RCE after surface ablation (PRK, LASEK, Epi-LASIK, transepithelial PRK)

[Rebecca Petris]

Every now and then I'll see or hear several of the same kind of thing in a short space of time and it'll get me thinking.

Today, it's the RCE-after-PRK (or LASEK/epi-lasik) pattern, where people who have had the surgery get recurrent erosions for months or years afterwards. Of course, this happens to people after LASIK as well but I guess I kind of think of that as a separate category because the epithelium is not removed, just possibly disrupted in the flap creation process so it's kind of got its own little set of issues.

I just happen to have talked to three or four people with RCEs after PRK in the last week or so. Plus we've got several already here - Ian (prattstar) probably one of the earliest. Then liz56's post reminded me about Dr. Stepp's research and the animal model where they basically induced limbal stem cell deficiency in mice eyes by doing a kind of pseudo PRK. And now we've got new member Teri (welcome, Teri, by the way!).

I'm pondering what kind of possible common thread there might be in RCE after surface ablation. Is it all just undiagnosed EBMD aggravated by surgery?

Out of curiosity, could any of you folks who have had surface ablations share some info like:

- Diameter of your treatment zone?
- Your prescription before surgery?
- What laser was used?
- Method of removing the epithelium? (Scrape... separate... laser...)
- Was MMC used?

I know those are technical details most patients don't know, but just in case some do....

[liz56]

I have a question about PRK and PTK, based on what I read at D'Eyealogues. Do these procedures (either or both of them) remove the Bowman's membrane (or the "basement" membrane)?

When I read about PTK online at a site that represented doctors who perform it, they said that it "smooths" the membrane. If the membrane is removed, what does that mean for the eye in the long term?

These surgeries are rather confusing to me, but they interest me, because a lot of people go to them for recalcitrant rce's, both people with abmd and those who have suffered from injuries.

(Sorry if I am taking this off the topic.)

--Liz

[Rebecca Petris]

I have a question about PRK and PTK, based on what I read at D'Eyealogues. Do these procedures (either or both of them) remove the Bowman's membrane (or the "basement" membrane)?

In PRK (and related procedures), yes, Bowman's is removed.

Longer version: The Bowman's membrane is removed in PRK as well as all other "surface ablation" procedures (PRK, LASEK, Epi-LASIK, etc). Basically what happens in all of these procedures is that they remove the epithelium right down to Bowman's and then they start lasering (vaporizing) everything under that. The epi grows back but Bowman's doesn't, or such is my understanding anyway. The only difference amongst the procedures I've just named is the way the epithelium is removed and what they do with it. For example, in PRK they just scrape it off. In LASEK, they make it into a hinged flap and roll it up like a rug left on one side of the cornea, then after the lasering they roll it back down and leave it temporarily as a 'bandaid' - the old epi dies but the new one is growing underneath. In Epi LASIK, they roll up a living sheet of epithelium and then put it back.

In PTK, some or all of it is removed. It depends what they're using it for. Here's an example of an abstract where they were comparing PTK and diamond burr polishing as a treatment for RCE/ABMD. They removed 5um (of a total 8-12um typical Bowman's thickness).

PTK is a rather generic term for manually controlled use of an excimer laser on the cornea (as opposed to programming the laser for vision correction). For example, at one stage after my LASIK I was considering getting PTK to hammer down some elevations in my central cornea. In that case they would have been lasering through the epi and bowman's and some stroma where the 'mountains' were.

When I read about PTK online at a site that represented doctors who perform it, they said that it "smooths" the membrane. If the membrane is removed, what does that mean for the eye in the long term?

I don't think anyone really knows.

And it's not off topic at all... it may even be more on topic than we know....

[liz56]

Thanks!

Rebecca,

You are a wealth of information. Thanks so much for the explanations.

This makes me respect the rather curt corneal specialist I first visited after being diagnosed. He said that he "could" do a diamond burr ablation but that he would encourage me to try Muro instead. I am so glad that he did that. Although I did not really like his chair-side manner, I felt like he was a good doctor, and now I feel even more certain of that.

I guess a question that I still have is whether or not ABMD is really injury related. My RCE's happen where I had injuries as a teenager. No one else in my family has RCE's, but almost all of them complain about "dryness" or "burning." Does ABMD really exist? I recall reading, I am unsure where, that there is some debate about whether it is truly a "dystrophy" or not. Some say that it is because it onsets at a certain age, but others say that it is not because "it is not progressive."

I'm sorry to hear about the irregularities that you had in your eye, Rebecca. The more I learn, the riskier these surgeries seem to be.

Thanks, again,
Liz

[Lucy]

This makes me respect the rather curt corneal specialist I first visited after being diagnosed. He said that he "could" do a diamond burr ablation but that he would encourage me to try Muro instead. I am so glad that he did that. Although I did not really like his chair-side manner, I felt like he was a good doctor, and now I feel even more certain of that.

I guess a question that I still have is whether or not ABMD is really injury related. My RCE's happen where I had injuries as a teenager. No one else in my family has RCE's, but almost all of them complain about "dryness" or "burning." Does ABMD really exist? I recall reading, I am unsure where, that there is some debate about whether it is truly a "dystrophy" or not. Some say that it is because it onsets at a certain age, but others say that it is not because "it is not progressive."

Liz, there is such a monster called "dystrophy". Not sure if it matters whether it's called: map-dot-fingerprints, ABMD, EBMD.....etc.. I have EBMD and/or map-dot-fingerprint...... I've had it since lasik in early 2000. It is mostly (but not all) in one eye. I've had corneal ulcers, debridement, trigeminal neuralgia, dry dry dry, in this one eye. Muro ointment does help the pain. My doc said I could use Muro "forever." Thanks, doc, doing Lasik, then telling me I have to use all this crap in my eyes forever.

