Expression of cellular fibronectin and tenascin in the rabbit cornea after excimer laser photorefractive keratectomy: a 12 month study

Corneal keratocytes, fibroblasts, and myofibroblasts exhibit distinct transcriptional profiles in vitro

Purpose

After stromal injury to the cornea, the release of growth factors and pro-inflammatory cytokines promotes the activation of quiescent keratocytes into a migratory fibroblast and/or fibrotic myofibroblast phenotype. Persistence of the myofibroblast phenotype can lead to corneal fibrosis and scarring, which are leading causes of blindness worldwide. This study aims to establish comprehensive transcriptional profiles for cultured corneal keratocytes, fibroblasts, and myofibroblasts to gain insights into the mechanisms through which these phenotypic changes occur.

Methods

Primary rabbit corneal keratocytes were cultured in either defined serum-free media (SF), fetal bovine serum (FBS) containing media, or in the presence of TGF-β1 to induce keratocyte, fibroblast, or myofibroblast phenotypes, respectively. Bulk RNA sequencing followed by bioinformatic analyses was performed to identify significant differentially expressed genes (DEGs) and enriched biological pathways for each phenotype.

Results

Genes commonly associated with keratocytes, fibroblasts, or myofibroblasts showed high relative expression in SF, FBS, or TGF-β1 culture conditions, respectively. Differential expression and functional analyses revealed novel DEGs for each cell type, as well as enriched pathways indicative of differences in proliferation, apoptosis, extracellular matrix (ECM) synthesis, cell-ECM interactions, cytokine signaling, and cell mechanics.

Conclusions

Overall, these data demonstrate distinct transcriptional differences among cultured corneal keratocytes, fibroblasts, and myofibroblasts. We have identified genes and signaling pathways that may play important roles in keratocyte differentiation, including many related to mechanotransduction and ECM biology. Our findings have revealed novel molecular markers for each cell type, as well as possible targets for modulating cell behavior and promoting physiological corneal wound healing.

Effects of Transforming Growth Factor-Beta 2, Interleukin 6 and Fibronectin on Corneal Epithelial Wound Healing

Purpose

The aim of this study was to compare the effects of topically applied transforming growth factor-beta 2 (TGF-beta 2) and interleukin 6 (IL-6), alone and combined with fibronectin, on the rate of corneal wound healing in rabbits.

Methods

Twenty-eight rabbits were used for the experiment. After the right eye of each rabbit was debrided with n-heptyl alcohol, the animals were divided into four treatment groups (six rabbits per group) and one control group (four rabbits). The debrided eyes were treated, beginning immediately after wounding and continuing every 2 hours from 8 a.m. to 8 p.m. for 48 hours. Group 1 received TGF-beta 2; group 2 IL-6; group 3, TFR-beta 2 and purified fibronectin; group 4, IL-6 and fibronectin; control group, balanced salt solution. At set intervals each eye was stained with fluorescein and photographed; epithelial defects were measured with a computer-assisted digitizer. The healing rate was calculated by linear regression analysis.

Results

The mean healing rates in groups 1, 2, 3, 4, and controls were respectively 1.65 ± 0.16, 1.68 ± 0.11, 1.99 ± 0.12, 2.23 ± 0.09, and 0.93 ± 0.18 mm2/h. Mean epithelial healing rates for all drug-treatment groups were significantly faster than controls. The healing rates of groups 3 and 4 were significantly faster than groups 1 and 2.

Conclusions

We conclude that cytokines, in combination with extracellular matrix proteins, facilitate corneal epithelial wound healing in vivo, possibly by making corneal epithelial cells more sensitive to fibronectin receptors.

Myofibroblast transdifferentiation: The dark force in ocular wound healing and fibrosis

Wound healing is one of the most complex biological processes to occur in life. Repair of tissue following injury involves dynamic interactions between multiple cell types, growth factors, inflammatory mediators and components of the extracellular matrix (ECM). Aberrant and uncontrolled wound healing leads to a non-functional mass of fibrotic tissue. In the eye, fibrotic disease disrupts the normally transparent ocular tissues resulting in irreversible loss of vision. A common feature in fibrotic eye disease is the transdifferentiation of cells into myofibroblasts that can occur through a process known as epithelial-mesenchymal transition (EMT). Myofibroblasts rapidly produce excessive amounts of ECM and exert tractional forces across the ECM, resulting in the distortion of tissue architecture. Transforming growth factor-beta (TGFβ) plays a major role in myofibroblast transdifferentiation and has been implicated in numerous fibrotic eye diseases including corneal opacification, pterygium, anterior subcapsular cataract, posterior capsular opacification, proliferative vitreoretinopathy, fibrovascular membrane formation associated with proliferative diabetic retinopathy, submacular fibrosis, glaucoma and orbital fibrosis. This review serves to introduce the pathological functions of the myofibroblast in fibrotic eye disease. We also highlight recent developments in elucidating the multiple signaling pathways involved in fibrogenesis that may be exploited in the development of novel anti-fibrotic therapies to reduce ocular morbidity due to scarring.

Retreatment strategies following Small Incision Lenticule Extraction (SMILE): In vivo tissue responses

With any refractive correction, including Small Incision Lenticule Extraction (SMILE), there may be a residual refractive error that requires a retreatment. Here, we investigated the tissue responses following various retreatment procedures in a rabbit model of SMILE. All rabbits underwent a -6.00D correction with SMILE. Two weeks later, they underwent -1.00D enhancement by: (i) VisuMax Circle, followed by excimer ablation (S+C); (ii) secondary SMILE anterior to the primary procedure (S+SE); or (iii) surface ablation (S+P), and were examined for 28 days. S+P induced corneal edema and haze, and more CD11b- (23±6 cells) and TUNEL-positive (36±4 cells) cells in the central stromal superficial layers early post-operatively (p<0.001 compared to other procedures). The corneas appeared normal on day 28 after S+P, but had a lower number of keratocytes near the laser ablated plane compared to other procedures. S+SE and S+C did not induce corneal haze and resulted similar level of fibronectin. However, S+C resulted in more inflammatory (10±2 cells; p = 0.001) and apoptotic cells (25±2 cells; p<0.001) compared to S+SE (7±1 inflammatory cells and 21±3 apoptotic cells) early post-operatively. In conclusion, each SMILE retreatment method resulted in unique tissue responses. S+SE offers advantages, such as minimal inflammation and cell death, as well as maintaining a ‘flap-less’ surgery, over other procedures. However, depending on the degree of enhancement, the lenticule may become too thin to be extracted and the procedure becomes more difficult to perform than S+C and S+P. S+P can maintain corneal integrity by avoiding flap creation and is technically more simple to perform than the others, but the surgery needs to be supplemented with mitomycin-C in order to reduce inflammation and modulate better wound healing.

