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BLOG: Timing is ... what?
The landscape is littered with the carcasses of doctor-patient relationships that didn’t survive a post-LASIK dry eye “surprise.” I have been beating the drum of preop diagnosis and treatment of even the most minor dry eye disease. We know that we will make the eyes drier in some way. What we don’t know is if the increased osmolarity, elevated MMP-9 activity and reduced tear breakup time will result in an uncomfortable patient.
More than a few of you have taken me to task for my aggressive stance on addressing any degree of DED preop. Some have invoked the effect on societal health care cost (shouldn’t be my concern when dealing with a single patient). Others worry about patients who will likely never have any symptoms whatsoever (a reasonable criticism). But how do you choose if you aren’t going to treat every dry eye?
Over the years, refractive surgeons have gotten much better at predicting who shouldn’t have LASIK or PRK, reducing serious complications 10-fold to 0.1% to 0.2%. Another 8% or 9% of patients end up with a wonderful result only after a rough postop journey marked by potholes and speed bumps. Many of these will be those DED patients who weren’t treated preop. You, or someone else, will treat them, but how and when?
Enter Schallhorn, Schallhorn, Schallhorn, Schallhorn, Schallhorn and Hannan (seriously Steve, how many kids to you have?), and their very optimistic article on using thermal pulsatile treatment (LipiFlow, TearScience) for post-LVC patients with intractable DED symptoms. Patients were treated more than 2 years after LASIK or PRK. There was a statistically significant improvement in TBUT, corneal staining and — wait for it — symptoms! Mean SPEED score was reduced from 17.5 to 10.2. The obvious take-home message is don’t give up. Be aggressive, think a bit outside the box, and use everything at your disposal, including LipiFlow (and Xiidra and Restasis and steroids and ... ).
Might not want to wait 2+ years though. Your patients may not like you enough to stick around.
Reference:
Schallhorn CS, et al. J Refract Surg. 2017;doi:10.3928/1081597X-20161006-05.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.