vitreoretinal pathology has rarely been observed after laser - assisted in situ keratomileusis ( lasik ) or photorefractive keratectomy ( prk ) .
posterior segment complications are more common in myopic eyes and no direct causal relationship with keratorefractive surgery has been established .
retinal breaks , rhegmatogenous detachments , posterior vitreous detachments , choroidal neovascularization ( cnv ) , and vitreous hemorrhage have all been reported [ 13 ] .
central serous chorioretinopathy ( cscr ) is generally a self - limited disease with the majority of patients recovering visual acuity to 20/30 or better within three months .
approximately 4% of patients will present with binocular involvement , while up to 40% may eventually have involvement of the fellow eye .
increased permeability of the choroidal vessels and dysfunction of the retinal pigment epithelium ( rpe ) have been observed with neurosensory retinal detachment and pigment epithelial detachment .
patients present with central visual aberrations including scotoma , metamorphopsia , dyschromatopsia , and micropsia . known risk factors for cscr include  type a  personality , pregnancy , and corticosteroid elevation either endogenously or through exogenous corticosteroid use .
cscr has been reported in 4 separate case reports after lasik [ 912 ] . to date , there have not been any reports of cscr after prk .
the goal of this study was to report the incidence of cscr after both prk and lasik through a retrospective chart review .
from january 2005 to december 2010 , an icd-9 code search for cscr ( 362.41 ) identified 250 cscr patients seen at the john a. moran eye center .
patients ' age , sex , medication history , pre- and postrefractive surgery exam findings , onset of cscr symptoms , clinical course , treatment , and visual outcomes were analyzed .
the university of utah hospital institutional review board approved the research protocol in accordance with the tenets of the declaration of helsinki .
database billing records of the moran eye center were reviewed to determine the total number of lasik and prk procedures performed during the 6-year study period .
prior to 2008 , a hansatome microkeratome ( bausch & lomb , inc , rochester , ny ) was used for flap creation .
thereafter , the intralase fs60 femtosecond laser ( abbott medical optics ( amo ) , santa ana , ca ) was utilized .
both prk and lasik were performed with either the visx star s4 customvue ( amo ) , ladarvision customcornea ( alcon inc . ,
fort worth , tx ) , or the wavelight allegretto ( alcon , inc . ) excimer laser platforms .  
all moran eye center refractive surgery patients are routinely followed at a minimum of 6 visits at 1 day , 1 week , 1 , 3 , 6 , and 12 months after surgery .
any retinal complications that are discovered during postoperative exams are routinely referred to our institution 's retina service .
because of our internal referral system , any cscr complication after lasik or prk would be identified in the review of retina record visits .
a medline keyword search for cscr and prk or lasik identified all previously reported cases of cscr after lasik or prk in the literature .
of the 250 cscr patients seen by the retina service , 7 patients were identified as having a previous history of lasik or prk at either the moran eye center or an outside facility ( table 1 ) .
all 7 patients were male with an average age of 37 years , and all presented with unilateral cscr .
all had myopic keratorefractive treatment , and none had a previous history of cscr or documented oral , topical skin , or inhaled corticosteroid use or other significant medical history . only 2 patients ( patients 1 and 2 ) had onset of disease within the immediate postoperative period of 1 month .
the remaining patients presented more than 4 years after refractive surgery and were not considered to have a potential causal relationship .
all 7 patients were followed at the moran eye center from the time of initial cscr symptoms to resolution or stabilization of disease .
two of the patients received treatment with focal laser photocoagulation , while 5 resolved spontaneously without treatment .
all 7 patients improved to an uncorrected distance visual acuity ( udva ) of 20/30 or better .
best corrected visual acuity ( bcva ) was not recorded in all patients . from january 2005 to december 2010 , there were 2,728 eyes which had lasik , and 2,148 eyes that received prk at the moran eye center .
only one of the combined 4,876 total lasik and prk cases at our institution developed cscr within one month .
the annual incidence of cscr over the 6-year study period was calculated to be 3.4 per 100,000 eyes for both prk and lasik cases , and 7.8 per 100,000 eyes of only prk cases .
a comprehensive literature search revealed 4 other reports of cscr after lasik ; however , long - term recovery was not available in all cases ( table 1 ) .
two patients presented with bilateral cscr [ 10 , 11 ] and 1 patient developed a rapid onset of cscr with cnv one week following lasik .
this is a 37-year - old male with an unknown employment who underwent prk in september 2010 with a preoperative manifest refraction of 4.50 + 0.25  134 and 4.50 sphere , right and left eyes , respectively .
spectral domain optical coherence tomography ( sd - oct , heidelberg engineering , heidelberg , germany ) demonstrated subretinal fluid accumulation consistent with cscr ( figure 1 ) in the affected eye .
consultation with a retina specialist led to the decision to keep the patient on standard corticosteroids drops with close observation .
after one month , the patient was switched to fluorometholone 0.1% ( allergan inc . )
udva improved to 20/20 bilaterally 1 month after initial symptoms with complete resolution of metamorphopsia by 5 months after prk .
anterior and posterior segment exam and sd - oct findings were normal and the patient was advised to monitor his symptoms without further intervention .
this is a 28-year - old male lab technician who underwent prk at an outside facility in august 2009 .
his preoperative manifest refraction was 4.50 + 1.00  90 and 4.75 + 1.75  90 , right and left eyes , respectively .
the diagnosis of cscr was confirmed by fundus exam and oct subretinal fluid in the left eye , with a normal exam in the right eye .