Temporal and spatial analysis of stromal cell and extracellular matrix patterning following lamellar keratectomy

Extracellular matrix (ECM) supplies both physical and chemical signals to keratocytes which can impact their differentiation to fibroblasts and/or myofibroblasts. It also provides a substrate through which they migrate during wound repair. We have previously shown that following transcorneal freeze injury (FI), migrating corneal fibroblasts align parallel to the stromal lamellae during wound repopulation. In this study, we compare cell and ECM patterning both within and on top of the stroma at different time points following lamellar keratectomy (LK) in the rabbit. Twelve rabbits received LK in one eye. Rabbits were monitored using in vivo confocal microscopy at 3, 7, 21 and 60 days after injury. A subset of animals was sacrificed at each time point to further investigate cell and matrix patterning. Tissue was fixed and labeled in situ with Alexa Fluor 488 phalloidin (for F-actin), and imaged using multiphoton fluorescence and second harmonic generation (SHG) imaging (for collagen). Immediately following LK, cell death occurred in the corneal stroma directly beneath the injury. At 7 and 21 days after LK, analysis of fluorescence (F-actin) and SHG results (collagen) indicated that fibroblasts were co-aligned with the collagen lamellae within this region. In contrast, stromal cells accumulating on top of the stromal wound bed were randomly arranged, contained more prominent stress fibers, and expressed alpha smooth muscle actin (α-SMA) and fibronectin. At 60 days, cells and matrix in this region had become co-aligned into lamellar-like structures; cells were elongated but did not express stress fibers. Corneal haze measured using in vivo confocal microscopy peaked at 21 days after LK, and was significantly reduced by 60 days. Cell morphology and patterning observed in vivo was similar to that observed in situ. Our results suggest that the topography and alignment of the collagen lamellae direct fibroblast patterning during repopulation of the native stroma after LK injury in the rabbit. In contrast, stromal cells accumulating on top of the stromal wound bed initially align randomly and produce a fibrotic ECM. Remarkably, over time, these cells appear to remodel the ECM to produce a lamellar structure that is similar to the native corneal stroma.

Progress in corneal wound healing

Corneal wound healing is a complex process involving cell death, migration, proliferation, differentiation, and extracellular matrix remodeling. Many similarities are observed in the healing processes of corneal epithelial, stromal and endothelial cells, as well as cell-specific differences. Corneal epithelial healing largely depends on limbal stem cells and remodeling of the basement membrane. During stromal healing, keratocytes get transformed to motile and contractile myofibroblasts largely due to activation of transforming growth factor-β (TGF-β) system. Endothelial cells heal mostly by migration and spreading, with cell proliferation playing a secondary role. In the last decade, many aspects of wound healing process in different parts of the cornea have been elucidated, and some new therapeutic approaches have emerged. The concept of limbal stem cells received rigorous experimental corroboration, with new markers uncovered and new treatment options including gene and microRNA therapy tested in experimental systems. Transplantation of limbal stem cell-enriched cultures for efficient re-epithelialization in stem cell deficiency and corneal injuries has become reality in clinical setting. Mediators and course of events during stromal healing have been detailed, and new treatment regimens including gene (decorin) and stem cell therapy for excessive healing have been designed. This is a very important advance given the popularity of various refractive surgeries entailing stromal wound healing. Successful surgical ways of replacing the diseased endothelium have been clinically tested, and new approaches to accelerate endothelial healing and suppress endothelial-mesenchymal transformation have been proposed including Rho kinase (ROCK) inhibitor eye drops and gene therapy to activate TGF-β inhibitor SMAD7. Promising new technologies with potential for corneal wound healing manipulation including microRNA, induced pluripotent stem cells to generate corneal epithelium, and nanocarriers for corneal drug delivery are discussed. Attention is also paid to problems in wound healing understanding and treatment, such as lack of specific epithelial stem cell markers, reliable identification of stem cells, efficient prevention of haze and stromal scar formation, lack of data on wound regulating microRNAs in keratocytes and endothelial cells, as well as virtual lack of targeted systems for drug and gene delivery to select corneal cells.

The effects of acacia honey on in vitro corneal abrasion wound healing model

Background

Acacia honey (AH) has been proven to improve skin wound healing, but its therapeutic effects on corneal epithelium has not been elucidated to date. This study aimed to investigate the effects of AH on cultured corneal epithelial cells (CEC) on in vitro corneal abrasion wound healing model. Six New Zealand white rabbits’ CEC were isolated and cultured until passage 1. Circular wound area was created onto a confluent monolayer CEC using a corneal trephine which mimicked corneal abrasion and treated with 0.025% AH supplemented in basal medium (BM) and complete cornea medium (CCM). Wound healing was measured as the percentage of wound closure by the migration of CEC on day 0, day 3 and day 6, post wound creation. The morphological changes of CEC were assessed via phase contrast microscopy. Gene and protein expressions of cytokeratin (CK3), fibronectin and cluster of differentiation 44 (CD44) in AH treated groups and control groups were determined by real-time PCR and immunocytochemistry, respectively.

Results

Cultured CEC exhibited similar morphology of polygonal shaped cells in all culture media. CEC cultured in AH-supplemented media showed higher percentage of wound closure compared to the controls. Gene expression of CK3 increased in AH-supplemented groups throughout the study. Fibronectin expression was increased at the initial stage while CD44 expression was increased at day 3, post wound creation. The protein expression of CEC cultured in all media was in accordance to their respective gene expressions.

Conclusion

Supplementation of AH in BM and CCM media accelerates CEC wound closure of the in vitro corneal abrasion model by increasing the expression of genes and proteins associated with CEC wound healing.

Comparison of TGF-β1 in tears and corneal haze following Epi-LASIK with and without mitomycin C

AIM

To compare transforming growth factor-β1 (TGF-β1) levels in tears and the degree of corneal haze formation following epithelial laser in situ keratomileusis (Epi-LASIK) with and without the use of mitomycin C (MMC) and to investigate the effect of MMC on corneal wound healing.

METHODS

Thirty-two patients (64 eyes) with high myopia underwent Epi-LASIK surgery, and MMC was randomly used in one eye in each patient. The epithelialization process was observed, and the TGF-β1 level in tears was measured at 1 day, 3, and 7 days postoperatively for comparison with baseline. Corneal haze was graded at 1 month, 3, and 6 months after surgery.

