LASIK Chronicles

Dr. Jay B Stockman O.D.

Dr. Brian Jon Lewy O.D.

New York Vision Associates

http://newyorkvisionassociates.com

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Regression with LASIK
Refractive surgery has grown in popularity over the last 5-10
years and millions of people have had the procedure. The
question that needs to be answered is how many of these folks
have actually stopped wearing glasses.

The answer is not as simple as it would appear. While many of

these patients have substantially reduced their need for eye
glasses, many still have some form of prescription that
improves their vision. However, having spent thousands of
dollars and endured the surgical procedures some chose not to wear glasses stating that
their vision is better then before the surgery and would rather not have eye glasses even
though their vision is not perfect. So having an accurate number of patients that were not
fully corrected following the surgery is impossible.

What is predictable is that all people at about the age of 40 or so WILL require
reading glasses. So if the goal is to completely eliminate eye glasses that will not happen
because of the natural aging process. Some surgeons are choosing to under correct 1 eye
to help the person read while the other eye sees in the distance. This is called monovision.
The problem is that many people can not adjust to the difference in image size between
the 2 eyes and the under corrected eye must then be redone to balance the vision between
the 2 eyes. Then reading glasses will of course be needed.

The other point is how many patients who have had LASIK will regress and shift
back toward their original prescription post surgically. That number is also vague because
there is not an accurate record being kept by the surgeons doing the procedures. This
reason is simple. With very stiff competition between the refractive surgeons, they do not
want to be known as the ones that require enhancement procedures. So, the patients are
having additional surgery and nothing is reported.

What is known is that farsighted people usually are not as well corrected as
nearsighted patients, and a large number of patients will regress after the surgery. The
patient will experience a decrease in vision weeks to months after the surgery and return
to the doctor. Usually, surgeons will not consider doing an enhancement surgery until
after 3 months and the prescription must be stable and not change for 2 consecutive visits.
Only then can an enhancement surgery be done, which is the same as the original
procedure with new calculations. Each time the surgery is done the cornea will become
thinner.

The bottom line is that any one having refractive surgery must be prepared for
less then perfect results and the possibility of needing a second procedure to get the final
and best results.

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A LASIK Complication-Oil Gland Secretions
In the hands of a well trained, experienced, and seasoned
refractive surgeon, LASIK is a very good procedure with
excellent results. IntraLASIK which is the same procedure
that employs a laser to create the flap is even. An often over
looked complication of the procedure is the affect that the oil
glands have on the final results.

Meibomian(oil) glands, or Tarsal glands as they are

sometimes known are sebaceous glands located in the tarsal
plate of the eye lids. These are found near the rim of the lids, and are responsible for the
production of sebum which is an oily material. This very important component of the tear
film prevents evaporation of the tears by maintaining tear /cornea contact evenly over the
entire surface. Since it thickens the tears, it also functions to prevent the tears from
spilling over the eye lids. The final affect of the sebum is creating a tight lid-lid seal
keeping the eyes moist at night.

The upper eye lid has approximately 50 glands and the lower 25. These very important
organs were first named in the late 1600s by the German physician Heinrich Meibom. So
how and why do these glands affect LASIK?

The Meibomian glands produce the sebum 24 hours per day, and will secrete it into
the eye upon every blink. Squeezing the eye lids tight will force out more sebum making
the eyes oilier.

The cornea is completely transparent, and must remain that way in order to see
clearly. The most important point that must always be maintained during LASIK is to
make sure that when the flap is placed back in position it goes back exactly as it was
before, and that the area under it is clear of any debris. Unfortunately, if the patient
squeezes his/her eyes during the surgery the Meibomian glands will secrete more sebum
into the eye and coat the exposed surface. If this occurs while the flap is lifted up, the
sebum will coat the inside area of the cornea and cause distorted vision. When the flap is
put back into position, it traps this excessive sebum under the flap. While there is no
health risk to this trapped sebum, is does leave an oily residue in the middle of the
cornea.

