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Femto-LASIK outcomes obtained by a fellowship trainee during a refractive surgery training program
Resultados de Femto-LASIK obtenidos por un fellow durante un programa de formación en cirugía refractiva
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The choroidal thinning (white arrow) at nasal level could be physiological and attributable to the patient’s myopia. Subfoveal hyperreflectivity resolved at two weeks (B) leaving a minimal sequel of subfoveal RPE thickening at 1.5 months (C). The outer nasal layers progressively recovered (B and C). In A-OCT 8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8 <span class="elsevierStyleItalic">en-face,</span> at ellipsoid layer level, hyperreflective points were observed surrounding the papilla (green arrow) at debut (D). After two weeks (E), these peripapillary hyperreflective points decreased but hyporeflective spots were observed (white arrow), which correlate with the disruption of the outer retina in autofluorescence. After 1.5 months (F), hyporeflective spots decreased and white peripapillary spots disappeared. The A-OCT 3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3 showed at choriocapillary level two apparent hypoperfusion spots in the debut of the disease (G), which correlate with the shadow of the subfoveal column hyperreflectivity.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Moll-Udina, I. Hernanz, M. Dotti, V. Llorenç, A. Adán" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Moll-Udina" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Hernanz" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Dotti" ] 3 => array:2 [ "nombre" => "V." "apellidos" => "Llorenç" ] 4 => array:2 [ "nombre" => "A." 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García de Oteyza, A.M. García-Albisua, M. Benedetti Sandner, V. Sánchez-Huerta, E. Hernández-Quintela, G. de Wit-Carter" "autores" => array:6 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "García de Oteyza" "email" => array:1 [ 0 => "gonzalo_gdeoteyza@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A.M." "apellidos" => "García-Albisua" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Benedetti Sandner" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "V." "apellidos" => "Sánchez-Huerta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Hernández-Quintela" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "G." "apellidos" => "de Wit-Carter" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Clínica Oftalmológica García de Oteyza, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Córnea y Cirugía Refractiva, Asociación Para Evitar la Ceguera en México, Mexico City, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados de Femto-LASIK obtenidos por un <span class="elsevierStyleItalic">fellow</span> durante un programa de formación en cirugía refractiva" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1232 "Ancho" => 1674 "Tamanyo" => 102242 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Responses to the third author-created question from the 50 patients in the study at 6 months follow-up.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Corneal refractive surgery is one of the most popular surgeries among ophthalmologists. Despite the huge market collapse in 2008 due to the economic crisis, the number of LASIK and PRK procedures has increased again during the last decade. The most likely trend is a progressive increase in cases as the incidence of myopia is set to rise dramatically in the future. Holden et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> estimate an increase in the total number of patients with myopia worldwide from 2.62 billion in 2020 (34% of the world’s population) to 4.758 billion in 2050 (49.8% of the world's population). Myopia would be considered an epidemic, especially in Asia, Europe and the Americas, where more than half of the population is expected to be affected.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite this perspective and the future need for refractive surgeons, the optimal environment for teaching corneal refractive procedures remains controversial and scarce. Should corneal refractive surgery be taught during residency and fellowship programmes? The main reasons against this concept are patient reluctance to accept a lower level of surgeon experience for a fee-based elective procedure and the potential complications that can occur during the learning curve that can lead to irreversible vision loss in healthy eyes.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, Randleman and Stulting pointed out that the technical aspects of refractive surgery training are the least challenging in the whole learning process. Preoperative assessment, recognition and management of postoperative complications as well as understanding and managing patient expectations are the critical aspects of learning the principles of refractive surgery. Therefore, the answer to the above question is an unequivocal “yes”.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">However, only 54% of residency programmes in the United States stated that trainee surgeons performed a corneal refractive surgery. Other programmes consulted stated that residents could only attend surgery or had no contact with refractive surgery at all.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The American Society of Cataract and Refractive Surgery (ASCRS) junior attendees and residents contradict these numbers in their latest survey,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> where up to 76% of residents surveyed stated that they had not performed any LASIK procedures. Furthermore, they claimed a lack of contact with the excimer laser and 81% believed that training in refractive surgery should occur during residency.