RESULTS

Mean preoperative spherical equivalent refraction was -8.24±2.18D (range -6.00 to -10.50D) in the MMC group and -7.82±1.55D (range -6.00 to -9.75D) in the non-MMC group. There was no significant difference between the two groups (P=0.38). Mean epithelialization time was (5.02±0.68) days in the MMC group and (4.86±0.57) days in the non-MMC group (P=0.31). Tear fluid TGF-β1 levels were similar before surgery (P=0.34), but were significantly higher in the non-MMC group at 1 day, 3, and 7 days postoperatively (P=0.004, 0.008, and 0.012, respectively). Corneal haze scores 1 month after surgery were significantly higher in the non-MMC group (P=0.03), and similar at 3 and 6 months after surgery (P=0.28 and 0.62, respectively).

CONCLUSION

MMC did not delay epithelialization. In early postoperative period, lower TGF-β1 levels in tears and a lower grade of corneal haze were observed in the MMC group. Our findings suggest that the ability of MMC to inhibit Epi-LASIK-induced haze might be mediated through TGF-β1 suppression.

Epidermal growth factor synergism with TGF-beta1 via PI-3 kinase activity in corneal keratocyte differentiation

PURPOSE

To investigate the action of epidermal growth factor (EGF) on corneal keratocyte differentiation and its effects in conjunction with transforming growth factor (TGF)-beta1.

METHODS

Rabbit corneal keratocytes (RCKs) were treated with EGF, TGF-beta1, or EGF plus TGF-beta1 in the presence or absence of inhibitors of EGF-receptor (EGF-R), neutralizing concentrations of EGF antibody and of signaling kinases for 2 days to 1 week. RCK differentiation to myofibroblasts was identified with anti-aldehyde dehydrogenase (ALDH)-1 and alpha-smooth muscle actin (alpha-SMA) antibodies. Cell proliferation was evaluated with anti-Ki-67 antibody. Extracellular matrix (ECM) components were assayed by immunochemistry and Western blot. Cell migration images were captured with a camera attached to the microscope, and the area of the wound was calculated using imaging software.

RESULTS

RCKs cultured in serum-free DMEM/F12 without frequent changes of medium maintained the phenotype for more than 1 month. EGF stimulated differentiation into a proto-myofibroblast phenotype with the loss of dendritic shape and the expression of alpha-SMA. Treatment with TGF-beta1 stimulated 12% of the cells to differentiate to defined myofibroblasts, but in the presence of EGF, TGF-beta1 induced 90% of RCKs to transform into myofibroblasts. Inhibition of EGF-R activation and of the phosphatidylinositol-3 kinase (PI-3K)/Akt-1 pathway prevented the action of EGF on TGF-beta1 cell differentiation. TGF-beta1 in the presence of EGF also increased cell migration, which is inhibited by blocking EGF-R activation.

CONCLUSIONS

These data show that EGF contributes to the differentiation and migration of myofibroblasts induced by TGF-beta1 through EGF-R activation and that it is an important modulator of wound healing and scar tissue formation.

Stroma remodelling during healing of corneal surface irregularities induced by PTK

PURPOSE

To study the histopathology of the remodelling process in the stroma after excimer-laser-induced corneal irregular injuries.

METHODS

Seven New Zealand white rabbits received in one eye a transepithelial plano photoablation (60 microm) and an additional plano ablation (25 microm). On the denuded stroma, an electron microscopy specimen grid was placed and another 25 microm ablation was applied to produce surface irregularities. Dichlorotriazinyl aminofluorescein (DTAF) was then applied for 45 seconds. Another seven right eyes of seven rabbits were ablated the same way but without using the grid, resulting in a plano ablation. All the rabbits were killed at weekly intervals after treatment. The harvested corneas from both eyes were further processed for haematoxylin-eosin staining and were also stained with monoclonal antibodies directed against Ki-67 antigen and alpha-smooth muscle actin (alpha-SMA). All specimens were examined under light and fluorescence microscope.

RESULTS

The corneal wounds were covered by epithelium during the first week. The 25 microm x 25 microm x 25 microm stromal irregularities were clearly discernible up to 3 weeks after treatment, during which time they melted and disappeared. A homogeneous zone was formed in which stroma cells laid down an initially disorganized stroma. This was sharply visible under a fluorescence microscope as a dark area between the dichlorotriazinyl aminofluorescein (DTAF) fluorescent stroma and autofluorescent epithelium. Very little response was seen in the plano-ablated wound microscopically and in terms of positive stained cells.

CONCLUSION

As the irregularities are flattened and the homogenous zone becomes repopulated with keratocytes forming extracellular matrix material (ECM), the cornea regains its previous architecture in both groups. The irregular wound surface promotes wound-healing reactivity, a process that allows the cornea to compensate for the irregularities and heal to a functional state.

Optical Quality Analysis After Surface Excimer Laser Ablation: The Relationship Between Wavefront Aberration and Subepithelial Haze

PURPOSE

To investigate the relationship between mild and moderate corneal haze and the distribution of higher order wavefront aberrations after photorefractive keratectomy (PRK).

METHODS

Thirty-six eyes from 18 patients who underwent PRK were divided into two groups: 10 eyes with corneal haze and 26 eyes without corneal haze (control). All eyes were evaluated up to 6 months after PRK. Wavefront aberrations were measured using a psychophysical wavefront sensor and the NIDEK OPD-Scan. Topography, point spread function, and modulation transfer function maps were obtained from the OPD-Scan.

RESULTS

The mean total higher order aberration was slightly higher in the corneal haze group than in the control group. This difference was not statistically significant. The mean third order coma aberrations were higher and mean fourth order spherical aberrations were lower in the haze group compared with the control group, although neither difference attained statistical significance. The t test values were 1.05, -0.38, -1.10, -0.08, and -0.23, when comparing the mean third, fourth, fifth, sixth, and seventh order aberrations, respectively. None of these differences attained statistical significance. In terms of Zernike coefficients, Z-1 and Z1 showed greater mean root-mean-square (RMS) in the haze group (0.33 and 0.35 microm, respectively) than those for the control group (0.26 and 0.23 microm, respectively) (t=0.71 and P=.49; t=0.84 and P=.43, respectively). However, ZO had lower RMS in the haze group (0.18 microm) than in the control group (0.28 microm). This difference also was not statistically significant.

CONCLUSIONS

In this study comparing the optical aberrations of eyes with and without corneal haze after PRK, corneal haze did not affect the magnitude and distribution of higher order aberrations in a predictable manner.

