Blepharoplasty in the Post–Laser In SituKeratomileusis Patient: PreoperativeConsiderations to Avoid Dry Eye SyndromeBobby S. Korn, M.D., Ph.D.
Don O. Kikkawa, M.D.David J. Schanzlin, M.D.
La Jolla, Calif
Background: The authors used a retrospective case series to describe the in-creased frequency of dry eye syndrome in patients who have undergone bothlaser in situ keratomileusis and blepharoplasty.Methods: The authors reviewed records from six patients who required surgicalcorrection for exposure keratopathy previously treated by both laser in situkeratomileusis and blepharoplasty.Results: All six patients developed significant exposure keratopathy postoper-atively requiring surgical intervention. Four patients had blepharoplasty fol-lowed by laser in situ keratomileusis, and two patients had laser in situ kerato-mileusis followed by blepharoplasty. Symptomatic dry eye symptoms followedthe second procedure 1 week to 4 months later. Surgical correction of eyelidmalposition and lagophthalmos markedly improved symptoms.Conclusions: Patients with a history of laser in situ keratomileusis contemplat-ing blepharoplasty are at higher risk of developing postoperative dry eye syn-drome. Surgeons performing these procedures should perform thoroughpreoperative evaluation and surgical planning to minimize this potentialcomplication. (Plast. Reconstr. Surg. 119: 2232, 2007.)
Blepharoplasty is one of the most frequentlyperformed cosmetic procedures in theUnited States, with over 465,000 cases
annually.1 Dry eye syndrome is a well-recognizedand dreaded complication after blepharoplastysurgery, with an incidence of 8 to 21 percent.2–5
There are multiple etiologic factors responsiblefor dry eye symptoms after blepharoplasty, withlower eyelid malposition as the principalmechanism.6 Lagophthalmos, eyelid retraction,alterations in the tear film, and diminished blinkreflex all result in increased tear evaporationand dry eye symptoms.4,5,7,8
Another frequent cosmetic procedure is laser-assisted in situ keratomileusis or laser in situkeratomileusis. Annually, over 1.3 million laserin situ keratomileusis procedures are performedin the United States alone.9 The laser in situkeratomileusis procedure itself is not without
complications. In a recent survey of the Ameri-can Society of Cataract and Refractive Surgeons,dry eye symptoms were the most common com-plaint after surgery, accounting for up to 15 to25 percent of all cases.10 With the increasingvolumes of these cosmetic procedures per-formed annually, there will no doubt be an in-creasing number of patients who have under-gone both operations.
Laser in situ keratomileusis surgery can in-duce dry eye symptoms by a variety of differentmechanisms. The cornea is richly innervated bythe long ciliary nerves of the ophthalmic divisionof the trigeminal nerve. The majority of theseterminal nerve fibers enter the cornea horizon-tally at the 3-o’clock and 9-o’clock positions. Ac-tivation of these sensitive nerve fibers by foreignbodies or ocular surface desiccation stimulatesthe blink reflex to sweep the corneal surface withtears.11,12 During laser in situ keratomileusis flapcreation and laser ablation, these nerves aretransected, resulting in decreased corneal sensi-tivity and a transient neurotrophic cornea.13,14 Asa result, the blink reflex arc is blunted, contrib-uting to dry eye symptoms. Battat et al. and Todaet al. reported other possible mechanisms fordry eye, including decreased rates of tear pro-
duction and clearance after laser in situkeratomileusis.8,13 Hori-Komai et al. reported anincrease in interpalpebral width after laser insitu keratomileusis surgery, suggesting that dryeye symptoms may result from a change in theapposition of the eyelids with the ocularsurface.15
In our clinical ophthalmic practice, we havenoted more frequent presentations of dry eyesymptoms in patients who have undergone bothblepharoplasty and laser in situ keratomileusis.The relationship between blepharoplasty and la-ser in situ keratomileusis in the development ofpostoperative dry eye has not been well studied.In this report, we present the findings in ourseries of patients with dry eye symptoms whopreviously had both blepharoplasty and laser insitu keratomileusis. To our knowledge, this is thefirst report to describe dry eye symptoms exac-erbated after both blepharoplasty and laser insitu keratomileusis.
