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LASIK can be an option after management to normalize ocular surface
LASIK can be an option for patients with dry eye and eyelid margin disease, but only after management to normalize the ocular surface and with use of surgical techniques and postoperative interventions that minimize dry eye.
By Cheryl Guttman Krader; Reviewed by Eric D. Donnenfeld, MD
Although LASIK can exacerbate pre-existing dry eye, affected patients can often be acceptable surgical candidates if they are managed intelligently with appropriate preoperative, intraoperative, and postoperative techniques.
Eric D. Donnenfeld, MD, addressed the question of whether to perform LASIK in patients with dry eye. He cited data presented during the 2008 meeting of the FDA Ophthalmic Devices Panel on LASIK safety showing that the procedure is not associated with a significant increase in dry eye.
In addition, Dr. Donnenfeld reiterated the panel’s conclusions that refractive surgeons should be vigilant in identifying LASIK candidates who have symptoms or signs of dry eye during the preoperative evaluation as these individuals are at greater risk for developing problems after surgery and their identification allows appropriate counseling, pretreatment, and in some rare cases, exclusion from LASIK.
“LASIK is not a big cause of dry eye, but rather it is a procedure done predominantly in patients who have dry eye because they can’t wear contact lenses,” said Dr. Donnenfeld, clinical professor of ophthalmology, New York University, and founding partner, Ophthalmic Consultants of Long Island and Connecticut, Rockville Centre, NY. “There are some patients with dry eye that should be excluded from LASIK, but they are the rare exception rather than the rule. The majority of patients with dry eye are excellent candidates for LASIK.”
Citing a 2005 paper by Smith and Maloney, Dr. Donnenfeld added that even patients with autoimmune disease and dry eye can undergo LASIK with excellent results if they are managed appropriately.
In screening for dry eye, Dr. Donnenfeld said he evaluates patients for eyelid margin disease and does testing for ocular surface damage, tear stability, tear osmolarity, and tear production. He performs lissamine green, fluorescein, and rose bengal staining. Any positive staining identifies patients who will have irregular topography, are at risk for a poor outcome, and who should not have LASIK until the condition of the cornea is improved.
“I like to look at the Hartmann-Shack image as well, and if there is dropout, it means the ocular surface is damaged enough that the reading is not good,” Dr. Donnenfeld said. “However, patients with dry eye are usually excellent candidates for LASIK if the Hartmann-Shack image is normal.”
In addition to identifying patients at risk for dry eye, Dr. Donnenfeld emphasized the need to maximize the tear film stability preoperatively, develop a surgical plan that minimizes dry eye, and intervene with appropriate postoperative therapy. His approach to dry eye management includes use of topical lubricants, immunotherapy, omega-3 supplements, and interventions for meibomian gland disease as indicated. For omega-3 supplementation, Dr. Donnenfeld noted patients should be instructed to use products where the fatty acids are in the triglyceride form as this formulation provides better bioavailability than the ester form. A short course of a topical corticosteroid will help control inflammation and improve tear production and can be used as induction with topical cyclosporine ophthalmic emulsion (Restasis, Allergan). Loteprednol gel (Lotemax, Bausch + Lomb) is particularly good as an immunomodulator with a great safety profile and a vehicle that supports the ocular surface, noted Dr. Donnenfeld.
His surgical technique involves a small (8.3 mm) thin flap created with a bevel-in sidecut as these flap characteristics have all been shown to reduce the incidence of dry eye.
“Previously, my standard flap diameter was 9.5-mm, which has almost 50% more surface area than an 8.3-mm flap, and it was associated with much more dry eye,” Dr. Donnenfeld said.
“The bevel-in side cut improves corneal nerve apposition.”
Eric D. Donnenfeld, MD
Dr. Donnenfeld is a consultant, receives grant support, and/or receives lecture fees from several companies that market devices used for LASIK or for the management of dry eye and eyelid margin disease, including Abbott Medical Optics, Alcon Laboratories, Allergan, Bausch + Lomb, Tearlab, and Tearscience. This article is adapted from Dr. Donnenfeld’s presentation during Refractive Surgery 2012 at the annual meeting of the American Academy of Ophthalmology.