.23,24 Although epithelial remodeling can compensate for stromal irregularities, it may also induce its own aberrations, creating a complex optical interplay.25 Therefore, persistent aberration-related visual symptoms should prompt careful multi-modal evaluation of both the stromal interface and epithelial profile. The current data suggest that intervention for asymptomatic SRL, even when objectively confirmed, may not be warranted, and management should likely be guided by patient symptoms. Complete lenticule extraction remains the ideal goal for optimizing postoperative optical quality.\\u003c/p\\u003e\\u003cp\\u003eThis study has several limitations. Firstly, the modest sample size (n\\u0026thinsp;=\\u0026thinsp;33 pairs) and specific cohort characteristics may limit statistical power and generalizability. Although the paired design controls for age, sex, and laterality, and the bilateral symmetry of HOAs is well-documented,26 exploration of these demographic-related factors in larger, more diverse cohorts is still warranted. Secondly, our multi-modal definition of SRL, while robust, is novel and requires further validation. Future studies could directly compare the diagnostic sensitivity and specificity of densitometry against other high-resolution modalities like AS-OCT for identifying SRLs. Thirdly, the three-month follow-up may not fully capture long-term corneal remodeling. Fourthly, correlating objective HOA changes with validated patient-reported outcomes is a crucial next step in the future. Fifthly, future studies could explore the relationship between specific SRL characteristics, such as area and location, and the precise magnitude of induced aberrations. Finally, the observational design limits definitive causal inference, despite associations strengthened by the contralateral comparison; confirming causality would require higher-level evidence, such as intervention trials or large prospective cohort studies.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn conclusion, SRL after SMILE directly induces negative HC within the 8.0 mm zone, likely impacting mesopic vision, while its association with increased SA appears indirect. Meticulous surgical technique aimed at complete lenticule removal remains the ideal goal for optimizing postoperative optical quality.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eSRL\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eSubtle residual lenticule\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eHOAs\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eHigher-order aberrations\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eSMILE\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eSmall incision lenticule extraction\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eAS-OCT\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eAnterior segment optical coherence tomography\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eSA\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eSpherical aberration\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eHC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eHorizontal coma\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eCDVA\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eCorrected distance visual acuity\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eCCT\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eCentral corneal thickness\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eEOZ\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eEffective optic zone\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eCOD\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eCorneal optical density\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eUDVA\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eUncorrected distance visual acuity\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eRE\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eRight eye\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eLE\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eLeft eye\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eEthics approval and consent to participate\\u003c/b\\u003e:\\u003c/h2\\u003e\\u003cp\\u003eThis specific retrospective study adhered to the tenets of the Declaration of Helsinki, received separate approval from the Institutional Ethics Committee of the Second Affiliated Hospital of Nanchang University ([2024] NO. (138)), and was independently registered at ClinicalTrials.gov (NCT06806085). Informed consent to participate was obtained from all participants.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication:\\u003c/strong\\u003e\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\u003ch2\\u003eCompeting interests:\\u003c/h2\\u003e\\u003cp\\u003eThe authors declare that they have no competing interests in this section.\\u003c/p\\u003e\\u003ch2\\u003eFunding:\\u003c/h2\\u003e\\u003cp\\u003eThis study was supported by the National Natural Science Foundation of China (82260214), the Science and Technology Program of Jiangxi Provincial Health Commission (202210631).\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eStudy concept and design (JX, WW); data collection (FG, MH, FH, HM, MZ, CA, YL); analysis and interpretation of data ((FG, MH, FH, HM); writing the manuscript (FG, MH, FH, HM); critical revision of the manuscript (JX, WW); statistical expertise (JX, FH, HM); supervision (JX, WW).