Photo from Unsplash
Originally Posted On: https://bluefinvision.com/blog/corneal-haze-after-transprk/
A Real Complication, A Real Patient, and What We Actually Did
Procedure: Bilateral TransPRK
Patient: Mr R.M., born 2004
Surgeon: Mr Mfazo Hove, Consultant Ophthalmologist, Blue Fin Vision®
We Do Not Only Write About What Goes Well
Most surgical practices publish their successes. Best corrected visual acuities, patient satisfaction scores, outcomes that validate the decision to proceed. We publish those too, and our data, audited through the National Ophthalmology Database across four consecutive years, stands behind everything we do.
But this is not one of those cases.
This is a case where a young patient had a significant complication. Where vision that had been excellent at six weeks deteriorated sharply by three months. Where we had to make difficult clinical decisions under uncertainty, fund a specialist second opinion from our own resources, post medication to a patient’s home address over the New Year period, and manage this across months rather than days.
We are writing about it because this is what ophthalmology actually looks like. And because how a surgeon responds when things do not go to plan tells you more about a practice than any highlight reel ever could.
What makes a clinic the best is not the claim that complications never happen, but the systems and values that determine what happens next when they do.
What This Case Shows About Blue Fin Vision®
Before the clinical detail: four specific, documented behaviours in this case that define how this practice operates.
- We chose the only safe procedure for thin corneas (TransPRK, not LASIK or SMILE) based on audited safety thresholds and ectasia risk data, not convenience or throughput.
- We funded £990 of external specialist care (two visits to a named corneal expert at Accuvision London) without the patient asking, without billing him, and before either appointment had taken place.
- We maintained treatment continuity over New Year by identifying a steroid gap as clinically non-trivial and physically posting replacement drops to his home address the same afternoon.
- We shared OCT imaging and plain-language explanations directly with the patient so a 21-year-old understood his own anatomy, his options, and the honest uncertainty about his outcome.
This is not presented as exceptional behaviour. It is how this practice is structured to operate.
Why This Patient Could Not Have LASIK or SMILE
Mr R.M. presented with bilateral myopia and was assessed for refractive surgery. Pre-operative Pentacam tomography revealed corneal dimensions that placed both LASIK and SMILE firmly outside safe parameters: thinnest pachymetry of approximately 444 µm right and 432 µm left, with anterior chamber and elevation findings consistent with borderline corneal architecture.
Both LASIK and SMILE require the creation of a stromal flap or lenticule within a tissue bed that must remain biomechanically adequate after treatment. In this patient, the residual stromal bed following ablation would have fallen below accepted safety thresholds, carrying a material risk of post-operative ectasia, progressive, potentially irreversible corneal steepening that can produce severe and uncorrectable visual loss.1 2
TransPRK was the correct and only appropriate choice. It removes the epithelium and performs the ablation in a single laser pass without flap creation, preserving maximum stromal depth while achieving the refractive target.3
Pre-operative counselling included explicit discussion of the risks unique to surface ablation, including a small but real risk of subepithelial fibrosis, documented in the consent record, with specific reference to the elevated risk conferred by this patient’s thinner corneas and pre-existing dry eye.4
It is important to state this directly: the development of corneal haze in this case does not indicate that TransPRK was the wrong choice. LASIK carried a material risk of ectasia. SMILE was not appropriate on the same grounds. Surface ablation remained the only procedure that could safely treat this patient’s myopia. The complication that occurred is a known, counselled risk of the only viable procedure, not a consequence of an avoidable decision.
Surgery and the Initial Result
Bilateral TransPRK was performed on 24 July 2025. At the six-week review on 5 September 2025 the result was what we had hoped for: right eye 6/4 unaided, left eye 6/6 unaided. Both eyes were dry and lubricants were commenced. IOP 15 mmHg bilaterally. The plan was routine follow-up in two months.
At that point, nothing suggested we were on an unusual course.
Why This Complication Does Not Mean the Wrong Surgery Was Chosen
Mr R.M. contacted us in October 2025 reporting that his vision had become blurred. He attended for review on 24 October 2025.