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Few studies explore the outcomes of LASIK performed by fellowship trainees and most of them took place in the United States. Showing the safety and efficacy of fellowship-performed surgeries is an excellent way to encourage the emergence of practical refractive surgery programmes. This study aims to show, for the first time, the visual and refractive outcomes and patient satisfaction in 100 eyes operated with femtosecond-assisted LASIK (F-LASIK) during a one-year corneal and refractive surgery fellowship programme in a Latin American hospital.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">After obtaining approval from the Institutional Review Board of the Association for the Prevention of Blindness in Mexico (Mexico City, Mexico), the medical records of 50 consecutive patients who underwent femtosecond-assisted refractive surgery (F-LASIK) performed by a corneal fellowship trainee (GGO) between March 2018 and June 2018 were reviewed. This is a prospective, interventional, non-randomised study of a consecutive case series. Six months after surgery, patients were invited to participate in a satisfaction questionnaire consisting of 5 questions created by the author. All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its subsequent amendments or comparable ethical standards.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The first 100 consecutive eyes operated on by the corneal fellowship trainee surgeon were included in the data analysis. This number was chosen to provide an extensive analysis of the results during the very early part of the LASIK learning curve. The fellowship trainee surgeon managed all patients from start to finish, i.e. he performed the preoperative assessment, surgical planning, surgery after receiving informed consent from the patient and postoperative care.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Inclusion criteria</span><p id="par0035" class="elsevierStylePara elsevierViewall">The inclusion criteria for a patient to undergo F-LASIK included age over 21 years, stable refraction for the past 2 years, myopia <9 dioptres (D) and astigmatism <6 D,flatter corneal curvature ≥40 D and more curved corneal curvature <47.5 D. Normal topographic and ophthalmic evaluation was mandatory to include patients in this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Exclusion criteria</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patients with a history of anterior segment surgery, any corneal disease, active ocular infection, best corrected visual acuity (BCVA) worse than 20/40, and refusal to sign the surgical informed consent form were excluded.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pre-operative assessment</span><p id="par0045" class="elsevierStylePara elsevierViewall">The medical and ophthalmological history was meticulously taken in all patients. A complete ophthalmic evaluation was performed including uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), manifest and cycloplegic refraction, ocular motility study and binocular vision, topographical and aberrometric studies (Pentacam®, Oculus, Wetzlar, Germany), pupil diameter under mesopic and scotopic conditions, anterior segment slit lamp examination, applanation tonometry and fundus examination. Soft contact lens wearers were instructed to discontinue use for a minimum of 15 days prior to the initial examination. All preoperative examinations were analysed and reviewed by attendees from the refractive surgery service. Once patients were confirmed to be included in the study, they were asked to sign the informed consent for surgery and the study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique and post-operative care</span><p id="par0050" class="elsevierStylePara elsevierViewall">First, all patient refractive data were entered into the excimer laser platform. Calculations of the surgical procedure were made based on the nomogram provided by the laser manufacturer. Patients were prepared with periocular skin cleansing with 10% povidone iodine and topical anaesthesia (0.1% tetracaine and 0.4% oxybuprocaine).</p><p id="par0055" class="elsevierStylePara elsevierViewall">All cases were performed with the VisuMax femtosecond laser (Zeiss, Oberkochen, Germany). A 9 mm superior hinge flap was created in both eyes before ablation with the WaveLight® EX500 excimer laser (Alcon, Fort Worth, Texas, USA). The optical zone ranged from 6.0 to 6.5 mm. After ablation, the flap was repositioned on the stromal bed, irrigating the interlayer for cleaning of any particles and finally the lenticule was allowed to dry in its exact position for one minute. The corneal flap was inspected at the slit lamp in each patient (between 15 and 30 min after surgery) and none had to be repositioned. All surgeries were performed by the same fellowship trainee under the supervision of an attendee in charge.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Postoperative treatment included a fourth-generation topical quinolone (Vigamoxi®, Alcon, Fort Worth, Texas, USA) 4 times daily for the first week. Topical prednisolone acetate 1% (Prednefrin® SF, Allergan, Dublin, Ireland) was started every 6 h for the first 5 days and then tapered every 5 days until completing 2 weeks after surgery. All patients were instructed to use the same preservative-free artificial tears at least 4 times daily for 1 month. Postoperative follow-up visits were scheduled as follows: 1 day, 1 week, 1 month, 3 months, 6 months and 1 year.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Variables studied</span><p id="par0065" class="elsevierStylePara elsevierViewall">Visual and refractive outcomes were recorded at each follow-up visit, as well as UCVA and BCVA, refraction, spherical equivalent (SE), refractive stability and complications.