CASE PRESENTATION
A 42-year-old female presents 3 years after undergoing LASIK. Her past medical history is not significant, but her past ocular history is notable. At the age of 31, she underwent bilateral thermal punctal occlusion to improve her comfort with contact lenses, which she had discontinued wearing due to dry eye symptoms. Prior to this procedure, she was labeled a medical failure. The patient began therapy with Restasis (Allergan, Inc., Irvine, CA), which sufficiently improved her symptoms and signs to permit her to undergo LASIK.
The patient currently uses over-the-counter unpreserved tears when she remembers and takes an over-the-counter flaxseed oil/Omega-3 medication b.i.d. She also uses Restasis b.i.d. The patient takes no other systemic medications.
She is not unhappy with her outcome. Nevertheless, her vision fluctuates from day to day despite a refraction of plano in her right eye and -1.00D monovision in her left eye, which she likes. The patient is looking for additional therapeutic options to improve her daily function. The slit-lamp examination shows that her lower puncta remain occluded from the previous intervention. Her eyes exhibit mild ( 1/4) staining of the nasal conjunctiva with Lissamine Green (Accutome, Inc., Malvern, PA), but no corneal staining is present. The tear breakup time is 9 seconds in both eyes. Schirmer testing shows wetting of 12mm in her right eye and 14mm in her left eye. The rest of the examination is normal.
What additional options or interventions would you suggest?
WILLIAM B. TRATTLER, MD
Chronic dry eye is a well-established problem following LASIK surgery, and the risk of it after LASIK is higher in patients with preexisting dry eye.1 Ophthalmologists need to evaluate a patient for dry eye carefully prior to refractive surgery. In my practice, contact lens intolerance due to dry eye is a common reason that patients pursue excimer laser ablation.
This patient had been diagnosed with dry eye more than 10 years before refractive surgery. The surgeon apparently identified dry eye as a significant issue preoperatively, and treatment with Restasis allowed the patient to undergo LASIK. The degree of dry eye has clearly progressed since her surgery 3 years ago.
A major issue that needs to be addressed in cases of significant dry eye after LASIK is the patient's feeling of discouragement. Not infrequently, individuals with significant dry eye after LASIK believe that they erred in choosing to undergo the procedure. Resolving their dry eye is therefore critical to improving their satisfaction with LASIK surgery.The patient in this case had clinical signs consistent with dysfunctional tear syndrome. The Schirmer test was borderline, so a lack of tear production is not the major condition to be treated. Rather, it is important to improve the quality of the patient's tear film, which will help improve the tear breakup time and ultimately improve her symptoms of visual fluctuation.
As a first step, I have found that dry eye signs and symptoms can be improved with a course of topical steroids lasting 1 to 2 weeks in addition to Restasis. Steroid drops such as Pred Forte (Allergan, Inc.) or Lotemax (Bausch & Lomb, Rochester, NY) can reduce ocular surface inflammation. Side effects from these drugs, such as elevated IOP and cataracts, are unlikely when the drops are used for just a few weeks.
A second treatment option is to combine the use of warm compresses and topical steroids. Standard warm compresses or the disposable variety (Eyefeel; Kao, Inc., Japan; FDA approved but not currently manufactured in the US) greatly relieve the signs and symptoms of significant dry eye in LASIK patients.2
A third option is the addition of oral tetracycline (eg, doxycycline and minocycline), which significantly reduces ocular flora and improves meibomian gland secretions.3,4 I have found that topical doxycycline (Leiter's Pharmacy, San Jose, CA) often provides similar improvements without the systemic side effects.
Of course, another approach is to plug the upper puncta. Although this maneuver sometimes can be successful, it is not uncommon for patients such as the one in this case to experience a significant overflow of tears. I would therefore assess the patient's tear film layer and decide if her level of tears is deficient. If so, I would consider placing external punctal plugs (Parasol Punctal Occluder System; Odyssey Medical, Inc., Memphis, TN) in the upper puncta with the understanding that she might experience epiphora and return in a matter of days for the plugs' removal.
Although challenging, helping patients with dry eye after LASIK can significantly improve their satisfaction with surgery.
