Article Date: 12/1/2006

dry eye
Defy Post-LASIK Dry Eye

Proper screening and patient education can reduce the likelihood of LASIK-induced dry eye.

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. /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