Severe Persistent Post-Operative Pain After LASIK

Primary Mechanism: Corneal Nerve Injury and Neuropathic Pain

Severe persistent post-operative pain after LASIK is primarily caused by corneal neuropathic pain resulting from nerve damage during flap creation, not by typical post-operative complications or dry eye alone 1, 2
Corneal neuralgia is a documented post-LASIK complication requiring multimodal local and systemic treatment beyond standard dry eye therapies 1

Normal LASIK recovery involves mild to moderate discomfort only during the first postoperative day because the central corneal epithelium remains intact 2
Severe pain with redness and photophobia suggests microbial keratitis rather than normal post-operative discomfort 3, 2
Persistent or worsening pain may indicate diffuse lamellar keratitis (DLK), central toxic keratopathy, or corneal neuralgia requiring specialized treatment 3, 4, 2
Importantly, DLK typically presents with little or no discomfort despite visible inflammation, making it an unlikely cause of severe pain 5, 3

Microbial keratitis: Pain with redness, photophobia, focal corneal infiltrates extending beyond the interface, and anterior chamber reaction 3
Pressure-induced stromal keratitis: Interlamellar fluid accumulation from steroid-induced IOP elevation mimicking DLK; measure IOP peripheral to flap edge 5, 3
Epithelial ingrowth with flap melt: Rare but can cause pain when extensive, with staining at flap edge indicating active cell migration 5, 4
Central toxic keratopathy: Non-inflammatory central corneal opacity within 9 days, but typically not associated with severe pain 3, 7

Management requires multimodal therapy unique to each patient, going beyond standard dry eye treatment, including topical treatments and systemic therapies for neuropathic pain 1
Visual aberrations cause eye strain and secondary headaches through sustained accommodation effort, particularly with smaller treatment zones, and may require treatment 1, 6