Dry Eye After LASIK? What You Should Do and the Best Eye Drops to Use
Each year, over 600,000 Americans undergo Laser-assisted in situ keratomileusis (LASIK) surgery to correct their vision. The surgery is rightfully hailed as a life-changing event, freeing people from their need for contacts or eyeglasses. Miraculous as it is, though, the procedure is not without its potential complications; the most common complication of LASIK is dry eye disease. Virtually all patients deal with dry eyes in the period immediately following the surgery but, for some, symptoms can continue for much longer than that.
Dry Eye After LASIK
For those who suffer from dry eye after having LASIK surgery, you may notice any of the following symptoms:
Pain and irritation (from mild to severe)
Light sensitivity or photophobia
Upon examination, your eye doctor may notice evidence of decreased tear production and volume on the surface of the eyes, increased evaporation of the tears, and an increase in the saltiness of the tears. So, why does LASIK cause dry eye?
The primary reason for dry eyes after LASIK is believed to be the inevitable damage to the corneal nerves that is a natural component of the surgery. During LASIK, the cornea is cut into with an excimer laser and the corneal nerves are severed. LASIK has been shown to disrupt the sub-basal nerve plexus and stromal corneal nerves when creating the flap and ablating (or flattening) the cornea. This disrupts the messaging between the corneal nerves and the brain, so it is more difficult for a signal of dry eyes to induce the lacrimal gland to produce aqueous tears and the meibomian glands to produce oil. Regeneration of these corneal nerves varies widely and has been shown in studies to take anywhere from three weeks to 16 months or longer. In some patients, the corneal nerves may never fully regenerate.
Another contributor could be the loss of conjunctival goblet cells. These small cells are responsible for creating the mucin layer of your tear film. This loss has been shown to occur after LASIK, and this is most likely because of direct damage from the suction device used during surgery.
Inflammation also plays a role, as it does in nearly all forms of dry eye disease. Any inflammation created post-surgery could exacerbate any dry eye that’s already there, and the cycle just continues over time.
It’s unclear exactly how many patients experience this extended and aggravating complication post-surgery; numbers have been reported ranging anywhere from 4% to 70%, with some patients reporting that their dry eye symptoms continued to bother them for years after surgery. The majority of patients, though, say that their dry eye symptoms ease within six months of having their surgery.
Risk Factors for Dry Eye Post-LASIK
Prior to undergoing LASIK surgery, it’s imperative that your eye doctor perform a detailed dry eye evaluation. Studies have found that patients who correct surface abnormalities on the eye prior to LASIK have a greatly reduced incidence of postoperative dry eye disease.
Because having dry eye before LASIK is the largest risk factor for dry eye post-LASIK, it’s incredibly important that doctors are completing a thorough evaluation and addressing any areas of concern. This may include starting artificial tears or even topical steroids to heal the ocular surface. In addition, eyelid hygiene can be a great way to decrease inflammation around the eyes prior to surgery. If needed, punctal plugs can be inserted prior to surgery as well. All of these things combined can help improve the health of the ocular surface and promote a healthier surface postoperatively. In addition, patients will likely have better comfort and vision after the procedure if this protocol is followed.
There’s also some statistical indication that both female patients and those who used contact lenses prior to surgery are more likely to experience dry eyes after LASIK surgery. It’s not uncommon for contact lens wearers to experience dry eyes, and many of those patients decide to get LASIK to be free from their contact lenses. Taking this all into consideration, your doctor should go over all of the pros and cons for you and make sure you understand the risks before undergoing the surgery.
LASIK Dry Eye Treatment
For those experiencing dry eye after LASIK, standard treatment is just as you’d expect although your doctor will want to do a thorough examination of your eyes to determine if there are any other contributors to your condition. The following details some of the potential treatments.
This will be the first recommendation for dry eye post-LASIK because we know that there is a decrease in tear production in those with LASIK-induced dry eye disease. It’s imperative to replace the tears that are not forming, and artificial tears can be used to do this. Make sure to stick with non preserved tears, as this will ensure that you’re not adding any preservatives onto your eyes. Non preserved artificial tears can be used as often as you need them, although many patients will find that they do not provide sufficient relief.
Punctal plugs are the next consideration for those with dry eye after LASIK because we want more tears to stay on the front surface of the eyes. These devices are inserted into the tear ducts, preventing your eyes from losing fluid (and thereby strengthening the tear film that lubricates your eyes). The insertion is a simple outpatient procedure, and in many cases does not even require an anesthetic. If punctal plugs work well for you, thermal punctal occlusion could be considered (although this is permanent).
The vast majority of dry eye patients have some form of meibomian gland dysfunction, and this includes those who notice dry eye after corneal surgery. Because of this, eyelid hygiene can go a long way in creating a healthier ocular environment and promoting healthy oil production for the tears. We recommend beginning with a warm compress routine followed by the use of hypochlorous acid for eyelid and eyelash cleansing.
Increasing humidity in your home and office can also help, as the increased moisture in the air can increase moisture on the eye itself, or at least prevent loss of moisture from the eyes. We recommend using a humidifier in your bedroom and office, and you may even want to consider a small desk humidifier for use while working at your computer. For sleep, moisture chamber goggles can be beneficial for sealing moisture in and locking it onto the front of the eyes. These can be especially helpful if you also sleep with your eyes slightly open.
Scleral Contact Lenses
One of our favorite treatments for aqueous deficient dry eye are scleral contact lenses. These large, gas permeable contact lenses vault over the entire cornea and are filled with non preserved saline or artificial tears before insertion. This effectively bathes the eye in tears all day, which is something patients with dry eye post-LASIK could benefit from. These lenses have been shown to improve patient comfort and support a healthy ocular surface. Although somewhat costly, they can be a very effective strategy to dealing with this form of dry eye.
Aside from the above mentioned treatments, some patients will just need more. Research into post-LASIK dry eye is ongoing and occasionally, some patients will present with neuropathic pain. This type of pain is persistent and severe despite there not being any signs of dry eye disease. More research is needed, but these patients may benefit from both neuromodulation (discussed in detail here) and Oxervate, or recombinant human nerve growth factor (rhNGF).
We also included these above, because they’re going to be the first treatment your eye doctor recommends. The use of artificial tears can be beneficial for those with dry eye, although they usually provide minimal long term relief. However, they can be great for symptom relief.
Anti-Inflammatory Eye Drops
Since inflammation is known to be such a large component of dry eye disease, topical steroid medications may be necessary in the short term and other anti-inflammatory eye drops may be considered for long term use. Since topical steroids are much safer for use short term, we recommend asking your doctor about cyclosporine. There are currently two topical medications available for those with dry eyes, Restasis and Cequa, and either of them could be beneficial for treating post-LASIK dry eye.
Using your own blood, autologous serum eye drops can be manufactured for you. Autologous serum contains anti-inflammatory components and growth factors that can be incredibly beneficial for healing the eyes. It contains the same balance of nutrients often found in your tears, and this can help heal the eyes after recurrent erosions, dry patches on the cornea, trauma and other instances where the cornea needs healing. Head here for more information on autologous serum eye drops.
Corneal refractive surgery presents a difficult challenge for eye doctors and patients alike, especially when the most common side effect is dry eye. If you’ve been experiencing dry eye post-LASIK, make sure to discuss all treatment options with your doctor. While the above list is a great starting point, we realize that many patients will need more, and we’re grateful for the vast amount of research going into this particular form of dry eye.
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