PATIENTS AND METHODSAll patients were examined at the Shiley Eye
Center at the University of California, San Di-ego, a university-based tertiary referral practice.This study was approved by the University ofCalifornia, San Diego Human Research Protec-tions Program and conforms with the principlesoutlined in the Declaration of Helsinki. A totalof six patients who had previously undergoneboth upper and lower eyelid blepharoplasty andlaser in situ keratomileusis were reviewed andanalyzed retrospectively. In our chart review, weexamined age, sex, medial and surgical history(including timing of both blepharoplasty andlaser in situ keratomileusis), and details fromophthalmic examination. The ophthalmic dataincluded the presence of ocular symptoms, vi-sual acuity, eyelid position, margin to reflex dis-tance (defined as the distance from the uppereyelid to the central corneal light reflex and thedistance from the lower eyelid to the corneallight reflex), lagophthalmos, and corneal stain-ing. Tear breakup time and tear meniscus levelwere measured as previously described.16
Laser in situ keratomileusis surgery was per-formed using the VISX Star excimer laser (VISX,Inc., Santa Clara, Calif.) or the Ladarvision exci-mer laser (Alcon, Inc., Fort Worth, Tex.). Beforecreation of the flap, topical anesthetic consistingof proparacaine 1% was instilled. The flap wascreated at a depth of 160 mm and a diameter of9.5 mm using the Hansatome microkeratome(Bausch & Lomb, Rochester, N.Y.), NIDEK mi-
crokeratome, or automated corneal shaper micro-keratome (Chiron, Claremont, Calif.). The lasercorrection was achieved with a 6.5-mm ablationzone for myopic correction or a 9.0-mm ablationzone for hyperopic correction. At the time of sur-gery, all patients received topical antibiotics [0.3%ofloxacin (Allergan, Inc., Irvine, Calif.) or 0.3%ciprofloxacin (Alcon, Inc., Fort Worth, Tex.)], ananti-inflammatory (0.1% ketorolac; Allergan),and a steroid (1% prednisolone acetate; Aller-gan). Postoperatively, all patients were given, fourtimes daily, 1% prednisolone acetate, ofloxacin orciprofloxacin, and nonpreserved artificial tears.
All procedures to correct ocular surface symp-toms were performed by one surgeon (D.O.K.).Initial treatment consisted of artificial tear sup-plementation followed by punctal plug placementor punctal cautery for refractory symptoms. Pa-tients with more severe symptoms required surgi-cal intervention. All operations were performedunder local anesthesia with lidocaine 0.5% andepinephrine 1:200,000, with monitored care, andplaced on Frost sutures for 3 to 5 days.
For cases of lower eyelid retraction with lessthan 1 mm of scleral show inferiorly, the lowereyelid was recessed beneath the inferior tarsal bor-der. A transconjunctival incision beneath the in-ferior tarsal border was performed to release thelower eyelid retractors. A 6-0 mild chromic suturewas then used to recess the palpebral conjunctiva2 to 3 mm beneath the inferior tarsal border. Incases of lower eyelid retraction with 2 mm ofscleral show, autologous hard palate was used as aspacer graft in the inferior fornix. The graft wassecured with 6-0 fast absorbing gut sutures. Forlower eyelid retraction with greater than 3 mm ofscleral show, hard palate grafting was combinedwith midface elevation. Lateral canthoplasty wasperformed using 5-0 polygalactin sutures to securethe inferior crus of the lateral canthal tendon tothe superior crus.
RESULTSA summary of demographic and clinical char-
acteristics is provided in Tables 1 and 2.
CASE REPORTSPatient 1
A 63-year-old woman underwent bilateral upper and lowereyelid blepharoplasty in October of 2001. Postoperatively, thepatient was noted to have 1 mm of lagophthalmos and lowereyelid retraction bilaterally but denied any dry eye symptoms.On clinical examination, there was no punctate keratopathy ofthe cornea. In November of 2001, she underwent bilateralhyperopic laser in situ keratomileusis. A superiorly hinged cor-neal flap was created with the Hansatome microkeratome. One
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month after laser in situ keratomileusis, the patient presentedto the clinic with foreign body sensation in both eyes. Inferiorpunctate staining of the cornea was noted bilaterally. Initialtreatment consisted of aggressive ocular lubrication followed bybilateral lower punctal plug placement. Despite these treat-ments, the patient continued to have intractable dry eye symp-toms and elected to undergo surgical correction. The patientunderwent bilateral lower eyelid retraction repair with hardpalate grafting (Fig. 1). Two months after surgery, the patientreported marked improvements in her dry eye symptoms, withno lagophthalmos. Visual acuity improved from 20/40 preop-eratively in both eyes to 20/25 postoperatively in the right eyeand 20/30 in the left eye.
