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CLINICAL SCIENCE

Mechanical Superficial Keratectomy for Corneal Haze After Photorefractive Keratectomy With Mitomycin C and Extended Wear Contact Lens
Hamid Khakshoor, MD, Mehran Zarei-Ghanavati, MD, and Ladan Saffarian, MD

Purpose: To evaluate the clinical results of a mechanical
keratectomy with mitomycin C (MMC) and extended wear contact lens (EWCL) for the treatment of corneal haze after photorefractive keratectomy (PRK) of high myopia.

Key Words: photorefractive keratectomy, corneal haze, mechanical keratectomy, scraping, mitomycin C, extended wear contact lens (Cornea 2011;30:117–120)

Setting: Eye Research Center, Khatam-al-Anbia Eye Hospital, Mashhad University of Medical Sciences, Iran. Methods: In a retrospective interventional case series, we enrolled 15 eyes of 9 patients who previously underwent PRK for high myopia and developed corneal haze and regression. Mechanical removal of corneal haze was done by using a surgical blade number 15. Then, MMC (0.02%) was used for 2 minutes. An EWCL was applied for 1 month. The main outcome measures were uncorrected visual acuity, best-corrected visual acuity, spherical equivalent (SE), and corneal haze grade. All patients were followed for a minimum of 6 months. Results: The mean age of the patients was 25.66 6 7.03 years;
7 patients were men and 2 patients were women. The mean bestcorrected visual acuity before superficial keratectomy was 20/80 (range, 20/200–20/50) and improved to 20/20 after treatment (P , 0.05). Thirteen eyes (86.6%) achieved an uncorrected visual acuity of at least 20/40. The mean preoperative SE was 3.91 6 1.30, and the mean final postoperative SE was 20.85 6 1.19 (P , 0.05). Eight eyes (53%) were within 1 diopter of emmetropia. Corneal haze in all patients declined to a trace haze or complete clearness. No recurrence occurred during the mean follow-up time of 12 months.

Conclusions: Superficial keratectomy with MMC and EWCLs is effective in reducing persistent and refractory corneal haze after PRK.

xcimer laser photorefractive keratectomy (PRK) was first introduced in 1988.1 Although it has less effect on the biomechanical integrity of the cornea compared with laser in situ keratomileusis, corneal haze that causes optical scattering and visual loss remains a major disadvantage of PRK.2 Moreover, it is associated with myopic regression.3 Clinically significant corneal haze after PRK has been seen in nearly 5% of patients.2,4 Corneal haze typically appears within the first few weeks after PRK (early onset) and increases in intensity at 1–2 months and gradually disappears during the next 6–12 months.5,6 The late-onset corneal haze develops at least 3 months or more after PRK.7,8 The exact pathological mechanisms of corneal haze remain unclear. Several studies have demonstrated that a single application of topical mitomycin C (MMC) is effective in preventing corneal haze after PRK.9–11 Surgical options available to treat corneal haze after failure of topical corticosteroids include phototherapeutic keratectomy (PTK) and the combination of mechanical scraping with MMC. The objective of this article is to evaluate the efficacy and safety of combining superficial keratectomy (SK) with topical MMC to treat corneal haze after PRK.

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MATERIALS AND METHODS
Received for publication May 5, 2009; revision received January 15, 2010; accepted January 24, 2010. From the *Khatam-al-Anbia Eye Hospital, Eye Research Center, Mashhad University of Medical Sciences, Mashhad, Khorasan, Iran; and †Islamic Azad University of Mashhad, Mashhad, Iran. Supported by Eye Research Center, Mashhad University of Medical Sciences, Iran. Presented at the 2009 American Society of Cataract and Refractive Surgery (ASCRS) Annual Meeting, April 3–8, 2009, San Francisco, CA. No author has a financial or proprietary interest in any material or method mentioned. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.corneajrnl.com). Reprints: Hamid Khakshoor, Eye Research Center, Khatam-al-Anbia Eye Hospital, Abootaleb Boulevard, Mashhad, Khorasan 91869-13556, Iran (e-mail: hkhakshoor@yahoo.com). Copyright Ó 2011 by Lippincott Williams & Wilkins