\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgement:\\u003c/h2\\u003e\\u003cp\\u003eWe thank all the patients involved for supporting this study\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eThe data can be provided upon request. All data associated with this study have been published. Requests for data should be directed to the corresponding author and are subject to ethical approval.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eWang Y, Xie L, Yao K, et al. Evidence-Based Guidelines for Keratorefractive Lenticule Extraction Surgery. Ophthalmology. 2025;132(4):397\\u0026ndash;419.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHan T, Xu Y, Han X, et al. Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism. Br J Ophthalmol. 2019;103(4):565\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eXin Y, Lopes BT, Wang J, et al. Biomechanical Effects of tPRK, FS-LASIK, and SMILE on the Cornea. Front Bioeng Biotechnol. 2022;10:834270.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eTitiyal JS, Kaur M, Shaikh F, Gagrani M, Brar A, Rathi A. Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives. \\u003cem\\u003eOPTH\\u003c/em\\u003e. 2018;Volume 12:1685\\u0026ndash;1699.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGanesh S, Brar S, Lazaridis A. Management and Outcomes of Retained Lenticules and Lenticule Fragments Removal After Failed Primary SMILE: A Case Series. J Refract Surg. 2017;33(12):848\\u0026ndash;53.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKligman BE, Baartman BJ, Dupps WJ. Errors in Treatment of Lower-order Aberrations and Induction of Higher-order Aberrations in Laser Refractive Surgery. Int Ophthalmol Clin. 2016;56(2):19\\u0026ndash;45.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eXu R, Kollbaum P, Thibos L, Lopez-Gil N, Bradley A. Reducing starbursts in highly aberrated eyes with pupil miosis. Ophthalmic Physiologic Optic. 2018;38(1):26\\u0026ndash;36.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGupta V, Bari A, Anjum S, Yadav A, Saxena R, Sinha R. Quantifying natural higher order aberration(s) in emmetropic human eyes and objectively evaluating retinal image quality. Ophthalmic Physiologic Optic. 2025;45(3):769\\u0026ndash;78.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLin HN, Zeng H, Ji R, Li J, Zhang R, Sun L. Decentration following small incision lenticule extraction (SMILE) in eyes with high myopia and its influence factors. Indian J Ophthalmol. 2025;73(3):389\\u0026ndash;95.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eChung B, Lee H, Roberts CJ, et al. Decentration measurements using Placido corneal tangential curvature topography and Scheimpflug tomography pachymetry difference maps after small-incision lenticule extraction. J Cataract Refract Surg. 2019;45(8):1067\\u0026ndash;73.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eWei R, Li M, Yang W et al. Corneal Densitometry After Small Incision Lenticule Extraction (SMILE) and Femtosecond Laser-Assisted LASIK (FS-LASIK): 5-Year Prospective Comparative Study. \\u003cem\\u003eFront Med\\u003c/em\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eDu Y, Di Y, Yang S, Li Y. Analysis of the changes in corneal optical density following small incision lenticule extraction for myopia and related influencing factors. Photodiagn Photodyn Ther. 2024;50:104397.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eChen M, Yoon G. Posterior corneal aberrations and their compensation effects on anterior corneal aberrations in keratoconic eyes. Invest Ophthalmol Vis Sci. 2008;49(12):5645\\u0026ndash;52.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLu F, Wu J, Qu J, et al. Association between Offset of the Pupil Center from the Corneal Vertex and Wavefront Aberration. J Optometry. 2008;1(1):8\\u0026ndash;13.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eYu M, Chen M, Liu W, Dai J. Comparative study of wave-front aberration and corneal Asphericity after SMILE and LASEK for myopia: a short and long term study. BMC Ophthalmol. 2019;19(1):80.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eDu Y, Di Y, Yang S, et al. Differences in ocular high order aberrations before and after small incision lenticule extraction for correction of myopia: a systematic review and meta-analysis. Front Med. 2024;11:1274101.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKepez Yıldız B. Comparison of corneal higher-order aberrations after femtosecond lasik and smile for patients with large scotopic pupil size. Eur Eye Res. Published online 2021.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eSchallhorn S, Brown M, Venter J, Hettinger K, Hannan S. The Role of the Mesopic Pupil on Patient-Reported Outcomes in Young Patients With Myopia 1 Month After Wavefront-Guided LASIK. J Refract Surg. 2014;30(3):159\\u0026ndash;65.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eFu Y, Yin Y, Zhao Y, et al. Changes of the effective optical zone after small-incision lenticule extraction and a correlation analysis. Lasers Med Sci. 2022;38(1):14.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eXiong J, Xu J, Zhou M, et al. Mesopic pupil indices as potential risk factors for glare disability after intraocular implantable collamer lens implantation: prospective study. J Cataract Refract Surg. 2024;50(6):565\\u0026ndash;71.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eMai ELC, Chang CK, Lee CY, Lian IB, Chao CC. Higher-Order Aberrations of Topography-Guided LASIK and Wavefront-Optimized LASIK in High- and Low-Myopic Eyes: A Non-Randomized Controlled Trial. J Pers Med. 2023;13(3):399.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eKim T im, Barrio Ali\\u0026oacute;D, Wilkins JL, Cochener M, Ang B. M. Refractive surgery. \\u003cem\\u003eThe Lancet\\u003c/em\\u003e. 2019;393(10185):2085\\u0026ndash;2098.