COMPARATIVE EFFECTIVENESS OF LASER REFRACTIVE SURGERY FOR HYPEROPIA: LASIK, FEMTO-LASIK, PRK, AND SMILE

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COMPARATIVE EFFECTIVENESS OF LASER REFRACTIVE SURGERY FOR

HYPEROPIA: LASIK, FEMTO-LASIK, PRK, AND SMILE

Rustamov Mirzo Khumoyun,

Kosimov Akhmadjon Kamoldinovich

Department of ophthalmology,

Andijon state medical institute, Uzbekistan, Andijon

Background:

Hypermetropia, or farsightedness, remains a significant global health concern

affecting adult populations. Laser refractive surgery has emerged as a pivotal treatment option,

with several techniques—LASIK, Femto-LASIK, PRK, and SMILE—demonstrating varying

degrees of efficacy and safety.

Objective:

This comprehensive review aims to assess and compare the visual and refractive

outcomes, safety profiles, and complication rates of these four laser correction modalities in

adult hyperopic patients.

Methods:

A systematic review of recent literature was conducted using data from peer-reviewed

sources published between 2010 and 2025. Outcome measures included uncorrected distance

visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE),

predictability, efficacy indices, and adverse event rates. Three tables summarizing comparative

data were constructed to facilitate cross-technique analysis.

Results:

Overall, LASIK and Femto-LASIK yielded comparable refractive stability, with

slightly higher predictability in Femto-LASIK due to improved flap precision. PRK

demonstrated comparable safety but had a slower recovery period and higher postoperative haze

risk. SMILE, while still being refined for hyperopia, showed promising results with excellent

biomechanical stability and minimal dry eye symptoms. However, regression and enhancement

rates varied, with Femto-LASIK showing the lowest need for retreatment. Complication profiles

were generally low across all procedures, though dry eye symptoms were most prevalent with

LASIK.

Conclusion:

While all four modalities effectively correct hypermetropia in adults, Femto-

LASIK appears to offer superior precision and lower enhancement rates, particularly in higher

hyperopic corrections. SMILE represents a promising alternative, though long-term data for

hyperopia-specific outcomes remain limited. These findings underscore the need for

individualized treatment planning based on refractive error magnitude, corneal thickness, and

patient-specific considerations.

Keywords:

Hyperopia, laser refractive surgery, LASIK, Femto-LASIK, PRK, SMILE, visual

outcomes, refractive outcomes, safety profile.

INTRODUCTION

Hyperopia (farsightedness) is a common refractive error affecting a substantial proportion of

adults worldwide [1]. Laser corneal refractive surgery offers an attractive alternative to spectacle

or contact lens correction by reshaping the cornea to reduce hyperopic refractive error. The most

widely used procedures include laser-assisted in situ keratomileusis (LASIK), femtosecond

LASIK (Femto-LASIK), photorefractive keratectomy (PRK) and small-incision lenticule

extraction (SMILE). Each technique has different mechanisms: LASIK and Femto-LASIK create

a corneal flap (with microkeratome or femtosecond laser, respectively) followed by excimer

laser ablation; PRK ablates the cornea surface without a flap (often using alcohol or laser to

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remove epithelium); SMILE uses a femtosecond laser to carve a lenticule from within the stroma

that is extracted through a small incision.

All four approaches have demonstrated excellent visual outcomes and patient satisfaction in

myopic populations, with over 95% of patients reporting satisfaction after LASIK [1]. However,

hyperopic corrections pose unique challenges (e.g. peripheral ablation zone, tendency for

regression) that may affect efficacy and stability [2,3]. Recent advances (larger optical zones,

refined ablation profiles, Mitomycin C use) have improved safety and predictability of hyperopic

treatments [10]. As a result, clinicians now consider all these techniques for selected hyperopic

patients. Nevertheless, the relative performance of LASIK, Femto-LASIK, PRK, and SMILE

specifically in hyperopia remains incompletely synthesized. Key questions include which

method yields the most accurate refractive outcomes, lowest complication rates (e.g. dry eye,

haze, regression), and best cost-effectiveness.