The final result is an imperfect cornea. When examining these post operative patients
one can see oily, hazy areas. The affect on one's vision will vary from mild to severe
haziness, photophobia (glare and light sensitivity), and decreased vision. If the oil slick is
out of the visual axis then glare will be the only visual side affect. If it is in the line of
sight then most patients complain of decreased vision. In severe cases, the surgeon must
go back into surgery, lift the flap, and clean out the area.

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 The best way to prevent this surgical complication is to listen to the doctor during
surgery and not force a blink or squirm around during the procedure. That is often more
easily said then done.

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Allergy Versus Dry Eyes
Patients often complain of many symptoms that may represent
more then one condition. One of the most common difficult
differentiations to make is whether it is an allergy or dry eyes.

The symptoms of both disorders are similar and often over lap.
They both cause red eyes, may create a burning sensation and both
can itch even though we were all taught that only allergies make
the eye itch. Tearing and mild discharge are common and
frequently the patient will have all of these symptoms and if a poor historian may confuse
when, where and how often they suffer. They are however, very different conditions and
treatment will only be affective if appropriate for the anomaly.

Each condition has specific pathophysiology. Dry eyes are caused by tear film
insufficiency, instability or a poor mixture of the required tear components. If there are
glandular irregularities such as Meibomianitis the lipid layer will suffer. This will result
in more rapid tear film evaporation. Goblet cells produce Mucin whose function is to
bind the tears to the epithelium layer of the cornea. Insufficient quantities of Mucin will
result in the tears running of the eye too rapidly. Lacrimal glands produce Aqueous, the
water part of the tears. Water represents most of the tears and an insufficient amount
obviously has a dramatic affect on the volume of tears. The most accurate method of
measuring the aqueous volume is with Fluorophotometry. Blinking mixes all these
components up and spreads them out over the cornea. Normal blink rate is once every 5-6
seconds. However, if one stares at a computer that rate will decrease to 10-12 seconds
drying the eyes out. Therefore, when someone has dry eyes, forcing a correct blink rate is
crucial to successful treatment.

The etiology or cause of dry eyes is also quite varied. Eyes tend to decrease tear
production with age or hormonal changes, certain diseases and treatments like for cancer
or surgeries such as LASIK. Blepharitis (lid inflammation) and contact lens wear are also
common causes of dry eye.

The pathophysiology of Ocular allergies is quite different. Exposure of a sensitive

individual to an allergen will result in the release of antibodies that bind to Mast cells.
The mast cells then release histamine that cause the full allergic reaction. The result is
itchy, puffy eyes, swollen lids, tearing and discomfort.

Unlike dry eyes, if an individual is not sensitive to an allergen then there will
NEVER be a reaction. The key to appropriate treatment is making the correct diagnosis.

Treatment for dry eyes begin with artificial tears several times per day. If that
does not help then going after the source is required. New theories include an allergic
reaction in the tear producing mechanism and thus prescribing a mild steroid like
Lotemax 3 times per day in conjunction with the artificial tears is done. If that still is not
adequate, then Restasis which is a reformulation of an old drug Cyclosporin is employed.

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Cyclosporin is an anti autoimmune drug that has found a new use. Care must be
employed when using this medication because any infection that occurs while taking it
may be much worse. Therefore, patients must be counseled to stop using it if any disease
occurs. Finally, punctal plugs can be inserted to keep tears in the eyes in addition to these
treatments. Wet cell eye glasses that trap moisture are not often used, but can be
employed as a last resort as well.

Allergy treatment is much simpler. Eye drops that are Antihistamine/Mast cell
inhibitors are the best. They attack the source and symptoms of the disease. Comfort is
fast and long lasting. The number 1 drug of choice these days is either Pataday or
Patanol. I have found that similar drops like Elestat, Optivar and the OTC drops are not
as effective. If these medications are not enough to alleviate the condition, then steroid
eye drops will do the trick. We start with Lotemax and graduate to the stronger ones if
needed.

In short, one must be sure of the diagnosis before starting treatment and then
modify it as required.

