Optimizing Dry Eyes for Refractive Surgery

Dry eye is not necessarily a contraindication for laser vision correction. However, its identification and effective management are crucial for successful outcomes and satisfied patients, says Steven E. Wilson, MD, staff refractive surgeon and Director of Corneal Research at Cleveland Clinic’s Cole Eye Institute.

Avoiding postoperative complications

Dry eye can affect tear composition and volume as well as ocular surface integrity. “If a patient complains about grittiness, irritation, fluctuating vision, use of artificial tears and/or trouble wearing contacts, the most likely problem is dry eye,” says Dr. Wilson. These symptoms, he said, should prompt further testing to identify the presence of dry eye disease and gauge its severity.

Laser assisted in situ keratomileusis (LASIK) has a neurotrophic effect on the cornea that can increase dry eye symptoms and signs. Along with changes to the corneal surface, it affects tear dynamics and causes ocular surface desiccation. Dry eye is one of the most common complications of LASIK surgery. Symptoms, including bothersome fluctuating vision, may occur in more than 50 percent of patients.

Preoperative dry eye is a major risk factor for more severe dry eye after surgery, and needs to be correctly identified and managed prior to surgery. If left untreated, it can confound the wavefront analysis to determine the correction to be applied at surgery, compromise the outcome of the custom ablation and cause complications that range from decreased best spectacle-corrected visual acuity to LASIK-induced neurotrophic epitheliopathy (LINE), Dr. Wilson says.

Assessing dry eye

Two overlapping groups of patients are affected by dry eye: those with symptoms, regardless of objective signs, and individuals with clinically significant dry eye who have objective signs as well as symptoms. The typical patient is in his or her 30s or 40s, with a Schirmer test score of around 7 to 10 and a lissamine green or rose bengal corneal and conjunctival staining pattern.

“Tests can have flaws,” says Dr. Wilson, “but dry eye tends to have characteristic effects on the lower eyelid tear lake and the ocular surface. Most dry eye patients also present with longstanding inflammation in the accessory and main lacrimal tear glands as well as the ocular surface.”

Optimizing the ocular surface

Dr. Wilson doesn’t operate unless a patient has a normalized ocular surface and a Schirmer test score of greater than or equal to 5 mm. “In 90 to 95 percent of cases, we can get to the point where the patient is considered a viable candidate for surgery with treatment,” he says.

The management plan of choice is most commonly topical cyclosporine 0.05% (Restasis, Allergan). This treats the underlying inflammation and may benefit nerve regeneration after surgery. To produce a faster response in cases of more severe dry eye, a topical corticosteroid can be added for a short period of time.

Restasis is routinely supplemented with non-preserved artificial tears or ointment. Other modalities for dry eye management include punctal plugs and dietary supplements. Attention to environmental factors, such as increasing humidity in the bedroom, also can be helpful.

Patients are re-evaluated after a month or two of treatment. Those with mild dry eye may show an adequate response and can proceed with surgery. Patients with more severe dry eye may need to continue with cyclosporine for another few months before re-evaluation. A small proportion of patients do not improve to the point that refractive surgery can be considered, Dr. Wilson says.