Comparison of surgical techniques for myopia correction: a systematic review and comprehensive network meta-analysis of refractive procedures

Abstract

Myopia is increasingly prevalent worldwide, and several refractive surgical options are available, including photorefractive keratectomy (PRK), laser-assisted in situ keratomileusis (LASIK), femtosecond laser-assisted LASIK (FS-LASIK), small-incision lenticule extraction (SMILE), laser-assisted subepithelial keratectomy (LASEK), and phakic intraocular lens (PIOL) implantation. This network meta-analysis compared their visual, refractive, and corneal outcomes. PubMed, Embase, Web of Science, Cochrane CENTRAL, and Scopus were searched through May 15, 2025. Randomized and comparative studies of adults undergoing refractive surgery for myopia or myopic astigmatism were included. Bayesian network meta-analysis using Markov chain Monte Carlo (MCMC) simulation estimated mean differences, 95% credible intervals, and surface under the cumulative ranking curve (SUCRA) values at 1, 3, and 6 months. The study was registered in PROSPERO (CRD420250651487). Seventeen studies including more than 1500 eyes were analyzed. At 1 month, uncorrected distance visual acuity (UDVA) did not differ significantly among LASIK, SMILE, PRK, and FS-LASIK, although SMILE ranked highest by SUCRA (0.86). At 3 months, LASIK showed superior UDVA versus PRK (mean difference [MD], −0.01; p = 0.0410), SMILE (MD, −0.02; p = 0.0267), and FS-LASIK (MD, −0.03; p = 0.0001). By 6 months, UDVA and corrected distance visual acuity (CDVA) were comparable across procedures. FS-LASIK best preserved central corneal thickness (CCT) at 1 and 3 months, whereas PRK showed early thinning (MD, −28.00 μm; p = 0.0150). SMILE reduced spherical error at 1 and 3 months, while PRK ranked best at 6 months. No procedure is superior across all outcomes; surgical choice should be individualized.