Patient 2A 73-year-old woman underwent bilateral upper and lower
eyelid blepharoplasty in June of 1998 resulting in 2 mm oflagophthalmos bilaterally. In April of 1999, she elected to un-dergo laser in situ keratomileusis for monovision in the righteye. A nasally hinged corneal flap was created with the auto-mated corneal shaper microkeratome. Four months after laserin situ keratomileusis, the patient began to experience intenseforeign body sensation in the right eye. Ocular examinationdisclosed confluent punctate staining of the cornea in the righteye and no staining in the left eye. Before laser in situ kerato-mileusis, the patient developed lagophthalmos and inferiordisplacement of the lateral canthus but was without dry eyesymptoms. She was managed with aggressive lubrication initiallybut continued to have persistent exposure keratopathy in theright eye. After lateral canthoplasty was performed, the patient’socular symptoms resolved.
aroplasty in 1981. In 1993, she underwent bilateral upper eyelidblepharoplasty. Her postoperative course was complicated by 1mm of lagophthalmos in the right eye, 3 mm of lagophthalmosin the left eye, and mild exposure keratopathy maintained withartificial tears for 9 years. In February of 2002, she underwentbilateral hyperopic laser in situ keratomileusis. One week afterlaser in situ keratomileusis, the patient reported intense dry eyesymptoms greater in the left eye than in the right eye. Oph-thalmic examination revealed dense inferior punctate staininggreatest in the left eye. Initial treatment consisted of nightlylubricating ointment with eyelid taping and punctal plug place-ment. Despite these measures, the patient continued to havepersistent symptoms necessitating further surgery. The patientunderwent bilateral lower eyelid retraction repair with hardpalate grafts and midface lifting. Two months after surgery,corneal staining was negative and the patient reported resolu-tion of all dry eye symptoms (Fig. 2).
blepharoplasty in 1992. In July of 2000, bilateral lower eyelidblepharoplasty was performed. Immediately after surgery,the patient reported mild foreign body sensation greater inthe right eye than in the left eye. The dry eye symptoms weremanaged successfully with artificial tears. In January of 2002, thepatient underwent bilateral laser in situ keratomileusis. Oneweek after this procedure, the patient reported marked exac-erbation of dry eye symptoms greatest in the right eye. Exam-ination revealed bilateral lower eyelid retraction with 1 mm of
Table 1. Patient Demographics and Timing of LASIK and Blepharoplasty
Case Age/Race/Sex Date of LASIK Operated Eye Type of Hinge MicrokeratomeDate of UpperBlepharoplasty
Date of LowerBlepharoplasty
1 63/W/F 11/2001 OU Superior Hansatome 10/2001 10/20012 73/W/F 4/1999 OD Nasal ACS 6/1998 6/19983 42/W/F 2/2002 OU Nasal Nidek 1993 19814 57/A/F 1/2002 OU Nasal Unknown 1992 20005 45/W/F 1999 OD Nasal Unknown 5/2000 5/20006 57/W/M 7/1997 OD Nasal Unknown 1/2002 1/2002LASIK, laser in situ keratomileusis; W, white; F, female, M, male, A, Asian; OU, both eyes; OD, right eye; ACS, automated corneal shaper.
