Pupil-Dependent Optical Quality In High Myopia: A Wavefront Comparison Of Icl And Lasik

To compare the surgical impact of Implantable Collamer Lens (EVO and EVO+ ICLs) implantation versus laser in situ keratomileusis (LASIK) on corneal and total ocular higher-order aberrations (HOAs) in highly myopic eyes. The study specifically investigates the pupil-dependency of induced aberrations, notably coma and spherical aberrations, to understand the optical performance of both techniques under mesopic conditions.

Fondation Adolphe de Rothschild Hospital, Paris, France.

This retrospective study evaluated highly myopic eyes treated with EVO/EVO+ ICLs or LASIK between 2016 and 2024. Analyses included eyes with complete wavefront data (from NIDEK OPD-Scan III) at the 6.0 mm (ICL n=24, LASIK n=42), 5.5 mm, and 5.0 mm diameters. Postoperative changes in corneal and total ocular HOAs, primary/secondary coma, and spherical aberrations (Z4,0; Z6,0) were evaluated. Cluster-adjusted regression models were used to account for bilateral eyes and follow-up duration without reducing sample size.

Refractive accuracy was comparable between groups. At the 6.0 mm diameter, LASIK induced significant median corneal primary coma (+0.37 µm) and Z4,0 (+0.27 µm, p<0.05), whereas ICLs left the cornea unchanged. Paradoxically, for the total ocular wavefront at 6.0 mm, ICLs induced marked median primary coma (+1.11 µm vs +0.26 µm for LASIK, p<0.001) and secondary spherical aberration Z6,0 (+0.24 µm vs +0.08 µm, p=0.007). These internal aberrations induced by ICLs were highly pupil-dependent, dropping significantly at 5.0 mm. Ocular MTF AUC at 6.0 mm trended better in the LASIK group.

While EVO/EVO+ ICLs effectively preserve corneal optical quality, they paradoxically induce significantly more total ocular coma and secondary spherical aberration than LASIK at large pupillary diameters (6.0 mm). This pupil-dependent induction of internal aberrations is likely driven by the implant's vault, micro-tilt, or optical zone edge effects. Consequently, for highly myopic patients with large mesopic pupils, modern LASIK may offer a more favorable total ocular optical profile than phakic IOLs.