Korneale Wundheilungsreaktionen nach hyperoper PRK und LASIK

BACKGROUND

The purpose of this study was to investigate the influence of different postoperative treatments on the wound healing reaction in the anterior stroma after PRK and in the interface area after LASIK.

METHODS

Seventy-two corneal buttons of refractively treated rabbit eyes underwent different postoperative eyedrop regimens with antibiotics and/or steroids or additional UV-B irradiation. Morphological and immunohistological investigations were performed 6 months postoperatively by light and transmission electron microscopy.

RESULTS

PRK eyes showed interdigitations between the epithelia and the anterior stroma. LASIK-treated eyes showed only minor changes between epithelia and stroma in the incisional region. Only a slight increase in deposits of fibrillar extracellular matrix components were detectable in the interface region.

CONCLUSIONS

The clinically important problem of haze after PRK is caused by the interdigitations between epithelia and anterior stroma. The delicate wound healing reactions in the interface region in LASIK eyes corresponded to the clinically visible minor changes in these corneas.

Pirenoxine prevents oxidative effects of argon fluoride excimer laser irradiation in rabbit corneas: biochemical, histological and cytofluorimetric evaluations

The production of reactive oxygen species (ROS) associated with excimer laser irradiation is recognized as a possible cause of corneal haze following photorefractive keratectomy (PRK). Our work was aimed at investigating in vitro the oxidative effects induced by subablative laser fluences and at demonstrating the protective effectiveness of pirenoxine. Comparative trials of subablative fluence on rabbit eyes with or without 10(-5) M pirenoxine were carried out. Superoxide anion (O(2)(-)), conjugated diene (CD), and thiobarbituric acid reagent substance (TBARS) formation were analyzed. Cellular death was evaluated by flow cytometry. Histological examinations were also performed. No appraisable differences in O(2)(-),CD,andTBARS formation were detected soon after irradiation, whereas they all increased following incubation. Pirenoxine inhibited such increases. Cytofluorimetric and histological observations gave coherent results. The experimental data indicate that oxidative and toxic effects are ascribable to ROS avalanches triggered by laser irradiation-induced photodissociation and are inhibited by pirenoxine.

Laser in situ keratomileusis in human corneas

PURPOSE

To establish an in vitro model of laser in situ keratomileusis (LASIK) in human donor eyes and to test its validity in comparison with animal models.

SETTING

Department of Anatomy, Friedrich-Alexander Unviersity, Erlangen, Germany.

METHODS

Laser in situ keratomileusis was performed on 20 organ-cultured human corneal buttons. The excimer laser ablations ranged from 0 to 12.0 diopters. The corneas were maintained in culture for up to 6 months and then evaluated with light microscopy and transmission electron microscopy. In addition, corneal sections were immunohistochemically stained for collagen type III, laminin, and fibronectin. The main outcome measures were the ultrastructural and immunohistochemical features of the stromal incision interface.

RESULTS

Ultrastructural investigations in the peripheral cornea revealed a disarrangement of collagen fibers, indicating scar formation. These findings were not observed in the central area. Immunohistochemical staining for fibronectin and collagen type III was detected over the entire stromal incision interface, whereas laminin staining was related to the ingrowth of epithelial cells.

CONCLUSIONS

The morphological changes after LASIK in an organ culture model can simulate the in vivo situation. Therefore, this model appears appropriate to use in further study of corneal wound-healing changes after LASIK.

Corneal wound healing after photorefractive keratectomy: a 3-year confocal microscopy study

PURPOSE

To perform a sequential quantitative analysis of corneal wound healing after photorefractive keratectomy (PRK) by using confocal microscopy in vivo.

METHODS

In a prospective, nonrandomized, comparative trial performed in an institutional setting, 24 eyes of 14 patients received PRK to correct refractive errors between -1.25 and -5.75 D. Central corneas were examined preoperatively and at 1 day, 5 days, and 1, 3, 6, 12, 24, and 36 months after PRK by using confocal microscopy. A masked observer randomly examined 3 to 6 confocal scans per eye per visit to determine epithelial and stromal thickness, keratocyte density in 5 anterior-posterior stromal layers, corneal nerve density in the subbasal region and the stroma, and corneal light backscattering (corneal haze).

RESULTS

Epithelial thickness increased 21% (P < .001) by 12 months after PRK and thereafter remained unchanged to 36 months after PRK. There was no change in stromal thickness between 1 and 36 months after PRK (P = .35). The dense keratocyte population in the preoperative anterior 10% of the stroma (32,380 +/- 5,848 cells/mm3) that was partially or completely removed during photoablation was not reconstituted at 36 months in the anterior 10% of the post-PRK stroma (17,720 +/- 4,308 cells/mm3, P < .001). Subbasal nerve fiber bundle density was decreased 60% at 12 months after PRK (P < .001) before returning to densities at 24 and 36 months after PRK that were not significantly different from preoperative values (P = 1.0). Activated keratocytes and corneal haze peaked at 3 months after PRK.

CONCLUSIONS

Wounding of the cornea by PRK alters the normal structure, cellularity, and innervation of the cornea for up to 36 months.

Some possible longer-term ocular changes following excimer laser refractive surgery

While the short- and medium-term refractive and acuity results of excimer laser refractive surgery may now be generally satisfactory, the relatively brief history of the procedures involved (around 10 years or less) means that those concerned with eye care must remain vigilant to the possibility of longer-term problems. This paper reviews some relevant studies of potential post-surgical effects, including imperfect corneal healing and recovery of innervation, reduced corneal sensitivity and dry eye problems, changes in corneal rigidity leading to slow refractive change, possibly misleading reductions in measured intraocular pressure, and retinal and vitreous pathology.

Haze after laser in situ keratomileusis in eyes with previous photorefractive keratectomy

In cases with previous photorefractive keratectomy (PRK), there is a risk of developing severe haze after laser in situ keratomileusis (LASIK). We report 3 patients (4 eyes) who developed severe haze after LASIK treatment for residual myopia following PRK. Both PRK and LASIK procedures were performed using the VISX 20/20 excimer laser. We report the grade of haze, amount of regression, and visual acuity after the patients were treated with topical steroids. In 2 eyes, the uncorrected visual acuity was 1.0 after 1 year with grade I haze. In the other 2 eyes, there was a residual refractive error, and the best spectacle-corrected visual acuity was 0.7 with grade II haze.

Cellular proliferation and leukocyte infiltration in the rabbit cornea after photorefractive keratectomy

PURPOSE

To map the proliferative activity of corneal cells during wound healing following photorefractive keratectomy (PRK) and to compare two markers for proliferation.

