The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Ophthalmology 360.
By Robert Schultze, MD
In my tertiary referral practice, I perform superficial keratectomy (SK) on a weekly basis. SK is an in-office procedure used to treat corneal opacity and ocular surface abnormalities. It can be helpful for the management of different conditions, such as epithelial basement membrane dystrophy, recurrent corneal erosion, and Salzman’s nodular degeneration. However, SK carries a risk of scarring; moreover, if the conditions it is used to treat recur, which can happen even years after the original procedure, there is an additional risk of scarring with each required revision.1
As such, minimizing scar tissue and reducing the likelihood of infection requires a judicious approach on the part of the treating ophthalmologist. The faster the ocular surface is able to heal, the less scar tissue is created, and the less likely it is that a bacterial infiltration will occur.1
Preventing Ocular Trauma
When performing SK, ophthalmologists should ensure the best possible view of the surgical plane, choose their surgical tools thoughtfully, and be aware of the depth of penetration. The procedure of SK involves the anterior surface of the cornea, the epithelium, being removed down to Bowman’s membrane. If necessary, a 20% solution of ethyl alcohol or an Amoils brush can help loosen the epithelium before removal with a Weck-cel sponge or mechanical stainless-steel spatula.1
Importantly, I think SK should be performed at the slit lamp (with or without a speculum) and not under the operating room microscope. While the operating room microscope provides a global view of the cornea, it does not allow enough focus on the Bowman’s membrane and the epithelium to find the right plane. In some cases, this could result in somewhat deeper penetration than desired, which can induce more trauma and scarring.
It is also helpful to consider the sharpness of the surgical tools, as they can affect the ability to appropriately dissect the epithelium without damage. I prefer a blunt spatula when performing an SK, because it is sharp enough to denude the epithelium but not sharp enough to damage the Bowman’s membrane or the deeper structures of the eye.
Moreover, the ophthalmologist should ensure that the epithelium is removed as thoroughly as possible. To help accomplish this, I always like to identify an unaffected, clear zone of Bowman’s membrane and then migrate into the affected area so I know exactly what plane of the cornea I’m working in and can ensure that I remove the entirety of the pathology without going too deep.
Adjunctive Therapies for Minimizing Scar Tissue
One adjunctive treatment option to assist with the prevention of scar tissue is mitomycin C. Mitomycin C is an antimetabolite that decreases activated fibrocytes and keratocytes and is used to prevent blood vessel recurrence on the sclera and minimize scar tissue on the cornea. In addition to SK, it is also used in many other procedures, such as pterygium excision, photorefractive keratectomy, and cosmetic procedures. Though mitomycin C reduces the regrowth of vasculature and minimizes corneal scar tissue growth, it is toxic to the cornea and may also slow healing and re-epithelialization.2,3
Another adjunctive therapy I frequently utilize is cryopreserved amniotic membrane (CAM), which has been shown to facilitate healing, reduce inflammation, and minimize scar tissue formation, partially due to the presence of the heavy chain-hyaluronan/pentraxin-3 matrix complex that is retained in the amnion. CAM can reduce scarring both indirectly through its anti-inflammatory effects and directly through the inhibition of growth factor signaling, which helps revert corneal fibroblasts and myofibroblasts back to keratocytes.4
Because of these benefits, I usually follow an SK with the placement of 1 ringless CAM under a collagen shield, which will typically dissolve within 48 hours. If the patient has not experienced complete healing at that point, I will place a standard bandage contact lens. If I feel that even more healing is needed, I might be inclined to use a self-retained CAM, which is also available as a double-layer membrane.
Preparation Considerations
Though mitomycin is an established option for adjunctively treating SK patients, there is some inconvenience and expense associated with its use, as it needs to be compounded and either shipped to the office by the compounding pharmacy or brought by the patient. Furthermore, the concentration is highly dependent on the exact compounding and storage techniques, so much so that it can affect the treatment outcome.5
Some preparations of CAM require storage in a deep freezer at –80 °C.6 However, a shelf-stable, ringless option is also available that has undergone a further sterilization process, allowing it to be stored at room temperature in the office. This ringless option may also be more tolerable, as some patients have reported that they feel the preparations with a plastic ring are uncomfortable for them.7
Providing Proactive Counseling
Patients need to be proactively counseled before their SK that some patients do find the procedure and subsequent healing to be uncomfortable; I have found that a thorough discussion can preempt many urgent calls and follow-ups in the days after the procedure. For example, I always let them know that they should not make any plans to go out to dinner that evening. In the most severe cases, I advise my patients that, if they just sit in a dark room and listen to some music, the discomfort will pass within 24 hours. However, in these cases, I also like to prescribe a regimen of acetaminophen/codeine to reduce pain.
Conclusion
Though SK is a well-established method for reducing corneal opacity, its outcomes heavily rely on the surgical precision and thoughtful management of the treating provider. Procedural choices can affect how well the provider can debride the epithelium without causing ocular trauma, and adjunctive therapies can help reduce the formation of scar tissue. Regardless of the specific treatment approach, it is critical to help our patients proactively understand what to expect from this procedure. When these choices come together felicitously, SK can become a more refined, deliberate strategy for restoring visual clarity in the patients who need it most.
Robert Schultze, MD, serves as Professor of Ophthalmology and Director of Cornea, Cataract, and Laser Vision Correction Surgery at the Albany Medical Center Department of Ophthalmology Lions Eye Institute. He is the medical director and a founding partner of his medical practice, Cornea Consultants of Albany, the Lions Eye Bank at Albany, and TLC Laser Eye Center. He can be reached at [email protected]. Dr. Schultze reports being a speaker for BioTissue.
References
- Salari F, Beikmarzehei A, Liu G, Zarei-Ghanavati M, Liu C. Superficial keratectomy: a review of literature. Front Med (Lausanne). 2022;9:915284. doi:10.3389/fmed.2022.915284
- Martins TG, Costa AL, Alves MR, Chammas R, Schor P. Mitomycin C in pterygium treatment. Int J Ophthalmol. 2016;9(3):465-468. doi:10.18240/ijo.2016.03.25
- Buss DG, Sharma A, Giuliano EA, Mohan RR. Efficacy and safety of mitomycin C as an agent to treat corneal scarring in horses using an in vitro model. Vet Ophthalmol. 2010;13(4):211-218. doi:10.1111/j.1463-5224.2010.00782.x
- Zhang Y, Helman A, Mead OG, Tighe S, Zhu Y, Tseng SCG. Processing methods affect biological properties of amniotic membrane sheet products. Cornea. 2025;44(6):671-678. doi:10.1097/ICO.0000000000003849
- Kinast RM, Akula KK, Mansberger SL, et al. Concentration accuracy of compounded mitomycin c for ophthalmic surgery. JAMA Ophthalmol. 2016;134(2):191-195. doi:10.1001/jamaophthalmol.2015.4970
- Witt J, Grumm L, Salla S, Geerling G, Menzel-Severing J. Cryopreservation in a standard freezer: -28 °C as alternative storage temperature for amniotic membrane transplantation. J Clin Med. 2022;11(4):1109. doi:10.3390/jcm11041109
- Cushman S. Shelf-stable, cryopreserved amniotic membrane for the management of ocular surface disease: a retrospective assessment. Clin Optom (Auckl). 2025;17:409-415. doi:10.2147/OPTO.S563708
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