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Patient satisfaction was measured according to 5 questions devised by the author (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">The medical records of 50 patients, 17 males (34%) and 33 females (66%) aged 21−44 years, with a mean age of 30.5 ± 5.9 (SD) years, were reviewed. Femtosecond-assisted LASIK was performed in all patients. Myopic correction was performed in 90 eyes and hyperopic correction in 10 eyes. All cases were performed by the same refractive surgery fellowship trainee under the supervision of an experienced surgeon.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Preoperative BCVA was 20/32 or better in all eyes; 80 eyes (80%) had an BCVA of 20/20 or better (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Preoperative ES was −3.91 ± 2.28 D (range −10.25 to +0.50 D). The mean preoperative cylinder was −2.07 ± 1.44 D (range −5.50 to 0.00 D). Cylinder had less than 1.00 D in 34 eyes (34%), between 1.01 and 2.00 D in 20 eyes (20%), between 2.01 and 3.00 D in 20 eyes (20%) and more than 3.01 D in 26 eyes (26%).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">At 12-month follow-up, mean BCVA was 0.01 logMAR and mean BCVA was −0.001 logMAR. Snellen NCVA was 20/16 in 4 eyes (4%); 20/20 or better in 87 eyes (87%); 20/25 or better in 96 eyes (96%); 20/32 or better in 99 eyes (99%) and 20/40 or better in all eyes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). No line losses were observed in BCVA and 22 eyes gained one or more lines at the end of follow-up (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The mean postoperative SE was −0.22 ± 0.28 D. The correlation between attempted and achieved SE is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C. The postoperative SE accuracy calculation showed that 81 eyes (81%) were within ±0.50 D and 99 eyes (99%) within ±1.00 D (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). One eye had more than 1.00 D of astigmatism at the end of the follow-up period. The stability of the SE at 2 weeks, 1, 3, 3, 6 and 12 months is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E. Refractive astigmatism was less than 0.50 D in 85 eyes (85%) and less than 0.75 in 98% of eyes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>F).</p><p id="par0090" class="elsevierStylePara elsevierViewall">Major complications occurred in one eye with macrostriae that were treated on the first postoperative day with repositioning of the flap without further clinical or visual sequelae. In the early postoperative period, micro-stretch marks were detected in 8 eyes (8%) and remnants of the interocular space in 9 eyes (9%). However, these complications had no significant effect on visual acuity. Mild diffuse diffuse lamellar keratitis was reported in 5 eyes (5%) without compromising results. Topical steroids resolved said inflammatory conditions during the first postoperative month. No epithelial growths were detected in the interocular layer and no defective epithelium was detected.</p><p id="par0095" class="elsevierStylePara elsevierViewall">With respect to the 5 questions devised by the author, 33 patients (66%) responded that they had great confidence in the fellowship trainee surgeon who performed the surgery, 9 patients (18%) felt completely confident and 8 patients (16%) felt somewhat confident (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Thirty-six patients (72%) were completely satisfied with the preoperative explanations, the resolution of doubts, the surgery and the postoperative process and 14 patients (28%) were very satisfied (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). When asked about the degree of satisfaction with postoperative visual acuity, 86% (43 out of 50) of the patients were completely satisfied and 7 patients (14%) were very satisfied (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Regarding the last 2 dichotomous questions, 49 patients (98%) would recommend surgery with a fellowship trainee and all our cases would repeat the same refractive surgery experience with the same surgeon.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Corneal refractive surgery is probably the most demanding ophthalmological procedure in terms of patient expectations of visual outcomes. In addition, it is a procedure of choice and payment. These are the main reasons why patients are generally reluctant to accept a novice surgeon.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In addition, training in refractive surgery is rare through residency programmes. In the United States, 76% of residents have not performed any refractive surgery during their ophthalmology training. In Spain, the first author’s country, 2 clinics provide such training in refractive surgery. In Mexico, refractive surgery is present in almost all resident programmes with the technology, most of them in the private training hospital setting. The evidence supporting the fact that refractive surgery during residency is scarce is the low number of published articles addressing this topic. The majority of publications are from the United States,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–10</span></a> except for one that took place in Saudi Arabia.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Therefore, this is the first time that visual and refractive outcomes obtained in a Latin American hospital by a corneal fellowship trainee surgeon are reported.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The results presented in this study are similar to those using the femtosecond laser for flap creation, and are better than studies using the microkeratome. In the femtosecond group of studies, Nehls et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> published a NCVA of 20/20 or better in 84.5% of cases and Weber et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> of 85.7%, which is close to the 87% obtained in this work. In contrast, in the microkeratome group of studies, the results are not better compared to Bowers et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> who obtained 77% of their patients with 20/20 or better. The results were even worse in the studies of LeBoyer et al. and Al-Swailem and Wagoner, where only 50% of patients achieved a visual acuity of 20/20.