AIMS/BACKGROUND: Keratoconus is generally held to be an absolute contraindication for photorefractive keratectomy (PRK). Corneas with inferior steepening on corneal topography are widely thought to have subclinical keratoconus. We were not convinced that this is always the case, as there seems to be a group of patients with a stable inferior steepening pattern on topography who show no other characteristics of clinical keratoconus. We thus decided to offer PRK to some of these patients under strictly defined criteria. METHOD: Four myopic patients with a topography pattern of inferior steepening were submitted to PRK. They were selected on the basis of being aged over 35, with a stable refraction, no slit-lamp signs of keratoconus, and a corrected vision of not less than 6/7 (0.9) with a spherical spectacle correction. They gave fully informed consent that this was an experimental procedure. RESULTS: The refractive results at 6 months after operation were within the range one would expect for PRK on corneas with a regular 'bow-tie' topography and similar level of myopia. No unusual problems were encountered. CONCLUSION: We feel that the corneal topography pattern of inferior steepening is not always a contraindication for PRK. The concept of a physiological 'displaced apex syndrome' is discussed and illustrated by corneal topography in different positions of gaze.