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Ocular surface management is key in corneal refractive enhancement
When lenticular refractive surgery is followed by corneal refinement, patients must be educated about the importance of preventing dry eye, a surgeon says.
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When patients are undergoing sequential lens and corneal surgery for correction of refractive error, maintenance of a healthy ocular surface before and after the surgeries is vital, according to Y. Ralph Chu, MD.
For patients undergoing lenticular refractive surgery, it is imperative to assess the health of the ocular surface first to determine whether they are appropriate candidates, Dr. Chu said in a telephone interview with Ocular Surgery News.
Preoperative patient education and postoperative follow-up also are important, he said.
“I tell the patient two things about ocular surface management,” Dr. Chu said. “Whether or not we’re thinking of further surgery, it’s important for the health of your eye. So if you’re going to have surgery, it helps you heal better and see better faster after the surgery if we manage the surface. And it gives me the ability to have more confidence and achieve more accuracy in my measurements of the eye if the ocular surface is healthy.”
Preparing the patient
Dr. Chu said that not all patients will need refinement after refractive lens surgery, but in case they do it is good to prepare them for the possibility before the initial surgery.
“A certain percentage of patients who receive a lens will potentially need an enhancement of their residual refractive error, whether it’s nearsightedness, farsightedness or astigmatism,” he said. “Educating about the potential approaches, whether it’s limbal relaxing incisions, laser surgery or piggyback IOLs, is important. If they are undergoing lens exchange, they need to know all these options preoperatively.”
Before any surgery takes place, patients should be screened to ensure that they have healthy corneas without abnormal topography or abnormal corneal thickness, Dr. Chu said. If the patient does not have a healthy ocular surface, the surgeon may not be able to deliver the results the patient wants.
Dry eye that was subclinical before lens surgery may cause discomfort or delay healing postoperatively, Dr. Chu said. Many lens replacement candidates are older patients, for whom ocular surface management is critical, he noted.
“Proper screening for the health of the ocular surface avoids all these postoperative dilemmas,” he said.
Concerns and potential issues regarding ocular surface health should be addressed as part of preoperative patient education and informed consent, setting the patient’s expectations at an accurate level, he said.
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Managing the ocular surface
Dr. Chu said the surgeon should ensure that patients have adequate ocular surface wetness both before and after lenticular refractive surgery. Schirmer’s testing, tear breakup time and conjunctival staining can help identify patients who might have dry eye problems after corneal enhancement surgery, he said.
If the patient has dry eyes, Dr. Chu recommends prescribing artificial tears, Restasis (cyclosporine ophthalmic emulsion, Allergan) or punctal plugs to improve the ocular surface preoperatively.
After lenticular refractive surgery, Dr. Chu waits for the refraction to stabilize. The minimum wait time is at least 3 months, he said. At that point, he determines what additional surgery might be necessary, whether LASIK, surface ablation or limbal relaxing incisions.
Dr. Chu said one of the biggest postoperative challenges between initial surgery and enhancement is managing patient expectations. If the physician has properly educated patients preoperatively about the postoperative stage, he said, they should be well prepared.
“If the patient feels educated before surgery, then these typical situations of needing enhancement, they can manage,” Dr. Chu said.
He said if patients have residual refractive error after the initial surgery, he prescribes either a thin pair of glasses or contact lenses to wear before enhancement. Contact lenses should be used with caution, he said, because patients will have to stop wearing them at some point before the enhancement.
He said ocular surface management is important before the enhancement surgery. Patients should be seen at least every 3 to 4 weeks to monitor the refraction’s stability, he said, and to maintain a dialogue with the patient to ensure they understand every step of the process.
Enhancement stage
Dr. Chu pointed out that patients who complain of blurriness or fluctuating vision after lenticular surgery may not need enhancement surgery; rather, they may simply need better management of their ocular surface. For those patients, Restasis can help to “calm” patients’ complaints, Dr. Chu said. It can also assist in ensuring that a dry ocular surface does not contribute to a false reading of refractive error or other visual complaints, he said.
Before laser enhancement surgery, Dr. Chu performs Schirmer testing with anesthesia. If patients have normal tear production, artificial tears and Restasis are prescribed. If they have low tear production (under 10 mm of wetting), a regimen of tears and Restasis is used, but Dr. Chu also considers inserting temporary or permanent punctal plugs to ensure the stability of the ocular surface during the post-enhancement phase.
“No matter which technique you choose for enhancement, management of the ocular surface postoperatively is important,” he said. “It’s all critical to the success of your enhancement surgery.”
For more information:
- Y. Ralph Chu, MD, can be reached at Chu Vision Institute, 7760 France Ave. South, Suite 140, Edina, MN 55435; 952-835-0965; fax: 952-835-1092; e-mail: yrchu@chuvision.com.
- Erin L. Boyle is an OSN Staff Writer who covers all aspects of ophthalmology.