Surgeons debate epithelial replacement after LASEK

CLEVELAND — Should the epithelial sheet be replaced on the cornea after surface ablation? This question was debated by refractive surgeons during a round table discussion here at the International Congress on LASEK and Advanced Surface Ablation.

Most refractive surgeons who perform laser epithelial keratomileusis (LASEK) prefer to try to rehabilitate the epithelial layer rather than remove and dispose of it after LASEK. However, debate continues about what is the best procedure.

“The more tissue that remains, the more stable the cornea is going to be,” Raymond A. Applegate, OD, PhD, told attendees.

Thomas Claringbold, DO, agreed. “I like pulling the epithelial layer back over the cornea after LASEK — whether it’s alive or dead — because it protects the eye,” he said.

“There is benefit in putting the flap on as best you can,” added Massimo Camellin, MD, the Italian surgeon who gave the LASEK technique its name. Dr. Camellin said he replaces the epithelial layer of all his patients after LASEK. After replacing the flap, he seals it in place with a contact lens to prevent shifting and aid wound healing.

“Even if the epithelial cells are dead, they can still help to regenerate a new series of cells. They will help to rebuild a healthy cornea,” he said.

Vikentia J. Katsanevaki, MD, who took the opposing view, said dead, traumatized cells could actually impede healthy growth.

“The dead cells could stand as barriers to cell growth, altering the natural biological state,” she said. Additionally, dead epithelial cells could further inhibit healing of the cornea by releasing toxins.

“I question the quality of wound healing where there are dead cells intact,” agreed panel moderator Richard W. Yee, MD. Wound healing can be slower when dead cells are present, he said.

Jose Matos, MD, explained the point further. “The vitality of the epithelium has a lot to do with the comfort patients have after LASEK. When the epithelium is healthier, wound healing is better and patients are happier,” Dr. Matos said.

Dr. Yee said he noted good results in LASEK patients who had their mostly healthy epithelial cells salvaged after surgery. However, he said, each LASEK case — depending on the health of the epithelial layer after surgery — should be approached individually.

“There is a time and a place for each type of method,” he said. “We still have a lot of work to do before we can truly determine which method is most conducive to successful surgical outcomes.”