Management of delayed corneal epithelial healing after refractive surgery: five case reports

Abstract

Background: Transepithelial photorefractive keratectomy using Smart Pulse Technology (SPT-TransPRK) is currently the leading method for superficial refractive surgery, offering advantages such as a non-contact procedure, shorter operation times, and excellent patient cooperation. Laser ablation of the corneal epithelium, Bowman's membrane, and the stroma can effectively correct refractive errors. Thus, the complete healing of the corneal epithelium post-surgery is essential for ensuring good vision. Refractive surgeons should enhance their understanding of corneal wound healing mechanisms and focus on the repair of the corneal epithelium following refractive surgery to ensure the quality of visual health of patients.

Case presentation: A total of five patients experienced varying degrees of delayed corneal epithelial healing following refractive surgery. In Case 1, unhealthy corneal epithelial debris was removed, and ophthalmic ointment was applied to cover the eyes instead of using bandage contact lenses (BCLs) to reconstruct the corneal epithelial barrier. This approach was also successfully implemented in Case 2. Furthermore, amniotic membrane transplantation (AMT) can quickly establish a corneal barrier and promote corneal epithelial regeneration, especially in cases of extensive corneal epithelial detachment. The remaining three patients were suspected of having corneal viral infections based on their medical history and the observation of corneal pathology using a slit lamp microscope. To prevent further infection and promote regeneration, topical steroid drops were discontinued early, and topical antiviral and corneal epithelial regeneration medications were administered alongside systemic antiviral therapy. Steroid drops were resumed after corneal epithelial healing to effectively prevent post-refractive haze.

Conclusion: Delays in corneal epithelial healing after refractive surgery should be taken seriously. BCLs, steroids, and both topical and systemic antiviral therapies should be properly utilized when there is a delay in corneal epithelial healing.

Keywords: corneal virus infection; delayed corneal epithelial healing; persistent epithelial defects; refractive surgery; trans-PRK.

Figure 1

Images of the anterior segment of the cornea in Case 1. (A) The corneal epithelium was not completely healed in both eyes during 1 week. (B) The corneal epithelial regeneration was not been improved within 1 week. (C) The central corneal epithelium defect of 3 mm in diameter was observed in the right eye at 3 weeks after the surgery. (D) At 4 weeks postoperatively, the bilateral cornea returned to be transparent.

Figure 2

Images of the anterior segment of the cornea in Case 2. (A) The corneal epithelium showed slight punctate defects in the right eye, and the epithelium debris accumulated in the central cornea in the left eye. (B) The punctate erosion of corneal epithelium was observed in both eyes. (C) The sodium fluorescein staining revealed diffuse staining in both eyes. (D) The corneal epithelium of the left eye was visibly repaired, whereas the right eye exhibited extensive epithelial erosion after 2 days. (E) The amniotic membrane in the right eye. (F) The stitches were removed at 2 weeks after the AMT. (G) The cornea was transparent at 5 months after SPT-TransPRK. (H) The cornea was transparent at 9 months after SPT-TransPRK.

Figure 3

Images of the anterior segment of the cornea in Case 3. (A) The slightly opacity zone underneath epithelium below the pupil of the left eye. (B) The infiltration spot in the opacity zone in the left eye. (C) The infiltrated spots in the superficial stromal layer of the left cornea subsided. (D) The left corneal epithelium had healed and the subepithelial corneal opacity was alleviated. (E) The corneal epithelium was healed and stable.

Figure 4

Images of the anterior segment of the cornea in Case 4. (A) Tthe corneal epithelial surface lacked smoothness in both eyes. (B) The accumulation of epithelial cell debris was below the pupil area. (C) The patient’s corneal epithelial cell debris accumulated the lower eyelid margin at 2 months postoperatively. (D) The dendritic staining of sodium fluorescein was orbserved after 1 week. (E) The rough corneal epithelia and haze grade 2 were observed in both eyes. (F) After 1 week, the corneal epithelium of both eyes healed well with haze grade 2. (G) The corneas of both eyes were transparent and smoothy at 4 months postoperatively.

Figure 5

Images of the anterior segment of the cornea in Case 5. (A) The punctate infiltration of cornea was in both eyes. (B) The conjunctival ciliary congestion, suspected arborization infiltrative zone on the temporal side, and sodium fluorescein staining showed diffuse detachment in the corneal epithelium of both eyes. (C) The confocal microscopy images. (D) The bilateral corneal epithelium detachment with secretion and conjunctival ciliary congestion. (E) The right corneal epithelium was repaired with corneal edema and the left corneal epithelium was defective. (F) The cornea of both eyes healed no better than before. (G) The epithelial defect gradually decreased in 1 week. (H) The corneal epithelium had healed with haze grade of 0.5.

Figure 6

Schematic diagram illustrating the healing of corneal epithelial injury. (A) The corneal epithelial cells, hemidesmosomes, basement membrane, anchoring fibers, and anterior stroma were all damaged as a result of corneal epithelial injury. (B) Regenerated epithelial cells covered the defect, and hemidesmosomes were observed after 24–72 h. (C) The incomplete lamina densa of the basal lamina was observed.