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Complication with LASIK and Case History
While LASIK usually heals very well with out incident there
are situations that may complicate the process resulting in
serious issues that may alter the final results. To best illustrate
this I have 2 case histories that will explain different problems.
The first is caused buy the patient, the second in no one’s fault.

A 25 year old man had LASIK with out incident on a Friday

and came in for his first post op visit on Saturday. All was
normal as his vision was 20/20 in each eye and aside from a
little redness he was fine. He was advised to avoid situations that may result in ocular
trauma, rubbing of the eyes or any place that may have windy conditions. He was of
course also told to wear his sunglasses outside and sleep with his shield at night.

On Sunday he went to the beach to play in a Volleyball tournament. After fighting

off multiple spike attempts, one of them did manage to hit him square in the face
resulting in eye trauma. He then fell to the ground landing face first in the sand. On
Monday he came in with red, painful eyes and blurry vision. Examination revealed that
the flap on the cornea had shifted out of place and there was sand under it. Both of those
are emergencies and required bringing him back into surgery to lift the flap and clean
under it. He was seen on Tuesday and he was not as happy as the first post op visit. He
had more redness, discomfort and his vision was only 20/40. He had to use the steroid
drops for 2 weeks until the swelling resolved and his vision returned to 20/20. He was
very fortunate that the problem that he caused was able to be corrected. Had the flap been
completely taken off during the volley ball game or a lot of sand got under the flap, the
results could have been devastating. He ultimately did achieve 20/20 in each eye and was
happy with the results. He did have more glare then the average patient because the
juncture where the flap was made scarred a little resulting in diffraction of light. It will
fade over time, but may not completely resolve itself.

The second patient was 100% compliant, but had bad luck. She was a 38 year old
woman who underwent LASIK and was perfect for the first week following surgery. She
returned 10 days after the procedure complaining of pain, decreased vision and redness in
both eyes. An examination revealed both flaps were milky white and the edges were
slightly lifted up. She stated that she was avoiding all the things that she was supposed to
and even visited her ailing friend in the hospital. The significance of the hospital visit is
that she had apparently been exposed to an infectious agent that was attacking the corneal
flaps. There was no additional surgery required, but aggressive medical treatment was
needed. She was put on several very strong antibiotic eye drops, steroids and even an oral
antibiotic to kill the infectious agent. She was followed up on a daily basis and after 1
week she began to show signs of improvement. The corneal flaps did reattach at the
edges and became almost perfectly clear. Her best vision was 20/25- in each eye and her
eyes were healthy.

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 The first patient was foolish and caused his problem, the second did nothing
wrong, but had bad luck. The bottom line is that when undergoing refractive surgery one
must always do as instructed, and hope for the best with factors that can not be
controlled.

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Complications with LASIK
LASIK, surgery to reduce or eliminate the need for eye glasses,
has become very popular over the past 5-10 years. While most
cases proceed quite well, the potential for complications does
exist, and is often not discussed prior to surgery. It should be
noted that all but one of the complications is NOT due to
surgeon error. Most potential problems are simply
physiological, and have nothing to do with how well the
surgeon performed the procedure.

The first is infection. While topical antibiotics are employed prior to, and after the
surgery, there is always the possibility of infection if the individual is exposed to an
infectious agent. The cure is simple; proper follow up and more antibiotics. There is
minimal risk of further issues.

The second is movement of the flap. This will occur if the individual rubs his/her
eye before the flap has had proper time to reattach itself to the underlying tissue. The
patient will experience pain, blurry vision and redness if this occurs. It is an emergency,
and does require being brought back into surgery to move the flap back into position.
Once this is done, the individual should heal normally without further complications.
This flap movement tends to occur more frequently when Intralase (laser is used to lift
the flap) is performed. While the incision is more precise, it results in a very thin flap
which tends to move easier post surgically. Once the flap heals though, the incision area
is barely noticeable.

The third complication is epithelial (outside) cell growth under the flap. This may
occur days to months after surgery. These cells grow around the edge of the flap, and
move inward causing haziness under the flap. When this occurs, the flap must me lifted
up and these epithelial cells washed away. No further problems will occur after this
procedure is done.

