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At Issue: tears versus plugs in post-LASIK patients
At Issueposed the following question to a panel of experts:
“What is the place of tears versus plugs in your post-LASIK patients?”
At Issueposed the following question to a panel of experts: “What is the place of tears versus plugs in your post-LASIK patients?”
Depends on symptomatology of patient
Eric D. Donnenfeld, MD: The treatment of the post-laser in situ keratomileusis (LASIK) dry eye patient is one of the most difficult problems facing refractive surgeons. Dry eye following LASIK is extremely common, and is probably multifactorial. These LASIK candidates are often pre-selected dry eye patients because they are contact lens intolerant due to their dry eye. In addition, LASIK surgery transects the corneal nerves, causing a neurotrophic cornea and loss of the feedback mechanism that promotes stabilization of the ocular surface. Finally, there is damage to the goblet cell population produced by the suction handpiece.
For patients who are symptomatic with dry eye and minimal corneal findings following LASIK, I recommend tears. These are patients who have minimal staining with Lissamine green or rose bengal, but have dry eye symptomatology. Usually, this subgroup of patients has normal visual acuity, as the ocular surface has not been disrupted. I recommend the use of transiently preserved or non-preserved tears. In this group of patients, I also have found the use of lubricating ointments at night to be beneficial.
For patients who have more significant symptomatology, and particularly those patients with significant corneal findings, especially if the epitheliopathy involves the visual axis, causing visual disturbance, then I will often begin my therapy with inferior punctal plugs. Punctal plug insertion is an innocuous procedure that rapidly stabilizes the ocular surface. Often, patients requiring punctal plugs also will require concomitant artificial tears as well, and in these patients, I use the same transiently preserved and non-preserved tears that I use for milder cases of dry eye following LASIK. In general, I like to evaluate all patients who are contact lens intolerant and seeking LASIK for dry eye prior to surgery. Pre-treating these patients with punctal occlusion prior to surgery when they have corneal staining, starting them on an artificial tear regimen, and treating pre-existing lid disease with lid hygiene or oral doxycycline significantly reduces the risk of post-LASIK dry eye, and when it does occur, the disease is usually significantly more manageable.
- Eric D. Donnenfeld, MD, can be reached at Rockville Centre, Ryan Medical Arts Bldg., 2000 N. Village Ave., Ste. 402, Rockville Centre, NY 11570; (516) 766-2519; fax: (516) 766-3714.
Recommends "saturation dosing"
Jeffrey P. Gilbard, MD: Based on Ken Wellish’s poster presented at the International Society of Refractive Surgery, I recommend giving LASIK patients a running start in their encounter with dry eye. In his study, he found that LASIK patients pre-treated for about 1 week preop with TheraTears (carmellose sodium; Advanced Vision Research) had far fewer problems with dry eye following LASIK than those not treated. I recommend what I call “saturation dosing” — using the entire contents of one container in both eyes within a 5-minute period of opening, four times per day. Using this regimen, Wellish found his need to place punctum plugs cut by about 75%. Patients are continued postoperatively on the same regimen.
At 2 weeks, I divide patients into two groups: 1) improved and happy and 2) better but still symptomatic. Both groups are continued on TheraTears, but in the second group, I also insert inferior plugs. This turbocharges the efficacy of TheraTears and keeps just about everyone happy. At 4 weeks, I re-evaluate and, if necessary, add upper plugs. TheraTears alone can manage most patients and, indeed, in a study by Lenton and Albeitz, published in the Journal of Cataract and Refractive Surgery, 87.5% of their TheraTears-treated LASIK patients were symptom free by 1 week and 100% were symptom free by 1 month. Unlike patients treated with the control tear, TheraTears-treated patients also demonstrated a virtually full recovery of the conjunctival goblet cells at 4 weeks postop. TheraTears works by lowering elevated tear film osmolarity, taking the gas out of the engine driving the disease process, while its patented electrolyte balance permits the re-blossoming of conjunctival goblet cells.
- Jeffrey P. Gilbard, MD, can be reached at Advanced Vision Research, Ste. 330, 7 Alfred St., Woburn, MA 01801; (800) 979-8327; fax: (781) 935-5075; e-mail: jgilbard@theratears.com. Dr. Gilbard is founder and CEO of Advanced Vision Research.
Reference:
- Wellish K. Does pre-treatment of minor dry eye syndrome with TheraTears enhance recovery following LASIK? Summer World Refractive Surgery Symposium. Miami, Fla: July 1999.
- Lenton L, Albeitz J. Effect of carmellose-based artificial tears on the ocular surface in eyes after laser in situ keratomileusis. J Cataract Refract Surg. 1999;15(suppl):S227-S231.
Recommends frequent non-preserved or transiently preserved tears
Richard L. Lindstrom, MD: Many patients seeking LASIK present with borderline to severe dry eyes. These patients are often contact lens intolerant. Many also have low-grade blepharitis or meibomian gland dysfunction. The LASIK procedure then puts significant additional stress on the ocular surface. Toxic medications including topical anesthetics are utilized. A mechanical microkeratome is run across the eye. The eye is allowed to dry during the surgical procedure. The ocular surface is rendered hypesthetic from severing of the corneal nerves. This combination of a preoperative dry eye subjected to significant surgical trauma and rendered hypesthetic is then compounded by postoperative topical medications with preservatives including an antibiotic, a topical steroid and, occasionally, a topical nonsteroidal anti-inflammatory. It is no wonder that many patients suffer dry eye symptoms following LASIK surgery.
Our clinic believes all patients should be advised that they should anticipate dry eye symptoms in the first 3 to 6 months postoperative. We recommend frequent non-preserved or transiently preserved tears in all patients beginning on the first postoperative day. We begin by instilling a topical lubricant on the table. We then recommend the patient return home and nap for 2 or 3 hours. This is quite rejuvenating for the ocular surface in itself. The patient upon awakening places artificial tears in the eye at least hourly on the first day. Depending on the appearance of the eye on the first postoperative day, all patients utilize artificial tears at least every 4 to 6 hours, and in some cases hourly. We do not hesitate to recommend an ointment at night or the use of a gel. Eighty to ninety percent of the patients respond well to topical lubricants with resolution of their symptoms over several months. In those patients that continue with significant punctate epithelial keratitis in spite of frequent artificial tears and nighttime ointment or gel, we recommend punctal occlusion.
Since we anticipate that most patients’ symptoms will resolve over several months, punctal plugs are a good choice. We are fairly aggressive in placing these plugs in the post-LASIK patient when symptoms persist and especially when there are signs such as punctate epithelial keratitis and reduced visual acuity. If necessary, these plugs can be removed later, but I do not recall more than a few patients where I eventually removed the plugs. Most patients find them beneficial in the long term. It also is possible to perform superficial cautery, which results in initial occlusion and eventual atresia of the puncta, but punctal plugs are our first line of treatment when frequent topical lubricants are inadequate.
- Richard L. Lindstrom, MD, can be reached at Minnesota Eye Associates, Park Avenue Medical Office Bldg., 710 E. 24th St., Ste. 106, Minneapolis, MN 55404; (612) 813-3600; fax: (612) 813-3660.