METHODS

PRK, 5- mm in diameter with a -6 D setting, was performed in one eye of 28 New Zealand White Rabbits. The rabbits were sacrificed at time points between 12 hours and three months after surgery. The treated and fellow corneas were fixed in 10% formaldehyde, paraffin embedded, and immunohistochemically stained for proliferate cell nuclear antigen (PCNA) and at one time point, 1 week, also for Ki-67.

RESULTS

Following initial sliding of the epithelial cells, the proliferative activity in the wound area starts in the leading edge (24 hours) and is spread towards the periphery. The proliferative activity peaks after one week and subsides during the following two weeks. Early (24 hours) proliferative activity is also seen in the limbal epithelium which peaks after three days. The keratocytes express PCNA in the peripheral stroma 48 hours after injury. They then also migrate to repopulate the stroma under the wound area. The expression period lasts 1 week and subsides the following week. Leukocytes are found in the wound as early as 12 hours after injury. The cells disappear around the time of epithelial wound closure, i.e. after 3 days. The two proliferative markers PCNA and KI 67 show a similar distribution after surgery.

CONCLUSION

Epithelial proliferative activity starts earlier after injury, and is preceded by leukocyte presence in the wound. The PCNA expression starts later in the keratocytes but lasts somewhat longer (3 weeks). PCNA expression appears more efficient than Ki-67 to show proliferative activity of slow cycling cells in the cornea

Laser in situ keratomileusis for treatment of residual myopia after photorefractive keratectomy

PURPOSE

To evaluate the results of laser in situ keratomileusis after photorefractive keratectomy.

METHODS

Eighty eyes of 80 patients with residual myopia after photorefractive keratectomy were reoperated with laser in situ keratomileusis. The study was retrospective. Laser in situ keratomileusis was performed using the automated corneal shaper microkeratome and Chiron Technolas 217-C d1 excimer laser. Data measured after laser in situ keratomileusis included uncorrected visual acuity, best-corrected visual acuity, refraction, haze, pachymetry, and keratometry. The follow-up was at least 12 +/- 1.6 months (range, 12 to 15 months).

RESULTS

After laser in situ keratomileusis the mean spherical equivalent was -0.24 diopters +/- 0.78. (range, -3 to +1.5) at 12 months, and the mean uncorrected visual acuity was 0.76 diopters +/- 0.24 (range, 0.1 to 1). Sixty-five eyes (81.3%) had various degrees of haze after laser in situ keratomileusis. One eye (1.2%) lost 2 lines of best-corrected visual acuity.

CONCLUSIONS

Laser in situ keratomileusis enhancement may be a good alternative to correct residual myopia and astigmatism after primary photorefractive keratectomy. Corneal haze is a common problem in these eyes, and the treatment after laser in situ keratomileusis enhancement should be the same as the treatment after primary photorefractive keratectomy.

Immunohistochemical Study of Subepithelial Haze After Phototherapeutic Keratectomy

PURPOSE

Subepithelial haze is a frequent complication and is often the cause of regression after photorefractive keratectomy (PRK). The lack of understanding of this undesirable complication following PRK is in part due to the limited availability of suitable tissues for pathological studies.

METHODS

We examined the expression of various extracellular components in the cornea of a 46-year-old man who underwent phototherapeutic keratectomy (PTK) to remove a central corneal scar secondary to trauma. The patient subsequently underwent penetrating keratoplasty. A scar-free region containing an area of slight subepithelial haze adjacent to normal cornea was used for immunohistochemical staining with antibodies directed against cytoskeletal proteins, ie, vimentin, desmin and smooth muscle actin, and the extracellular components, laminin, heparan sulfate, keratan sulfate, and collagen types III, IV, V, and VII.

RESULTS

Immunohistochemistry revealed that basal epithelial cells expressed components of basement membrane. The stromal fibroblasts within the haze tissue were labeled by anti-smooth muscle actin antibodies, a characteristic of myofibroblasts, which synthesized and secreted extracellular matrix components that contributed to the formation of the disorganized collagenous matrix and may account for subepithelial haze.

CONCLUSIONS

The expression patterns for the cytoskeletal proteins and extracellular components indicated that the formation of subepithelial haze is a process of tissue remodeling, involving both corneal basal epithelial cells and keratocytes during wound repair.

Effects of amniotic membrane on epithelial wound healing and stromal remodelling after excimer laser keratectomy in rabbit cornea

AIMS

To investigate if the amniotic membrane (AM) promotes epithelial migration while inhibiting stromal remodelling associated with corneal haze after excimer laser keratectomy.

METHODS

A wound 150 microm in depth and 6.0 mm in diameter was produced in 40 rabbits using an excimer laser. One eye was randomly chosen to be covered by the AM while the other eye served as a control. Epithelial wound healing was evaluated, together with any morphological changes of the anterior stroma connected with corneal haze. These morphological changes were histopathologically analysed using dichlortriazinyl aminofluorescein (DTAF), Masson trichrome staining, and an image analyser.

RESULTS

The AM group had a short latent phase followed by fast epithelial healing (p<0.001) during the early wound healing period and a significant decrease in the inflammatory response, together with a smaller change in the number of keratocytes than the control group. The mean thickness of the regenerated stroma was significantly thinner in the AM group than in the control group at 8 weeks (p<0.0001). The AM group had a more regular architecture of regenerated stromal lamella at 8 weeks and significantly less haze after 4 weeks than the control group (p<0.05).

CONCLUSION

Use of the AM as a dressing on a corneal wound created by excimer laser surgery, in which severe haze is expected, may induce rapid epithelial healing with less inflammatory response. The AM may inhibit the irregular synthesis of stromal collagen that is associated with corneal haze.

Can we produce a human corneal equivalent by tissue engineering?

Tissue engineering is progressing rapidly. Bioengineered substitutes are already available for experimental applications and some clinical purposes such as skin replacement. This review focuses on the development of reconstructed human cornea in vitro by tissue engineering. Key elements to consider in the corneal reconstruction, such as the source for epithelial cells and keratocytes, are discussed and the various steps of production are presented. Since one application of this human model is to obtain a better understanding of corneal wound healing, the mechanisms of this phenomenon as well as the function played both by membrane-bound integrins and components from the extracellular matrix have also been addressed. The analysis of integrins by immunohistofluorescence labelling of our reconstructed human cornea revealed that beta(1), alpha(3), alpha(5), and alpha(6) integrin subunits were expressed but alpha(4) was not. Laminin, type VII collagen and fibronectin were also detected. Finally, the future challenges of corneal reconstruction by tissue engineering are discussed and the tremendous applications of such tissue produced in vitro for experimental as well as clinical purposes are considered.