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The femtosecond laser has not only been shown to achieve better results for fellowship trainees and corneal residents, but also appears to be a preferable option for patients. In one of the 5 satisfaction questions proposed by Nelhs et al., 68% of patients responded that it was very important and 29% somewhat important that a laser performed all steps of the surgery instead of a blade.</p><p id="par0120" class="elsevierStylePara elsevierViewall">When comparing complication rates, the femtosecond laser demonstrated a higher safety profile during the surgeon training period. Complications in this work were not critical to the final outcome, and the eye with macrostriae had a satisfactory recovery after reintervention. As reported by Shtein et al.,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> the femtosecond laser is more predictable, reliable and safer than the microkeratome and provides greater accuracy and reproducibility in flap creation, fewer complications and better flap adhesion.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The visual and refractive outcomes obtained by trainee surgeons compared to experienced surgeons are very similar. In fact, in the only study comparing outcomes in both groups of surgeons using femtosecond lasers, Shtein et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> conclude that there are no clinical or statistical differences in visual acuity outcomes. Finally, with regard to patient satisfaction, 83% of patients in the study by Nehls et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and 84% in the present work had a great deal or complete confidence in the fellowship trainee surgeon performing the surgery. Satisfaction was also measured by the high percentage of patients who would refer other patients to a fellowship trainee surgeon (85% in the Nehls et al. study and 98% in the present study).</p><p id="par0130" class="elsevierStylePara elsevierViewall">This study is the first of its kind in a Latin American hospital showing good clinical outcomes and patient satisfaction. The main difference between the present study and other studies on this subject is that in our study the results of a single surgeon were analysed. This avoids the surgeon bias that may exist in other articles. However, the results presented here support the fact that well-trained surgeons can obtain results as good as those of experienced surgeons using a femtosecond laser for flap creation. These findings may persuade training hospitals to implement safe and effective refractive surgery training programmes. As Randleman and Stulting<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> pointed out, making refractive surgical education an essential part of all ophthalmology residency programmes is one of the foundations for the future.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">This research has not received specific support from public sector agencies, the commercial sector or non-profit organisations.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">No conflict of interest was declared by the authors in relation to this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1545871" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1397206" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1545872" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1397205" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Material and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Inclusion criteria" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Exclusion criteria" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Pre-operative assessment" ] 3 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgical technique and post-operative care" ] 4 => array:2 [ "identificador" => "sec0030" "titulo" => "Variables studied" ] ] ] 5 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-27" "fechaAceptado" => "2020-10-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1397206" "palabras" => array:4 [ 0 => "Refractive surgery training" 1 => "Refractive surgery fellowship" 2 => "Femto-LASIK" 3 => "LASIK outcomes" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1397205" "palabras" => array:4 [ 0 => "Formación en cirugía refractiva" 1 => "Fellowship en cirugía refractiva" 2 => "Femto-LASIK" 3 => "Resultado de LASIK" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">To report, for the first time, the clinical outcomes and patient satisfaction of laser refractive surgery performed by a trainee during a corneal and refractive surgery fellowship program in Latin America.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">This prospective and interventionist study reviewed the clinical charts of the first 100 consecutive refractive surgery cases performed by a single Cornea Fellowship trainee between March 2018 and June 2018 in the Blindness Prevention Association of Mexico (Asociación para Evitar la Ceguera en Mexico). Femtosecond LASIK was performed in all eyes. Visual and refractive outcomes were evaluated during the first year of follow-up. Patient satisfaction was measured using 5 author-created questions 6 months after surgery.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Data of 100 eyes of 50 consecutive patients were evaluated. One year after the surgery, mean uncorrected distance visual acuity (UDVA) was 0.01 logMAR. Spherical equivalent error passed from −3.91 ± 2.28 D preoperatively to –0.22 ± 0.28 D. No eyes lost lines in corrected distance visual acuity (CDVA). Manifest refraction maintained stable during the first year after surgery. The five author-created questions revealed a high level of confidence and patient satisfaction.