MARGUERITE McDONALD, MD, FACS
I would suggest bilateral upper punctal occlusion (with plugs, in case it has to be reversed), the addition of bland ointment at night, and a 2- to 3-week course of doxycycline (50mg b.i.d.). Other potential measures include the bilateral q.i.d. use of Tears Again Liposome Lid Spray (Cynacon/Ocusoft, Inc., Richmond, TX) and controlling environmental factors. With the former alternative, the tiny liposomes in the spray decrease the evaporation rate of the tear film by melting on contact, thereby sealing off the tear film with an enhanced lipid layer. Controlling environmental factors includes limiting the consumption of alcohol, minimizing drafts in the office and the home, and discontinuing the use of ceiling fans. I would also increase the use of unpreserved artificial tears to at least every 2 hours while awake.
Last, I would prescribe topical diquafosol as soon as it is approved by the FDA and available in the US. This purinergic P2Y2 agonist is an analog of UTP. Diquafosol is a potent, selective agonist at the P2Y2 receptor that increases the secretion of ions, fluid, mucin, and surfactant on the mucosal surface. The agent causes the eye to produce more of all three layers of the tear film, even in a rat model in which the lacrimal glands had been removed.5 Because diquafosol works differently than cyclosporine, these drugs will doubtless be used in concert, especially for cases of moderate-to-severe dry eye.
ASIM PIRACHA, MD
The patient does not appear to have any past medical conditions or any systemic medications to explain her symptoms. Her only apparent risk factor is being perimenopausal with declining hormone levels. Of course, prior to the initiation of any further treatment, a thorough past medical history and review of symptoms are critical. The presence of connective tissue disease or any autoimmune conditions, systemic medications, or past ocular history should be investigated. Also, the ocular surface requires close evaluation. At the slit lamp, I would look for any signs of meibomian gland dysfunction or blepharitis.
Schirmer testing was normal after occlusion of the lower puncta, and the tear breakup time was slightly reduced. Based on this history and positive staining with Lissamine Green, I would classify the problem as one of tear film instability and not aqueous tear deficiency.
With tear film instability from meibomian gland pathology, I typically do not use punctal occlusion, because it increases the proinflammatory factors in the tear film and worsens the condition. My first-line therapy typically includes lid-margin hygiene, warm compresses, and artificial tears. In this case, I would create a better balance of Omega-3 with Omega-6 fatty acids and continue therapy with Restasis. If significant disease of the lid margins were present?especially observable signs of rosacea?I would prescribe oral doxycycline, starting at 50mg b.i.d., if not contraindicated. Oftentimes, I also add a short course of topical steroids to quicken the resolution of symptoms and further reduce the inflammatory response.
Section editors Karl G. Stonecipher, MD, and Parag A. Majmudar, MD, are cornea and refractive surgery specialists. Dr. Stonecipher is Director of Refractive Surgery at TLC in Greensboro, North Carolina. Dr. Majmudar is Associate Professor, Cornea Service, Rush University Medical Center, Chicago Cornea Consultants, Ltd. They may be reached at (336) 288-8523; stonenc@aol.com.
Marguerite McDonald, MD, FACS, is Clinical Professor of Ophthalmology at Tulane University School of Medicine in New Orleans. She is a consultant for Allergan, Inc.; Ocularis Pharma, Inc.; Advanced Medical Optics, Inc.; Refractec, Inc.; and Acufocus, Inc. Dr. McDonald may be reached at margueritemcdmd@aol.com.
Asim Piracha, MD, is Partner at the John-Kenyon Eye Center, Cornea, Cataract, and Refractive Surgery in Louisville, Kentucky. Dr. Piracha is also Clinical Instructor in Ophthalmology and Visual Sciences (Gratis) at the University of Louisville. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Piracha may be reached at (812) 288-9011; apiracha@johnkenyon.com.
William B. Trattler, MD, is Director of Cornea at the Center for Excellence in Eye Care in Miami. He has received honoraria and research support from Allergan, Inc. Dr. Trattler may be reached at (305) 598-2020; wtrattler@earthlink.net.
