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Combat post-LASIK dry eye with aggressive preventive measures
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By all measures, laser in situ keratomileusis (LASIK) is quite impressive. Its ability to withstand scientific scrutiny, yield impressive outcomes and provide patient satisfaction speaks volumes. And with an anticipated 1 million LASIK procedures this year alone, it’s become pretty routine. Well, almost.
True, we are ever mindful of significant LASIK complications: flap defects, striae, diffuse lamellar keratitis and epithelial ingrowth, among them. Fortunately, these occurrences are fairly rare and don’t account for the majority of patient symptoms or practitioner chair time. Because of the relatively few significant complications with LASIK, it’s easy to become complacent.
However, in the predictable world of LASIK there is at least one pervasive complication. A complication that – admittedly — is neither terribly exciting to diagnose nor manage. A complication often resulting in patient symptoms, but often dismissed as insignificant. The complication, of course, is LASIK dry eye. Granted, LASIK dry eye is pretty mundane and usually self-limiting. But ask any patient suffering from LASIK dry eye, and it’s anything but insignificant!
Theories vary
The theories behind LASIK dry eye are quite varied. In certain patients, keratoconjunctivitis sicca predates LASIK and is only exacerbated by the procedure. Indeed, some patients self-select LASIK because of contact lens-intolerant dry eye. For others, it may be the suction ring resulting in perilimbal conjunctival compression, goblet cell damage and associated mucin-deficient dry eye. Yet another plausible explanation implicates microkeratome and excimer laser corneal dennervation – an iatrogenic neuroparalytic keratitis of sorts. Finally, LASIK dry eye symptoms may simply result from flap manipulation. In essence, what makes LASIK such a successful procedure may be what actually induces a dry eye.
While LASIK dry eye is mostly transient, it can be a source of fear and frustration for those with persistent symptoms. Because we can’t always predict who will be symptomatic, it’s best to be proactive with all patients. In short, LASIK dry eye management begins with prevention. Preoperatively disclosing LASIK dry eye isn’t just considerate, it’s imperative.
At-risk patients should be managed with eyelid hygiene, tear supplementation or punctal occlusion. Every postoperative therapeutic regimen should include some form of LASIK dry eye prophylaxis. This aspect can be challenging, as patients often equate improved vision with wound healing and promptly discontinue all eye drops. Fortunately, discussing LASIK dry eye prophylaxis at each visit goes a long way in assuring compliance. After all, most patients realize that they have invested too much to risk it all.
Despite prevention, some still suffer
Even with vigilance some LASIK patients endure significant dryness. For these chronic sufferers a comprehensive management strategy is even more important. Arguably, support, encouragement and assurance may be the most important therapeutic adjuncts.
In the final analysis, the vast majority of LASIK dry eye patients do get better. However, the road to being symptom free is occasionally a long one. An aggressive approach to prophylaxis and management will save your patient a great deal of symptoms and you a great deal of time.