The findings were significant. Unaided acuity had deteriorated to 6/12 right and 6/36 left. Manifest refraction had regressed almost entirely to pre-operative levels: −2.50/−0.75 × 101 right, −2.50/−0.75 × 100 left. Slit-lamp examination revealed central corneal haze, left worse than right. Topography confirmed scarring at the level of the anterior stroma. This is subepithelial fibrosis, a recognised complication of surface ablation, disproportionately associated with higher corrections, thinner corneas, and pre-existing dry eye.4 5
The pathophysiology is well characterised. After epithelial removal, anterior stromal keratocytes undergo apoptosis and repopulation. In some corneas this repopulation is dysregulated: activated keratocytes differentiate into myofibroblasts under the influence of transforming growth factor-beta, depositing disorganised extracellular matrix that scatters light and reduces optical transparency.5 6
In plain terms: the healing process had deposited scar tissue in the visual axis. The vision that had been excellent at six weeks was now severely compromised. At 21, he had gone from independence to uncertainty within weeks. This was a hard conversation. I had it directly and completely, without minimisation.
This occurred despite appropriate patient selection, counselling, and technique. Subepithelial fibrosis is not a surgical error. It is a biological response that cannot be fully predicted or prevented in every patient, even when every correct clinical decision has been made. Even with optimal technique and evidence-based prophylaxis, individual corneal healing responses remain biologically variable.4 5
What the OCT Showed, and Why We Showed the Patient
In November 2025, I performed anterior segment OCT and sent the images directly to Mr R.M. with an explanation of what he was looking at. The OCT demonstrated anterior stromal hyperreflectivity, a bright, irregular signal representing the zone of subepithelial fibrosis. In a normal post-TransPRK cornea, the anterior stroma appears uniformly dark and homogeneous. In this patient the affected area was unmistakable, left eye more extensive than right.
I sent those images because Mr R.M. was 21 years old and had gone from spectacle independence to significantly blurred vision in weeks. He deserved to understand exactly what was happening in his own eyes. Transparency is not separate from clinical management. It is part of it.
How We Shared the Costs and Responsibility
Topical Corticosteroids
The first-line treatment for established post-PRK subepithelial fibrosis is topical corticosteroid therapy, suppressing the myofibroblast-mediated fibrotic cascade and facilitating partial stromal remodelling.7 8
Prednisolone acetate 1% (Pred Forte) was commenced with a slow taper over an extended course, with monitoring for steroid-induced IOP elevation throughout.
Specialist Referral: Professor Will Ayliffe
By November 2025 this patient needed expert input beyond my own assessment. I referred Mr R.M. to Professor Will Ayliffe at Accuvision London, a consultant with recognised expertise in corneal complications following refractive surgery, including phototherapeutic keratectomy and cross-linking.
Message thread, 20 November 2025: referral to Prof Will Ayliffe arranged, £500 to be transferred upfront
Funding the Second Opinion
I want to address the financial dimension of this directly.
Before Mr R.M.’s first appointment on 16 December 2025, I transferred £500 to cover the consultation and scanning costs. The payment confirmation below was sent to the patient on 3 December 2025. After his appointment he sent through the Accuvision receipt for £670, confirming what was spent on the day.
Message thread, 3-17 December 2025: £500 bank transfer confirmation sent; Accuvision receipt £670 received after appointment
Bank Transfer Records: Blue Fin Vision® to Patient
Two separate transfers. Both referenced “2nd opinion fee”. Neither was asked for.
£500 – 3 December 2025 | £320 – 29 January 2026
New Year’s Day: Medication Posted to Home Address
On 2 January 2026 Mr R.M. messaged to say he had run out of Pred Forte a week early and could not reach Professor Ayliffe. A gap in steroid treatment during active fibrotic remodelling is not a trivial matter, it can allow the myofibroblast-mediated fibrotic process to re-accelerate.
Message thread, 2 January 2026: patient reports running out of Pred Forte, unable to reach Prof Ayliffe
Message thread, 2 January 2026: drops posted to home address that afternoon, delivered by 12pm next day
I went to the post office that afternoon and posted a supply to his home address. I was still awaiting the formal letter from Professor Ayliffe at that point. Clinical continuity did not wait for paperwork.