The fourth issue is striae, or wrinkles in or under the flap. This is corrected by
lifting the flap and flattening it out. No long term issues after this point.

Issue five is extreme swelling often called ” Sands of the Sahara”, because it
looks like a sand dune to the examining eye doctor. This may occur more frequently, but
is dealt with higher doses of steroid eye drops to reduce the inflammation. As with the
other complications, the results are most often successful.

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 The final and most serious of the potential complication is ectasia. This occurs
when the inner most layer of the cornea, the endothelium, has irregularities in it. If this
issue is not detected prior to surgery the final results after LASIK may be terrible. The
patient may have poor, distorted and irregular vision that is NOT surgically correctable,
nor corrected with glasses. Most often the individual will either have to wear hard contact
lenses, and may even require a cornea transplant to improve his/her vision. This
complication is the only one that could be surgeon related. A test called the Orbscan
MUST be performed prior to surgery, and the potential for ectasia can be easily detected.
NO INDIVIDUAL SHOULD EVER consider LASIK with out having an Orbscan done.
Any office that does not have an Orbscan should not perform LASIK.

As with all surgical procedures, patients must be comfortable with the surgeon
and the office they choose, and understand all the potential complications prior to
surgery.

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Contact Lenses to Correct Complications After LASIK
The goal of LASIK is to reduce or eliminate the need for eye
glasses and contact lenses. Unfortunately, that does not always
happen and contact lenses are then either desired or required at
that time.

Two situations often arise. The first is that the post LASIK
patient needs visual correction in order to see and refuses to
wear eye glasses. Thus, contact lenses need to be fit. The
second situation is that the only way the patient CAN see
clearly is with contact lenses because of corneal distortion as a result of the LASIK. In
both situations, frequently special design contacts are required because of the flat,
unusual curve of the post surgical cornea. Standard contact lenses are designed for the
basic curves of the cornea which is shaped like an ellipse. Post surgical corneas are flat
like a plateau. Therefore, the post LASIK cornea needs a lens that has curves that can
accommodate the new shape.

Most of the time visual correction can be achieved by getting a flat base curve
lens that vaults over the flat edges of the cornea. However, when there is corneal
distortion and irregularities such as with Ectasia as a result of the surgery, then custom
design Hard or Gas Permeable lenses are needed. These lenses mimic the unusual curves
and can mask the distortions in the cornea. While the fitting process is more complicated,
in the hands of an experienced eye doctor the results are usually very good.

In short, all patients should be aware that if refractive surgery is chosen there may
be complications that will require expensive contact lenses in order to see clearly post
surgically.

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Dangers for LASIK and PRK for Certain Professions
LASIK involves creating a corneal flap and treating the
underlying tissue. PRK brushes aside the outer epithelial layer
of the cornea and treating the underlying tissue with the same
laser as with LASIK. Which procedure is best for a patient’s
needs?

The question often asked is “Should I have LASIK or PRK and

why?” The answer is not as easy and choosing the procedure
involves both physiological testing results which determines which surgery will get the
best final results, patient time line and expectations. LASIK patients can expect to get up
after surgery and see better that same day, although it may take several to achieve the
final results. The issue to consider is what environment the patient lives in. For example,
if the individual is in a high risk profession like a police officer, military personnel or any
other occupation that may expose that person to eye trauma, there is a real chance that the
flap may dislodge and move. Moving a flap can be devastating to the eye and require
immediate surgery to correct the problem. In addition, if exposed to certain chemicals
like pepper spray the flap may experience Diffuse Lamellar Keratitis (DLK) which makes
the cornea hazy. Also, debris may work itself under the flap if the environment is filled
with pollution. This would mean that someone may have to delay entrance into the
Police, Fire or military academies for 6-9 months following surgery to give the cornea
adequate time to fully heal.

PRK does not have a corneal flap and therefore is not at risk for the DLK or flap
movement if exposed to trauma. In addition, nothing can get under a flap. Therefore the
risk of post surgical complication is less. Healing time and time required to have good
vision is much longer then with LASIK. It may take several weeks to achieve that point.
So if time is an issue LASIK will get there faster, but for reduced likelihood of flap
complications PRK is much safer. The only issue with PRK is that the corneal
Keratocytes are very sensitive to UV light and thus the patient must wear sunglasses
every day for at least a year until the cornea is fully healed.

