Aggressive dry eye treatment at all stages boosts patient satisfaction after LASIK

Las Vegas-A rigorous preoperative dry eye treatment regimen can help ensure patient satisfaction after LASIK whether the IntraLase femtosecond laser (IntraLase Corp) or the Amadeus microkeratome (Advanced Medical Optics) was used to create the flap, according to Kent L. Wellish, MD.

Dr. Wellish, assistant professor, University of Nevada, Las Vegas, and in private practice in Las Vegas, described his experience with the two devices and his aggressive treatment of dry eye that included eye drops, tablets, and punctal plugs. He compared the dry eye signs and symptoms of patients who had a superior- hinged flap created by the femtosecond laser or a nasal-hinged flap created by the Amadeus microkeratome. The latter device resulted in more frequent signs and symptoms of dry eye, but neither group had severe dry eye after LASIK.

"Previous studies have reported less dry eye after LASIK when flaps with a nasal hinge were created presumed due to the location of the anterior ciliary nerves," Dr. Wellish said. "These studies have also reported a high incidence of dry eye or probable dry eye with more severe symptoms and findings in patients with preexisting dry eye who undergo LASIK with no dry eye treatment except artificial tears."

Dr. Wellish and colleagues used the IntraLase 30-kHz femtosecond laser that allowed faster treatment times, lower energy, smoother beds, and other advantages over previous generations of the IntraLase femtosecond laser. They sought to determine whether less dry eye would be an additional benefit. A total of 100 patients undergoing bilateral LASIK were included in the study. The patients were randomly assigned to flap creation with either the femtosecond laser or the Amadeus microkeratome. All patients were treated with the VISX S4 excimer laser (Advanced Medical Optics).

The patients were followed for up to 3 months postoperatively for signs and symptoms of dry eye.

"Each patient was asked a series of questions after 3 months (modeled after a similar study on Hansatome LASIK and PRK-treated patients1 ) to determine the incidence and severity of dry eye in each flap group and to assess the impact on patient satisfaction," he explained.

Dr. Wellish also explained that the practice is located in Las Vegas, which is a very arid environment, and because of that he and his colleagues wanted to know if the aggressive measures they used to assess and treat dry eyes preoperatively had an impact on the outcomes.

Circumventing dry eye

"We routinely postpone surgery and treat aggressively if dry eye signs and symptoms are present. These patients are always treated until symptoms and findings are gone," Dr. Wellish emphasized. "We use a combination of TheraTears (Advanced Vision Research), BioTears Oral Gel Caps (Biosyntrx), and/or cyclosporin ophthalmic emulsion 0.05% (Restasis, Allergan), and lacrimal plugs. Other patients without preoperative dry eye findings are also treated with TheraTears four times a day and BioTears two tablets twice daily before surgery and for 1 month postoperatively."

Silicone and/or collagen lacrimal plugs were used in all patients on the day of surgery based on clinical assessment.

"Our goal was to treat all dry eye symptoms and signs aggressively as completely and promptly as possible," he said.

In the group of patients randomly assigned to the Amadeus microkeratome, 34% of the surgeries were postponed because of dry eye findings. The patients were treated for weeks to months until the dry eye signs and symptoms resolved. In the group randomly assigned to the femtosecond laser, he found this preventive measure to be necessary in 19% of the patients.

"We found that there were less frequent dry eye symptoms with the IntraLase laser at months 1 and 3. The devices were comparable in the early stages, but the IntraLase laser with the superior hinge seemed to cause less dry eye symptoms at months 1 and 3," Dr. Wellish said. "The signs of dry eye, staining and blurred vision, were comparable in the two groups early after surgery, but by months 1 and 3 the IntraLase group seemed to outperform the Amadeus microkeratome group," he reported.

Patient satisfaction