The influence of corneal stromal matrix proteins on the migration of human corneal fibroblasts

Motivated by the alterations seen in the corneal matrix composition after photorefractive keratectomy and the migration of corneal keratocytes seen following this procedure, the locomotor response of corneal stromal fibroblasts to various extracellular matrix proteins was determined. In addition, the involvement of integrin mediated attachment to the matrix proteins was investigated. Quantitative invasion assays were performed using collagen gels, supplemented with either fibronectin, tenascin, collagen type V, collagen type VI, chondroitin sulfate or keratan sulfate. The ultrastructure of the gels was visualized by scanning electron microscopy and related to the migration results. The extent of alpha(1)beta(1), alpha(2)beta(1), alpha(3)beta(1)and alpha(5)beta(1)integrin mediated attachment to the matrix proteins was evaluated using blocking antibodies. Fibronectin increased corneal fibroblast migration significantly, and served as an excellent substrate for cellular attachment, mediated by the alpha(5)beta(1)integrin. Addition of tenascin to the fibronectin-containing gels disrupted these effects, while attachment to this matrix also involved the integrins alpha(2)beta(1)and alpha(3)beta(1). Chondroitin sulfate and collagen types V and VI primarily altered the structure of the collagen matrix, resulting in an inhibition of migration by the collagens and an increase by chondroitin sulfate. They all served as poor substrates for attachment. Thus, the migratory activity of corneal fibroblasts in vitro is influenced by the composition of the surrounding extracellular matrix, either by integrin mediated cell-matrix interactions or through matrix-matrix interactions. This study provides evidence that the provisional matrix deposited in a corneal stromal wound may facilitate the entry of migrating corneal fibroblasts.

Effect of anti-inflammatory agents on corneal wound-healing process after surface excimer laser keratectomy

PURPOSE

To investigate the effect of anti-inflammatory agents on conjunctival inflammation and corneal haze formation after excimer laser keratectomy.

SETTING

Department of Ophthalmology, University of Tokyo Faculty of Medicine, Tokyo, Japan.

METHODS

After excimer laser keratectomy was performed in 21 rabbits (42 eyes), saline, betamethasone 0.1%, or diclofenac 0.1% was topically applied 6 times a day for 4 weeks and then 3 times a day for 8 weeks. The degree of conjunctival inflammation was determined 1, 2, 3, and 7 days after the keratectomy. The degree of corneal haze was quantitatively measured using a digital analyzer before and once a week after the keratectomy. The expression of type IV collagen in the corneas at baseline and 4 and 12 weeks after the keratectomy was examined immunohistochemically.

RESULTS

Compared with saline, betamethasone and diclofenac significantly decreased early-phase conjunctival inflammation. Betamethasone significantly inhibited corneal haze formation compared with saline at 3 to 5 and 8 to 12 weeks. Diclofenac did not inhibit corneal haze formation significantly. Although betamethasone tended to be more effective in inhibiting corneal haze formation and deposition of type IV collagen than diclofenac, there was no statistical difference between the 2 anti-inflammatory agents.

CONCLUSION

Topically applied betamethasone effectively suppressed corneal haze formation after excimer laser keratectomy. Diclofenac was not statistically effective in inhibiting corneal haze formation.

Wound healing after photorefractive keratectomy

For more than 15 years, the excimer laser has been used as a surgical instrument on the cornea. Photorefractive keratectomy (PRK) followed radial keratotomy as researchers sought a more precise technique. In PRK, precision turned out to depend on surgical technique as well as the wound-healing process, with the 2 factors interdependent. The PRK technique has evolved toward a large diameter, flat ablation curvatures, and an even surface. The role of such factors as cytokines and interleukins has become more clear in the past 10 years. However, understanding the wound-healing process becomes more complicated with increasing know edge. Learning the contributing factors and performing trials with new drugs and antibodies to modulate wound healing have shown positive results on the experimental level. Patient selection based on the concentration of epidermal growth factor in tears may be another way to increase PRK s precision. The PRK technique has taught much about wound healing. For the technique to be competitive, increased precision, particularly in eyes with high myopia, is needed. Two other factors are imperative: controlling postoperative pain and decreasing visual rehabilitation time.

Corneal Wound Healing After Laser in situ Keratomileusis in Rabbits

BACKGROUND

The aim of this study was to characterize the cell biology of wound healing in rabbit corneas subjected to laser in situ keratomileusis (LASIK).

METHODS

Rabbit corneas underwent LASIK with various multizone photoablations or only a lamellar keratotomy followed by repositioning of the flap. We looked for indications for an active wound healing process. Immunohistochemistry for the extradomain A cellular fibronectin (EDA-cFn) or tenascin (Tn) and routine histology were examined.

RESULTS

Four days after LASIK or lamellar keratotomy followed by repositioning of the flap, epithelial plugs and prominent keratocytes as well as Tn and EDA-cFn immunoreactions-indicative of a wound-healing process-appeared in the wound margins. Epithelial plugs were less conspicous, and prominent, presumably activated, keratocytes were no longer identified at the wound margin at 2.5 and 5 months after wounding. However, EDA-cFn and Tn immunoreactivities could still be observed. Only the stromal cells located in the periphery of the flap and in relatively close contact with the epithelium were surrounded by scar tissue expressing immunoreactivity for EDA-cFn or Tn. The central corneal stroma was devoid of scar tissue.

CONCLUSION

Results indicate that the wound healing reaction after LASIK takes place only at the periphery of the microkeratome wound, leaving the central optical zone clear.

Extracellular matrix changes in human corneas after radial keratotomy

Extracellular matrix and basement membrane alterations were identified in human corneas after radial keratotomy. Ten normal and five radial keratotomy autopsy corneas (two at 6 months post surgery, and three at 3 years post surgery) were studied by immunofluorescence with antibodies to 28 extracellular matrix and basement membrane components. Outside of radial keratotomy scars, all studied components had a normal distribution. Of stromal extracellular matrix, only type III collagen accumulated around the scars. The basement membrane around epithelial plugs had a normal composition except for type IV collagen. Its alpha1-alpha2 chains, normally present only in the limbal basement membrane, appeared around all plugs. alpha3 and alpha4 chains were very weak or absent in these areas, contrary to nonscarred areas. This basement membrane pattern was similar to the normal limbal but not to the central corneal pattern. Keratin 3 also had a limbal-like, suprabasal expression in the plug epithelium. The stroma around the scars accumulated tenascin-C, fibrillin-1, types VIII and XIV collagen, all of which were absent from normal corneal basement membrane and extracellular matrix. Only tenascin-C showed less staining in anterior scars 3 years post surgery than 6 months post surgery, but still persisted in posterior scars. Incomplete scar healing was evident even 3 years post radial keratotomy. It was manifested by the accumulation of abnormal extracellular matrix in the anterior and posterior scars and by the limbal-like pattern of type IV collagen isoforms in the basement membrane around epithelial plugs.

