J CATARACT REFRACT SURG - VOL 31, OCTOBER 2005

ARTICLES
Effect of hinge location on corneal sensation
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and dry eye after laser in situ

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keratomileusis for myopia

David T. Vroman, MD, Helga P. Sandoval, MD, Luis E. Fernández de Castro, MD, Terrance J. Kasper, MD,
Mike P. Holzer, MD, Kerry D. Solomon, MD

PURPOSE: To evaluate the effects of a superior or nasal hinge location on corneal sensation and dry
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eye after laser in situ keratomileusis (LASIK).

SETTING: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South
Carolina, Charleston, South Carolina, USA.
METHODS: This prospective randomized masked study included 47 patients having bilateral myopic
LASIK surgery. The first eye was randomly assigned to have a nasal or superior hinge flap; the fellow
eye had the alternate location. Visual acuity, contrast sensitivity, corneal sensation, basic secretion test,
tear film breakup time, conjunctival and corneal staining, and a subjective questionnaire were evalu-
ated preoperatively and postoperatively at 1 week and 1, 3, and 6 months. The Wilcoxon signed rank
test and paired t test were used for comparison.
RESULTS: Dry eye occurred with the same frequency in both groups. However, eyes with the nasal
hinge had significantly better nasal sensation than those with the superior hinge (P<.05) at 1 month.
CONCLUSION: Better nasal corneal sensation was found at 1 month in the nasal hinge group but there
was no difference in any other parameters measured.
J Cataract Refract Surg 2005; 31:1881–1887 Q 2005 ASCRS and ESCRS

Corneal sensation is essential to maintaining the integrity dry-eye symptoms are the most common problem encoun-
of the ocular surface. Neurotrophic keratitis can result tered after LASIK and occur in 15% to 25% of patients. Sev-
from common ocular disorders such as herpes simplex, eral factors may influence these symptoms, but decreased
herpes zoster infections, or from uncommon insults affect- corneal sensation may play a major role. Wilson et al.11,12
ing the Vth cranial nerve such as tumor, irradiation, or have described corneal staining after surgery as LASIK-in-
strokes.1 In its early stages, neurotrophic keratopathy can duced neurotrophic epitheliopathy. Other potential factors
manifest as an interpalpebral punctate keratitis and visual include difficulty wetting the ocular surface due to me-
fluctuation and can progress to loss of epithelial integrity chanical and shape factors and a loss of neuroregulatory
and corneal stromal melting.2 factors derived from the corneal nerves that promote epi-
Corneal surgical procedures may disrupt the normal thelial health.
organization of corneal innervation; this includes refractive The subject of corneal innervation has gained impor-
surgery, which has been shown to cause decreased corneal tance in recent years because of the observation that corne-
sensation. This has been documented after epikeratopha- al nerves are routinely injured following modern refractive
kia,3 radial keratotomy,4 photorefractive keratectomy,5 surgical procedures. An example is LASIK surgery, in which
and laser in situ keratomileusis (LASIK).6–9 a microkeratome is used to create a hinged lamellar corneal
As the popularity of LASIK has grown, the number of flap, disrupting the normal organization of corneal innerva-
patients experiencing dry-eye symptoms has grown as tion. This damage can lead to transient or chronic neurotro-
well. According to the 2003 Refractive Surgery Survey,10 phic deficits.11,12 Some authors suggest the corneal nerves