Table 2. Clinical Characteristics before Corrective Surgery
Case
MRD1/MRD2
LagophthalmosSuperficial Punctate
KerabottomathyReports Symptoms
of Dry EyesOD OS
1 3/8 3/8 OD, 1 mm OU 1 mo after LASIKOS, 1 mm
2 4/8 4/8 OD, 2 mm OD inferior 4 mo after LASIK ODOS, 2 mm
3 4/7 4/9 OD, 1 mm OU 1 wk after LASIKOS, 3 mm
4 4/7 4/7 OD, 1 mmOS, 1 mm
OU inferior Baseline 1 mo after lower blepharoplasty, markedlyworsened 1 wk after LASIK
5 3.5/7 3/7 OD, 2 mm OU inferior 1 mo after blepharoplastyOS, 2 mm
6 5/8 5/7 OD, 2 mm OD 2 mo after blepharoplastyOS, 2 mm
MRD, margin to reflex distance (MRD1 and MRD2, defined as the distance from the upper eyelid to the central corneal light reflex and distancefrom the lower eyelid to the corneal light reflex, respectively); LASIK, laser in situ keratomileusis; OD, right eye; OS, left eye; OU, both eyes.
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Fig. 1. (Above) Preoperative photographs of a patient demonstrating lower eyelid retraction and lagophthalmos. (Below) Postop-erative photographs showing return of normal eyelid position after repair consisting of bilateral mucosal hard palate grafting.
Fig. 2. (Above) Preoperative photographs of patient 3 demonstrating lower eyelid retraction and lagophthalmos. (Below) Postop-erative photographs showing return of normal eyelid position after repair consisting of bilateral mucosal hard palate grafting andmidface lifting.
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lagophthalmos and inferior punctate staining. Initial treatmentconsisted of increased frequency of artificial tear instillationfollowed by bilateral punctal plug placement. Despite thesetreatments, the patient continued to experience exposure kera-topathy. Bilateral canthoplasty was subsequently performed toaddress the eyelid retraction. After surgical correction, the pa-tient reported marked improvement in her dry eye symptoms,with decreased punctate staining.Patient 5
A 45-year-old woman underwent laser in situ keratomileusisfor monovision in the right eye in July of 1999. She toleratedthe procedure well, without any dry eye symptoms. In May of2000, the patient had bilateral upper and lower eyelid bleph-aroplasty. Within 1 month after surgery, the patient notedmarked foreign body sensation greatest in the right eye. Use ofcopious artificial tears and adjunct placement of punctal plugsdid not alleviate the dry eye symptoms. Definitive surgical treat-ment consisted of repair of lid retraction with hard palatemucosal grafting and bilateral canthoplasty with resolution ofsymptoms.Patient 6
A 57-year-old man underwent laser in situ keratomileusis formonovision in the right eye in 1997. One month after laser insitu keratomileusis, the patient noted increasing foreign bodysensation in the right eye. Initial treatment consisted of artificialtears followed by punctal placement to control dry eye symp-toms. Ophthalmic examination of the cornea revealed no punc-tate staining. In January of 2002, bilateral upper and lowereyelid blepharoplasty was performed. Two months after bleph-aroplasty, the patient reported marked worsening of dry eyesymptoms greatest in the right eye. Examination disclosed bi-lateral inferior punctate staining with bilateral lower eyelidretraction and lagophthalmos. Despite aggressive lubricationand punctal plug placement, the patient continued to experi-ence exposure keratopathy necessitating surgical correction.Lower eyelid retraction repair consisting of canthoplasty andhard palate mucosal graft was performed bilaterally. After sur-gical correction of eyelid malposition and lagophthalmos, thepatient reported partial improvement in dry eye symptoms withreduced punctate staining.
DISCUSSIONThe association between blepharoplasty and
laser in situ keratomileusis in the development ofpostoperative dry eye syndrome has not been wellstudied. Each procedure has been shown to inde-pendently cause dry eye.4,5,7,8,13 In this case series,we report the development of dry eye syndrome inpatients with previously stable blepharoplasty andlaser in situ keratomileusis patients who subse-quently underwent the second procedure.
Symptoms of dry eye occurred within an av-erage of 1.2 months (range, 1 week to 4 months)after the second procedure and persisted on av-erage 12.6 months until surgical treatment (Table2). In each case, initial management consisted ofartificial tear supplementation followed by punc-tal plug placement. Benitez and Toda previouslynoted that decreased tear secretion and cornealsensation were maximal up to 3 months after laserin situ keratomileusis surgery, and by 6 months
after laser in situ keratomileusis, most patientsreturned to baseline tear secretion and cornealsensation.13,17 In patients undergoing uncompli-cated blepharoplasty, exposure keratopathy wasnoted maximally up to 8 weeks postoperatively.4 Inour series, none of the patients experienced reliefwith artificial tears and punctal plugs and eachrequired surgical correction. Depending on theseverity of the eyelid malposition, repair of lowereyelid retraction with or without mucosal hardpalate grafting was required for resolution of dryeye symptoms.
