The information below applies to all patients with a dry eye whether you are preparing for LASIK or whether you simply want educational information and relief from the often debilitating symptoms of dry eye.
The surface of the eye is covered with a lining of tears called the tear film. The tear film is made up of three layers: a Lipid (oil) layer which lubricates and prevents evaporation of the water layer of tears; an Aqueous (water) layer, which nourishes and protects the eye surface; and a Mucin layer, which allows the water layer to adhere to the eye. Since the tear film is exposed directly to the air, the outer protective lipid layer is essential to maintaining a healthy tear film on the eye. When the protective lipid layer of the tear film is lacking, the eye surface can become irritated and dry eye symptoms can occur.
Dry eye disease affects more than 100 million people worldwide
Of those, 65 percent suffer from Evaporative Dry Eye as a result of poor quality oil or not enough oil. Common symptoms of dry eye include dryness, grittiness, soreness, irritation, burning, watering, and eye fatigue. These symptoms can hinder people’s daily activities such as reading, using the computer, wearing contact lenses and being outdoors on windy days, or in an air conditioned environment. Many dry eye patients complain that symptoms worsen throughout the day.
Other factors that can contribute to a dry eye are poor blinking and not fully closing the eye at night. Some patients do not fully blink. An “incomplete blink” will not allow the tears to lubricate the entire surface of the eye (like a defective windshield wiper), and can contribute significantly to the dry eye. Additionally, some people (especially after upper eyelid lifts/ blephaplasty ) do not completely close the eye at night. This can dry out the lower part of the eye and cause considerable symptoms.
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 is critical to ensure a salubrious result and will require some sacrifice on your part. This will be a short-term sacrifice for a long-term gain. Specifically, you must stop wearing your contact lenses while we are treating the dry eye. We are aware that patients accustomed to contact lens wear will find it extremely annoying and difficult to not wear contact lenses – particularly someone 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. It may be necessary to see you 6 to 8 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 teardrops. We will recommend certain teardrops, but any non-preserved drop in a vial is acceptable. Please do not use a bottled teardrop, even if they claim to be “non-preserved”. We usually start by having you apply one drop every hour.
Omega 3 (dietary supplement): Flax see oil, or fish/krill oil, which is rich in omega 3 fatty acids, have been shown to be effective in treating the dry eye. This can be taken as 2 gel-caps twice a day with meals. However, we recommend 2 tablespoons of the actual flaxseed oil in 2 ounces of juice or oatmeal once a day. It may take at least 6 to 8 weeks to show positive effects.
Punctual Plugs: The eye is constructed somewhat like a sink. There is a “faucet” located up under your eyebrow which produces tears, 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. Patients can occasionally feel the plug for the first few days after insertion and notice some itching of the lower lid by the nose. 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.
LipiFlow Treatment: We are one of the first centers in the country to offer the LipiFlow treatment. This advancement in the treatment of the aqueous deficient dry eye aims to restore the health of the oil-producing glands of the eyelid so as to decrease the evaporation of the water layer and allow for better lubrication of the surface of the eye. Please CLICK HERE to learn more about the LipiFlow treatment.
Other Medications: We may add Restasis (cyclosporine) eye drops. These are non-preserved drops and may be effective in helping resolve the dry eye. However, like all medications, they do not work in every case and may have to be discontinued due to irritation. We may also add doxycycline (a tetracycline antibiotic pill taken orally), which can be an effective adjunctive treatment.
Additional Factors to Consider:
Medications such as diuretics, antihistamines, some sleeping pills and tranquilizers, some anti-hypertensives, and the birth control pill may make your eyes 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 make your eyes drier. Additionally, in the winter the cool air holds less moisture and the eye will be drier. Also, while reading or using the computer, your eye will dry out more quickly because your blink rate decreases. Please use the artificial tears more frequently under these circumstances. In the 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. Try using an ultrasonic humidifier. This will make the atmosphere in your home less dry. Also, consider 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, you can wear regular swim goggles to seal in the moisture.
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 not a member of your insurance plan, then we will offer you a discounted price for the plugs and 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 30 years of practice I have never seen a case of dry eye in a young, otherwise healthy patient that did not resolve with treatment.