Q 2005 ASCRS and ESCRS 0886-3350/05/$-see front matter

Published by Elsevier Inc. doi:10.1016/j.jcrs.2005.03.074

1881
 EFFECT OF HINGE LOCATION AFTER LASIK FOR MYOPIA

predominantly enter the cornea at the 9 and 3 o’clock posi- the Amadeus microkeratome (Advance Medical Optics) with
tions, thus creating a LASIK flap with a hinge that provides a 160 mm plate depth. The Hansatome had a standard hinge that
was not adjustable. The Amadeus unit was adjusted based on kera-
a potential conduit for superficial innervation. A vertical
tometry values and a nomogram to achieve a 5.0 mm hinge width.
flap (superior hinge) would transect both major areas of The hinge position was randomly assigned to the first eye, and the
corneal innervation, whereas a horizontal flap (nasal alternate hinge location was created in the patient’s other eye.
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hinge) would transect only 1 of these areas.13 This suggests Hinge location was masked to the patient and technicians collect-
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that a nasally hinged corneal flap may cause less loss of sen- ing the data. An 8.5 mm ring size was used in all cases. The hinge
width was measured with calipers at the time of surgery.
sation than a superior hinge.13–16 However, Müller et al.17
Postoperatively, all patients were given prednisolone acetate
report finding that leashes extend across the corneal apex 1% ophthalmic solution (Pred Forte) and ofloxacin 0.3% ophthal-
preferentially in the 6 to 12 o’clock direction and other mic solution (Ocuflox) to use 4 times a day for 1 week. Patients
leashes approach the apex in the 5 to 11, 7 to 1, 9 to 3, 2 were also directed to use nonpreserved artificial tears (Refresh
to 8, and 4 to 10 o’clock directions. Descriptions of the Tears) 4 times a day for 2 weeks and then as needed.
Every patient had preoperative and postoperative (1 week
anatomy of mammalian corneal innervation are numerous;
and 1, 3, and 6 months) evaluations. Uncorrected and best
nevertheless, many aspects of corneal nerve architecture re- corrected visual acuity (CSV-1000ETDRS, Vector Vision), con-
main incompletely understood. The true distribution of trast sensitivity (CSV-1000E, Vector Vision), corneal sensation
corneal nerves is controversial and still being elucidated. (Cochet-Bonnet Corneal Aesthesiometer, Luneau Ophtalmolo-
The purpose of this study was to determine the effects gie), basic secretion test, tear breakup time (TBUT), ocular surface
staining, and a questionnaire containing 12 questions evaluating
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of hinge position (superior versus nasal) on corneal sensa-

dry eye under specific conditions (Ocular Surface Disease Index
tion and dry-eye signs and symptoms after LASIK. [OSDI])17 were obtained for each patient.

PATIENTS AND METHODS Corneal Sensation

Included in this prospective randomized masked study were The Cochet-Bonnet corneal aesthesiometer was used to as-
94 eyes of 47 myopic patients of both sexes with low to moderate sess corneal sensation, as previously described.18 It consists of
myopia up to –8.00 diopters (D) with or without astigmatism up a thin 6.0-cm adjustable nylon monofilament touching the cornea.
to –3.00 D who had bilateral LASIK treatment. Patients were iden- The filament is soft when fully extended and becomes firm when
tified from those accepted and scheduled for LASIK surgery at the retracted into the handpiece, creating a pressure gradient that
Magill Laser Center. Once identified as a LASIK candidate, in- ranges from 11 to 200 mg/mm2. To measure corneal sensation,
formed consent to participate in the study; the patient had to pro- the filament is applanated against the corneal surface perpendic-
vide in accordance with the guidelines of the Medical University ularly until a small bend is noted; subsequently, the filament is re-
of South Carolina Institutional Review Board. tracted until the patient feels it. The length of the filament at this
Laser ablation in both eyes was performed using the Visx S3 point is the numeric measurement of corneal sensation. The
laser (n Z 43) using an optical zone of 6.5 mm or the LADARVi- higher the number obtained, the more sensitive the cornea. Cor-
sion 4000 laser (Alcon Laboratories) (n Z 4) with an optical zone neal sensation was measured centrally, superiorly, inferiorly,
of 7.0 mm, under topical anesthesia. The superior hinge flap was nasally, and temporally approximately 3.0 mm from the central
created using the Hansatome microkeratome (Bausch & Lomb) point.
with a 180 mm plate depth and the nasal hinge was created using
Basic Secretion Test
After installing a drop of proparacaine 1% in each eye and
Accepted for publication March 1, 2005. drying the fornix, a sterile standardized Schirmer Tear Test Strip
From Magill Research Center for Vision Correction, Storm Eye In- (Alcon Laboratories) was placed in both inferior fornices at the
stitute, Medical University of South Carolina, Charleston, South junction of the lateral and middle third and then measured at
Carolina, USA. 5 minutes. The strip wetting was measured and recorded in
millimeters.
Presented in part at the ASCRS Symposium on Cataract, IOL and
Refractive Surgery, Philadelphia, Pennsylvania, USA, June 2002,
Tear Breakup Time
and the XXth Congress of the European Society of Cataract and
Refractive Surgeons, Nice, France, September 2002. Sodium fluorescein was instilled into the eye and the time
Supported in part by National Institutes of Heath grant EY014793 (seconds) from the last blink to the first area of breakup was
and unrestricted grants to Magill Research Center SEI-MUSC from recorded.
Allergan Laboratories, Irvine, California, USA, and SEI-MUSC Re-
search to Prevent Blindness, New York, New York, USA. Ocular Surface Staining
No author has a financial or proprietary interest in any material or The conjunctival and corneal staining measurements were
method mentioned. graded from 0 (none) to 4 (severe) based on the amount of stain-
Reprint requests to David T. Vroman, MD, Magill Research Center ing when compared to the Oxford Scheme of ocular surface stain-
for Vision Correction, Storm Eye InstitutedMUSC, 167 Ashley Av- ing. The cornea was divided into the central cornea the superior,
enue, Charleston, South Carolina 29425, USA. E-mail: vromandt@ inferior, nasal, and temporal quadrants, similar to the segments
musc.edu. suggested at the National Eye Institute Industry Workshop.19

