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Laser refractive surgery has no place in dry eye


Pre-existing dry eye should be identified and controlled before surgery is considered


Dry eye is an important cause of patient dissatisfaction after LASIK, is a risk factor for regression, and may be a persistent complaint.


By Cheryl Guttman Krader; Reviewed by Christopher J. Rapuano, MD

Philadelphia-Dry eyes and laser refractive surgery don’t mix.

“Careful preoperative evaluation is needed to identify patients with active dry eye disease who should not undergo surgery,” said Christopher J. Rapuano, MD, chief, cornea service, Wills Eye Institute, and professor of ophthalmology, Jefferson Medical College of Thomas Jefferson University, Philadelphia. “Treat the dry eye first, consider surgery only if the ocular surface is normalized, and and perform the procedure only with an appropriate preoperative discussion and thorough informed consent.

Results from published studies provide evidence that dry eye is a leading cause of patient dissatisfaction after LASIK. One such study undertaken by Dr. Rapuano and colleagues at Wills Eye Hospital included 109 postLASIK patients representing 157 operated eyes. Poor distance vision was the most common chief complaint (63%) among these patients seen on referral, but 20% of patients were unhappy because of dry eye. On clinical examination at the time of consultation, 28% of patients had dry eye or blepharitis.

A second study included 161 eyes of 101 patients who sought consultation because they were dissatisfied after refractive surgery; the majority had undergone LASIK (83%) and a smaller proportion had PRK (14%). Similar to the findings from the Wills Eye Study, 59% of patients complained about poor distance vision, 21% were dissatisfied because of dry eye, and 30% were diagnosed with dry eye.

Other research findings highlight the potential persistence of postrefractive surgery dry eye. In a retrospective study, investigators reviewed data from the preoperative visit and from 1 week, 1 month, 3 months, and 6 months postsurgery for a group of 190 LASIK-treated eyes. The study found significant worsening in Schirmer scores and tear film breakup time for the duration of follow-up and that symptoms of dry eye were present at 6 months in 20% of eyes. The risk for dry eye was higher in eyes treated for higher refractive errors as well as in women.

Findings were similar in a prospective study comparing dry eye symptoms in patients undergoing LASIK with a superior-hinged femtosecond laser flap versus a nasal-hinged mechanical microkeratome. Overall, 50% of patients had dry eye symptoms after 1 week and 20% were still bothered at 6 months. While hinge location was not associated with dry eye, higher refractive error was again a risk factor.

In a prospective study of 48 eyes of 48 patients undergoing LASIK, significantly decreased conjunctival and corneal sensitivity along with worsened symptom scores were found present at 1 week and persisted at 16 months after LASIK. Another retrospective study compared 20 eyes of postLASIK patients seen 2 to 5 years after surgery for high myopia with 10 age-matched controls. The researchers found no difference between groups in signs of tear insufficiency or hypoesthesia, but dry eye symptoms were significantly worse in the postLASIK group.

Quality of life affected

Other research highlights the negative effect of dry eye on quality of life. Data from participants in the Women’s Health Study and Physician’s Health study found those with dry eye were significantly more likely than their unaffected counterparts to have difficulty with reading, professional work, computer use, and daytime and nighttime driving.

The adverse consequences of dry eye also include an increased risk for refractive regression. As reported in a study of 565 eyes followed for 1 year postLASIK. Among the subgroup of 45 patients with dry eye, 27% experienced regression compared with only 7% of eyes without dry eye.

Concerns about patient dissatisfaction and complications after LASIK, including dry eye, were the impetus for the FDA to convene an advisory committee meeting in 2008. The proceedings from that meeting should raise a red flag for surgeons.

“Disturbingly, a review of the minutes of this meeting showed suicide was mentioned 15 times, and a clinical psychologist interviewing 300 patients with LASIK complications reported 100 had suicidal ideation that was strongly associated with dry eye,” Dr. Rapuano said.

“Laser refractive surgery is an elective cosmetic procedure to enhance a patient’s lifestyle and well-being,” he said. “It is highly successful in the majority of patients. However, surgeons do not want to turn a patient who is mildly unhappy with having to wear glasses or contact lenses into somebody who is miserable because of dry eye.”


Christopher J. Rapuano, MD

E: cjrapuano@willseye.org

Dr. Rapuano has no relevant financial interests to disclose. This article is adapted from Dr. Rapuano’s presentation during Refractive Surgery 2012 at the annual meeting of the American Academy of Ophthalmology.


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