Regression and epithelial hyperplasia after myopic photorefractive keratectomy in a human cornea

Chris P. Lohmann, MD, PhD, Udo Reischl, PhD, John Marshall, PhD
ABSTRACT
We present the histology of a cornea of a woman who had excimer laser photorefractive keratectomy (PRK) for myopia 6 months before she died in an accident. Preoperative spherical refraction was 6.00 diopters (D) with an astigmatism of 0.50 D. Six months postoperatively, refraction was 4.50 D. Slight corneal haze was noted at 1 and 3 months. The corneal histology showed marked epithelial hyperplasia in the center of the ablation zone without subepithelial deposition of newly synthesized collagen, proteoglycans, or both. The epithelial thickness was 38 m in the untreated area and 93 m in the center of the ablation. In conclusion, postoperative epithelial hyperplasia was responsible for regression after PRK in this eye. J Cataract Refract Surg 1999; 25:712715 1999 ASCRS and ESCRS

xcimer laser photorefractive keratectomy (PRK) is a commonly performed procedure to correct low and medium myopia, with thousands of patients worldwide having this surgery each year. In most cases, the refractive outcome is within 1.00 diopter (D) of that intended. The predictability and efficacy of PRK tend to decrease with increasing dioptric corrections.13 However, there is also variation in refractive outcome among individuals with lower diopter procedures, with some showing excessive myopic regression. The magnitude of regression in any given cornea may be predominantly determined by the genetic control of wound healing. Much of the histological data on corneal wound healing after excimer laser radiation is derived from animal studies (i.e., rabbit and monkey corneas4 6). Three
Accepted for publication November 23, 1998. From University Eye Clinic Regensburg, (Lohmann) and Institute of Medical Microbiology and Hygiene, University of Regensburg (Reisch), Regensburg, Germany; Department of Ophthalmology, St. Thomas Hospital, London, United Kingdom (Lohmann, Marshall). Reprint requests to Chris P. Lohmann, MD, PhD, University Eye Clinic, Franz-Josef-Strauss-Allee, D-93042 Regensburg, Germany.
1999 ASCRS and ESCRS. Published by Elsevier Science Inc.

elements involved in wound healing have been identified: epithelium, activated keratocytes, newly synthesized collagen and proteoglycans. In monkeys, loss of induced refraction is mainly caused by epithelial hyperplasia or collagen synthesis, whereas in rabbits regression is almost entirely related to synthesis of new collagen. In contrast, in humans little is known of the cellular and subcellular components present after PRK. In this study, we present the histopathology of a human cornea 6 months after myopic PRK.

Case Report
A 24-year-old woman had excimer laser PRK for myopia 6 months before her death in a car accident. Her spherical refraction preoperatively was 6.00 D with astigmatism of 0.50 D. The PRK was performed with the Chiron Technolas 116 laser set at a fluence of 120 mJ/cm2 and a repetition rate of 10 Hz. Maximum ablation zone was 7.0 mm. Postoperative treatment included topical antibiotics (ofloxacin 5 times a day for 1 week) and topical corticosteroids (dexamethasone 0.1% 5 times a day for 2 months). Postoperative refrac0886-3350/99/$see front matter PII S0886-3350(99)00014-0

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tion was 1.50 D at 1 week, 0.75 D at 1 month, 1.75 D at 3 months, and 4.50 D at 6 months. Only slight disturbances in corneal clarity were notable during the postoperative time, with a maximum haze of 0.5 at 1 and 3 months. No corneal haze was observed at 6 months. The enucleated globe was immediately immersed in glutaraldehyde 2.5% buffered in 0.1 M sodium cacodylate with 10 g/L calcium chloride at a final pH of 7.4. The cornea was then isolated by a circumferential limbal incision, postfixed for 1 hour in osmium tetroxide 2% buffered in alcohol, and then embedded in araldite (CY212) via epoxypropane. Sections were cut at 1 m on glass knives and examined by light microscopy. The histological appearance of the ablated area is shown in Figure 1. The thickness of the epithelium was 38 m in the untreated area. However, toward the center of the ablation, the epithelial thickness increased to 93 m. No deposition of newly synthesized collagen types I and III, laminin, keratin, or fibronectin could be detected subepithelially by immunohistochemical analysis.