1882 J CATARACT REFRACT SURG - VOL 31, OCTOBER 2005

 EFFECT OF HINGE LOCATION AFTER LASIK FOR MYOPIA

The conjunctiva in the superior, middle, and inferior third of the Table 1. Preoperative and hinge width measurements in 47 patients.
exposed conjunctiva was evaluated. Lissamine green and fluores-
cein were used to stain the ocular surface. Parameter Nasal Hinge Superior Hinge
UCVA 20/300 (20/50–CF) 20/300 (20/50–CF)
Ocular Surface Disease Index SE (D) ÿ4.19 G 1.91 ÿ4.07 G 1.77
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K-average 44.24 G 1.32 44.11 G 1.26

The Ocular Surface Disease Index (OSDI) was developed by
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Pachymetry (mm) 552.48 G 3.52 552.43 G 3.81

the Outcomes Research Group (Allergan) and consists of a 12-
BST (mm) 11.03 G 7.53 11.32 G 7.69
item questionnaire designed to provide a rapid assessment of
the symptoms of ocular irritation consistent with dry-eye disease TBUT (s) 10.57 G 3.99 9.98 G 3.82
and their impact on vision-related functioning. The 12 questions Corneal sensation (mm) 5.28 G 1.23 5.26 G 1.09
are subscaled into 3 categories: vision-related function (6 ques- (central)
tions), ocular symptoms (3 questions), and environmental trig- Hinge width (mm) 5.0 G 0.5 4.7 G 0.5
gers (3 questions). The grading of the OSDI is from 0 to 4, (Intraoperative)
where 0 indicates none of the time; 1, some of the time; 2, half Ablation depth (mm) 58.2 G 28.2 58.6 G 26.7
of the time; 3, most of the time; and 4, all of the time. The total (intraoperative)
OSDI score was calculated on the basis of the following formula:
OSDI Z [(sum of scores for all questions answered)  100] / [(to- BST Z basic secretion test; CF Z counting fingers; K Z keratometry;
tal number of questions answered)  4].17 The results are numer- TBUT Z tear breakup time; UCVA Z uncorrected visual acuity
ical from 0 to 100, where the higher scores represent a greater
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disability. the nasal-hinge group to 4.8 G 1.13 mm and 4.9 G

Wilcoxon signed rank test and paired t test were used for sta-
tistical analysis. A P value less than 0.05 was considered statistic- 1.11 mm in the superior-hinge group. There was no statis-
ally significant. It should be noted that a large number of tical difference between preoperative and 6-month postop-
comparisons have been performed, so actual P values have been erative sensation in either group. There was no difference
reported when results were found to be significant. Assuming between groups at both time points.
the listed standard deviations, this study has 80% power to pick Baseline mean central corneal sensation was 5.28 G
up differences in mean scores of 0.7 mm G 1.5 for corneal sensa-
tion, 0.8 G 1.8 seconds for TBUT values, 2.3 G 5.0 mm for 1.23 mm in the nasal group and 5.26 G 1.09 mm in the su-
Schirmer’s scores, and 0.8 G 0.17 logMar for visual acuity. perior group. Central corneal sensation was significantly
(P!.001) depressed at all postoperative visits in both
RESULTS
eyes compared to baseline (Figure 1). However, there was
no difference in central corneal sensitivity between eyes
Forty-seven patients with a mean age of 38.6 G 9.9 at any postoperative visit. Sensation was lowest at the first
years (range 22 to 55 years) had bilateral LASIK with postoperative week (mean 2.86 G 2.55 mm nasal group;
1 eye randomly having a superior-hinge and the other a 3.09 G 2.43 mm superior group) and gradually improved
nasal-hinge flap. All patients had myopia with or without with time but was significantly lower at 6 months (mean
astigmatism, with a mean preoperative spherical equivalent 4.24 G 1.87 mm nasal group; 4.43 G 1.58 superior group).
(SE) of –4.2 G 2.0 D (range –0.5 to –9.75 D). Corneal sensation measured postoperatively in the
Table 1 summarizes the preoperative values for visual temporal, nasal, and inferior quadrants was generally less
acuity, average keratometry, pachymetry, central corneal than at baseline. At 1 month, there was a significant differ-
sensitivity, TBUT, basic secretion test (BST), SE, intraoper- ence in nasal sensation between the 2 groups. The eyes with
ative hinge width measurements, and ablation depth. No
preoperative differences were found between groups.
6
Bilateral small epithelial slides without frank defects
Nasal
were noticed in 3 patients (6 eyes). A unilateral epithelial
Mean Cochet-Bonnet