Second Accuvision Visit: January 2026
At his second appointment on 29 January 2026, the patient reported noticeable improvements. Professor Ayliffe prescribed further steroid drops and asked him to return on 7 July 2026. The second visit cost £320, again funded by this practice. The patient’s update and the receipt are below.
Message thread, 29 January 2026: update after second Accuvision visit, improvements noted, steroid course extended, return July 2026
The Patient’s Own Words
On 24 March 2026, Mr R.M. sent the following messages unprompted, alongside photographs of his topography maps taken at Accuvision showing comparative improvement across successive visits. These are not testimonials. This is a message thread.
Message thread, 24 March 2026: patient sends topography showing improvement; expresses gratitude
I want to be precise about what those messages do and do not mean. This case is not resolved. The option of PTK with or without cross-linking remains on the table depending on how the cornea continues to remodel. Long-term visual outcome is not yet determined. But this is a patient who understands his situation, is actively engaged, and has not been left to navigate a complication alone.
What We Did That Most Clinics Do Not Do
Surface ablation in thin corneas carries a higher fibrosis risk than ablation in corneas of standard thickness. This was part of this patient’s pre-operative counselling and is established in the literature.4 9
What the literature does not address is the management structure that must exist when it happens. Who funds the specialist opinion. Who maintains the steroid supply over Christmas. Who sends the OCT images with a plain-language explanation. Who picks up the phone and goes to the post office on New Year’s Day.
In many clinics, patients fund their own second opinions and manage prescriptions themselves over holiday periods. In this case, our clinic funded the external care in full and arranged urgent medication delivery before the specialist’s formal report had even arrived.
These are not clinical questions. They are questions about what kind of practice you are running and what your obligations to a patient actually mean after the procedure is complete.
We also carry a specific clinical learning from this case. In thin-cornea surface ablation patients with co-existing dry eye, we will apply intraoperative mitomycin C prophylactically with greater consistency. The evidence base is strong and the risk profile in single-application intraoperative use is well characterised. This case has directly informed refinement of our TransPRK protocol.9 10
Why This Case Is Evidence of a Best-in-Class Practice
To position as the best without overclaiming, three elements matter to both patients and regulators: data, transparency, and process. This case demonstrates all three explicitly.
Data: This case sits alongside four consecutive years of independently audited National Ophthalmology Database (NOD) outcomes, which we also publish. Our PCR rate is approximately 0.2% against a national benchmark of approximately 1%. We measure everything, including the cases that test us.
Transparency: This document shows the full arc: regression, haze, the difficult conversation, the ongoing uncertainty, and the real possibility of PTK ± CXL. We do not publish only resolved successes.
Process: This case demonstrates a repeatable management structure: rapid review on patient-reported symptoms, immediate steroid therapy, named specialist referral within weeks, full financial accountability, holiday medication cover, and longitudinal follow-up to at least July 2026.
The Blue Fin Vision® Advantage
When things are straightforward, many clinics perform well.
The Blue Fin Vision® Advantage does not appear in a routine six-week post-operative appointment. It does not appear in a highlights reel of excellent outcomes or a testimonial filmed in a consulting room when everything went to plan.
It appears on 2 January when a patient has run out of medication and cannot reach his specialist over New Year.
It appears in a bank transfer made before the consultation has taken place, because the question of who bears the cost of investigating a complication does not, in this practice, require deliberation.
It appears in OCT images sent to a twenty-one-year-old with a plain-language explanation, because he deserved to know what was happening in his own eyes.
It appears across months of messages, not performed for an audience, not constructed retrospectively, but simply what this practice does when a patient is in difficulty.
To achieve the immeasurable, you must measure everything. Including the things that did not go perfectly. Including what you did about them.
Blue Fin Vision®: Our Standard When Things Go Wrong
- Fund necessary independent opinions when complications require specialist expertise beyond our own, without billing the patient.
- Maintain uninterrupted access to critical medication, even over holiday periods, including direct posting to the patient’s home address.
- Share imaging and letters with patients in accessible language, because informed patients manage their care better and deserve to understand their own anatomy.
- Track topography, acuity, and refraction until the case is genuinely closed, not until the paperwork suggests it should be.