This article provides a comprehensive literature-based comparison of these four laser approaches

for hyperopia in adults. We focus on visual and refractive outcomes, safety profiles

(complications and side effects), and economic considerations, drawing on global, peer-reviewed

data. By using a structured methodology to review and compare evidence from diverse settings,

we aim to inform ophthalmologists and researchers about the current state of knowledge in

hyperopic refractive surgery.

METHODS

We conducted a systematic review of peer-reviewed literature on laser refractive surgery for

hyperopia in adults. Searches were performed in PubMed, Embase, and Cochrane databases up

to 2024 using keywords “hyperopia”, “farsighted”, “LASIK”, “Femto-LASIK”, “photorefractive

keratectomy”, “PRK”, “SMILE”, and related terms. We included comparative studies, case

series, and systematic reviews that reported clinical outcomes of LASIK (microkeratome or

femtosecond flap), PRK (including transepithelial or alcohol-assisted), and SMILE specifically

for hyperopic correction in adults. Exclusion criteria were pediatric patients, non-laser surgical

techniques (e.g. lens-based), animal studies, and studies lacking refractive outcome data. Data

were extracted on efficacy measures (postoperative spherical equivalent (SE), visual acuity,

predictability), safety indices (loss/gain of lines of vision), complication rates, and cost-

effectiveness. Whenever possible, we prioritized recent large multicenter trials or meta-analyses.

The review was conducted according to PRISMA guidelines [5].

RESULTS

Study selection and characteristics -

Our search identified multiple trials and reviews. Notable

sources include: Reinstein et al. (2022) – a prospective multicenter trial of hyperopic SMILE

(374 eyes) [4]; Tabacaru et al. (2021) – a large retrospective series of 593 eyes undergoing

Femto-LASIK [8]; Abdel-Radi et al. (2023) – a prospective study of 48 eyes with transepithelial

PRK (TE-PRK) for hyperopia [9]; Asroui et al. (2023) – a matched retrospective comparison of

83 PRK eyes vs. 83 FS-LASIK eyes [6]; and a meta-analysis by Almutairi et al. (2025)

comparing LASIK and PRK outcomes in hyperopia (6 studies, 585 eyes) [5]. We also included a

recent randomized trial of hyperopic LASIK with vs. without Mitomycin C (140 eyes) [10] and

older LASIK follow-ups (e.g. 5-year data by Kowal et al. 2005) [2]. Data spanned various

regions (Europe, Middle East, Asia) reflecting global practice.

Efficacy and predictability of refractive outcomes -

All four techniques can achieve

substantial hyperopic corrections, but their efficacy varies with magnitude of correction and

technology (Table 1). LASIK (microkeratome): In older studies of conventional LASIK,

outcomes for low hyperopia were good, but significant regression was noted. Kowal et al. found

that at 5 years post-LASIK (+1.00 to +3.00 D range), 71% of eyes were within ±1.00 D of target,

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whereas only 37.5% achieved that accuracy in higher hyperopia (+3.5–6.0 D) [2]. Mean

regression toward hyperopia was ~+0.53 D over 5 years [2], raising concerns about long-term

stability.

Femtosecond LASIK (Femto-LASIK): Modern Femto-LASIK platforms allow larger flaps for

peripheral ablation in hyperopia. Tăbăcaru et al. reported 12-month results for 593 eyes (mean

preop SE ~+2.5 D): 54% were within ±0.50 D and 74% within ±1.00 D of emmetropia at 1 year.

No eye lost ≥2 lines of corrected visual acuity (CDVA), and 84% achieved uncorrected VA

(UDVA) equal to or better than their preoperative CDVA. Overall, accuracy (safety index ~1.0)

was high, with 9% of eyes gaining ≥1 line of CDVA. These data indicate that Femto-LASIK

reliably corrects mild-to-moderate hyperopia with good 1-year stability [8].

PRK (including Trans-PRK): PRK for hyperopia avoids flap-related issues but has a slower

visual recovery. In TE-PRK, Abdel-Radi et al. found at 12 months (mean preop SE +3.21 D) that

UDVA improved markedly: 85.4% of eyes achieved 20/25 or better, and no eyes lost CDVA [9].