ten months after prk his udva was 20/15 in the left eye with no visual complaints .
cscr as a complication of refractive surgery is rare with only 4 previously reported cases [ 912 ] .
these reports identified 2 hyperopic [ 9 , 10 ] and 1 myopic patient   who developed cscr shortly after lasik and 1 patient   who developed cscr with cnv .
the annual age - adjusted incidence of cscr has been reported to be 5.8 per 100,000 , with a male incidence of 9.9 and a female incidence of 1.7 per 100,000 .
although not directly comparable with population studies , our findings support a large male predominance with a low annual incidence of 7.8 per 100,000 eyes after prk and 3.4 per 100,000 eyes after both prk and lasik , based on analysis of the cases performed at our institution over 6 years .
there were 5 patients who developed cscr 4 years or more after lasik or prk .
these patients were excluded from our analysis as having cscr potentially caused by lasik or prk .
limitations in our study include the retrospective nature , possible loss of followup , and development of cscr after the time period of medical chart review .
chronic cscr often is bilateral , with symptoms lasting longer than 6 months and can occur with recurrent disease .
the high percentage of spontaneously resolving cases is the reason conservative management is initially advised .
corticosteroids should be discontinued and if resolution is not observed within 3 months more aggressive management can be considered .
half - fluence photodynamic therapy ( pdt ) and photocoagulation result in more rapid resolution of subretinal fluid , and may also limit recurrences .
previous studies that explored processes leading to vitreoretinal pathology following refractive surgery have identified two possible exposures .
the first is potential shock wave damage in the posterior segment during excimer laser treatment .
however , krueger et al . reported insignificant retinal stress wave amplitudes in experimental models after excimer photoablation .
the second potential risk during lasik is the rapid change in intraocular pressure from the suction ring used to stabilize the microtome .
although less vacuum is required with femtosecond - laser - assisted lasik , the longer flap creation time may still predispose patients to retinal pathology .
both mechanisms can theoretically destabilize a structurally altered retina such as in the case of cscr .
corticosteroids are often used after prk for their anti - inflammatory properties as an attempt to prevent long - term sequelae of haze and unpredictable refractive outcomes . although , some reports have shown no difference in outcomes following prk treated with or without topical corticosteroids [ 15 , 16 ] , most prk surgeons reported using some form of topical corticosteroids postoperatively .
early corticosteroid treatment has also been reported more effective than nonsteroidal anti - inflammatory drugs .
multiple routes of corticosteroid administration   have been associated with cscr , including oral , intravenous , epidural , intra - articular , inhaled , topical skin application , and also following intravitreal triamcinolone injections . however , to our knowledge there have been no reported cases of cscr following topical ocular corticosteroid use .
the lack of such cases may reflect low penetration of topical drugs in reaching the posterior segment , with even lower systemic absorption due to further dilution in the tear film . in rabbit eyes ,
difluprednate showed dramatically decreased concentrations in the posterior retina and barely detectable blood concentrations , suggesting that even a highly lipophilic topical corticosteroid with excellent corneal penetration may not significantly alter retinal pathology .
alternatively , the stress and anxiety of refractive surgery inducing elevated levels of systemic cortisol may contribute to exacerbations in cscr patients .
the dilemma for the surgeon is how to treat such a patient who develops cscr after prk .
continuing topical corticosteroids may prolong or exacerbate cscr symptoms , whereas early removal may decrease control over inflammation potentially leading to long - term haze .
whether topical corticosteroids are discontinued or changed to less potent formulations , worsening cscr may still require consideration of pdt or laser photocoagulation .
the decision was made to continue our patient on topical corticosteroids with close clinical observation .
the patient was noted to have mild rpe changes preoperatively which may have indicated prior cscr disease activity .
a dilated fundoscopic exam is an important part of both the refractive screening process and postoperative evaluation when outcomes are not as expected . in summary , from review of the literature and analysis of over 4,800 consecutive lasik and prk cases at our institution , we report a low incidence of cscr after lasik or prk without a direct causal association .
cscr after keratorefractive surgery may rarely be induced by extensive topical corticosteroids , elevated cortisol levels from stress of the surgery , or mechanical disturbances after excimer laser or lasik flap creation in susceptible patients .
 
 purpose . to assess the incidence of central serous chorioretinopathy ( cscr ) following laser in situ keratomileusis ( lasik ) and photorefractive keratectomy ( prk ) 
 . 
 methods . 
 
 a chart review was performed to identify all patients with cscr and a previous history of lasik or prk . 
 results . over the 6-year study period , 
 1 of 4,876 eyes which had lasik or prk at the moran eye center was diagnosed with cscr . 
 one other patient was referred from an outside center , developed cscr symptoms one month after prk . 
 both patients were managed conservatively with a final visual acuity of 20/20 or better . 
 all other patients presented 4 or more years after refractive surgery . 
 
 conclusions . 
 we report the first 2 cscr cases developing within one month after prk . 
 the low incidence argues against a causal association . 
 topical corticosteroids or anxiety may elevate cortisol levels presenting therapeutic challenges for the management of cscr after prk or lasik . 
 
1. Introduction
2. Methods and Patients
3. Results
4. Patient 1
5. Patient 2
6. Discussion