My lasik doc had problems during the lasik procedure with the flap in "that" eye. It basically fell apart. (I have a video of the whole procedure.) I've asked him on occasion if "I had EBMD before lasik?" He said, "no, I would not have done lasik if you had it before." Well, it must have happened right when the laser touched my left eye.

You mentioned that "it sets in at a certain age." Well, as you can tell all ages are represented on this board, so that sounds like a doctor's remark. To me, it doesn't matter what the stuff in my eyes is called. It's painful, a real pain in the eye, and much, much more. If this stuff was curable, I think it would be cured for me in almost 9 years of post-op treatment. Maybe I'm just special. Lucy

[Teri]

RCE after PRK

Rebecca,

Thanks for the welcome. I am very curious about this, as well.

I had no history or indication of EBMD or dry eyes before the surgery, and as far as I know no one in my family has EBMD or dry eyes. Actually, I am unaware of any eye problems in my family, not even grandparents with cataracts or glaucoma.

I have a copy of my records from the surgeon, but I don't know how to find the diameter of the treatment zone. What shorthand do they use for it?

To answer your questions:
1. See above
2. I was -3.25 +0.25 +040 (R) and -4.5 (L)
3. Ladarvision Excimer Laser System (probably not specific enough)
4. The epithelium was removed via an instrument that reminded me of the thing dentists use to "buff" your teeth. I called it the miniature floor buffer.
5. What is MMC?

Teri

[liz56]

Liz, there is such a monster called "dystrophy".

Hi, Lucy. I guess what I meant was really "what do they know about it?" As you pointed out, your doctor did not even see it before surgery.

I really do believe that I have something there and that the basement membrane has an uneven surface. I just wonder how much it can be considered to be a "dystrophy," since it is not progressive (and progressive conditions characterize all other dystrophies).

You are so right. I got the information that abmd usually begins "after the fourth decade of life" from reading about it on various doctors' pages. I still have loads of questions about it. How is it related to injury? How does it come to create spontaneous problems for some (10%) of those with it but not others (90%)? It seems like there is a lot that is unknown about it.

I'm so sorry about how it all began in your case. If it were present, and it sure sounds like it was, then your doctor should have identified it and not gone through with the surgery.

--Liz

[Nowty]

I am another statistic who has posted a couple of times on here.

Epi-Lasek Oct 2006 and have had RCE's ever since although I am now having less severe ones. Eyes still dry as hell in evening and overnight.

And I found another person on my laser clinic's forum who also is having what seems the same problem after Epi-Lasek. See link below.

www.optimax.co.uk/InstantForum/Topic502-4-1.aspx

I sent him an email and invited him to look at our dry eye forum.

[Guest]

- Diameter of your treatment zone?
- Your prescription before surgery?
- What laser was used?
- Method of removing the epithelium? (Scrape... separate... laser...)
- Was MMC used?

Rebecca

I feel so inferior reading this post as I simply don't know the answers to these questions.

I thought I was well up on my procedure and understood it but the reality is I have no idea what the treatment zone is,
My prescription prior to treatment was L-2.5 and r -2.0 with mild astigmatism
I have no idea what brand the laser way
My epithelium was loosened with alcohol solution and then pushed aside with some round instrument (put in place before the alcohol solution was put on).
Don't know what MMC is.

Your post has prompted me to seek this information from my clinic and I will post when I receive it.

Ian

[indrep]

I think Rebecca is refering to Mitomycin C with the MMC abreviation.

[MyDryEyes]

Okay, so I am feeling a bit freaked out by this thread. I am about 10 months out from PRK. I haven't had any problems with RCE's - is this a problem that I could still develop??

Also, I find it incredibly freaky that there is an entire layer of the cornea that doesn't grow back. YIKES!!

Diameter of your treatment zone? NOt sure
- Your prescription before surgery? -11.75 left eye, -12 right eye
- What laser was used? not sure
- Method of removing the epithelium? (Scrape... separate... laser...) scrape I do believe.
- Was MMC used? not sure

[Guest]

MDE

I wouldn't worry yourself too much about this.

The fact that you had your cornea lasered is in fact removing tissue.

I initially had a similar reaction to you but then put it in perspective.

As far as the RCE's go, my GUESS is that if you haven't had them by now than it is unlikely that you will develop this condition as a result of your surgery.

Normally RCE's occur soon after surgery as the epithelium is trying to reattach itself to the underlying cornea.

Don't worry too much about this, you probably already have enough to deal with and the reality is you can't do a lot about it now.

Ian.

[liz56]

Ian makes a great point. RCE's don't happen to everyone who has these procedures. I keep hearing from various doctors about an "enzyme," and when my second ophthalmologist told me about it, he said that I was lacking it. When I read about RCE's on line, it seemed to suggest that I may have an errant kind of enzyme. I never really did sort that out or understand it.

Also, it is interesting to note that people who suffer from RCE's often note significant improvement after having PRK or PTK. So, go figure! Maybe it is like fighting fire with fire? I don't know, but every case is individual, and it is hard to know what is really happening there in those thin, specialized cell layers that interact so significantly with lipids, saline, and water in the tear film!

--Liz

[MyDryEyes]

Ian and Liz,

Thank you for the reassurances!! I hope that your RCE's diminish to nothing!! It must be incredibly painful.

MDE

[Mcgoldilocks]

Just to add my experience to this thread, a year ago I saw a doctor who examined my eyes thoroughly and said I was fine to go ahead in having laser eye surgery. I did tell him I have had eye pain upon waking several times over the years, and one bad corneal abrasion but he didn't seem to think that was a problem.

I've definitely got ABMD so it's a very good thing I didn't go ahead with it.