Dry Eye and the LASIK Patient
The LASIK procedure itself can either precipitate a dry eye, or exacerbate an underlying dry eye. Accordingly, as not only LASIK specialists but experts in the cornea and external eye, we strive to ensure that you will have the best possible result from your LASIK procedure. If we diagnose a dry eye prior to your LASIK procedure, we must postpone the surgery until the dry eye is resolved. We realize that this can be extremely disappointing and inconvenient to the patient who has planned for and is excited about their upcoming LASIK. However, your safety is our primary concern and we will do nothing to compromise your care and everything to ensure that you have an outstanding result. To this end, we must vigorously treat your dry eye condition before proceeding with the laser procedure.
Treating the dry eye is a team approach. The patient, myself, my staff, and your optometrist will be intimately involved in your care. Your cooperation and compliance with our recommendations are critical to ensure a salubrious result and will required some sacrifice on your part. This will be short term sacrifice for long term gain. Specifically, you must stop wearing your contact lenses while we are treating the dry eye. We are aware that patients used to contact lens wear will find it extremely annoying and difficult to not wear a contact lens - particularly the person with high degrees of nearsightedness and astigmatism. Some patients may even need to purchase new spectacles. However, the use of the contact lens will exacerbate the dry eye and significantly prolong the treatment. Most importantly, we ask for your patience with the seemingly long time it takes to improve. It is not uncommon for us to treat the dry eye for up to six months before we can proceed with your LASIK.
Your treatment will consist of a number of different steps designed to increase the moisture available to the surface of your eye and possibly the use of Cyclosporin, which is an anti-inflammatory drop. It may be necessary to see you 4 to 6 times while treating the dry eye before we are able to proceed with your laser procedure.
As mentioned above, a dry eye can develop following the LASIK procedure, especially in women. This can be annoying and will require one or more of the treatment steps delineated below. Fortunately, most cases of post-LASIK dry eye are self-limiting and resolve within 9 to 12 months.
A Brief Overview of the Step-Wise Treatment Program for the Dry Eye
Artificial Tears: The mainstay treatment for the dry eye is the frequent application of non-preserved artificial tear drops. We will recommend certain tear drops, but any non-preserved drop in a vial is acceptable. Please do not use any tear drops in a bottle, even if they claim to be "non-preserved". We usually start by having you applying one drop every hour.
Flax seed oil (dietary supplement): Flax seed oil, which is rich in omega 3, 6 and 9 fatty acids, has been shown to be extremely effective in treating the dry eye. No one knows how the supplement works to improve the dry eye - but it works quite well - and has very few side effects. It can be taken as a gel-cap 1000mg twice a day with meals. We recommend 2 tablespoons of oil in 4 ounces of juice once a day. Please start the flax seed oil dietary supplement ASAP. However, it takes at least 6 to 8 weeks to show positive effects. Please be patient.
Punctal Plugs: The eye is constructed somewhat like a sink. There is a faucet located up under your eyebrow, a drain in the lower lid by your nose, and a drain in the upper lid by your nose. In order to fill the sink if your faucet is not working properly, we must close one or both of the drains. This not only preserves the natural tears that your eye makes, but also allows the artificial tear to stay in contact with the ocular surface for a longer period of time. We will start by closing the lower drain (punctum) with a permanent, but removable, silicone plug. This plug is deposited in the canal of the drain and does not cause irritation. However, patients can occasionally feel the plug for the first few days after insertion and may notice some itching of the lower lid by the nose. It is permissible to scratch the lid, as these plugs cannot be dislodged. If closure of the lower drain is not effective, then after 4 to 6 weeks we may elect to close the upper drain. In some patients both the upper and lower drains are plugged at the same time. Occasionally, closure of the upper drain may result in watering of the eye and the patient may request removal of the upper drain plug due to excessive tearing.
Other Medication: If the drains have been plugged and the dry eye is not substantially better, we may add Cyclosporin .05% eyedrops in a cyclodextran base. These are non-preserved drops that are specially made for us by Park Avenue Pharmacy in San Jose. These drops may be effective in eliminating the signs of dry eye. However, like all medications, they do not work in every case and may have to be discontinued due to irritation. Cyclosporin is a drug which has been used for many years in organ transplant patients to decrease rejection of the transplant. Of course, we are using the drop for a different purpose in this case. Please note that the use of Cyclosporin in the dry eye has not yet been approved by the FDA. This is called "off label" use. This does not mean that the drug is not safe or effective for the dry eye, but simply means that the FDA has not studied or completed the studies and has not yet granted approval for the use of this medication for this condition. We may also add doxycycline which is a tetracycline antibiotic pill which can be an effective adjunctive treatment.
Additional Factors to Consider
Some medications such as diuretics, antihistamines, some sleeping pills and tranquilizers, some anti-hypertensives, and the birth control pill will make your eyes feel drier.
Air conditioning (at home, at the office, or in the car), the furnace in the winter, a smoke-filled room, or wind and sun will all make your eyes feel drier. Additionally, in the winter the cool air holds less moisture and the eye will be drier. You should avoid hair dryers, drafty areas, and polluted air. Under these circumstances use your drops more often. In an office it is usually the air conditioning and not the fluorescent lights that irritate your eyes.
If your eyes are extremely dry there are other things you might try. Get a few cold water (ultrasonic) humidifiers at the drug store. This will make the atmosphere in your home less dry. Also, try leaving a pan of water on the stove or radiator. Wraparound glasses will help prevent the evaporation of tears and, in the privacy of your home, wear regular swim goggles.
Costs for Treatment for the Dry Eye for the Pre-Operative and Post-Operative LASIK Patient
The cost for insertion of the plugs and/or the cost of the follow-up visits is not included in the price of your laser surgery. We participate in most, but not all, insurance plans in the Bay Area. If we are a participating provider for your insurance plan, then we will assist you in billing your insurance for treatment. However, if we are non-participating providers on your insurance plan, we will offer you a deeply discounted price for the plugs and their insertion, as well as for the follow-up visits.
We know that the treatment of the dry eye can be complex, occasionally confusing, and prolonged. Although we share in your frustration, we are committed to providing you with the highest quality care and will not compromise the safety of your eye or the outcome of your procedure by proceeding with laser vision correction prior to the rehabilitation of your dry eye. Fortunately, in over 20 years of practice I have never seen a case of dry eye in a young, otherwise healthy, patient that did not resolve with treatment.
Please feel free to call 510.886.3937 ext. 3 or 877.210.2020 ext. 3