dry eye
Defy
Post-LASIK Dry Eye
Proper screening and patient education can
reduce the likelihood of LASIK-induced dry eye.
BY
ANDREW S. MORGENSTERN, O.D.
Dry
eye syndrome can turn a 20/15 O.D. post-LASIK patient into a horror story, and unfortunately
for some patients, it has. But, you can reduce the likelihood of this outcome by
taking two steps prior to referring the patient for this refractive procedure: Ascertain
the patient's candidacy for LASIK, and educate him on the procedure itself and its
link to dry eye. Here, I will discuss these two steps.
Ascertain the patient's candidacy
To determine if the patient is a good candidate for LASIK:
• Examine the patient's history. Include a section on your
patient history form that asks questions about dry eye, and take time to read it.
If the patient's ocular history reveals a prior diagnosis of dry eye syndrome; keratoconjunctivitis
sicca; use of dry eye therapy; a medical condition that can cause dry eye (rheumatoid
arthritis and lupus erythematosus); or use of oral medications (antibiotics, antidepressants,
birth control pills, blood pressure medications and antihistamines) known to cause
dry eye; the patient may not be a good candidate for LASIK. "Patients who have dry
eye issues prior to LASIK are likely to worsen their condition by undergoing the
procedure," says Andrew Holzman, M.D., a corneal specialist and medical director
of Millennium Laser Eye Center, in Tysons Cor-
However, you may be able to reduce or eliminate the likelihood
of postoperative dry eye conditions in patients who have pre-existing dry eye by
immediately starting them on preservative-free artificial tears q2h, sodium chloride
hypertonicity ophthalmic solution 5% ung qhs, at least 1,000 mg of oral omega-3
fatty acid supplementation and cyclosporine ophthalmic emulsion 0.05% (Restasis,
Allergan) b.i.d. — an immune modulator that has been shown to help increase
a patient's natural ability to produce tears, which may be decreased by inflammation
due to chronic dry eye.1,2 (I prefer to start cyclosporine at least one
month prior to LASIK to maximize the effect of the drug prior to the procedure.
The only time I discontinue cyclo-sporine is 48 hours post-LASIK.3 Then,
I restart the drug for a minimum of three months). Have the patient use all these
drugs simultaneously with a few minutes in between drops. Studies have shown that
dry-eye patients who undergo treatment prior to LASIK can have safe and effective
outcomes.4
• Conduct preoperative testing. Use Phenol red thread tear
test, Schirmer test, tear break-up time (TBUT) with sodium fluor-escein (NaFl),
SLE and proper slit lamp evaluation of the tear film, tear lake height and corneal
(NaFL for SPK/PEE) and conjunctival staining using lissamine green or Rose Bengal
stains to evaluate dry eye.
If the patient exhibits a below average score on any of these
tests, make a tentative diagnosis of dry eye, and counsel him on the increased likelihood
of post-LASIK dry eye and the possibility of obtaining a non-candidacy status for
LASIK from your practice. (The patient's dry eye diagnosis is tentative because
several environmental causes, such as smoke, can lead to temporary dry eye.) Therefore,
make at least two more attempts to rule out dry eye syndrome before making a definitive
diagnosis.
If the patient continues to exhibit dry eye signs (subjectively
or objectively), do not refer him for LASIK. But, if he has already chosen a LASIK
surgeon, review the case with that surgeon.
Educate the patient
|
Managing
Post-LASIK Dry Eye Patients |
|
Here are three things you should do when managing
post-LASIK dry eye patients:
• Acknowledge the patient's concerns.
When you minimize the patient's complaints, you likely only increase his anxiety,
thus increasing the patient's perceived or actual symptoms.
• Prescribe dry eye treatments.
