and photorefractive keratectomy. Ophthalmology 2000;107: 640 –52. 4. Lovisolo CF, Fleming JF. Intracorneal ring segments for iat- rogenic keratectasia after laser in situ keratomileusis or pho- torefractive keratectomy. J Refract Surg 2002;18:535– 41. 5. Parmar D, Claoue C. Keratectasia following excimer laser photorefractive keratectomy. Acta Ophthalmol Scand 2004; 82:102–5. Dear Editor: In their recent article describing a patient with corneal ectasia after photorefractive keratectomy (PRK), 1 Malecaze et al state that “no case report about iatrogenic ectasia after . . . PRK has been published,” that they are reporting “the first case of a patient in whom bilateral corneal ectasia developed after uneventful PRK,” and make other, similar claims throughout the article. Apparently, they are unaware of at least 3 previously published reports of ectasia after PRK. Holland et al 2 reported 6 eyes of 4 patients with ectasia after PRK in 2000. Two of these eyes developed scarring and thinning after hyperopic PRK. Two eyes of a third patient showed classic ectasia with inferior steepening after PRK for myopic astigmatism with inferior steepening pre- operatively. Two eyes from a fourth patient developed ec- tasia after PRK for high myopia with multiple retreatments. Lovisolo and Fleming 3 reported 2 patients with ectasia after PRK in 2002. One eye of one patient had PRK for high myopia followed by phototherapeutic keratectomy for haze, and the other patient had moderate keratoconus preopera- tively in the operative eye. In 2004, Parmar and Claoue 4 reported a patient with myopic regression, corneal haze, and posterior corneal ec- tasia who underwent PRK for high myopia. In this case, the scar may have created an artifactual appearance of posterior corneal ectasia. Nevertheless, this report should be ac- knowledged and discussed by the authors. These publications may be identified by online search strategies because they contain the terms complications, 2 keratectasia, 3,4 and photorefractive keratectomy 2–4 in their titles. The current English literature contains approximately 150 reported cases of ectasia after LASIK and 10 cases of ectasia after PRK, but the percent of eyes that develop ectasia after PRK may be higher than one might expect, because LASIK is performed much more frequently today than PRK. In fact, 4 cases of ectasia after PRK have been referred to our office within the past year. 5 We agree with Malecaze et al that topographic asym- metry between eyes and relatively thin corneas should alert the refractive surgeon to the possibility of postop- erative ectasia— even if the topographic pattern does not strictly fulfill the accepted criteria for forme fruste ker- atoconus. We also consider chronic trauma such as eye rubbing, 6 a family history of keratoconus, forme fruste keratoconus in the contralateral eye, and an unstable refraction to be possible risk factors. Although some authors have advocated surface ablation for eyes with forme fruste keratoconus, these cases highlight the need for caution and appropriate informed consent for any patient undergoing corneal refractive surgery with to- pographic abnormalities. Case reports like this are necessary to further our under- standing of corneal ectasia after excimer laser corneal re- fractive surgery, but Malecaze et al’s report is not the first report of ectasia after PRK. Neither is it likely to be the last, because we still do not have a complete understanding of risk factors for ectasia after corneal surgery. An online registry is being developed to facilitate reporting of cases like this and to speed dissemination of information that could help eliminate this unfortunate complication of re- fractive surgery in the future. Case information can be submitted to http://www.ectasiaregistry.com. Meanwhile, we caution authors against making a claim that theirs is the first published case of any entity without a thorough search of the literature, and we hope that reviewers will verify such statements when evaluat- ing articles for publication, so that articles with awkward claims of being the first published case will not appear in the literature. J. BRADLEY RANDLEMAN, MD R. DOYLE STULTING, MD, PHD Atlanta, Georgia References 1. Malecaze F, Coullet J, Calvas P, et al. Corneal ectasia after photorefractive keratectomy for low myopia. Ophthalmology 2006;113:742– 6. 2. Holland SP, Srivannaboon S, Reinstein DZ. Avoiding serious corneal complications of laser assisted in situ keratomileusis and photorefractive keratectomy. Ophthalmology 2000;107: 640 –52. 3. Lovisolo CF, Fleming JF. Intracorneal ring segments for iat- rogenic keratectasia after laser in situ keratomileusis or pho- torefractive keratectomy. J Refract Surg 2002;18:535– 41. 4. Parmar D, Claoue C. Keratectasia following excimer laser photorefractive keratectomy [letter]. Acta Ophthalmol Scand 2004;82:102–5. 5. Randleman JB, Caster AI, Banning CS, Stulting RD. Corneal ectasia after photorefractive keratectomy. J Cataract Refract Surg 2006;32:1395– 8. 6. Jafri B, Lichter H, Stulting RD. Asymmetric keratoconus attributed to eye rubbing. Cornea 2004;23:560 – 4. Author reply Dear Editor: We thank Drs Randleman and Stulting for their interest in our recent article. They have expressed reservations about the “first case report” aspect of our article dealing with bilateral corneal ectasia after uneventful photorefractive keratectomy (PRK). They have cited others and have criti- cized us for not reporting them in our “Discussion.” In fact, although we were aware of these reports, to clarify and shorten our manuscript, as required by a clinical case report format, we had decided to exclude from the text those reports that did not strictly fulfill our criteria for uneventful PRK. Holland et al’s article 1 reported 3 patients with corneal ectasia after high-hyperopic PRK. All the treated eyes had undergone multiple enhancements, leading to severe cor- Ophthalmology Volume 114, Number 2, February 2007 396