Tenascin-C expression in normal, inflamed, and scarred human corneas

AIMS/BACKGROUND

In adult tissues the expression of tenascin-cytotactin (TN-C), an extracellular matrix glycoprotein, is limited to tumours and regions of continuous renewal. It is also transiently expressed in cutaneous and corneal wound healing. There are limited data regarding its expression in inflammation and scarring of the adult human cornea. In this study, TN-C expression patterns in normal, inflamed, and scarred human corneas have been examined.

METHODS

Penetrating keratoplasty specimens were selected from cases of herpes simplex keratitis, herpes zoster ophthalmicus, rheumatoid arthritis ulceration, bacterial keratitis, rosacea keratitis, interstitial keratitis, and previous surgery so as to encompass varying degrees of active and chronic inflammation and scarring. TN-C in these and in normal corneas was immunodetected using TN2, a monoclonal antibody to human TN-C.

RESULTS

There was no TN2 immunopositivity in normal corneas except at the corneoscleral interface. In pathological corneas, TN2 immunopositivity was localised in and around regions of active inflammation, fibrosis, and neovascularisation. TN2 positivity was less in acute inflammation than in active chronic inflammation. Mature, avascular scar tissue and epithelial downgrowth were TN2 negative.

CONCLUSION

These results indicate that in the adult human cornea, TN-C expression is induced in regions of inflammation, fibrosis, and neovascularisation, but that expression is absent in mature, avascular scar tissue. This suggests a role for this glycoprotein in inflammation, healing, and extracellular matrix reorganisation of the cornea.

Real-time confocal microscopic observations on human corneal nerves and wound healing after excimer laser photorefractive keratectomy

PURPOSE

Corneal wound healing after excimer laser photorefractive keratectomy (PRK) passes through a series of characteristic stages which have earlier been defined by means of histological, histochemical, and biochemical approaches. We investigated the potential of confocal microscopy to verify morphological changes in human corneas in vivo after PRK.

METHODS

Ten corneas of eight patients that had earlier undergone PRK were examined at different postoperative time points (7 days-34 months). One of the PRK patients was examined sequentially three times. Three additional corneas, which had earlier undergone corneal grafting surgery and then were subjected to excimer laser photoastigmatic keratectomy (PARK), were studied as well. Seven healthy untreated corneas served as controls to define the normal morphology of human cornea. A tandem scanning confocal microscope (TSCM) was used to generate real-time images of the corneas on an S-VHS videotape. The images were either digitized and further processed or the individual video frames were produced with a video printer.

RESULTS

Seven days post-PRK in vivo confocal microscopy revealed the presence of morphologically immature surface epithelial cells. Delicate nerves, activated keratocytes and deposition of extracellular light-reflecting scar tissue were perceived. The epithelium appeared normal one month post-PRK. Ongoing activation of the anterior stromal keratocytes along with extracellular scar tissue were detected. We also observed increasing numbers of regenerating subepithelial nerve leashes with somewhat twisted pattern. Highly reflective, presumably activated keratocytes were no longer detected 6-7 months post-PRK. Hypercellularity with scar tissue could still be found up to 30 months post-PRK. Only one cornea examined 34 months post-PRK showed normal keratocyte morphology and recovery of the anterior stroma. However, the morphology of subepithelial nerves was still somewhat abnormal. The two corneal grafts examined 11 or 32 months post-PARK exhibited a normal-appearing epithelium but considerable stromal hypercellularity and extracellular scar deposition. The subepithelial nerves were poorly regenerated in one eye and fairly well detectable in the other. The third graft examined 15 months post-PARK revealed the presence of enlarged surface epithelial cells and dense stromal scarring but no nerves.

CONCLUSION

TSCM clinically confirms the earlier histological data on healing of excimer laser wounds. It offers a distinct improvement in the assessment of excimer laser-treated corneas, as it enables cellular details and nerves to be perceived in vivo. In addition the thickness of the stromal scar can be be measured for e.g. planning of phototherapeutic keratectomy.

Hyaluronan facilitates corneal epithelial wound healing in diabetic rats

We investigated the effect of hyaluronan on corneal epithelial wound healing in rats affected by diabetes. Furthermore, because hyaluronan is thought to affect corneal epithelial wound healing through the mechanism of binding of hyaluronan to provisional fibronectin in the wounded area, we compared the localization of fibronectin immunohistochemically during corneal epithelial wound healing in diabetic and non-diabetic rats. Streptozotocin was used to induce diabetes in half the rats. Two weeks after treatment, the whole corneal epithelium of diabetic and untreated rats was debrided. The rats were divided into groups (seven or eight rats per group), and hyaluronan eye drops at concentrations of 0.03, 0.1, or 0.3%, chondroitin sulfate (3%), or phosphate buffered saline (PBS) was given in eye drops 6 times a day for 4 days, starting immediately after debridement. The area of the corneal epithelial wound was measured immediately after debridement and at 12, 18, 24, 30, 48, 72, and 96 hours afterwards. Although the healing process was similar in non-diabetic and diabetic rats, the healing rate in diabetic rats was slower than that in normal controls. In both diabetic and non-diabetic rats, hyaluronan increased the healing rate in a dose-dependent manner; the difference was significant compared with the PBS-treated group, at hyaluronan doses of 0.1% and 0.3%. However, chondroitin sulfate did not affect corneal epithelial wound closure, regardless of whether the rats were diabetic or not; the healing rates were identical to those of PBS-treated diabetic and non-diabetic controls. In both diabetic and non-diabetic corneas, fibronectin was localized in the corneal subepithelial region, and in streaks between collagen fibers of the stroma. One day after debridement, a layer of fibronectin immunofluorescence was clearly visible on the surface of the denuded stroma. As healing progressed staining of fibronectin diminished at the interface between the new epithelium and the stroma. These changes in localization of fibronectin during corneal epithelial wound healing were similar in both diabetic and non-diabetic rats. Our results demonstrate that hyaluronan facilitates corneal epithelial wound healing in diabetic rats, and suggest that one possible mechanism of its stimulatory effect lies in its binding to a provisional fibronectin matrix, in both diabetic and non-diabetic rats.