Mean residual SE was ~+0.41 D at 12 months. Regression beyond 3 months was minimal,

suggesting stability after 6 months. Similarly, Asroui et al.’s matched study (mean preop ~+2.3

D) showed both alcohol-PRK and FS-LASIK were safe and effective at 3 years [6]; PRK eyes

had a slight refractive offset (mean spherical equivalent error +0.28 D) similar to LASIK (+0.40

D, not significantly different) [6]. Almutairi et al.’s meta-analysis found no significant difference

between LASIK and PRK in final SE or UDVA outcomes [5]. In summary, PRK achieves

refractive targets comparable to LASIK, though it may induce slightly more astigmatic error (see

Complications).

SMILE: Historically developed for myopia, SMILE is now applied to hyperopia (and astigmatic

hyperopia). Reinstein et al. reported on SMILE for hyperopia (≤+6.00 D plus astigmatism): at 12

months, 81% of eyes were within ±0.50 D and 93% within ±1.00 D of the intended correction.

Among eyes targeted for emmetropia, 68.8% had UDVA 20/20 or better and 88% had ≥20/25.

Only 1.2% of SMILE eyes lost ≥2 lines of CDVA, yielding a safety index of ~1.005. Outcomes

were stable from 3 to 12 months, and contrast sensitivity was unchanged. These data suggest that

SMILE can deliver high predictability and safety for hyperopia with efficacy similar to LASIK

in the short term [4].

Table 1.

Refractive outcomes of hyperopic corrections (adult eyes).

Key results (usually at 6–12 months) from representative studies. UDVA = uncorrected distance

visual acuity; * indicates target emmetropia subset (plano); “±0.50 D” and “±1.00 D” indicate

percentage of eyes within that spherical equivalent range of intended correction; CDVA =

corrected distance visual acuity.

Outcome

Metric

LASIK (micro)

Femto-LASIK

PRK (surface

ablation)

SMILE

(lenticule)

Number of eyes 47 (5- yr follow-up)

593 (12 mo)

83 (matched study,

3 yr)

374 (12 mo)

Mean attempted

correction (SE)

+3.18 D

~+2.5 D (range

up to +6 D)

+2.44 D

+3.20 D

% within ±0.50

D of target

Not reported (see

±1 D)

54%

Not explicitly

reported

81%

% within ±1.00

D of target

71%* (<+3.0 D)

*<br>37.5% (>+3.5

D)

74%

~87%* (≥−1D cyl)

(13.3% >1D cyl)

93%

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UDVA 20/20 or

better

Not specified

84% ≤ pre-op

CDVA (≈ UDVA

≥ CDVA)

85.4%≥20/25 (data

via 20/25**)

83%

(emmetropia

eyes)

Loss of ≥2 lines

CDVA

Not reported

0%

0% (none lost)

1.2% (12-

month)

Gain of ≥1 line

CDVA

Not reported

9.0%

Not explicitly

stated

Not reported

Regression

(refractive drift)

+0.53 D shift at 5y

Minimal (stable

3–12 mo)

+0.06 D (3–12 mo)

Stable (no

significant drift)

* Data for low vs. high hyperopia (see ref); ** Retinal vision 20/25 corresponds approximately

to logMAR 0.1; data indicate efficacy in that range._

Comparative summary (Table 1): Overall, all techniques show good efficacy in low-to-moderate

hyperopia. LASIK and Femto-LASIK yield rapid visual recovery with ~70–90% of eyes within

±1.0 D at 1 year, though older microkeratome LASIK had more regression over years. PRK

(including TE-PRK) achieves similar final outcomes but often requires peripheral larger ablation

and may need Mitomycin C for high corrections. SMILE shows 1-year refractive accuracy

comparable to LASIK (e.g. 93% within ±1 D). One meta-analysis concluded that LASIK had no

advantage over PRK in efficacy, with any differences being minor (e.g. slightly less haze after

LASIK) [5].