Selection of Patients
Between April 2004 and August 2006, we conducted a retrospective noncomparative study of 9 consecutive patients with corneal haze at least 1 year after PRK. PRK was performed using a Technolas 217z excimer laser system (Bausch & Lomb). All procedures were performed at the Navid Didegan Eye Center, with the exception of 2 patients who were referred from other centers. All patients were treated for myopia. MMC was used intraoperatively for varying times of exposure, which was dependent on the degree of myopia. No patient had any systemic risk factors for corneal haze. Corneal haze initially appeared in the first few weeks (early onset) and was present after at least 1 year. All patients were treated with topical betamethasone without significant response and had corneal haze ranging from grade 2 to grade 4. All patients had
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whereas only 8 eyes (53%) were within 1 D of emmetropia (Fig. It was totally eliminated in 7 eyes (46. OD OD OS Female OD Male OS Male OD OS Female OD OS Male OD OS Male OD OS Male OD OS Surgical Technique Informed consent was obtained from all patients. 0. Under topical anesthesia. 2. An extended wear night and day bandage contact lens (CIBA Vision) was applied for 1 month (see Video. Supplemental Digital Content 1.25 25. MMC was applied again for 1 minute and then washed out. keratitis or other lens-related complications were present (Table 1).com/ICO/A11).75 24. Preoperative Characteristics of 9 Patients (15 Eyes) With Corneal Haze Age Number (Yrs) 1 2 3 4 5 6 7 8 9 39 24 19 22 19 29 34 25 20 Sex Male Male MSE Corneal Haze BCVA Eye (Before SK) (Before SK) (Before SK) 25. The results are expressed as mean 6 SD.Khakshoor et al Cornea  Volume 30.25 25. trace or faint corneal haze seen only by indirect broad tangential illumination. Epithelialization was complete by the fourth day. severely dense opacity that completely obscures the details of intraocular structures. 1 patient (1 eye) had grade 4. 1).5 diopter (D). Thirteen eyes (86.5) differed from that before scraping (grade range. Betamethasone was replaced with fluorometholone given 4 times daily for 1 month and then tapered by 1 drop every month over the following 3 months until cessation. and pachymetry.12 The systematic definitions are as follows: grade 0.66 6 7. The mean spherical equivalent showing significant regression was 23. 4. and ghost image.03 years. 0.19 (P .75 21. mild haze that is easily visible with direct focal slit illumination.02%) was directly applied over the exposed cornea for 1 minute. BCVA was 20/50. 2–4) (P .05). Inc). TABLE 1. totally clear. Patient number 6: A 29-year-old woman who had undergone PRK 13 months before participating in the study. and 12 months after surgery.25 months. grade 3. and 5 patients (10 eyes) had grade 3 (Fig.05) (Fig.25 23 23. grade 0.25 24 25 24. tonometery.75 23. but more than 1 D of myopia was seen in 6 eyes. MSE. February 2011 best-corrected visual acuity (BCVA) below 20/40 and significant optical symptoms such as halo. Number 2. The mean BCVA before SK was 20/80 and ranged from 20/200–20/50. ciprofloxacin drops were applied twice a day until bandage contact lens was removed. No bacterial FIGURE 1. 0–0. and grade 4.com . The postoperative therapeutic regime included topical ciprofloxacin and betamethasone (4 times a day) for the first week.30 (Table 1). Superficial keratectomy was performed after 2 years of haze formation in 3 patients (cases 2.25 22.). Corneal haze after scraping (grade range.25 24.91 6 1.05 was considered statistically significant.75 21. K. The mean BCVA after treatment improved to 20/20 and ranged from 20/25–20/16 (P . Two eyes were overcorrected for more than +0. grade 2. and all surgeries were performed by a single surgeon (H. A sponge soaked with MMC (0. 0.5 3 2 2 2 2 3 3 3 3 3 3 3 4 3 3 20/125 20/80 20/80 20/50 20/50 20/200 20/160 20/50 20/50 20/125 20/125 20/160 20/250 20/120 20/160 Clinical Evaluations Detailed ophthalmological examinations were done for all patients including a slit-lamp examination. A P value less than 0.11 6 3. 2). 4. and 9). Follow-up examinations were done on postoperative days 1. Three patients (4 eyes) had grade 2 corneal haze. After the first week. Corneal scars were graded using a slit-lamp microscope according to the grading system of Fantes et al.5. examinations were done weekly until the end of the first month and then at 3. 3).lww. glare. The mean spherical equivalent was changed to 20. RESULTS This case series included 9 patients (15 eyes of 7 men and 2 women). q 2011 Lippincott Williams & Wilkins 118 | www. Uncorrected visual acuity (UCVA) and BCVA were determined using Early Treatment Diabetic Retinopathy Study visual acuity charts (ETDRS). Afterward. grade 1. The mean follow-up time after keratectomy was 12. moderately dense opacity that partially obscures the details of the iris.85 6 1. manifest spherical equivalent. minimal haze seen with difficulty using direct and diffuse illumination. and 7. mechanical removal of the corneal epithelium and stromal haziness was performed with a surgical blade (number 15) until complete smoothness and clearness of the underlying stroma were achieved.05). The mean age of the patients was 25. http://links.75 24.6%) and Statistical Analyses The Wilcoxon signed rank and x2 tests were used for statistical analyses and performed using SPSS software (SPSS. The cornea and conjunctival sac were irrigated with 20 cc balanced salt solution.6%) achieved UCVA of at least 20/40 (range from 20/80–20/16).corneajrnl. indirect fundoscopy. 6.

