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J Refract Surg. 2014 Jun;30(6):380-7. doi: 10.3928/1081597X-20140508-01.

Transepithelial phototherapeutic keratectomy protocol for treating irregular astigmatism based on population epithelial thickness measurements by artemis very high-frequency digital ultrasound.



To report the outcomes of transepithelial phototherapeutic keratectomy (TE-PTK) in the treatment of irregular astigmatism and define a standard treatment protocol based on population epithelial thickness measurements.


Retrospective analysis of 41 TE-PTK procedures in cases of irregular astigmatism after refractive surgery or with corneal irregularities. The TE-PTK ablations were performed according to preoperative epithelial thickness maps obtained using an Artemis very high-frequency digital ultrasound arc-scanner (ArcScan, Inc., Morrison, CO). Visual and refractive outcomes were analyzed 12 months after the procedure. The efficacy of the stromal surface regularization was evaluated as the change in epithelial thickness range (ie, the difference between minimum and maximum epithelial thickness). A further refractive ablation was performed immediately after TE-PTK in 12 eyes.


Corrected distance visual acuity was improved by one or more lines in 58% of eyes, whereas 1 eye lost one line and no eyes lost two lines. Significant stromal surface regularization was achieved with epithelial thickness range reduced on average from 41 to 29 μm. There was an unpredictable refractive shift in the TE-PTK only group with a change of more than 0.50 diopter (D) in 59% of eyes. Refractive accuracy in the TE-PTK with refractive ablation group was reasonably good, although there were two outliers (18%) outside ±1.00 D. A therapeutic window was identified between the highest thinnest epithelium of 51 μm and lowest thickest epithelium of 60 μm.


TE-PTK can be a safe and effective method of reducing stromal surface irregularities by taking advantage of the natural masking effect of the epithelium. There can be a significant refractive shift due to lenticular epithelial masking. A standard protocol of targeting an initial TE-PTK ablation for 55 μm will likely achieve breakthrough of the thinnest epithelium without total epithelial removal, allowing the treatment to be continued in a stepwise fashion.

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