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Phototherapeutic keratectomy with an epithelial flap for recurrent erosion syndrome

Ardjomand, Navid MD*; Fellner, Peter MD; Vidic, Bertram MD

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Journal of Cataract & Refractive Surgery: March 2004 - Volume 30 - Issue 3 - p 543-545
doi: 10.1016/j.jcrs.2003.09.049
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Recurrent erosion syndrome is a common condition in which the patient has severe eye pain. Several therapeutic strategies for recurrent erosion syndrome have been introduced in the past 20 years.1 One, phototherapeutic keratectomy (PTK), is a safe and effective treatment for refractory recurrent erosion syndrome.2 One disadvantage of PTK is postoperative pain caused by epithelial removal; the pain can last for several days. We introduce a technique similar to laser-assisted subepithelial keratectomy (LASEK) to reduce postoperative pain and encourage fast visual rehabilitation after PTK.

Patients and Surgical Technique

Nine patients with recurrent erosion syndrome for 3 months to 4 years were admitted to our hospital. The etiology of recurrent erosion syndrome was a fingernail injury in 5 cases and a gardening injury in 4 cases. Topical ointment or lubricants were given in all cases before the procedure without success. The patients' ages ranged from 27 to 56 years. Informed consent was obtained from all patients, and institutional review board approval was not required.

Since the recurrent erosion was within the central 8.0 mm in all cases, the epithelium was first marked with an 8.0 mm trephine (Geuder) and peeled with an epipeeler (Geuder). Peeling was easy, and treatment with ethanol 20% before peeling was not necessary. The epithelium was left at the 12 o'clock hinge, the cornea was dried with a swab, and excimer laser application was started. All treatments were performed with a Schwind keratome, which produces a flat beam. A 7.0 mm diameter circular beam was programmed to deliver a depth of 9.8 μm. This corresponds to 35 scans. The epithelium was placed back on the stroma at the end of the procedure. A silicone contact lens (PureVision,® Bausch & Lomb) was applied, and tobramycin and dexamethasone (TobraDex®) eyedrops and hyaluronic acid 0.25% eyedrops were given. All procedures were performed by the same surgeon (N.A.).

On day 3, the contact lens was removed and the TobraDex stopped. The patients continued using topical lubricants (hyaluronic acid 0.25%) for another 2 weeks. Postoperative follow-ups were at 1, 3, 7, and 30 days and at 3 and 6 months (Figures 1 and 2).

Figure 1.
Figure 1.:
(Ardjomand) Left: Erosion in the central 7.0 mm of the cornea before treatment. Right: The cornea 1 week after treatment.
Figure 2.
Figure 2.:
(Ardjomand) A: The corneal epithelium is gently peeled off within the central 8.0 mm. B: The epithelium is left at the 12 o'clock hinge. C: After laser treatment, the epithelium is placed back on the stroma. D: A contact lens is put on the eye.


Six of the 9 patients were pain free on the first postoperative day. Three patients reported dry eye and itching on the first postoperative day only. The best spectacle-corrected visual acuity (BSCVA) was 0.4 to 0.6 logMAR on the first postoperative day, which improved to 0.8 to 1.0 logMAR in all patients after 7 days. After 1 month, the BSCVA was 1.0 logMAR in all cases. The patients reported ocular discomfort shortly after contact lens removal, but all were free of symptoms by day 7. Haze formation or recurrence of erosion was not seen during the 6-month follow-up.


Phototherapeutic keratectomy is an effective treatment for recurrent erosion syndrome, with a success rate between 60% and 100%.2–9 This variability may be explained by the indication and treatment modality for PTK. Treatment of recurrent erosion syndrome from trauma has a higher success rate than treatment for corneal dystrophies.

Two disadvantages of PTK are immediate postoperative pain that lasts a few days and reduced visual acuity. We present our experience with a modified PTK technique in which the peeled epithelium is placed back on the stroma. The main advantage of this modification is fast postoperative visual rehabilitation and reduction of ocular pain in the immediate postoperative period. Because these patients have weak adherence of the epithelium to the stroma, ethanol treatment before epithelial peeling is not necessary. Unlike in the LASEK technique, we did not rinse the stroma with physiologic sodium chloride after laser application as it may reduce wound healing and adherence of the epithelium to the stroma. The dry epithelium was placed back on the stroma and a contact lens applied. No patient had a recurrence of the erosion during the 6-month follow-up.

From this experience, we conclude that PTK with an epithelial reflap is a safe and effective treatment for recurrent erosion syndrome after trauma and has the advantages of fast postoperative visual rehabilitation and reduced postoperative pain.


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© 2004 by Lippincott Williams & Wilkins, Inc.