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Femto-LASIK performed by a corneal and refractive surgery fellowship trainee showed good refractive and visual outcomes, as well as high patient satisfaction and confidence in a refractive surgery centre in Latin America.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Informar por primera vez sobre los resultados clínicos y la satisfacción de los pacientes operados de cirugía refractiva con láser por un fellow durante un programa de formación en cirugía corneal y refractiva en Latinoamérica.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">En este estudio prospectivo e intervencionista se revisaron las historias clínicas de los primeros 100 casos consecutivos de cirugía refractiva realizados por un solo fellow del departamento de córnea de la Asociación para Evitar la Ceguera en México entre marzo de 2018 y junio de 2018. La técnica LASIK asistida por femtosegundo se realizó en todos los ojos. Los resultados visuales y refractivos se evaluaron durante el primer año de seguimiento. La satisfacción del paciente se midió 6 meses después de la cirugía con 5 preguntas creadas por el autor.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se evaluaron datos de 100 ojos de 50 pacientes consecutivos. Después de 12 meses de la cirugía, la agudeza visual no corregida (AVNC) fue de 0,01 logMAR. El equivalente esférico pasó de –3,91 ± 2,28 D preoperatoriamente a –0,22 ± 0,28 D. No se perdieron líneas en la agudeza visual mejor corregida (AVMC). La refracción manifiesta se mantuvo estable durante el primer año después de la cirugía. Las 5 preguntas creadas por el autor revelaron un alto grado de confianza y satisfacción del paciente.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Los resultados refractivos y visuales obtenidos mediante Femto-LASIK por un fellow de cirugía corneal y refractiva fueron buenos. Del mismo modo se demostró una alta satisfacción y confianza del paciente en el cirujano en periodo de aprendizaje en un centro formativo de cirugía refractiva en Latinoamérica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García de Oteyza G, García-Albisua AM, Benedetti Sandner M, Sánchez-Huerta V, Hernández-Quintela E, de Wit-Carter G. Resultados de Femto-LASIK obtenidos por un <span class="elsevierStyleItalic">fellow</span> durante un programa de formación en cirugía refractiva. Arch Soc Esp Oftalmol. 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.oftal.2020.10.009">https://doi.org/10.1016/j.oftal.2020.10.009</span></p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3928 "Ancho" => 3175 "Tamanyo" => 1072598 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Cumulative uncorrected visual acuity (shown in Snellen) in 100 eyes with a mean follow-up of 12 months. (B) Loss or gain of best-corrected visual acuity lines at the end of follow-up. (C) Linear regression analysis, regression equation and coefficient of determination (R2) of target SE sought versus achieved SE. (D) Accuracy of postoperative SE. (E) Stability of SE at 2 weeks, 1, 3, 3, 6 and 12 months follow-up. (F) Accuracy of postoperative refractive astigmatism correction. BCVA: best corrected visual acuity; D: dioptre; SE: spherical equivalent; UVA: uncorrected visual acuity.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1251 "Ancho" => 1674 "Tamanyo" => 144504 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Responses to the first author-created question from the 50 patients in the study at 6 months follow-up.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1378 "Ancho" => 1674 "Tamanyo" => 181690 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Responses to the second author-created question from the 50 patients in the study at 6 months follow-up.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1232 "Ancho" => 1674 "Tamanyo" => 102242 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Responses to the third author-created question from the 50 patients in the study at 6 months follow-up.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Questions \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Possible answers \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. How confident did you feel about the fellowship trainee who performed your surgery before you had it? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Numerical answers from 0 (no confidence) to 5 (full confidence) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Were you satisfied with the preoperative explanations, resolution of doubts, with the surgery and with the postoperative process? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Numerical answers from 0 (not at all satisfied) to 5 (completely satisfied) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Are you satisfied with the visual result? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Numerical answers from 0 (not at all satisfied) to 5 (completely satisfied) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Would you advise other patients to have surgery with a fellowship trainee? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dichotomous answer: Yes/No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Would you repeat the experience? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dichotomous answer: Yes/No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2651513.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Satisfaction questionnaire created by the author with questions and possible answers.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.A. Holden" 1 => "T.R. 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