Comparison of Corneal Epithelial Wound Healing after Photorefractive Keratectomy in the Rabbit with Two Types of Excimer Lasers

PURPOSE

To evaluate the differences in epithelial wound healing following photorefractive keratectomy when performed with the Summit UV 200 LA and the VISX 20/20 excimer lasers.

METHODS

Sixteen New Zealand rabbits were divided into two groups. One group was treated with the Summit laser and the other group treated with the VISX 20/20 laser. The treatment consisted of a -6.00 diopter photorefractive keratectomy with a 5-mm diameter treatment zone. Epithelial wound healing was followed by photography at 4 hour intervals for 64 hours. The length of the wound edge and the size, shape, and closure time of the wound were measured.

RESULTS

The median wound edge length at 4 hours was 18.3 mm for the Summit laser and 16.7 mm for the VISX laser. The median wound size at 4 hours was 22.0 mm2 for the Summit and 21.2 mm2 for the VISX. The median wound closure time was 53.4 hours for the Summit laser and 54.0 hours for the VISX laser.

CONCLUSION

There was no statistically significant difference in the epithelial healing of rabbit corneal wounds created by photorefractive keratectomy when performed with two current ophthalmic excimer lasers, the Summit UV 200 LA and the VISX 20/20.

The expression of tenascin and fibronectin in keratoconus, scarred and normal human cornea

BACKGROUND

The etiology and pathogenesis of keratoconus remain unclear, and therefore we decided to study the distribution of different isoforms of tenascin (Tn) and fibronectin (Fn) in normal human corneas and in those obtained from penetrating keratoplasty for keratoconus and corneal scarring.

METHODS

Frozen sections of human cornea and conjunctiva were stained by immunohistochemical methods with a panel of monoclonal antibodies (MAbs) against different isoforms of Tn and Fn.

RESULTS

In the normal human eye, Tn was found in the limbal and conjunctival basement membrane region, in the conjunctival blood vessels and at the junction of the cornea and sclera, but no immunoreaction was seen in the normal cornea. In the corneas from the keratoconus patients, a clear immunoreaction for Tn was seen in the defects of Bowman's membrane as well as in the distorted stroma beneath the defects. In some of the keratoconus corneas, basement membrane adjacent to the defects also showed reactivity for Tn, and in clinically and histologically scarred keratoconus corneas the scars expressed Tn. In the scarred corneas, only blood vessels in the posterior portion of the cornea showed immunoreactivity for Tn, while no Tn was noted in the scar area or in Bowman's membrane. No major differences were noticed in the reactivity of different MAbs against Tn isoforms. Fn, extradomain A Fn (EDA-Fn) and oncofetal Fn (onc-Fn) were found in the basement membrane of the central cornea of the normal eye. In keratoconus corneas, the defects and clinical and histological scars bound MAbs against Fn, EDA-Fn and onc-Fn, but in the scarred corneas no enhancement in the expression of Fns was noted. Extradomain B cellular Fn (EDB-Fn) was not expressed in any of the eyes studied.

CONCLUSIONS

The results suggest that the anterior portion of the cornea is involved in the pathogenesis of keratoconus. Furthermore, it seems that the expression of Tn and Fns in the clinically scarred keratoconus corneas is due to a process in which both repairing and scar-forming mechanisms operate at the same time. However, the origin of the defects in Bowman's membrane seen in keratoconus still remains unclear. They may be minor scars due to the disease or primary defects in the process leading to keratoconus.

Upregulation of alpha 9 integrin and tenascin during epithelial regeneration after debridement in the cornea

Stratified epithelia are exposed to abrasive forces and are required to respond rapidly to injury to minimize fluid loss and the risk for microbial infection. Healing involves a cell migratory phase to reestablish barrier function and cell proliferation to restratify the epithelium. Cell migration during re-epithelialization involves cell sliding, termed sheet movement, during which cells retain their cell-cell junctions while dynamically altering their shape and cell-substrate interactions to permit movement across the exposed wound bed. Proteins of the integrin family of receptor molecules modulate cell shape, cell migration, and signal transduction in many cell types. In epithelial cells, integrins of the beta 1 family have been implicated in regulating cell proliferation and differentiation, alpha 9 beta b1 is one of the newer members of the integrin beta family and has been recently shown to function as a tenascin receptor. Although little is known about its function in vivo, studies in developing mouse cornea and eyelid suggest that it may play a role in epithelial differentiation. Using a debridement wound model in the mouse cornea, we show in this study that (a) in response to small debridement wounds that close without cell proliferation, alpha 9 integrin protein and mRNA are not induced during migration but are induced during restratification, (b) larger debridement wounds that require cell proliferation to generate the cells necessary for sheet movement result in a dramatic induction of alpha 9 protein and its mRNA during both migration and restratification, and (c) tenascin, an alpha 9 beta 1 ligand, accumulates beneath epithelial cells during restratification but not during cell migration. Therefore, alpha 9 integrin protein production and tenascin accumulation are dynamically regulated in response to corneal epithelial injury.

Corneal Wound Healing and Nerve Morphology after Excimer Laser In Situ Keratomileusis in Human Eyes

BACKGROUND

Our aim was to describe wound healing and nerve regeneration in the human cornea after excimer laser in situ keratomileusis.

METHODS

Excimer laser in situ keratomileusis was done in three human eyes 8 days, 54 days, and 4 months prior to enucleation. Acetylcholinesterase reaction was used to histochemically demonstrate the corneal nerves. Immunohistochemical methods were used to demonstrate the following wound healing proteins: cellular fibronectin, tenascin, transforming growth factor-beta 1, and alpha-smooth muscle actin.

RESULTS

All corneas healed without complication. No epithelial hyperplasia appeared and the Bowman's layer was smooth and acellular. An epithelial plug extending up to 100-300 microns under the flap margins was seen in all specimens. Regenerative nerve fiber bundles emerging from sharply cut anterior stromal nerves were observed, but the deeper nerves were normal. Restricted expression of fibronectin and tenascin was found at the wound area. All corneal cell types were positive for transforming growth factor-beta 1 antibody. Cells lining the limbal vessels were positive for alpha-smooth muscle actin antibody whereas the corneal cells were negative.

CONCLUSIONS

The nerve morphology showed only a few abnormalities, especially in deep stromal nerves. Epithelial plugs at the flap margins may maintain a delayed wound healing process for several months but otherwise the process remained active for a relatively short time.