5
Superior
slide without frank defect was found in 1 patient (nasal
4
Score (cm)

hinge group). In these patients, LASIK was performed cau-

tiously and proper care was taken in the postoperative pe- 3
riod. There were no other intraoperative or postoperative 2
complications at the 6-month examination.
1

Corneal Sensation 0
Preop 1 Week* 1 Month* 3 Months* 6 Months*
The mean preoperative corneal sensation was 5.21 G
1.17 mm (out of 6.0 mm) in the nasal group, and 5.27 G Figure 1. Mean central corneal sensation: Cochet-Bonnet. Decrease in na-
1.12 mm (out of 6.0 mm) in the superior group. At 6 sal and superior groups compared with preoperative values (*P!.01,
months, there was a return from preoperative levels in paired t test).

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 EFFECT OF HINGE LOCATION AFTER LASIK FOR MYOPIA

the nasal hinge had significantly better nasal sensation 30

Nasal
(mean 5.1 G 1.44 mm) than those with the superior hinge

Mean Schirmer Score (mm)

Superior
25
(mean 4.46 G 1.87 mm) (P Z.007). This trend was present
at all postoperative visits but obtained statistical signifi-
20
cance only at 1 month (Figure 2). Corneal sensation in
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the superior quadrant was significantly depressed in both 15

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eyes at 1 week (P!.03) and 1 month (P Z .02), and in

the superior-hinge group at the 3-month visit (P Z .039). 10
It returned to baseline in both groups by the 6-month visit.
5

Basic Secretion Test 0

Preop 1 Week* 1 Month 3 Months 6 Months
Preoperative mean BST was 15.61 G 11.9 mm in the
nasal group and 15.35 G 11.6 mm in the superior group.
Figure 3. Mean BST scores. Decreased in both groups compared with pre-
Eyes in the Amadeus and Hansatome groups had a signifi- operative values (*P!.05, paired t test).
cant (12.1 G 9.16 mm, P Z .038; 11.57 G 7.94 mm,
P Z .037, respectively) decrease in tear production at the
1-week visit compared with preoperative levels. In neither postoperative scores for either microkeratome. Further-
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group was the BST statistically different from baseline at more, there was no difference between groups at any time
any other time point. There was no difference between point.
groups at any examination (Figure 3).
Tear Breakup Time
Corneal and Conjunctival Staining
At the 1-week and 1- and 3-month visits, TBUTwas low
Corneal staining was present in all areas in 18 patients compared with baseline. However, statistical significance
(38.3%) preoperatively. Three patients (6.4%) presented was found at the 3-month visit when comparing the 2
staining in the central area. Although the mean scores groups (nasal, 8.14 seconds; superior, 7.70 seconds) to
were less than 1 in all 5 areas at all time points, there was the baseline (10.6 and 9.98 seconds respectively; P Z .002
no statistical difference between the preoperative and post- and P Z .001, respectively) and at the 1-week visit
operative staining scores. Additionally, there was no differ- (P Z.026) in the nasal hinge group. At the 6-month visit,
ence between the staining scores between groups at any TBUT levels returned to normal (Figure 5). Values between
time point. Preoperative and 6-month postoperative central groups were never significantly different.
corneal staining scores are seen in Figure 4.
Results of conjunctival staining were similar to those
Ocular Surface Disease Index
found in the cornea. At no time point was the average
staining for the entire group above 1 in any sector. There The mean preoperative OSDI score was 17. The scores
was no statistical difference between preoperative and were significantly elevated at 1-, 3-, and 6-month

100
Nasal Pre-op
6 Superior Pre-op
Nasal 80
Nasal 6 Months
Percent of Eyes

5 Superior
Mean Cochet-Bonnet

Superior 6 Months
60
4
Score (cm)

3 40

2 20

1
0
0 1 2 3 4
0
Preop 1 Day 1 Week 1 Month* 3 Months 6 Months Corneal Staining Score

Figure 2. Mean nasal corneal sensation: Cochet-Bonnet. Eyes with the na- Figure 4. Preoperative (n Z 47) and 6-month (n Z 44) distribution of cor-
sal hinge had significantly better nasal sensation than those with the su- neal staining scores.
perior hinge (*P!.01, paired t test).

