Central Toxic Keratopathy Following Photorefractive Keratectomy: A Case Series And Conservative Management

To describe the clinical course, refractive and tomographic changes, timing of onset, and outcomes of central toxic keratopathy (CTK) following photorefractive keratectomy (PRK), and to evaluate a structured conservative management protocol.

Magrabi Health , Almurjan Eye Center, Jeddah , KSA.

This retrospective case series included 4 eyes that developed CTK after PRK. All eyes had an unremarkable postoperative day-1 examination showing only epithelial defects without stromal abnormalities. At postoperative day 6, during BCL removal, all eyes demonstrated complete epithelial healing with acute-onset, painless, dense central stromal opacification associated with corneal thinning and flattening. Patients were followed with serial visual acuity, manifest refraction, keratometry, pachymetry, epithelial thickness mapping, and AS-OCT images. Management consisted of reassurance, preservative-free lubricants, and fluorometholone 2–4 times daily for 3 months, followed by topical cyclosporine for an additional 3 months.

Preoperative mean spherical equivalent was −3.03 D. Mean steep keratometry decreased from 45.88 D preoperatively to 41.40 D at 1 week, indicating approximately 4.5 D of central flattening. Minimum corneal thickness decreased from 557 µm preoperatively to 433 µm at 1 month. AS-OCT demonstrated central anterior stromal hyperreflectivity with focal stromal thinning and preserved peripheral architecture, without signs of inflammatory infiltration. Epithelial thinning at 1 month (36.25 µm) was followed by compensatory thickening at 6 months (47.5 µm). By 6 months, partial tomographic regression was observed, and all eyes achieved UDVA and CDVA of 20/20 despite mild residual hyperopic shift.

CTK following PRK presents with delayed onset around day 6 after epithelial healing and demonstrates significant transient stromal thinning and flattening. Conservative management results in excellent visual recovery, emphasizing the importance of early recognition to avoid unnecessary intervention.