Progressive post-LASIK keratectasia (PPLK) is a progressive deformation of corneal anatomy that occurs rarely but may have severe consequences. Using the scientific literature and new hypotheses, we attempted to determine whether PPLK is a biomechanical result of laser in situ keratomileusis (LASIK), a chronic disease process affecting individuals predisposed to the condition, or a combination of processes. We look at whether the combination of fatigue, specifically a form of dynamic fatigue, and proteolysis provides an environment conducive to the occurrence and progression of PPLK. This review may raise more questions than it answers and in so doing may move us toward a better understanding of this occasionally serious consequence of LASIK.