1884 J CATARACT REFRACT SURG - VOL 31, OCTOBER 2005

 EFFECT OF HINGE LOCATION AFTER LASIK FOR MYOPIA

18 Table 2. Mean numerical OSDI score comparison between superior hinge

Mean Tear Break-up Time (sec)

Nasal and nasal hinge groups at various time points.

16
Superior
14 Mean Total OSDI Score
12
Nasal Hinge Superior P
10
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Time Point (n) (SD) Hinge (SD) Value

8
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Preoperative (47) 17 G 6 17 G 5 .99

6
Month 1 (43) 42 G 19 39 G 19 .37
4 Month 3 (38) 25 G 13 24 G 12 .40
2 Month 6 (44) 22 G 11 22 G 11 .92
0 OSDI Z ocular surface disease index, SD Z standard deviation
Preop 1 Week 1 Month 3 Months* 6 Months

production based on an inhibited feedback loop from the

Figure 5. Mean TBUT scores, showing a statistical difference at 3 months cornea to the lacrimal gland. The decrease in basic secre-
when comparing the 2 groups to preoperative values (*P!.01, paired
t test).
tion test at the first-week visit in our patients may be related
to this inhibition. Damage to the corneal nerves may also
have a direct effect on the health of the epithelium. In dis-
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postoperative visits compared with preoperative scores eases in which the trigeminal nerve has been damaged,
(P!.01). Table 2 illustrates the numerical OSDI scores a nonhealing epithelial defect can occur. This epithelial
that range from 17 to 42, where the higher scores represent breakdown may be due to poor blinking, decreased tear
a greater disability. The scores were highest at 1 month and production, or loss of direct neurotrophic effects on the ep-
gradually decreased to near baseline at month 6. The ques- ithelium. In some patients with dry eye after LASIK, there
tionnaire showed no statistical difference between the are signs of dryness with relatively few symptoms and am-
hinge positions and the patient’s complaints between the ple tear production. These patients may be suffering from
2 groups. the loss of the direct effects that the corneal nerves may
have in maintaining a healthy epithelium.
Contrast Sensitivity This study confirms the alteration in the ocular surface
that has been previously reported. Central corneal sensa-
With the exception of the 1-week visit, there was no
tion was significantly depressed in both groups for the en-
statistically significant difference in contrast sensitivity be-
tire 6-month duration of the protocol. This is compatible
tween the groups. There was a statistically significant differ-
with results from several other studies.14,16,22 Nasarella
ence (P Z.047) at 18 cpd, with a decrease in contrast in the
et al.16 demonstrated a decrease of corneal sensitivity at
nasal hinge group at the 1-week visit only.
the central and paracentral areas for as long as 9 months.
Furthermore, Battat et al.21 found that corneal and con-
DISCUSSION
junctival sensitivity did not return to preoperative levels,
Normal tear function is essential for maintaining cor- even by 18 months postoperatively. We noted a transient
neal function and structure. Dry eye has become an increas- decrease in tear production at 1 week that increased to nor-
ingly well documented complication following LASIK. A mal levels at 1 month. The TBUT was also reduced at the 1-
number of possible etiologies explaining the appearance week and 1-month visits. These alterations were shown to
of this complication have been proposed, including damage be subjectively important because patients reported in-
of the globlet cells by the pressure generated by the suction creased dryness using the OSDI 1, 3, and 6 months postop-
ring, alteration of the corneal curvature affecting tear stabil- erative visits.
ity, and medications that can induce transient dry-eye Donnenfeld et al.13 and Lee and Joo,15 among others,
symptoms.11 More significant is the transection of a signif- have described differences between nasal and superior
icant number of afferent sensory nerves in the cornea dur- hinges in corneal sensation and dry eye, based on the obser-
ing the formation of the flap, and therefore interruption of vations of studies that showed nerve fibers oriented in
the cornea–trigeminal nerve–brain stem–facial nerve–lacri- a 9 o’clock to 3 o’clock (temporal-to-medial) orientation.
mal gland reflex arc that influences both basal and stimu- Our study demonstrated improved nasal corneal sensation
lated tear production.6,12–14,16,20,21 at 1 month in the nasal hinge group but found no difference
The microkeratome severs most of the nerves that in dry eye. This agrees with recent studies using in vivo
course from the limbus to innervate the stroma and epithe- confocal microscopy that show that subbasal nerve fibers
lium in the central cornea. This may produce a neurotro- run in a 6 o’clock to 12 o’clock (superior-to-inferior) orien-
phic epitheliopathy that could cause decreased tear tation.17 As mentioned earlier, Muller et al.17 reported

