Two Strategies in Transepithelial PRK: A Systematic Review and Network Meta-Analysis

TOPIC: To compare efficacy, refractive predictability, safety, and early recovery after single-step transepithelial photorefractive keratectomy (TransPRK) using StreamLight and SmartSurfACE in myopic eyes through network meta-analysis. CLINICAL RELEVANCE: TransPRK is a flap-free surface ablation option for myopic patients. Direct comparative evidence between TransPRK technologies remains limited. METHODS: PubMed/MEDLINE, Embase, Cochrane Central, and Web of Science were searched from inception to October 31, 2025. Randomized trials, cohort studies, and case series evaluating single-step TransPRK using StreamLight or SmartSurfACE were included. Alcohol-assisted photorefractive keratectomy (aaPRK) served as the common comparator. Random-effects network meta-analysis was performed. RESULTS: Forty-two studies were included; 15 contributed to the network meta-analysis. No significant differences were detected between StreamLight and SmartSurfACE in efficacy (uncorrected distance visual acuity [UDVA] ≥20/20; odds ratio [OR] 0.75, 95% confidence interval [CI] 0.13-4.22), predictability (±0.50 diopters; OR 1.11, 95% CI 0.27-4.61), postoperative spherical equivalent (standardized mean difference [SMD] 0.02, 95% CI -0.31 to 0.35), or safety index (SMD -0.28, 95% CI -1.89 to 1.34). Loss of ≥2 lines of corrected distance visual acuity (CDVA) was rare. StreamLight was associated with faster epithelial healing (SMD -2.03, 95% CI -3.26 to -0.80), approximately 1-1.5 days earlier. Pain and haze were similar. No significant inconsistency was detected. CONCLUSION: No significant differences were detected between StreamLight and SmartSurfACE in efficacy, refractive predictability, or safety for myopic TransPRK. The observed epithelial-healing advantage with StreamLight was based on indirect evidence and should be interpreted cautiously.