Lagophthalmos was a common finding in allsymptomatic patients. In four of the cases, bleph-aroplasty was performed before laser in situ kera-tomileusis. Pre–laser in situ keratomileusis lagoph-thalmos was present and dry eye symptoms weremanaged conservatively with ocular lubrication.However, after creation of the corneal flap andlaser in situ keratomileusis, conservative manage-ment with artificial tears was no longer sufficientto control dry eye symptoms in these patients.Presumably, despite the lagophthalmos, cornealsensation was intact, and during periods of ocularsurface dryness, the corneal reflex arc would stim-ulate increased blinking, lessening the dry eyesymptoms. After laser in situ keratomileusis, theblink reflex was blunted, exacerbating the dry eyesymptoms.
The additive effect of laser in situ kerato-mileusis and preexistent postblepharoplasty lag-ophthalmos is best demonstrated in the monoc-ular laser in situ keratomileusis cases (cases 2, 5,and 6). Dry eye symptoms in those patients onlydeveloped in the eye that underwent both laser insitu keratomileusis and had postblepharoplastylagophthalmos. The non–laser in situ keratom-ileusis eye with postblepharoplasty lagophthalmosremained at baseline state, with no exacerbationof dry eye symptoms, presumably because theblink reflex remains intact in the fellow eye.
In the post–laser in situ keratomileusis patientconsidering eyelid surgery, the responsibility is onthe blepharoplasty surgeon to avoid lid retractionand lagophthalmos. In our practice, we delay anyelective eyelid surgery until 6 months after the lastlaser in situ keratomileusis surgery. The return ofnormal corneal sensation after creation of laser insitu keratomileusis flaps generally occurs after a6-month period.18,19 We propose the following al-gorithm, outlined in Figure 3. First, the patient isevaluated for any dry eye symptoms. Next, we eval-uate for quantitative signs of tear dysfunction withSchirmer’s testing, tear breakup time, and tearmeniscus evaluation. If any of these findings are
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abnormal, any surgery is delayed for an additional3 months. Artificial tear supplementation andpunctal plug placement are performed if neces-sary. If the preoperative evaluation is normal, wewill consider conservative blepharoplasty with sev-eral considerations. First, we avoid excessive skinand fat removal, particularly in the lower eyelid.Next, during the dissection, we remove the skinonly, leaving the orbicularis oculi muscle intact.To prevent lid retraction after blepharoplasty, weaddress any lower eyelid laxity and midfacial de-scent at the time of surgery.20,21 Finally, all patients
receive postoperative artificial tear supplementa-tion for 1 month after surgery. Aggressive ocularlubrication is particularly important in the earlypostoperative period because of transient paralysisof eyelid closure by local anesthesia.
When contemplating laser in situ keratomileu-sis surgery in the postblepharoplasty patient, par-ticular attention is paid to the periocular exami-nation. Any preexisting lagophthalmos or eyelidretraction should be surgically corrected beforeperforming laser in situ keratomileusis. Correc-tion requires a two-fold approach: (1) increasing
Fig. 3. Algorithm for preoperative blepharoplasty evaluation.
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tear availability with removable punctal plugs orpermanent closure supplemented with artificialtears, and (2) return of the eyelids to physiologicposition with eyelid retraction repair, with possi-ble hard palate grafting and/or midface elevationin severe cases. There are multiple proceduresdesigned to address correction of lower eyelid re-traction. The surgical techniques for the patientsin this study are described in the Patients andMethods section and represent the personal ex-periences of the authors and are not implied to bethe standard of care. Once all eyelid abnormalitiesare corrected, laser in situ keratomileusis surgerycan be considered.
