How to Avoid Refractive Surgery Complications

Maintaining a healthy ocular surface is critical to surgical success, and complications can be avoided thanks to good optimisation, protection, and monitoring at every stage, according to Sotiria Palioura PhD. She highlighted four ocular surface complications to consider: dry eye disease (DED), neuropathic corneal pain, persistent epithelial defects (PEDs), and Salzmann nodular degeneration.

Almost every patient has dry eye disease after corneal laser refractive surgery, which should improve after six months. If the dry eye is still present after nine months, it can be quite severe.

“Dry eye is the number one complaint, responsible for about 20% of post-LASIK dissatisfaction referrals,” she said.

Dry eye disease causes significant visual fluctuations and decreases contrast sensitivity, undermining the primary benefits of refractive surgery. Contributing factors in LASIK procedures are corneal nerve damage, suction ring and conjunctival goblet cell damage, and the use of topical drops with preservatives, or NSAIDs, which can be toxic to the corneal epithelium. KLEx and PRK procedures can also lead to postoperative dry eye, with some differences.

The main risk factor for postoperatively developing DED is preexisting dry eye, which Professor Palioura said should be treated more aggressively before the surgery—especially in female patients, those older than 40 years of age, or in cases of contact lens intolerance, blepharitis, and meibomian gland dysfunction (MGD). Frequently lubricating the cornea using a longer steroid taper and long-term immunomodulators such as cyclosporine are effective treatments.

Neuropathic corneal pain is characterised by hypersensitivity and pain without obvious injury that affects LASIK, PRK, and SMILE patients. Distinguishing between peripheral and central pain components is crucial for treatment, Prof Palioura pointed out. Peripheral pain can be managed with surface optimisation using serum tears or plasma rich in growth factors (PRGF). Central pain may require a pain specialist and systemic medications, such as gabapentin, pregabalin, and duloxetine. Recent case reports suggest the use of intranasal neurostimulation or corneal neurotisation in severe cases and in specialised centres.

PEDs occur when the epithelium fails to close after surgery, especially in PRK and LASIK surgeries.

“During LASIK flap creation, we see epithelial defects in 1.6% to 5.0% of cases, and most tend to heal [quickly],” she said. “If they do not heal, it may be because the patient had EBMD, age over 40, diabetes, dry eye, or intraoperative trauma. Early consequences include delayed healing, discomfort, and higher risk of microbial keratitis and diffuse lamellar keratitis. Late consequences include epithelial ingrowth, flap melt, and corneal haze in PRK cases.”

Initial treatment should include bandage contact lenses, intensive lubrication, and broad-spectrum antibiotics. NSAIDs and preservatives should be avoided to minimise epithelial toxicity. If the PED persists, amniotic membrane, autologous serum, PRGF, and topical insulin or NGF drops may be used. Close monitoring and restarting topical steroids after closure are necessary to prevent haze, she added.

While Salzmann nodular degeneration is a rare condition, its nodules are grey or white, subepithelial, and linked to chronic irritation or prior corneal injury. They appear years or decades after refractive surgery and can cause significant irregular astigmatism if central and large. Small, peripheral nodules can be managed with lubrication and surface inflammation control. Central nodules require surgical removal using diluted alcohol and a crescent blade, as well as caution to avoid disturbing the flap.

“You really have to trim the nodule and be more tolerant of leaving some scarring behind,” she advised. “And if that scarring is still visually significant, you can consider PTK afterwards, but you do not have to remove everything if the nodule is deep at the flap edge.”

Prof Palioura spoke at the 2025 ESCRS Annual Congress in Copenhagen.

Sotiria Palioura MSc, PhD, CEBT, FEBO, FEBOS-CR is Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute, University of Miami, US.