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For post-LASIK dry eye, effective comanagement is essential
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A certain amount of postoperative dry eye is to be expected among LASIK patients and may persist for up to 12 weeks after surgery. In response to this phenomenon, most comanaging optometrists have developed postoperative regimens for treating dry eye. Successful mitigation of post-LASIK dry eye generally begins with a thorough preoperative evaluation, according to practitioners.
“Regardless of the cause, dry eye needs to be treated,” said Robert F. Haverly, MD, FACS, a practitioner in Erie, Pa. “I recommend a good preoperative evaluation of the tear film in any case where there is suspicion of dry eye prior to surgery.”
Drops and gels
Artificial lubricants are currently considered the mainstay of post-LASIK dry eye therapy. A wide variety of drops, gels and ointments are available for treating this condition.
Artificial tears are available both in both preserved and preservative-free formulations. Because preservatives found in artificial tears can cause itching, irritation or inflammation, some practitioners prefer the preservative-free variety.
“I prefer nonpreserved artificial tears. In fact, I make it mandatory that they are non-preserved,” said Cindy Beeks, OD, executive director of the TLC Laser Eye Center in Denver. “My favorite nonpreserved drop is Bion Tears (Alcon, Ft. Worth, Texas).”
Dr. Beeks said she uses preservative-free drops regardless of whether or not she notices a dry eye problem. “I’m in Denver, and it is really dry here, so I make it mandatory in all cases,” she said. “I have patients use nonpreserved artificial tears every hour for the first week post-op.” After that, Dr. Beeks said she generally will taper off the dosage, depending on the patient’s level of improvement.
Dr. Haverly agreed that nonpreserved drops are the best approach to post-LASIK lubrication, but added that he has no preference among brands. “I’ve tried every brand, and I don’t see a difference among brands, but I do see a difference in preservative vs. preservative-free,” he said.
Dr. Haverly said he generally prescribes his patients a fluoroquinolone such as Ciloxan (ciprofloxacin HCl, Alcon), Econopred (prednisolone acetate, Alcon) or Flarex (fluorometholone acetate 0.1%, Alcon) immediately post-LASIK. “I usually keep them on that for 5 days postop,” he said. “I usually keep them on artificial tears for at least a month afterward.”
Dr. Haverly strongly advised against the use of drops with preservatives.
“I have had a few patients who were taking these drops every hour who had reactions to the preservative,” he said. “The preservatives were interfering with healing or damaging the epithelium. It wasn’t until we actually stopped the drops and got the patient on preservative-free drops that the dry eye problem resolved.”
The use of steroids
Another approach to treating post-LASIK dry eye is the use of steroids. Corticosteroids are often used after LASIK to reduce postoperative inflammation and to relieve dry eye symptoms.
“I begin steroid treatment in patients with severe dry eye that we have not been able to control by any other means, such as punctual occlusion, lubrication or bandage contact lens,” Dr. Beeks said.
Dr. Haverly said he avoids the use of steroid treatment postoperatively when possible. “The reason is that some of the preservatives in steroid drops can exacerbate the problem,” he said.
Punctal plugs
For some LASIK patients, the most effective treatment for postoperative dry eye is the insertion of punctal plugs.
Dissolvable punctal collagen inserts are a temporary solution to the problem of dry eye. The collagen inserts are effective for 3 to 5 days and dissolve in approximately 7 to 10 days.
Dr. Beeks said she is contemplating the use of the dissolvable plugs for all of her LASIK patients. “I know some practices that do that already,” she said. “I think if it’s a really dry time of year or if you are seeing a lot of dry eye, it is really a good thing to do.”
Dr. Haverly said he also finds punctal occlusion to be very effective, both in terms of mitigating and preventing dry eye. “I am liberal in using punctal plugs,” he said. “I will use them in patients who have a problem after LASIK. If I notice a dry eye problem prior to LASIK, I will put in a punctal plug then as well.”
According to Dr. Beeks, knowledge of punctal occlusion is crucial for optometrists involved in LASIK. “For comanaging optometrists, it is imperative that they know how to do punctal occlusion,” she said. “I don’t think you can comanage LASIK without being comfortable with punctal occlusion.”
Other recommendations
Dr. Beeks said for cases of post-LASIK dry eye that haven’t responded to other treatments, she may prescribe doxycycline.
“Typically, if I have a chronic dry eye that I can’t get cleared up, I will use doxycycline,” she said. “It can be a great adjunct therapy for dry eye. Normally, copious amounts of lubrication and punctal occlusion are enough, but sometimes it’s not.”
Some practitioners have also found success in dry eye treatment through various nutritional supplements such as flaxseed oil. This supplement, which is rich in omega 3, 6 and 9 fatty acids, has been shown to be effective in treating dry eye.
Dr. Beeks said that although she has had limited experience with flaxseed oil, some of her colleagues have reported great success with it. “I know some doctors who have used it very successfully,” she said. “I haven’t used it as much, but I have been told that it can be very useful by itself.”
Dr. Beeks said, at this point, she is somewhat cautious in prescribing supplements such flaxseed oil. “I am always a little bit hesitant, because I know in some cases you can overdo it,” she said. “That’s why I always suggest working with the patient’s nutritionist on something like that.”
In situations where she has used supplements, Dr. Beeks said she has seen positive results. “In some of the severe cases I’ve seen, those natural mineral and oil supplements have been very helpful,” she said.
For Your Information:
- Robert F. Haverly, MD, FACS, is a LASIK surgeon with TLC Vision at Laser Eye Surgery of Erie in Erie, Pa. He can be reached at 311 West 24th St., Erie, PA 16502; (814) 455-7591; fax: (814) 454-1467. Dr. Haverly has no financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Cindy Beeks, OD, is executive director of the TLC Laser Eye Center in Denver. She can be reached at 1200 17th St., Denver, CO 80202; (303) 607-0174; fax: (303) 607-0149. Dr. Beeks has no financial interest in the products mentioned in this article, nor is she a paid consultant for the companies mentioned.