- State clearly when a case remains open, when outcomes are uncertain, and what options remain, because honesty is not a risk, it is the foundation of clinical trust.
Case Summary
For rapid reference and clinical record.
Indication: Bilateral myopia with thin corneas (OD 444 µm, OS 432 µm). LASIK and SMILE contraindicated due to insufficient residual stromal bed.
Procedure: Bilateral TransPRK, 24 July 2025. Six-week result: R 6/4, L 6/6 unaided.
Complication: Central subepithelial fibrosis, left worse than right. Presenting at three months with regression to R 6/12, L 6/36 and refraction returning to pre-operative levels. Occurred despite appropriate patient selection, counselling, and technique.
Management: Extended topical prednisolone acetate 1%. Second opinion funded by Blue Fin Vision® (£990 total): Professor Will Ayliffe, Accuvision London. Medication supplied directly to patient during New Year period. PTK ± CXL under consideration pending further remodelling.
Current status: Topography showing measurable improvement as of March 2026. Steroid course ongoing. Next review July 2026. Case remains open.
References
- Randleman JB, Russell B, Ward MA, Thompson KP, Stulting RD. Risk factors and prognosis for corneal ectasia after LASIK. Ophthalmology. 2003;110(2):267-275.
- Shortt AJ, Allan BD, Evans JR. Laser-assisted in situ keratomileusis (LASIK) versus photorefractive keratectomy (PRK) for correcting myopia. Cochrane Database of Systematic Reviews. 2013;1:CD005135.
- Sia RK, Ryan DS, Edwards JD, Bower KS. Visual outcomes and complications after surface ablation refractive surgery. Journal of Cataract and Refractive Surgery. 2015;41(4):778-786.
- Fantes FE, Hanna KD, Waring GO III, Pouliquen Y, Thompson KP, Savoldelli M. Wound healing after excimer laser keratomileusis (photorefractive keratectomy). Archives of Ophthalmology. 1990;108(5):665-675.
- Netto MV, Mohan RR, Sinha S, Sharma A, Gupta PC, Wilson SE. Stromal haze, myofibroblasts, and surface irregularity after photorefractive keratectomy. Experimental Eye Research. 2006;82(5):788-797.
- Wilson SE, Mohan RR, Ambrosio R Jr, Hong J, Lee J. The corneal wound healing response: cytokine-mediated interaction of the epithelium, stroma, and inflammatory cells. Progress in Retinal and Eye Research. 2001;20(5):625-637.
- Gartry DS, Kerr Muir MG, Marshall J. The effect of topical corticosteroids on refraction and corneal haze following excimer laser treatment of myopia: an update. Eye. 1993;7(Pt 4):584-590.
- Kymionis GD, Grentzelos MA, Plaka AD, Tsoulnaras KI, Diakonis VF, Liakopoulos DA, Pallikaris AI, Pallikaris IG. Long-term follow-up of corneal haze after photorefractive keratectomy. Clinical Ophthalmology. 2014;8:2041-2047.
- Thornton I, Xu M, Krueger RR. Comparison of standard and wavefront-guided ablation with and without mitomycin C in the same patient. Journal of Refractive Surgery. 2008;24(7):S68-S76.
- Gambato C, Ghirlando A, Moretto E, Busato F, Midena E. Mitomycin C modulation of corneal wound healing after photorefractive keratectomy in highly myopic eyes. Ophthalmology. 2005;112(2):208-218.
ABOUT THE AUTHOR
Mr Mfazo Hove
Consultant Ophthalmic Surgeon
MBChB MD FRCOphth CertLRS
Mr Hove is a consultant ophthalmic surgeon who has performed more than 57,000 procedures. His training includes 6.5 years of specialist development at Moorfields Eye Hospital, followed by five years as a consultant at the Western Eye Hospital (Imperial College Healthcare NHS Trust). He is a consultant at Blue Fin Vision®, an elite ophthalmology clinic serving London, Essex and Hertfordshire, working alongside an experienced clinical team delivering comprehensive ophthalmic care. He specialises in cataract surgery and advanced vision correction, including laser procedures, lens replacement and implantable Collamer lenses (ICL).
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