Post-LASIK dry eye can be managed effectively, surgeons say

Nonpreserved artificial tears and post-LASIK punctal plugs are essential tools for keeping patients with dry eye comfortable.

Post-LASIK dry eye has become a concern in many practices with the increasing use of this popular refractive surgery procedure. Some leading refractive surgeons say the complication can be effectively managed with aggressive use of preservative-free tears and with punctal plugs when necessary.

“This seems to be the trend. In my opinion, it’s mandatory to use single-use drops that are preservative free. It is necessary to take precaution against allergy, because preservatives normally increase the chance of allergy development,” said Matteo Piovella, MD, of Monza, Italy, in an interview with Ocular Surgery News.

Stefano Bonini, MD, of Rome, agreed.

“When treating ocular surface conditions, we are looking for preservative-free topical compounds because it’s clear from the literature that the components of eye drops may damage the ocular surface after long-time use,” he said.

According to recent U.S. studies by Frank A. Bucci, Jr., MD, treating dry eye syndrome postoperatively with silicone punctal plugs and/or transiently preserved tears with carboxymethylcellulose significantly reduced the potential for epitheliopathy post LASIK. Tears containing carboxymethylcellulose are highly preferred vs. those containing hydroxypropyl methylcellulose, Dr. Bucci reported.

“I now advise aggressive treatment of ocular surface diseases, such as dry eye and blepharitis, with the use of nonpreserved or transiently preserved tears and/or punctual plugs preoperatively,” Dr. Bucci said.

According to Dr. Bucci, it is crucial to let the epithelium heal from whatever ocular diseases it may have preoperatively and not to agitate the area with preserved medications.

“Often, patients become sensitized to eye drop preservatives and drugs. This is why we need to use unpreserved medication,” Dr. Piovella added.

Post-LASIK treatment

Following LASIK surgery, there is a decreased level of tear reflex because the neural arc has been cut by the microkeratome, Dr. Bucci said.

“Corneal sensitivity occurs because corneal nerves have been severed during LASIK. That arc starts at the ocular surface, and travels through the corneal nerves to the pons in the brainstem and back to the lacrimal gland,” he said.

Immediate symptoms from the effect of exposed nerves around the edge of the flap resolve between 2 and 6 hours after the procedure, he added. However, the intermittent blurred vision from compromised epithelium that often occurs after LASIK can last for weeks or months.

“The predominant symptom following LASIK from decreased tear production is fluctuating and decreased vision secondary to a progressive epitheliopathy. Patients do not have a classic foreign body sensation or grittiness because the sensory nerves of the cornea have been cut,” he said.

According to Dr. Bucci, treating ocular surface diseases aggressively before and after LASIK helps mitigate these problems. He recommends minimizing the use of drugs containing preservatives, topical anesthetics and corneal markers during surgery.

“You also want to lubricate the corneal surface before the microkeratome pass. I also suggest lubricating the microkeratome head,” he said.

Postoperatively, Dr. Bucci recommends a viscous tear for the first 24 hours. Then, application of a tear supplement containing carboxymethylcellulose between four and 10 times a day is advised, for as many months as needed.

“It’s easy to treat patients with these eye drops because they normally have no contraindication and the patient can control the dosage,” Dr. Piovella said. He said that with this form of treatment patients can increase the frequency of drops themselves, depending on necessity.

“However, the most important thing is the preservative-free element,” he added.

Both Drs. Piovella and Bucci recommend punctal plugs to aggressively treat dry eye when preservative-free tears are not effective enough for the severity of the disease. In addition, Dr. Bucci suggests punctal plugs be used proactively before LASIK surgery in high-risk patients.

Punctal plugs

“With the second possibility of dry eye treatment — plugs — the quantity of natural tears stays in the conjunctival sac and doesn’t escape into the lacrimal punctum,” Dr. Piovella said.

In a study, Dr. Bucci observed significantly higher levels of tear lactoferrin in eyes treated with plugs after LASIK surgery than in eyes that did not receive plugs.

“The difference between the plugged and the unplugged eye, with regard to lactoferrin, was maintained for 6 months,” Dr. Bucci said.

Lactoferrin decreased significantly (P = .016) in unplugged eyes (22%) immediately following LASIK, but the decrease was only 9% in plugged eyes. According to Dr. Bucci, lactoferrin increased steadily over 1 month in both groups, but significantly higher levels were maintained in the plugged eyes (P = .004) vs the unplugged eyes.

Dr. Piovella’s punctal plug of choice is currently the SmartPlug (Medennium). The SmartPlug was granted the CE mark in Europe in September 2001. Made of an acrylic polymer, it is thin and rigid at room temperature. It becomes gel-like upon insertion into the punctum and conforms to the patient’s punctum, he said.

Because it is completely contained within the punctum, it’s very comfortable and effective for the patient.

“It’s very comfortable and effective for the patient. I believe the number of doctors implanting these plugs will increase, because of the comfort,” Dr. Piovella said.

Additionally, Dr. Bucci also said “higher lactoferrin levels suggest that the punctal plug creates a healthier ocular surface vs the baseline condition.”

Dr. Piovella agreed.

“Both plugs and preservative-free tears are simple ways through which an ophthalmologist can manage, control and understand the most common and simple conditions of post-LASIK dry eye without the risk of complication,” he added.

For Your Information

Matteo Piovella, MD, can be reached at Centro Microchirurgia Ambulatoriale, Via Donizetti 24, 20052 Monza, Italy; +(39) 03-938-9498, fax: +(39) 03-9230-0964; e-mail: piovella@galactica.it. Dr. Piovella has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Frank A. Bucci Jr, MD, can be reached at 158 Wilkes-Barre Township Blvd., Wilkes-Barre, PA 18702 U.S.A.; +(1) 570-825-5949; fax: +(1) 570-825-2645; e-mail: bclvi@aol.com. Ocular Surgery News could not confirm whether Dr. Bucci has a financial interest in any of the products mentioned or if he is a paid consultant for any of the companies mentioned.

Stefano Bonini, MD, can be reached at Department of Ophthalmology, University of Rome, Tor Vergata; +(39) 06- 350-3416; fax: +(39) 06 301-7436; e-mail:sbonini@mclink.it.

Medennium Inc., manufacturer of the SmartPlug, can be reached at 15350 Barranca Parkway, Irvine, CA 92618 U.S.A.; +(1) 949-789-9000; fax: +(1) 949- 789-9035; e-mail: info@medennium.com; Web site: www.medennium.com.