Preoperative Versus Intraoperative Detection of Asymptomatic EBMD in LASIK/SMILE: Risk of Recurrent Corneal Erosion Requiring PTK, PTK Success, and Need for Repeat PTK.
Reinstein D, Archer T, Gupta R, Potter J • Journal of refractive surgery (Thorofare, N.J. : 1995) • 2026
Eyes with preoperatively identified mild asymptomatic EBMD had a lower risk of recurrent erosion syndrome requiring PTK compared with eyes in which EBMD was only detected intraoperatively, suggesting femtosecond laser-assisted LASIK and SMILE can be performed safely in eyes with preoperatively detected asymptomatic EBMD.
Key Findings
Results
EBMD was diagnosed preoperatively in 3.18% of eyes undergoing LASIK/SMILE.
Total cohort included 25,204 eyes undergoing femtosecond laser-assisted LASIK or SMILE at London Vision Clinic between February 2009 and March 2019.
802 eyes (3.18%) had preoperatively diagnosed EBMD and underwent LASIK/SMILE.
Eyes with moderate or symptomatic EBMD were triaged to primary PRK and excluded from the LASIK/SMILE epithelial safety analysis.
Only eyes with mild asymptomatic EBMD and no signs or history of recurrent corneal erosion were considered for LASIK/SMILE.
Results
Intraoperative epithelial slide occurred in 8.98% of preoperatively diagnosed EBMD eyes and 1.50% of eyes without preoperative EBMD diagnosis.
365 of 24,377 eyes without preoperative EBMD diagnosis (1.50%) experienced intraoperative epithelial slide and were classified as intraoperatively detected (subclinical) EBMD.
An epithelial stress test was performed at the clinician's discretion based on severity and location of map-dot-fingerprint changes; marked epithelial displacement prompted triage to PRK.
Results
Eyes with intraoperatively detected EBMD had a higher risk of requiring PTK for recurrent erosion syndrome than eyes with preoperatively diagnosed EBMD.
PTK for recurrent erosion was required in 12 of 802 eyes (1.50%) in the preoperatively diagnosed EBMD group.
PTK for recurrent erosion was required in 19 of 365 eyes (5.21%) in the intraoperatively detected EBMD group.
This represents a more than 3-fold higher rate of PTK requirement in the intraoperative detection group compared to the preoperative detection group.
Results
The rate of repeat PTK was higher in the preoperatively diagnosed EBMD group than in the intraoperatively detected EBMD group.
Repeat PTK was needed in 5 of 12 eyes (41.7%) in the preoperative EBMD group.
Repeat PTK was needed in 2 of 19 eyes (10.5%) in the intraoperative EBMD group.
Despite a higher initial PTK requirement in the intraoperative group, those eyes were more likely to achieve success with a single PTK treatment.
Methods
All eyes underwent preoperative slit-lamp examination with fluorescein screening for EBMD as part of the standardized assessment protocol.
Slit-lamp examination with fluorescein screening was performed preoperatively on all 25,204 eyes.
An epithelial stress test was performed at the clinician's discretion based on severity and location of map-dot-fingerprint changes or other features suggestive of epithelial instability.
Eyes with intraoperative epithelial slide despite no preoperative signs were classified as intraoperatively detected subclinical EBMD.
The study period spanned February 2009 to March 2019.
Conclusions
Postoperative epithelial complications following LASIK/SMILE in EBMD eyes were described as infrequent and effectively managed.
Overall, only a small proportion of EBMD eyes required PTK: 12/802 (1.50%) in the preoperative group and 19/365 (5.21%) in the intraoperative group.
The authors concluded that 'postoperative epithelial complications were infrequent and effectively managed.'
The study supports that modern femtosecond laser platforms combined with careful preoperative assessment allow safe LASIK/SMILE in eyes with mild asymptomatic EBMD.
What This Means
This research examined whether it matters if a corneal condition called epithelial basement membrane dystrophy (EBMD) — a subtle irregularity of the eye's surface layer — is identified before or during laser vision correction surgery (LASIK or SMILE). EBMD can cause the top layer of the cornea (the epithelium) to be less firmly attached, which can lead to painful recurring surface injuries after surgery known as recurrent corneal erosion syndrome. The study analyzed over 25,000 eyes treated at a single clinic over 10 years, comparing outcomes between patients whose EBMD was spotted during routine pre-surgery screening versus patients whose EBMD was only discovered when the corneal surface slid unexpectedly during the procedure itself.
The key finding was that patients whose EBMD was caught before surgery had a much lower risk of developing recurrent corneal erosion after surgery requiring a corrective laser treatment called PTK (1.50%) compared to patients whose EBMD was only discovered during surgery (5.21%). Interestingly, when the pre-surgery EBMD group did need PTK, they were more likely to need it repeated (41.7% needed a second PTK), whereas the intraoperative group more often succeeded with just one PTK treatment (only 10.5% needed a repeat). Overall, complications were uncommon and treatable in both groups.
This research suggests that thorough pre-surgical eye screening using slit-lamp examination and fluorescein dye is important for identifying patients with mild EBMD before laser vision correction. When EBMD is identified ahead of time, surgeons can take extra precautions, obtain additional informed consent, and potentially perform a stress test to assess epithelial stability — which appears to result in better outcomes. The findings also suggest that LASIK and SMILE can be performed safely in patients with mild, asymptomatic EBMD as long as the condition is identified and managed appropriately before surgery.
Reinstein D, Archer T, Gupta R, Potter J. (2026). Preoperative Versus Intraoperative Detection of Asymptomatic EBMD in LASIK/SMILE: Risk of Recurrent Corneal Erosion Requiring PTK, PTK Success, and Need for Repeat PTK.. Journal of refractive surgery (Thorofare, N.J. : 1995). https://doi.org/10.3928/1081597X-20260702-01