GPT-5–assisted versus expert surgeon refractive planning in smooth incision lenticule keratomileusis (SILK): comparative analysis and visual outcomes

PURPOSE: To assess the performance of GPT-5 in refractive surgery planning by comparing its recommendations with expert surgeons and reporting visual outcomes of surgeon-planned Smooth Incision Lenticule Keratomileusis (SILK) procedures. METHODS: This retrospective, observational study included 134 eyes from 67 patients who underwent SILK procedure using the ELITA femtosecond laser platform from January 2024 to September 2025. GPT-5 generated refractive plans based on manifest and cycloplegic refraction, autorefractometry, visual acuity, keratometry, and pachymetry. These were compared with surgeon-derived values using paired t-tests and correlation analysis. Preoperative and postoperative (1- and 3-month) uncorrected and corrected distance visual acuity (UDVA, CDVA), mean keratometry (Km), and thinnest corneal point were analyzed. Axis concordance was quantified as the absolute angular deviation (Δ Axis) between AI- and surgeon-planned astigmatism axes. RESULTS: AI-generated spherical corrections were more conservative than surgeons' (- 4.29 ± 2.42 D vs. - 4.70 ± 1.98 D; p = 0.0025), whereas cylindrical power did not differ significantly (p = 0.9241). The mean Δ Axis was 61.9° ± 50.1°, indicating substantial misalignment. UDVA improved from 0.74 ± 0.36 logMAR preoperatively to - 0.06 ± 0.07 logMAR at 3 months (p < 0.0001), and postoperative UDVA did not differ significantly from preoperative CDVA, confirming excellent visual recovery. CONCLUSIONS: GPT-5 generated refractive plans that were partially consistent with expert surgeon decisions but lacked the clinical precision required for clinical implementation. In contrast, surgeon-planned SILK procedures achieved excellent visual acuity, corneal stability, and refractive predictability, reinforcing the safety and efficacy of Kerato Lenticule Extraction (KLEx) in real-world clinical practice.