Evaluating a LASIK candidate who has external disease issues

Physicians discuss the preoperative and postoperative approaches to handling a patient who has dry eye.

Issue: September 15, 2007

ByEric D. Donnenfeld, MD

Eric D. Donnenfeld

Eric D. Donnenfeld, MD: This is a patient who is coming in for LASIK. This is such a common presentation for LASIK and one that we see every day. Patients come in for LASIK because they want to see better, but they also cannot wear contact lenses comfortably. The most common reasons why people cannot wear contact lenses are dry eye and atopy.

So here is a 47-year-old patient who has contact lens intolerance, giant papillary conjunctivitis (GPC), a history of asthma and is using oral antihistamines (Figure 1). This is a setup for a bad LASIK result. What are the risk factors in this patient’s history for a poor LASIK outcome? Dr. Kenyon, why is this patient going to have a bad result if you don’t do anything preoperatively?

Kenneth R. Kenyon, MD: First, at her age of being perhaps perimenopausal, she is at significant risk of intrinsic dry eye to the extent that she still may have some residual inflammation from GPC-related problems. This could be an additional inflammatory stimulus. The use of oral antihistamines could contribute to ocular surface drying. And her history of asthma may put her at risk of atopy with difficulties in wound healing. This patient deserves a full-court-press preoperative workup by a cornea/external disease specialist. You cannot assume that just because she is here for LASIK, that is all she gets. That is extremely risk-taking. At my office, our preoperative LASIK intake sheet, for example, mandates that we do a fluorescein staining and document it, a basic Schirmer’s test and document it. These are important medicolegal aspects as well, which is the other risk factor that needs to be put on the list. But I think the comprehensive approach to the diagnosis and multifaceted management of these elements before any consideration of laser vision correction is mandatory.

Figure 1: 47-year-old patient with contact lens intolerance, giant papillary conjunctivitis, a history of asthma and is using oral antihistamines
This 47-year-old patient has contact lens intolerance, giant papillary conjunctivitis, a history of asthma and is using oral antihistamines

Images: Ophthalmic Consultants of Long Island

Dr. Donnenfeld: So this patient walks in and you ascertain that from a refractive perspective she is a good candidate, but she has these external disease issues. How do you manage this patient preoperatively, and would you perform LASIK on this patient?

Peter A. D’Arienzo, MD, FACS: I think it is important to mention the incidence of diffuse lamellar keratitis and ocular allergy for patients who are considering LASIK. Dr. Scott MacRae published a report that showed these patients had a higher incidence of grade 2 or grade 3 diffuse lamellar keratitis. And I think Drs. Dhaliwal and Mah were involved in the Pittsburgh protocol where they would stop the oral antihistamines and switch these patients to nasal steroids and maybe put them on a topical antihistamine as well as a way of optimizing the ocular surface before LASIK. I think it is important, too, to discuss contact lenses with patients because maybe they have not tried all of the new contact lenses that are out there. She might be a contact lens failure, but a lot of patients are doing well with the newer silicone hydrogel contact lenses, the Acuvue Oasys (Vistakon) or the Focus Night and Day (CIBA Vision). But if this patient were to have LASIK, I think I would put her on a nasal steroid, stop the oral antihistamine, start a topical antihistamine and maybe put her on flaxseed oil. Dr. Donnenfeld always talks about treating lid disease too, so doxycycline preop would be something that would help the patient.

Dr. Donnenfeld: Any other suggestions on what you might do for this patient?

Christopher J. Rapuano, MD: Depending on the exam and how bad I think the dry eye is at this point, I might start the patient on Restasis (cyclosporine ophthalmic emulsion, Allergan). Oftentimes I would say, “You have some things going on here. Let’s do a lot of the changes that were already mentioned and see you back before LASIK.” I do not want this patient to think she is a normal, excellent LASIK candidate like all of her friends are. So I’ll say, “We’re not going to schedule you today. We’re going to see you back in a few weeks and make sure your eyes are doing better.” And if she is not, then we can take the next step, which at that point might be Restasis. And if she is doing better, we’ll say, “Great. You have dry eyes. You have these other issues, but I think they are under good control now. Now we can safely go ahead with the LASIK.” I think the expectations need to be managed in patients like this.

Dr. Donnenfeld: Drs. Salib and McDonald published a study that showed that pre-treating these patients with Restasis gives better refractive results. I think this is one of the cases in which it would be well-indicated. And I agree 100% with Dr. D’Arienzo that the use of a topical antihistamine and possibly nasal steroids would all be good ideas. But I think this is a patient you have to be aggressive with and then reassess before you consider surgery.

The patient came back 6 months after LASIK and has had a good result. All of a sudden, the vision drops off and is now 20/25, 20/30, so you do a topography (Figure 2). What is the significance of this topography postoperatively? Well-centered ablation, corneal flattening. Dr. Perry, what do you see here that you think is important?

Figure 2: Topography of same patient 6 months after LASIK
Topography of same patient 6 months after LASIK. Patient has had a good result but had sudden vision drop.

Henry D. Perry, MD: I think you see the white areas where you do not really have data information. When I see this, it makes me think that there is a tear problem and that this patient has dry eye associated disease that is causing this abnormality.

Dr. Donnenfeld: This patient stopped her medicine and has dry eye. I think that is the most common reason, by far, for visual fluctuation after LASIK. When you see this type of problem after surgery, don’t think of refractive therapies, but think of ocular surface therapy as your first line of treating the visual complaints of these patients.

Dr. Perry: And the analogy to that is that these patients will often “eat minus.” In other words, they may refract at –0.5 D or –0.75 D or –1 D and you think they were undercorrected. And if you do an enhancement, you will not be solving their problem.

Dr. Donnenfeld: The most common symptom of dry eye after LASIK is not dry eye. It is not tearing. It is not burning. It is visual fluctuation, a very important concept.

For more information:

Peter A. D’Arienzo, MD, FACS, can be reached at Manhasset Eye Physicians, PC, 1615 Northern Blvd., Manhasset, NY 11030; 516-627-0146; fax: 516-365-4750; e-mail: eyedoc63@aol.com.

Eric D. Donnenfeld, MD, is a cornea specialist in private practice at Ophthalmic Consultants of Long Island and co-chairman of Cornea and External Disease at Manhattan Eye, Ear and Throat Hospital. He can be reached at Ryan Medical Arts Building, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com.

Kenneth R. Kenyon, MD, can be reached at Eye Health Vision Centers, 51 State Road, North Dartmouth, MA 02747, or Cornea Consultants International, Tal 13, 80331, Munich, Germany; 508-994-1400; fax: 508-992-7701; e-mail: kenrkenyon@cs.com.

Henry D. Perry, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 N. Village Ave., Suite 402, Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: hankcornea@aol.com.

Christopher J. Rapuano, MD, can be reached at Wills Eye Institute, 840 Walnut St., Suite 920, Philadelphia, PA 19107; 215-928-3180; fax: 215-928-3854; e-mail: cjrapuano@willseye.org.