Have the patient use preservative-free artificial tears qh to q3h, artificial tear
gel at bedtime, at least 1,000mg of oral omega-3 fatty acid supplementation, a humidifier
while sleeping to decrease environmental dryness and cyclosporine b.i.d. By integrating
cyclosporine into our practice, I have noted a significant reduction in the number
of dry eye related non-candidates as well as an increased postoperative satisfaction
rate. Temporary and permanent punctual plugs are also an option for these patients,
but I find that most patients are resistant to the idea of placing a "permanent
plug" in their eye, as the plug can get stuck in the inferior cannaliculus, and
many patients prefer using an eye drop rather than undergoing another procedure.
• Involve the surgeon immediately.
If the patient experiences dry eye symptoms for more that six weeks after the procedure,
refer him to the surgeon. Although you conduct the postoperative care, this does
not ever discontinue the patient relationship with the surgeon. Offering your patient
the opportunity to meet with the surgeon postoperatively could be the most important
step in caring for the patient, as the surgeon can also reassure him or her that
dry eye is most likely temporary. |
If after following the above steps, you deem the patient a good
candidate for LASIK, educate him not only on what the procedure itself entails,
but on the possible temporary and permanent outcomes he can expect from the surgery.
This is extremely important, as the topic of LASIK has been thrust into our media,
providing each patient with his own preconceived notions about this refractive sur-gery.
So, it's your responsibility to correct whatever distorted impressions the patient
may have of the process. One such distorted impression: that the patient will not
experience post-LASIK dry eye because he passed the dry eye tests and was deemed
a candidate for LASIK.
Educate your patient that despite diligent preoperative work,
it's not uncommon for an excellent LASIK candidate to present with a complaint of
dry eye and have punctate staining covering the cornea. In fact, approximate-ly
10% to 15% of my patients undergo LASIK with no evidence of dry eye syndrome, yet
develop some type of dryness. This includes complaints of dryness upon waking, generalized
dryness throughout the day, dryness at the end of the day and decreased visual acuity
as a result of dryness. In addition, some patients have no subjective complaints,
yet still display clinical evidence of dry eye. The good news: "For the large majority
of patients that exhibit some form of dry eye symptoms post-LASIK,
these symptoms typically are temporary and generally last from six weeks to three
months," says Mark Whitten, M.D., medical director of Whitten Perraut Laser Eye
Centers, in Rockville, Md. (He has performed more than 70,000 laser vision correction
procedures.)
Discuss all this information with LASIK candidates prior to surgery.
After all, if the patient's expectations exceed your own and/or those of the surgeon,
the likelihood of a happy postoperative patient decreases dramatically. (See "Managing
Post- LASIK dry eye patients," page 64.)
By following the two steps mentioned above, you play a vital role
in ensuring that the patient has an excellent chance of not becoming a horror story,
but a success story, should he or she elect to undergo LASIK.
1. Perry HD, Donnenfeld ED. Topical 0.05% cyclosporine in the
treatment of dry eye. Expert Opin Pharmacother 2004 Oct;5(10):2099-107.
2. Kunert KS, Tisdale AS, Stern ME, et al. Analysis of topical
cyclosporine treatment of patients with dry eye syndrome: effect on conjunctival
lymphocytes. Arch Ophthalmol 2000 Nov;118 (11):1489-96.
3. Kim T., Slepser SB, Dell SJ, et al. Treating Post-LASIK Dry
Eyes: Refractive surgeons share their advice. www. crstoday.com/PDF%20Articles/0505
/crst0505_f8_dry_eye.pdf (Accessed November 17, 2006).
4. Toda I, Asano-Kato N, Hori-Komai Y, Tsubota K. Ocular surface
treatment before laser in situ keratomileusis in patients with severe dry eye. J
Refract Surg 2004 May-Jun;20(3):270-5.
Dr. Morgenstern
is clinical director of TLC Laser Eye Centers in Rockville, Md. He also teaches
clinical refractive didactics at the Ophthalmology Residency Program at The Georgetown
University School of Medicine, De- partment of Ophthalmology and Washington Hospital
Center/Washington National Eye Center.
Optometric Management, Issue: December 2006