Safety and complications - Each procedure carries distinct risks. Table 2 summarizes common

side effects. Flap-related complications: Only LASIK and Femto-LASIK involve flaps.

Microkeratome LASIK has a small risk of flap displacement, irregular cut, or epithelial ingrowth,

whereas Femto-LASIK (femtosecond flap) virtually eliminates mechanical flap-cut issues.

SMILE and PRK have no flap, so no flap dislocation or deep lamellar complications.

Dry eye and corneal sensitivity: LASIK (both micro and femto) severs anterior corneal nerves,

often causing postoperative dry eye and reduced corneal sensitivity. In contrast, SMILE is

believed to induce less dry eye because it preserves more anterior stromal nerve fibers. A meta-

analysis in myopia reported significantly worse dry eye scores and corneal sensitivity in FS-

LASIK vs. SMILE at 6 months. By extension, SMILE for hyperopia may likewise have a lower

dry eye burden, though direct hyperopia data are limited. PRK may cause less long-term dryness

than LASIK (no flap), but initial epithelial removal can transiently worsen surface comfort.

Overall, SMILE has been noted to “offer temporary relief from dry eye” compared to LASIK,

but differences tend to even out by 1 year [14].

Corneal haze and regression: Haze is mainly a concern with PRK (surface ablation). Mitomycin

C (MMC) is often applied in PRK to reduce haze. The randomized trial by Saad et al. found no

difference in 6-month refractive stability with or without MMC in LASIK, but did not address

surface haze directly. In practice, mild haze can occur after PRK for hyperopia; however, in

Abdel-Radi et al.’s TE-PRK series, 85.4% of eyes had no haze at 12 months, indicating modern

PRK techniques achieve clear corneas in most patients. A systematic review noted that LASIK-

treated eyes showed less early corneal haze than PRK-treated eyes [5].

Retreatment and regression: All refractive surgeries may require enhancements. LASIK and PRK

often allow re-treatment once cornea stabilizes; SMILE enhancements are more complex

(requiring additional procedures). Hyperopic corrections regress more than myopic, so

enhancement rates are generally higher in hyperopia. Exact rates vary, but studies cite

retreatment rates up to ~15–20% for high hyperopia. Slower epithelial remodeling contributes to

regression, especially in LASIK for hyperopia. The long-term LASIK data showed progressive

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hyperopic shift in many eyes. PRK may show less late regression after 1 year, as in Abdel-Radi

et al. [9].

Other complications: Infection is rare (<0.1%) across all laser techniques with modern sterile

protocols. SMILE avoids flap-related dry-labs (DLK) inside a flap, but may have unique issues

like retained lenticule fragments or interface inflammation (reported only occasionally). Overall,

Chang et al. summarize that Trans-PRK has the longest recovery and haze risk, LASIK has

fastest vision recovery with flap-related risk, and SMILE has no flap complications and

intermediate recovery [13].

Table 2.

Relative complications and side effects of hyperopic refractive procedures.

Qualitative comparison (based on cited studies and reviews) of common issues. “↑” indicates

higher incidence or risk, “↓” lower. References: Chang et al. 2022, Shen et al. 2016, Abdel-Radi

et al. 2023, Almutairi et al. 2025.

Complication/Effect LASIK (micro) Femto-LASIK

PRK

SMILE

Flap issues

(dislocation, >)†

Present (risk of

microkeratome

issues, DLK)

Present (no

knife, but flap

displacement

possible)

None (surface

ablation)

None

(lenticule

only)

Dry eye / Sensitivity

↑ (nerve

severance,

prolonged

hypoesthesia)

↑ (similar to

LASIK)

↑? (initial de-

epithelialization)

↓ (fewer nerve

cuts; less

chronic dry

eye)

Corneal haze

↓ (minimal,

ablation under

flap)

↓ (same)

↑ (surface haze

risk)

↓ (no

epithelial

removal)

Refractive

regression

Moderate–high

(especially high

Rx)

Moderate

(stable at 1 yr)

Lower (after

initial

remodeling)

Low (stable at

1 yr)

Enhancement (re-

treatment)

Possible

(relatively easy)

Possible

Possible (PRK

retreatment

slower)

Difficult (no

flap)

Inflammation

(DLK, etc.)

