Publication Exclusive: Dry eye can be a surgical disease

For some reason I get all confessional with you here. Doubtless it has something to do with our shared experience in the trenches, stomping out dry eye wherever it threatens our patients. Here is my latest: I would really rather be in the operating room.

There. I said it.

That may seem a bit weird coming from a dry eye guy, but after all, this is a column in Ocular Surgery News. Although I do enjoy my work taking care of dry eye patients, when people ask me what I do for a living, I tell them that I am an eye surgeon. I like John Hovanesian’s premise that dry eye can be thought of as the “new glaucoma,” and as long as we are using that analogy, we should probably also realize that the new paradigm is that glaucoma is becoming more and more of a surgical disease. While this is unlikely to be the case in dry eye, there are two specific surgical interventions that we should all become comfortable recommending to those patients who qualify.

Surgery for ectropion

The first of these is an entity that we see in a large percentage of our patients regardless of age or gender: ectropion. We all fight gravity every day; gravity always wins. As I noted in a previous column on computer vision syndrome (Computer vision syndrome: Does looking at a screen cause dry eye?, Ocular Surgery News, February 25, 2015, page 8), exposure of the ocular surface while doing office work or other near tasks is an inflammatory stimulus. Depending on the degree of ectropion involved and the extent to which the lower lid has ceased to function normally, one can see large areas of conjunctiva that would normally be covered but are now exposed to the air. No amount of medicine will fix this. You could prescribe enough fish oil to depopulate every aquarium in North America, and your patient would still be uncomfortable.

It is a physical problem, and it therefore requires a physical solution. Someone needs to fix that lid.

Reasonable people can disagree on the specifics on how to address a loose, malpositioned lower eyelid, but there are just a couple of endpoints that you should strive for. Most cases of ectropion involve a significant loosening of the lid with an associated loss of elasticity. In and of itself, this will have a negative effect on the pump function of the lower lid. After surgery, the lid should be snug against the globe.

The position of the punctum is key. Your endgame includes not only normal tear production but also normal tear drainage. It is important to make sure that the inferior punctum is in contact with the tear lake. By the same token, by re-establishing the lateral canthal angle, you not only create a more attractive contour but also reduce the area of inferotemporal conjunctiva that is exposed between blinks.

While it is slightly more difficult technically to perform a tarsal strip, in my experience the outcome both cosmetically and functionally is superior to a simple wedge resection. In addition, quite often it is possible to rotate the lid margin with just this one technique. If the punctum stubbornly remains aimed more toward the slit lamp than the tear lake, excising an ellipse of tarsal conjunctiva nasally and then suturing or cauterizing the edges together will likely do the trick. If you, like me, don’t like the sight of blood, this is an excellent time to get chummy with your local ophthalmic plastic surgeon. (Mark Levine: Don’t retire.)

Click here to read the full publication exclusive, The Dry Eye, published in Ocular Surgery News, U.S. Edition, February 25, 2016.