Discussion
The algorithms used to compute the amount of tissue removed during excimer laser PRK and the attendant surface profile were designed so the immediate postoperative surface creates the corneal contour required to achieve emmetropia.7 The underlying concept allows for re-epithelialization of the induced profile without significant refractive change. However, any process that modifies this profile, such as epithelial hyperplasia or excessive production of collagen or proteoglycans, tends to negate the induced refractive change. Most investigators have postulated that the deposition of new collagen and proteoglycans is a major cause of myopic regression after PRK and thus have introduced topical corticosteroids in their postoperative treatment regimen to inhibit keratocyte activity and collagen synthesis. However, overall results show that the use of topical corticosteroids after PRK might be of benefit for some patients but not in general.8 14 Lohmann et al.15,16 and Epstein and coauthors17 questioned the stromal remodeling hypothesis in their report of the presence of the original pattern of laser ablation rings below the epithelium as long as 2 years after the surgery.

Figure 1. (Lohmann) Light micrograph showing a human cornea after a 6.00 D PRK procedure. At 6 months postoperatively, refraction regressed to 4.50 D because of the hyperplastic epithelium in the center of the ablation zone. Top: The total area of the ablation with an increase in the epithelial thickness toward the center of the ablation zone. Middle: The junctional zone between normal region and ablated region. Bowmans layer (closed arrows) can be seen in the unablated region and in the ablated region; epithelial thickness tends to increase as a result of enlarged basal epithelial cells. Bottom: The center of the ablation zone with a marked hyperplastic epithelium. The epithelial thickness in the untreated region was 38 m (open arrows, middle) and 93 m (open arrows, bottom), respectively. 713

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The persistence of the rings indicates that there was no significant remodeling of collagen. In these studies, both hyperplastic epithelium and synthesis of basal-membrane proteins, such as collagen type IV and hyaluronic acid, were observed after PRK. In excimer laser PRK, the healed epithelium determines the final surface contour of the cornea and consequently the final refractive outcome. If the epithelium covers the ablated area smoothly and epithelial architecture shows a normal 5-layered structure, postoperative outcome should be good. Lohmann and coauthors18 and Corbett et al.19 correlated postoperative refraction with epithelial thickness measurements in corneas after PRK. In a histological study in rabbit corneas, Lohmann and coauthors18 found that every 10 m difference in epithelial thickness compared with preoperative thickness produced a 1.00 D refractive change. These results are comparable to the finding in the human eye reported here. In a human study, Corbett et al.19 correlated postoperative epithelial thickness and refraction over time and found that early hyperopic shift was associated with a negative-power effect of the epithelial lenticule, in which the epithelium is thicker in the periphery than in the center of the ablation zone. Over time, the thickness of the central epithelium increased and refraction returned toward emmetropia. The cause of epithelial hyperplasia after PRK is still unknown. Several mechanical and chemical factors may play a significant role in this phenomenon. It has been postulated that smaller ablation zones are associated with the development of hyperplastic epithelium. A sudden change in the wound contour, as occurs at the edge of an PRK ablation, modulates the wound-healing process by initiating epithelial cell proliferation. In smaller ablation zones, the slope of the wound is stronger than in larger ablation zones; clinically it has been shown that regression is less common in eyes treated with 6.0 mm zones or larger.20,21 Other studies have concentrated on molecular biological aspects of corneal wound healing in that variations of epithelial growth factor (EGF) concentration (i.e., EGF in the tear fluid) was measured before and at various times after PRK. In individuals with postoperative regression, EGF levels in the tear fluid were significant higher than in patients with postoperative emmetropia.22 Ignoring the refractive role of the epithelium may contribute to the unpredictable results in higher order
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corrections and investigations to control epithelial wound healing; in particular, epithelial hyperplasia should be studied to improve the outcome of myopic PRK. Currently, nearly all clinics use ablation diameters larger than 6.0 mm; however, investigations concerning a pharmaceutical control of epithelial cell proliferation and growth factor activity should be done.

References
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