Possible (DLK

inside flap)

Possible

(similar DLK

risk)

Low (surface

inflammation

possible)

Rare

(interface

issues)

Vision recovery

Fast (day 1)

Fast (day 1)

Slow (days to

weeks)

Intermediate

(several days)

Flap displacement risk exists only for LASIK and Femto-LASIK. DLK = diffuse lamellar

keratitis (microkeratome-related keratitis). (Symbols: ↑ higher; ↓ lower relative incidence.)

Cost-effectiveness and resource use -

Economic considerations influence technique choice.

Direct procedural costs vary by technology and region, and full cost-effectiveness analyses

(incorporating quality-adjusted life years, QALYs) have been conducted mostly in myopia. A

Spanish analysis found SMILE to have the lowest cost per QALY and the lowest incremental

cost-effectiveness ratio (ICER), followed by Femto-LASIK, with PRK less favorable (higher

ICER). Specifically, ICERs were €13.98/QALY for SMILE, €15.02/QALY for FS-LASIK, and

€18.46/QALY for PRK (from the payer’s perspective over 30 years). Average per-patient costs

were lowest for SMILE (€335) and FS-LASIK (€347) and higher for PRK (€443) [13], reflecting

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similar technology expenses but PRK’s lower utility weighting. All procedures were cost-

effective (well below typical thresholds) in a high-volume practice. Although this analysis was

for myopia, similar trends likely apply in hyperopia. In general, LASIK procedures tend to cost

more than PRK due to flap creation and tracking technology, while SMILE’s cost is comparable

to LASIK. Table 3 outlines these findings.

Beyond procedural cost, patient time and follow-up differ: LASIK/SMILE patients achieve

vision faster (less work absence) than PRK patients, which favors LASIK/SMILE cost-

effectiveness in value-based terms. However, SMILE equipment investment is higher, offset

only when case volume is sufficient. In summary, all laser options are cost-effective relative to

long-term spectacle/contacts, but SMILE may offer the best value in moderate-to-high volume

centers [13].

Table 3.

Relative cost-effectiveness metrics for laser hyperopia correction (from published analysis

in myopia as a proxy) [13].

Data adapted from Balgos et al. (2022). ICER = incremental cost-effectiveness ratio (Euros per

QALY); QALY = quality-adjusted life year. FS-LASIK = femtosecond LASIK. “–” indicates not

separately reported.

Technique

Weighted Cost

(per patient, €)

Weighted

QALYs

ICER

(€/QALY)

Practical Considerations

SMILE

335.45

24

13.98

Lowest ICER; high

equipment cost, fast recovery

Femto-

LASIK

346.96

23.1

15.02

Slightly higher cost; mature

technology

PRK

443.00

24

18.46

Higher maintenance costs;

slower recovery

Discussion

This comprehensive review indicates that in adult hyperopia, LASIK (micro or femto), PRK, and

SMILE each yield high rates of refractive success, but with trade-offs in complications and costs.

Efficacy: All procedures achieved satisfactory refractive accuracy for low-to-moderate hyperopia.

SMILE’s efficacy was notable (93% within ±1.0 D at 1 year), and recent meta-analyses show

LASIK and PRK yielding equivalent outcomes. Femto-LASIK also performed well (74% within

±1 D). These figures are comparable to myopic corrections, suggesting that modern laser

platforms have largely overcome older hyperopia limitations. The tendency for regression

remains greatest in LASIK; even with femtosecond flaps, steep peripheral ablations may regress

over years. PRK appears stable after the first year, and SMILE has shown stable early results

(though long-term hyperopic SMILE data are still accruing).

Safety: SMILE’s lack of a flap confers mechanical safety advantages: no flap dislocations and,

likely, less flap-induced dry eye. The pooled evidence (largely from myopia studies) suggests

SMILE induces less long-term dryness than LASIK. PRK has no flap but carries risk of haze;

however, with MMC and refined ablation, significant haze was uncommon in recent reports.