An interesting point this study raises is thepotential cause of dry eye symptoms in patientswho have undergone laser in situ keratomileusisalone. Up to 15 to 25 percent of patients under-going routine laser in situ keratomileusis experi-ence dry eye symptoms.10 Although laser in situkeratomileusis is predominantly a procedure per-formed in younger patients, the presence of senileeyelid malposition was not addressed in thesepatients, and a subset of these dry eye cases mayin fact be attributed to preexisting malposition.Thus, a thorough ocular adnexal examinationshould be performed in the routine preoperativeassessment of the nascent laser in situ kerato-mileusis patient.
This study underscores the need for completepreoperative periocular examination before laser insitu keratomileusis. In addition to a thorough oph-thalmic preoperative evaluation, the examinationshould document, at a minimum, the presence oflagophthalmos, margin-to-reflex distance measure-ment, eyelid position, Schirmer’s testing, and cor-neal sensation. The shortcomings of our series areinherent in the retrospective nature of this type ofstudy. Some selection bias may be present in thatonly patients with the most severe exposure kera-topathy present. Presumably, there are patients whohave undergone both procedures with subclinicaldry eye but do not present clinically. These patientscould have served as suitable controls, but we wereunable to identify these individuals. However, cases2, 5, and 6 do serve as excellent internal controlsbecause each of these patients with preexistent bi-lateral lagophthalmos underwent monocular laserin situ keratomileusis and only experienced symp-toms in the post–laser in situ keratomileusis eye. Inaddition, we did not study outcomes of patients whounderwent eyelid malposition correction before la-ser in situ keratomileusis.
CONCLUSIONSWe report an association between laser in situ
keratomileusis and blepharoplasty to induce dryeye syndrome. The combination of an eyelid mal-position with the transient neurotrophic keratopa-thy induced by laser in situ keratomileusis canresult in debilitating dry eye symptoms. With thenumbers of patients undergoing both of thesecosmetic procedures increasing, the incidence ofdry eye symptoms will likely increase. Ophthal-mologists must complete thorough preoperativeadnexal evaluation in postblepharoplasty patientsbefore performing laser in situ keratomileusis.Likewise, surgeons performing blepharoplasty mustbe aware of the potential complications in thepost–laser in situ keratomileusis patient. Futureprospective studies should be designed to evaluatethe efficacy of correcting eyelid malposition fromblepharoplasty before performing laser in situkeratomileusis and to identify the optimal timingfor performing laser in situ keratomileusis afterblepharoplasty.
Don O. Kikkawa, M.D.Department of Ophthalmology
Shiley Eye CenterUniversity of California, San Diego
9415 Campus Point DriveLa Jolla, Calif. 92093-0946
ACKNOWLEDGMENTThis work was supported by a grant from the Bell
Family Foundation.
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3. Saadat, D., and Dresner, S. C. Safety of blepharoplasty inpatients with preoperative dry eyes. Arch. Facial Plast. Surg. 6:101, 2004.
4. Vold, S. D., Carroll, R. P., and Nelson, J. D. Dermatochalasisand dry eye. Am. J. Ophthalmol. 115: 216, 1993.
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6. Hamako, C., and Baylis, H. I. Lower eyelid retraction afterblepharoplasty. Am. J. Ophthalmol. 89: 517, 1980.
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10. Solomon, K. D., Fernandez de Castro, L. E., Sandoval, H. P.,et al. Refractive surgery survey 2003. J. Cataract Refract. Surg.30: 1556, 2004.
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14. Donnenfeld, E. D., Solomon, K., Perry, H. D., et al. The effectof hinge position on corneal sensation and dry eye afterLASIK. Ophthalmology 110: 1023, 2003.
15. Hori-Komai, Y., Toda, I., and Tsubota, K. Laser in situ kera-tomileusis: Association with increased width of palpebralfissure. Am. J. Ophthalmol. 131: 254, 2001.
16. Burkat, C. N., and Lucarelli, M. J. Tear meniscus level as anindicator of nasolacrimal obstruction. Ophthalmology 112:344, 2005.
17. Benitez-del-Castillo, J. M., del Rio, T., Iradier, T., et al. De-crease in tear secretion and corneal sensitivity after laser insitu keratomileusis. Cornea 20: 30, 2001.
18. Kanellopoulos, A. J., Pallikaris, I. G., Donnenfeld, E. D., et al.Comparison of corneal sensation following photorefractivekeratectomy and laser in situ keratomileusis. J. Cataract Re-fract. Surg. 23: 34, 1997.
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