In short, for professions that may expose an individual to eye trauma or air
pollutants LASIK may not be the best procedure to have. PRK is much better, but does
require more time to see better post surgically.

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Expectations for LASIK
When deciding whether refractive surgery like LASIK or PRK
is right for you, one of the most important factors to consider is
expectation. A patient must have realistic expectations
BEFORE having any procedure in order to be happy with the
results.

Important factors to consider are time of healing, vision during

that time, pain/discomfort, final results and side effects.
Looking at each of these issues; time of healing leads the pact.
LASIK will most likely have the shortest healing time. The day following surgery most
people have some discomfort, redness and 20/20 or very close to it. However, there is no
guarantee that all will be perfect on day 2. There are some patients that will need days to
weeks to reach the final best vision and eye drops are required for at least a week. Glare,
haloes around lights and dryness are very common side effects following the procedure.
These may last several days to months. Any one having surgery must be prepared to live
through these visual effects until they resolve. In addition, if the final vision is not what
was expected before surgery, then an enhancement may have to be done. This is the same
procedure as was initially done to refine the results.

PRK takes at least several days and most often several weeks to reach the best
vision and there is considerable discomfort during that time. Several eye drops are taken
to help in the healing, but individuals should not expect perfect vision during the first few
weeks. Ultimately, the vision should be great, but the path there is longer and less
comfortable then with LASIK.

The bottom line is that any one having refractive surgery should not c0mplain that
the healing process is taking too long or that they are uncomfortable during that time. It is
part of the process and patients must be willing and able to accept this as a part of what
they must do to reduce their need for eye glasses. We had a patient recently that 3 weeks
after PRK was complaining bitterly that his eyes were still not clear and that it was
affecting his job performance. He said that he was very unhappy that he had to keep
taking eye drops and that it was not what he expected. It should be noted that he was
20/25 in each eye (and was worse then 20/400 before surgery) and he had read, signed
and was explained to before the surgery all the side effects and healing time required. He
had a very short memory.

Go into all eye surgeries with both “eyes open” and understand that it will take
time.

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Keratoconus, LASIK and Contact Lenses
Keratoconus is a genetic recessive condition that results in the
steepening and thinning of the cornea. There are several
degrees of severity of this condition which may cause mild
corneal change and decreased vision to a severely distorted
cornea and very poor vision. Treatment and best corrected
vision will be determined by how much this genetic condition
is expressed.

The mildest display will simply require eye glasses and should
permit the patient to see 20/20. As the condition appears worse, special contact lenses
such as custom design soft lenses, lenses with hard centers and soft skirts, hard contact
lenses and ultimately hard lenses with soft lenses underneath may be required. If
acceptable vision still can not be achieved, then most often corneal transplants are
required.

Some studies have demonstrated that a small percentage of these corneal

transplant patients will have the new grafted corneas become Keratoconic again. This
requires the same treatment plan as before the surgery. Keratoconus patients should
NEVER have LASIK or PRK since that may results in permanently distorted corneas and
may even cause corneal rupture.

There is a surgical procedure called Intacs, which implants a plastic ring in the
stromal (middle) layer of the cornea to flatten out the cone and improve vision. Hard
contact lenses may then permit the individual to see much better with out a corneal
transplant which requires a long recuperation period and often a large amount to
astigmatism.

The point to remember is that if you have Keratoconus you should be seen by an
eye doctor that has a lot of experience with that condition.

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LASIK and Corneal Haze
LASIK involves creating a corneal flap with either a
blade or if a laser is used, Intralse and lifting the flap
up. A laser is then used to reshape the underlying tissue
to mold it into a better refractive surface. In doing so
nearsightedness, farsightedness and astigmatism are
either reduced or eliminated.