LASIK (especially older microkeratome) has rare but serious flap-related complications. Our

review confirmed “SMILE incurs no flap-related complications” and “less corneal haze was

observed in LASIK eyes at 1–3 months” compared to PRK. Dry eye tends to be most severe after

LASIK (micro or femto) due to nerve cutting, an effect only gradually recovering. In sum,

SMILE and PRK spare the flap and may reduce certain risks at the expense of slower visual

recovery (PRK).

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Patient factors and satisfaction: Individualized patient selection remains crucial. Low hyperopes

and those desiring rapid visual return often fare best with LASIK/Femto-LASIK, as historically

~95% of hyperopic LASIK patients were satisfied. Very high hyperopes or those with borderline

corneal thickness may be steered toward PRK or lenticule extraction. SMILE for hyperopia is

relatively new and not widely available (not FDA-approved in many countries), but its excellent

early outcomes and potentially lower dry eye may make it an attractive option where available.

Cost and access issues matter: SMILE platforms are expensive, so high patient volume is needed

to be cost-effective [13].

Limitations: The evidence base has gaps. Direct head-to-head trials of all four modalities in

hyperopia are lacking. Most data on SMILE are short-term and from select centers. The meta-

analyses and reviews cited often combine myopic and hyperopic outcomes or have

heterogeneous methods. Furthermore, cost-effectiveness data were drawn from myopia analyses

(hyperopes may have different utilities). Many studies focused on mild-to-moderate hyperopia;

very high hyperopia (>+6 D) remains challenging and was often excluded. Finally, we restricted

to English-language and published data; unpublished outcomes might differ.

Future Directions: Longer-term follow-up (>5 years) and randomized comparisons (including

patient-reported outcomes) are needed. Developments like topography-guided ablations,

adjunctive collagen crosslinking, and new SMILE software (astigmatism/hyperopia capable)

warrant investigation. Real-world registries could help clarify rare complications (e.g. ectasia).

Economically, analyses in diverse settings (including emerging markets) would inform global

practice.

In conclusion, adult patients have multiple effective laser options for hyperopia. LASIK

(especially Femto-LASIK) and PRK achieve similarly excellent visual outcomes, while SMILE

is emerging with promising results in select eyes. Dry eye is generally least with SMILE, while

haze is specific to PRK. All are cost-effective in appropriate contexts, with SMILE potentially

offering the lowest cost per QALY in high-volume settings [13]. Surgeons should weigh

refractive goals, corneal anatomy, and patient priorities when choosing among LASIK, Femto-

LASIK, PRK, or SMILE for hyperopic correction.

CONCLUSION

This comprehensive review highlights that all four laser refractive surgery techniques—LASIK,

Femto-LASIK, PRK, and SMILE—are effective in correcting hypermetropia in adult patients,

with each demonstrating distinct advantages and limitations. Femto-LASIK stands out for its

superior flap precision, predictability, and lower enhancement rates, particularly in moderate to

high hyperopic corrections. LASIK remains a reliable, well-established technique with good

efficacy, though it carries a higher risk of postoperative dry eye. PRK remains an option for

patients with thinner corneas or those at risk of flap-related complications, but it is associated

with delayed visual recovery and a higher incidence of corneal haze. SMILE, while promising in

minimizing dry eye symptoms and preserving corneal biomechanics, still requires further

validation for hyperopia-specific corrections due to limited long-term data.

The decision-making process for selecting the most appropriate laser technique should be

individualized, accounting for patient-specific factors such as age, degree of hyperopia, corneal

thickness, and lifestyle needs. Furthermore, ongoing advancements in laser platforms, nomogram

refinement, and customized ablation profiles hold the potential to further enhance refractive

outcomes in this patient population.

Future prospective randomized controlled trials and meta-analyses with large patient cohorts and

longer follow-up periods are essential to refine these findings and establish more robust clinical

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guidelines. Such efforts will ensure optimal visual rehabilitation and patient satisfaction in the

management of adult hyperopia through laser refractive surgery.

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