J CATARACT REFRACT SURG - VOL 31, OCTOBER 2005 1885

 EFFECT OF HINGE LOCATION AFTER LASIK FOR MYOPIA

finding that leashes extend across the corneal apex prefer- Factors such as flap size, hinge width, and flap depth
entially in the 6 to 12 o’clock, whereas other leashes ap- play an important role in the health of the corneal surface.
proach the apex in the 5 to 11, 7 to 1, 9 to 3, 2 to 8, and Flap thickness can be among the key issues because corneal
4 to 10 o’clock direction. nerves can be severed at various stromal levels. It is well
The current description is that nerve bundles enter the known that there is variability between microkeratome
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cornea at the periphery in a radial fashion parallel to the cor- models.26 To control differences in flap thickness due to
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neal surface. Most stromal nerve fibers are located in the an- the variability between the 2 microkeratomes used in this
terior third of the stroma; however, thick stromal nerve study, head serial numbers for our 2 microkeratome models
trunks move from the periphery toward the center below with the closest mean flap thickness were used. Our data in-
the anterior third of the stroma due to the organization of dicated that our Amadeus 160 had a mean flap thickness of
the collagen lamellae.17 Eventually, the stromal nerve fibers 152 G 25 mm and our Hansatome 180 generated a mean
turn abruptly 90 degrees and proceed toward the corneal flap thickness of 167 G 39 mm.26
surface. The nerves penetrate Bowman’s layer throughout In conclusion, it is important that surgeons attempt to
the peripheral and central cornea.23 After penetrating Bow- avoid inducing dry eye after LASIK. Careful preoperative
man’s layer, the large nerve bundles divide into several evaluation to identify patients at risk for dry-eye symptoms
smaller ones. Each small nerve bundle then turns abruptly and preoperative treatment may minimize this common
once more at 90 degrees and continues parallel to the cor- finding postoperatively. Use of a vertically hinged flap im-
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neal surface, between Bowman’s layer and the basal epithelial proves corneal sensation in the nasal quadrant and may
cell layer, as an epithelial leash. The exact orientation and theoretically decrease the chance of dry-eye symptoms, al-
the depth of nerve fiber bundles is not known and may vary though we could not confirm this. Further elucidation of
between patients.17,23–25 There is also a question as to how corneal nerve organization and regrowth patterns may
the nerves regenerate. Will nerve fibers reinnervate the cen- help us understand how to minimize dry eye after LASIK.
tral cornea by growing from underlying stroma or will pe-
ripheral nerves grow centrally? The pattern of regrowth
could affect the speed of reinnervation as well as our under-
standing of the potential benefits of certain hinge locations. REFERENCES
Donnenfeld et al.13 demonstrate a significant reduction 1. Martin XD, Safran AB. Corneal hypoesthesia. Surv Ophthalmol 1988;
in corneal sensation that did not return to preoperative lev- 33:28–40; see notes, 217
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whereas there was full recovery at 6 months in the nasal keratopathy. Curr Opin Ophthalmol 1999; 10:270–276
3. Koenig SB, Berkowitz RA, Beuerman RW, McDonald MB. Corneal sen-
hinge group. We did not note such a large difference be- sitivity after epikeratophakia. Ophthalmology 1983; 90:1213–1218
tween groups. One difference between the studies was 4. Shivitz IA, Arrowsmith PN. Corneal sensitivity after radial keratotomy.
flap diameter. We used an 8.5 mm ring in all cases, whereas Ophthalmology 1988; 95:827–831; discussion by JP Gilbard, 831–
they used a 9.5 mm ring. A larger flap could denervate 832
a larger surface area of the cornea and enhance any differ- 5. Kanellopoulos AJ, Pallikaris IG, Donnenfeld ED, et al. Comparison of
corneal sensation following photorefractive keratectomy and laser
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