Excimer laser refractive surgery : corneal wound ... - Helda - Helsinki.fi

et al. 1994, Kanellopoulos et al. 1997, Tervo and Moilanen 2003) and in the corneatrigeminal
nerve-brainstem-facial nerve-lacrimal gland reflex arc (Battat et al. 2001,
Benitez-del-Castillo et al. 2001, Linna et al. 2000b, Wilson and Ambrosio 2001).
PRK injures the epithelial nerve ends, epithelial and subepithelial plexuses, and
anterior stromal nerves. Histological (Tervo et al. 1994, Trabucchi et al. 1994) and CM
studies (Erie et al. 2005, Tervo and Moilanen 2003) have assessed information on nerve
regeneration after PRK. These findings showed regenerated fibres at one day post-PRK in
histological sections, and visible by CM by seven days post-PRK. Corneal sensitivity
correlated with the changes observed. Sensitivity begins to recover after one week and
reached almost normal values three months later (Matsui et al. 2001, Perez-Santonja et al.
1999). However, long-term morphological alterations were visible even one year later
(Tervo et al. 1994) and subbasal nerve density examined by CM was not reached until two
years after PRK (Erie et al. 2005, Moilanen et al. 2008).
In LASIK, the lamellar incision cuts the bundles of nerve fibres of the superficial
stroma and the subbasal nerve plexus. Yet postoperatively in the flap, the epithelial and
basal epithelial/subepithelial nerves took a few days to disappear except for the hinge (Lee
et al. 2002, Tervo and Moilanen 2003). Regeneration of anterior stromal, subbasal and
epithelial fibres occurred approximately three months later although deep stromal nerves
showed abnormal morphology five months after LASIK (Latvala et al. 1996, Linna et al.
1998). Corneal sensitivity after LASIK measured by mechanical aesthesiometers reported
a decrease of sensitivity one to two weeks after LASIK (Donnenfeld et al. 2004, Linna et
al. 2000a) which recovered to normal level six to 12 months later. New noncontact
aesthesiometers reported hypersensitivity one week post-LASIK followed by a decrease in
sensitivity three to five months later. Near normal values has been reported two years after
the procedure (Gallar et al. 2004, Tuisku et al. 2007). Post-LASIK corneal subbasal nerve
density measured by CM showed a slower regeneration compared to PRK reaching nearly
preoperative values five years after LASIK (Erie et al. 2005). An earlier study (Tuunanen
et al. 1997) stressed the importance of corneal nerve density and nerve recovery to avoid
haze. LASIK-induced neurotrophic epitheliopathy (LINE) is a term proposed by Wilson
and Ambrosio (Wilson and Ambrosio 2001, Wilson 2001) to describe an entity in post-
LASIK patients complaining of ocular discomfort resembling dry eye symptoms although
corneal sensitivity and dry eye are normal (Tuisku et al. 2007). Transection of afferent
sensory nerve fibres and aberrant regenerated corneal nerves are likely to be among the
most important factors associated with this entity (Ambrosio et al. 2008). Some studies
(Tuunanen et al. 1997, Wilson 2001, Tuisku et al. 2007) suggest that the modulation of
corneal wound healing, post-operative anterior stromal scarring, or even symptoms
showed a direct relation with corneal subbasal nerve plexus to maintain corneal healing
and transparency.
Several factors have been associated with more severe compromise of sensitivity after
LASIK compared to PRK, including lamellar cut, thickness, (Nassaralla et al. 2005)
orientation and width of the flap, (Donnenfeld et al. 2004) and ablation depth (Bragheeth
and Dua 2005, De Paiva et al. 2006, Kim and Kim 1999, Shoja and Besharati 2007). Thin,
nasally placed flaps, broader hinge and smaller ablations are associated with less
compromise of corneal sensitivity.
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