Ideally, when the corneal flap is replaced it will heal

and reattach itself so there will be a smooth surface
similar to presurgery. The edges of the flap must heal
so that the epithelial cells (outer most layer of the
cornea) heal over and stay outside of the cornea. If this
occurs then the flap should remain clear and glare will be at a minimum assuming all else
has healed properly as well.

Unfortunately, that is not always what happens. On occasion, some of the

epithelial cells will grow around the edge of the flap and into the cornea. When this
occurs the outside has joined the inside. This results in a hazy cornea and potentially
dangerous condition that must be remedied. If left untreated the entire flap may become
opaque resulting in devastating vision loss. Epithelial cells have different physiology then
stromal and endothelial cells and must be kept out of the inside of the cornea. When this
happens, the flap must be lifted up once again and the epithelial cells washed out. When
done properly all the foreign cells will be gone and the problem solved.

A common complication of the procedure is that the area where the epithelial
cells were may remain hazy and scar over. When this happens, that area will always be a
poor refractive area and depending on the location in the cornea may cause permanent
glare, haloes and vision loss. If that scared section is close to the pupillary axis, this result
will be much worse then if it is farther toward the edge of the cornea. It is a one way
ticket and can not be cured with additional surgery or medication. It is a possible side
affect of the surgery and is not a result of surgical skill. It simply happens when the cells
decide on their own to grow where they do not belong.

Careful follow up for a year is therefore suggested to monitor this potential

surgical complication. The sooner it is diagnosed the better the final results should be.
That and luck as to where the cells decide to grow.

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LASIK and the Ectasia Complication
LASIK is a refractive surgical procedure that reduces or
eliminates the need for eye glasses and contact lenses. It
involves creating a flap in the cornea, lifting it up and using a
laser to reshape the underlying tissue. The basic concept is to
shape the cornea to focus light on the retina with out the need
of any refractive aid. The flap may be created by a blade or a
laser called Intralase. The Intralase method is more precise and
heales with minimal scaring, but because the flap is so thin
increases the possibility of corneal striae. These are folds in the
tissue that can reduce vision. In mild cases of striae no additional therapy is required, but
if more pronounced does require going back into surgery to lift and smoothen out the
flap.

The most serious complication of LASIK is Ecatsia. This occurs when the cornea
heals in an irregular fashion resulting in distorted refractive tissue. The results can be
devastating. A recent patient in our office who had LASIK 4 years previously had best
corrected visual acuities of 20/60 in each eyes. He was mildly nearsighted prior to
surgery with a prescription of -200 in each eye. Post surgically he has an Rx of about -
700 in each eye and astigmatism of -450. Even with this prescription he has distorted
vision of 20/60. As a result of these strong eye glasses, he was also fit with custom made
contact lenses. This maximizes his visual comfort, but the lenses are very expensive and
take 2-3 weeks to manufacture.

How then can a patient avoid getting Ectasia with LASIK and how should the
surgeon determine if LASIK should be performed. The answer to both questions is an
instrument called an Orbscan. This computer evaluates the front and back surface of the
cornea in extreme detail. NO LASIK should ever be done with out an Orbscan being
done first. If the posterior surface (endothelium) of the cornea deviates more then .47
from the average cornea as determined by the computer, then LASIK should not be done.
That measurement determines the likelihood of getting Ectasia post surgically. If the
patient is not a LASIK candidate then PRK can be performed since Ecatasia does not
occur with PRK.

The best refractive surgeons always do an Orbscan and will perform PRK as often
as required. LASIK is not for everyone and should not be performed on all patients.

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LASIK Disaster: A Case History
A 40 year old male went for a LASIK consultation and was told
that he would be a great candidate for the procedure. He had
complained prior to surgery that he had very dry eyes and often
woke up with painful eyes, but the surgeon told him that he would
still do well with the procedure.