5 20. Porges et al13 studied the use of PTK with MMC for treatment of corneal haze. is a safe and effective method for treating corneal haze after PRK. Efron et al18 observed a loss of www. DISCUSSION Superficial keratectomy.15 showed that corneal haze returned to some extent after treatment with MMC. previous studies13.75 21. No evidence of corneal haze was observed in the left eye where the contact lens remained in place. It is possible that the benefit observed using EWCLs is from their effects in posterior distribution and reduction of stromal keratocytes.25 0. all patients reported improvement of symptoms regarding optical aberrations. Although surgery is more time consuming in these patients with old corneal haze. Vigo et al15 recommend that scraping should be done 8–10 months after PRK because mechanical removal would be difficult after a longer period of haze formation. the patient presented with corneal haze in the right eye (grade 3) where the contact lens had been lost.15 Loewenstein et al14 showed that only 38% of patients had UCVA of 20/30 or better. They reported that FIGURE 3. Talamo et al16 first used MMC to treat corneal wounds after excimer laser surgery.14. Number 2. When the treatment of corneal haze with topical corticosteroids is unsuccessful. the corneal surface is uneven after ablation because of presence of fibrous tissue in the corneal stroma.17 Moreover. this complication still occurs after PRK. No patients had recurrence of corneal haze during follow-up.75 20. The procedure decreased regression but usually led to undercorrection of myopia. Using confocal microscopy.5% of patients were within 1 D of emmetropia and the mean BCVA after treatment was 7/10. PTK often results in overcorrection of myopia because refraction is imprecise in the presence of corneal haze.75 20.25 0. In our study.25 20. there are 2 alternative therapeutic modalities. Postoperative Results of Superficial Keratectomy in Eyes With Corneal Haze MSE Corneal Haze BCVA UCVA Last F/U Number (Last F/U) (Last F/U) (Last F/U) (Last F/U) (Mo) 1 2 3 4 5 6 7 8 9 21.25 20.25 23 0. The measured increase in BCVA was $ 3 lines in all eyes measured. This is based on an incidental finding in 1 patient who underwent PRK with MMC for correction of myopia (26.5 20/25 20/20 20/16 20/16 20/20 20/20 20/20 20/20 20/20 20/20 20/16 20/16 20/16 20/20 20/20 20/40 20/80 20/40 20/25 20/30 20/25 20/20 20/20 20/25 20/25 20/25 20/16 20/40 20/40 20/50 14 11 11 12 19 13 13 9 9 8 8 10 10 13 13 FIGURE 2. A 29-year-old woman who had UCVA of 20/25 and trace corneal haze at 9 months after superficial keratectomy. as demonstrated here.corneajrnl. significantly reduced in others (Table 2).5 0 0 0. the results were comparable with that achieved in other patients. These results demonstrate that PTK leads to less predictable and regular stromal removal than mechanical keratectomy. Final spherical equivalent refractive outcomes after SK.com | 119 .Cornea  Volume 30.5 0 0 0. Eight eyes (53%) were within 1 D of emmetropia.5 0 0. 53% of eyes had UCVA of at least 20/30.5 0 0 0 0.25 22. q 2011 Lippincott Williams & Wilkins only 37. We used therapeutic bandage contact lenses for 1 month with all patients. with the exception of one. Additionally.5 21. Two previous studies that used mechanical keratectomy with MMC to treat corneal haze reported favorable results.75 20.5 22. February 2011 Mechanical Keratectomy for Corneal Haze TABLE 2. We performed superficial keratectomy after 2 years of haze formation in 3 of our patients.5) of both eyes.5 0.5 0. They did not publish final BCVA of their patients. PTK and SK. Corneal haze was significantly reduced and stabilized during follow-up without side effects. Most patients achieved UCVA of 20/40 or better. After 1 month.25 1. Moreover. Although prophylactic application of MMC reduces corneal haze. We noticed that extended wear contact lenses (EWCLs) might provide benefit with regard to preventing corneal haze.

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