After surface ablation, patients may experience variable degrees of pain, from minimal to severe, and some may need oral NSAID, narcotic, or neuropathic pain medications. Studies have shown that topical NSAID drops reduce postoperative pain, although they may also slow the rate of re-epithelialization and promote sterile infiltrates (see Chapter 6). Corneal melting and stromal scarring have been described after the use of some topical NSAIDs. For patients who are not healing normally after surface ablation, use of any topical NSAID should be discontinued.
Patients should be monitored closely until the epithelium is completely healed, which usually occurs within 4–7 days. As long as the bandage contact lens is in place, patients are treated with topical broad-spectrum antibiotics and corticosteroids, usually 4 times daily. Once the epithelium is healed, the bandage contact lens, antibiotic drops, and NSAID drops (if used) may be discontinued. In addition, most clinicians recommend avoidance of swimming and the use of hot tubs for at least 2 weeks postoperatively to help lessen the risk of infection.
The use of topical corticosteroids to modulate postoperative wound healing, reduce anterior stromal haze, and decrease regression of the refractive effect remains controversial. Although some studies have demonstrated that corticosteroids have no significant long-term effect on corneal haze or visual outcome after PRK, other studies have shown that corticosteroids are effective in limiting haze and myopic regression after PRK, particularly after higher myopic corrections. Some surgeons who advocate use of topical corticosteroids after the removal of the bandage contact lens restrict their use to patients with higher levels of myopia (eg, myopia greater than –4.00 or –5.00 D). When used after removal of the bandage contact lens, corticosteroid drops are typically tapered over a 1- to 4-month period, depending on the patient’s corneal haze and refractive outcome. Patients who received mitomycin C at the time of surgery have a reduced risk of haze formation and thus may have a shorter duration of corticosteroid use. Patients who had PRK for hyperopia may experience prolonged epithelial healing because of the larger epithelial defect resulting from the larger ablation zone, as well as a temporary reduction in best-corrected visual acuity (BCVA; also called corrected distance visual acuity, CDVA) in the first week to month, which usually improves with time. Many patients with hyperopia also experience a temporary myopic overcorrection, which regresses over several weeks to months. In the absence of complications, routine follow-up examinations are typically scheduled at approximately 2–4 weeks, 2–3 months, 6 months, and 12 months postoperatively and perhaps more frequently, depending on the steroid taper used.
Many surgeons instruct their patients to use topical antibiotics and corticosteroids postoperatively for 3–7 days. With femtosecond laser procedures, some surgeons prescribe more frequent applications of corticosteroid eye drops or a longer period of use due to a tendency of older femtosecond lasers to create more intrastromal inflammation. LASIK flaps made with current generation femtosecond lasers have similar inflammation profiles to microkeratome cut flaps. In addition, it is very important for the surface of the flap to be kept well lubricated in the early postoperative period. Patients may be told to use the protective shield for 1–7 days when they shower or sleep and to avoid swimming and the use of hot tubs for 2 weeks. Patients are examined 1 day after surgery to ensure that the flap has remained in proper alignment and that there is no evidence of infection or excessive inflammation. In the absence of complications, the next examinations are typically scheduled at approximately 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively.
Santhiago MR, Kara-Junior N, Waring GO IV. Microkeratome versus femtosecond flaps: accuracy and complications. Curr Opin Ophthalmol. 2014;25(4):270–274.
Santhiago MR, Wilson SE. Cellular effects after laser in situ keratomileusis flap formation with femtosecond lasers: a review. Cornea. 2012;31(2):198–205.
Solomon KD, Donnenfeld ED, Raizman M, et al; Ketorolac Reformulation Study Groups 1 and 2. Safety and efficacy of ketorolac tromethamine 0.4% ophthalmic solution in post–photorefractive keratectomy patients. J Cataract Refract Surg. 2004;30(8):1653–1660.
Excerpted from BCSC 2020-2021 series: Section 13 - Refractive Surgery. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.