I had laser surgery
and my vision has worsened:
can I be re-operated?

Every year, we receive patients who were operated elsewhere — years or decades ago — who have experienced a regression or an unsatisfactory result. They put their glasses back on, resigned themselves, and think there is nothing more to be done. In many cases, they are wrong.

Why vision has worsened after laser

The causes vary according to the technique and the time elapsed. In most cases, the deterioration is not due to a surgical error but to a predictable biological process:

Epithelial hyperplasia — the epithelium thickened to compensate for the ablation profile, reducing the treatment effect. This is the most common cause of regression after PRK and TransPRK, rarely exceeding 0.50-1.00 D.

Defect progression — myopia or hypermetropia continued to progress after surgery, especially in patients operated too young or without documented refractive stability.

Lens changes — with age, the lens changes its refractive index and can cause a myopic shift (nuclear cataract) or hypermetropic shift.

Presbyopia — the emmetropic patient after laser becomes presbyopic like everyone else around age 45. This is not a regression: it is physiology.

Post-LASIK corneal instability — in rare cases, the LASIK flap can cause progressive biomechanical weakening with late ectasia. MS-39 tomography identifies these cases before any touch-up.

Case by case: what can be done

After radial keratotomy (1980s-1990s)

Radial keratotomy (RK) is the oldest technique: radial incisions in the cornea to flatten it and correct myopia. These corneas are the most complex to retreat because the structure has been modified non-uniformly, thickness varies along the incisions, and the cornea is often biomechanically unstable. However, many RK patients develop a progressive hypermetropic shift over the years (the cornea continues to flatten) which can be significant.

TransPRK is the only reasonable technique for these patients: a flap cannot be created on a cornea with radial incisions (risk of irregular rupture), and SMILE is contraindicated for the same reason. TransPRK works on the surface, without mechanical contact, and the ablation profile can be calculated on the specific topography — including the irregularities induced by the incisions. ForeSight simulation is indispensable in these cases.

After LASIK

The touch-up after LASIK can theoretically be performed by re-lifting the original flap. But this option carries increasing risks over time: the flap progressively adheres to the underlying stroma, re-lifting becomes difficult, and the interface can develop epithelial ingrowth (epithelial growth beneath the flap) or Diffuse Lamellar Keratitis. After 2 to 3 years, re-lifting the flap is advised against by the majority of refractive surgeons.

The solution? TransPRK on the flap. The laser works on the surface of the existing flap — without re-lifting it, without touching it, without creating a new interface. Ablation takes place on the epithelium and the superficial stroma of the flap, exactly as on a virgin cornea. The MS-39 epithelial map shows the thickness of the flap and the epithelium above the flap, enabling precise calculation of the safe ablation depth.

After PRK or TransPRK

The touch-up after a surface treatment is the simplest: no flap, no interface, no cap. TransPRK works on the surface again, with a new profile calculated from current post-operative data. Epithelial hyperplasia — if present — is ablated together with the epithelium in the first laser pass. The touch-up is technically identical to the primary treatment.

After SMILE

The touch-up after SMILE is the most problematic case. SMILE does not create a flap: it creates a cap (intact cap) and removes an intrastromal lenticule. There is no interface to re-lift as in LASIK. The options are two: create a LASIK flap above the cap (technically risky — the cleavage plane of the cap may interfere with the flap), or perform a surface TransPRK above the intact cap.

TransPRK is the choice recommended by the literature and by the majority of refractive surgeons. The laser works on the surface — epithelium and superficial stroma — without touching the cap or the intrastromal plane of the lenticule. It is the only technique that does not interact with the SMILE interface.

What we assess before re-operating

The touch-up is not automatic. Before proceeding, we perform a complete diagnostic examination including:

MS-39 tomography — to check the residual corneal thickness (which must be sufficient for a new ablation), the regularity of the anterior and posterior surface, and the absence of post-surgical ectasia.

Epithelial map — to quantify hyperplasia and distinguish epithelial regression from stromal regression. This information changes the ablation calculation.

Peramis aberrometry — to decide whether the touch-up should be aberration-free or wavefront-guided. After a previous procedure, high-order aberrations are often elevated — a wavefront-guided treatment can improve not only acuity but also the quality of vision.

ForeSight simulation — to visualise the expected result of the touch-up on an already modified cornea. In these cases, simulation is even more valuable than in primary treatment.

Residual stromal pachymetry — the fundamental safety parameter. If the residual thickness after touch-up would fall below 250 µm, we do not operate.

When the touch-up is not possible

In a minority of cases, laser touch-up is not feasible: cornea too thin, post-surgical ectasia, irregularity not correctable by laser. In these cases, the alternatives are rigid gas-permeable contact lenses (RGP) — which correct the irregular surface — or, in the most complex cases, cross-linking to stabilise the cornea before any further procedure.

Our experience

In over 30 years of refractive surgery (since 1996), I have re-operated patients from every type of previous surgery: radial keratotomies from the 1990s, LASIK from the 2000s, PRK, and more recently SMILE. The AMARIS 1050RS laser, MS-39 tomography, epithelial map and ForeSight simulation make these touch-ups safer and more predictable than ever. But the essential condition remains the same: measure everything before touching the cornea.

If you have had laser surgery and your vision has worsened, do not resign yourself. Come for a free diagnostic examination. We measure, we simulate, and we tell you honestly what is possible — and what is not.