ALK was in vogue in the pre-LASIK era (late 1980s) and consisted of a microkeratome free cap cut followed by a second lamellar excision (depth determined by a nomogram) of anterior stroma with the microkeratome to flatten the cornea after which the original cap was replaced. The procedure was notoriously unpredictable and in this case the patient had an over-correction which left him hyperopic. Dr. R. Bruce Grene described a procedure in which two 10-0 Mersilene sutures were passed in purse-string fashion around the central cornea and tied down tight to vault the anterior cornea inducing myopia to treat hyperopic over-corrections after radial keratotomy (RK). This patient eventually had endothelial dysfunction for which a penetrating keratoplasty was performed. Endothelial keratoplasty could have been considered, but there was signficant irregular astigmatism and optical distortion with prior ALK and lasso that PKP was felt to provide the best vision. He is now 20/20 in the eye with an RGP contact lens.
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