During the course of the surgery the flap kept folding over and
sticking to itself resulting in multiple wrinkles called striae. When
the surgery was over the outer most layer of the cornea appeared to be dry resulting in a
mild corneal abrasion. Therefore a bandage contact lens was place on that eye as a
protective measure. The patient called the office early the next day complaining of
EXTREME pain and light sensitivity and was instructed to come right in. Upon
evaluation it was determined that there was a large abrasion resulting in the edge of the
flap lifting up. There were also multiple striae in the flap which caused substantial visual
decrease.
Since the abrasion was present it was decided to leave the lens on for another 24 hours
and to reevaluate the eye the next day. On the next follow up, there were more striae
present and the vision was now down to 20/200. To improve the refractive surface and
improve the vision, the corneal flap was “re floated” to flatten it out and eliminate the
striae. This was accomplished, but during this procedure the entire outer layer of the
cornea pealed off. Aside from being extremely painful this further reduced the vision.
While the flap was now smooth, it lost the epithelial layer. Another bandage contact lens
had to be reapplied until the epithelium grew back.

Two days later the patient returned, still in pain, still blurry. The epithelial layer had
regenerated and was beginning to cover the cornea again. Unfortunately, it was also
growing under the cornea which required going back into surgery to once again lift the
flap to clean out these cells. Once again, the outer layer came off and needed another
contact lens. Finally after 10 more days, the epithelium regrew and the pain was
eliminated. However, the central cornea was now hazy and the vision was still 20/200.
Pred Forte steroid eye drops were prescribed to treat this new problem.

This individual also suffered from severe allergies and constantly had the need to rub his
eyes. After fighting the feeling for several weeks, in his sleep he gave in and rubbed his
eye …vigorously. Feeling substantial pain he woke up to notice that he could not see out
of that eye. Early the next morning he once again returned to the office with a red,
painful, blurry eye. An examination disclosed that the cornea flap had been torn off the
eye and was no where to be found. With out the flap, there was no hope of helping this
cornea and an emergency corneal transplant had to be performed. This was accomplished
and many months later the patient had his vision restored with a noticeable degree of
astigmatism. He was fit with a custom designed contact lens which restored his vision to
20/30.

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While this case scenario is quite unusual and fortunately is a rare occurrence, any one
considering refractive surgery must consider that it may occur to them. It may not be as a
result of the surgeon or the follow up care, but simply a series of bad side effects that
could happen to anyone. In short, all candidates must be aware of all the potential
complications and be willing to accept them if they occur.

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PRK and Other Treatment for Recurrent Corneal
Erosions
An injury to the outer layer of the cornea, the
Epithelium, usually heals with in a few days, and
results in no long term damage. However, if the
Epithelium does not fully reattach to the underlying
layer, Bowman’s Layer, then that focal point may be a
source of future problems. This is called a Recurrent
Corneal Erosion, RCE.

An individual wakes up in the morning in severe pain upon opening their eyes. The
affected eye is red and extremely light sensitive. It improves as the day progresses, but
takes several days to fully remediate. This event re-occurs every few weeks, or months
each time being worse then the time before. Lasting longer, hurting more, and not fully
remediating. This is a typical course of action for RCE. Since the Epithelium did not fully
re-attach to the Bowman’s layer after the injury, it gets pulled off at the point of injury.
During sleep, it gets stuck to the inner layer of the eye lid and tears as a result of REM
sleep. These events can be mild or extremely painful resulting in decreased vision, and
constant foreign body feelings in the eyes.

Treatment varies substantially from using lubricating ointment at bedtime to keep the
cornea from getting stuck to the eye lids during sleep; to Anterior Stromal Puncture. This
involves sticking a needle into the cornea at the affected site in the hope of forcing the
epithelium to re-heal, thereby attaching to Bowman’s membrane. It has proven to be
moderately successful. The newest treatment has come about as a result of refractive
surgery.

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 Photo therapeutic Refractive Keratotomy (PRK) has been used to fully treat this
condition. The corneal area is first bathed in alcohol to delaminate the epithelium, or
remove the top layer. Then PRK is performed to treat the damaged area. Upon healing,
the epithelium is now fully re-attached to Bowman’s membrane.

While there have not been a significant number of these cases as of yet, this treatment
has shown dramatic results. Ultimately PRK may prove to be the treatment of choice in
severe cases of RCE.

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 LASIK Chronicles
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