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eSiedlecki J, Schmelter V, Schworm B et al. Corneal wavefront aberrations and subjective quality of vision after small incision lenticule extraction. Acta Ophthalmol. 2020;98(7).\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eDu H, Zhang B, Wang Z, Xiong L. Quality of vision after myopic refractive surgeries: SMILE, FS-LASIK, and ICL. BMC Ophthalmol. 2023;23(1):291.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLiu M, Jin C, Lu L, et al. The Impact of Corneal Epithelial Thickening and Inhomogeneity on Corneal Aberrations After Small Incision Lenticule Extraction. J Refract Surg. 2023;39(1):23\\u0026ndash;32.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eArba Mosquera S, Verma S. Bilateral symmetry in vision and influence of ocular surgical procedures on binocular vision: A topical review. J Optom. 2016;9(4):219\\u0026ndash;30.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-ophthalmology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"boph\",\"sideBox\":\"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/boph\",\"title\":\"BMC Ophthalmology\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Subtle Residual Lenticule, Higher-Order Aberrations, Small incision lenticule extraction, Corneal Densitometry\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7862892/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7862892/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e\\u003cp\\u003eTo investigate the impact of subtle residual lenticule (SRL) on corneal higher-order aberrations (HOAs) after small incision lenticule extraction (SMILE).\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e\\u003cp\\u003eThis prospective, contralateral eye study included 33 myopic patients with unilateral SRL identified 3 months postoperatively. SRL was defined as retained fragments spanning fewer than two quadrants, identified via a novel protocol using corneal densitometry and anterior elevation maps, and confirmed with anterior segment optical coherence tomography (AS-OCT). Postoperative changes (Δ) in corneal HOAs (6.0/8.0 mm zones) were compared between SRL and control eyes. Multiple linear regression explored factors associated with Δ8.0mm spherical aberration (SA) and horizontal coma (HC).\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e\\u003cp\\u003eCompared to controls, SRL eyes showed significantly greater changes in 6.0 mm/8.0 mm total HOA root mean square (ΔRMS: P\\u0026thinsp;=\\u0026thinsp;0.006 / P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and ΔSA (P\\u0026thinsp;=\\u0026thinsp;0.026 / P\\u0026thinsp;=\\u0026thinsp;0.001), and a negative shift in HC (8.0 mm zone; P\\u0026thinsp;=\\u0026thinsp;0.001). Regression analysis identified only SRL presence associated with negative Δ8.0mm HC (P\\u0026thinsp;=\\u0026thinsp;0.004). Conversely, increased Δ8.0mm SA was associated with higher preoperative myopia and a smaller postoperative effective optical zone (all P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), not directly with SRL (P\\u0026thinsp;=\\u0026thinsp;0.990).\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e\\u003cp\\u003eThe presence of SRL after SMILE is associated with statistically significant increases in postoperative HOAs, notably a negative shift in horizontal coma. Furthermore, the densitometry-guided protocol offers a practical tool for screening these subtle fragments. Complete lenticule removal remains the ideal goal for optimizing postoperative optical quality.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Impact of Densitometry-Detected Subtle Residual Lenticule on Post-SMILE Corneal Higher-Order Aberrations: A Contralateral Eye Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-11-21 01:12:27\",\"doi\":\"10.21203/rs.3.rs-7862892/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-06T08:57:28+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-06T05:15:01+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"49244680051825609974828229099537438464\",\"date\":\"2026-04-06T04:31:51+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"37453780638424997708827483649535849049\",\"date\":\"2026-04-05T12:07:07+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-11-11T18:18:14+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"316588555889512741886497152382617785438\",\"date\":\"2025-11-11T12:11:23+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-11-11T07:16:07+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-11-05T08:16:46+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-10-17T12:17:31+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-10-17T02:24:43+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Ophthalmology\",\"date\":\"2025-10-17T02:21:00+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-ophthalmology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"boph\",\"sideBox\":\"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/boph\",\"title\":\"BMC Ophthalmology\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"32e1c8cc-8c62-4072-8074-7b20f2f8b7bb\",\"owner\":[],\"postedDate\":\"November 21st, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-11-21T01:12:27+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-11-21 01:12:27\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7862892\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7862892\",\"identity\":\"rs-7862892\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}