*Dr. Desai is a paid consultant of Nordic Pharma
The following case study is the second in a series of cases that highlight treatment intervention with LACRIFILL Canalicular Gel (Nordic Pharma). Here, Neel Desai, MD, and Subhashini Chandrasekaran, MD, illustrate how lacrimal occlusion using LACRIFILL Canalicular Gel can markedly improve visual acuity and optical quality in a patient with fluctuating vision after cataract surgery.
Presentation
In December 2024, a 64-year-old woman, who had undergone a previous 4-cut radial keratotomy (RK) OU over 30 years ago, presented for bilateral cataract extraction with implantation of Light Adjustable Lenses (LALs; RxSight).
Corneas that have had RK present unique challenges during cataract surgery, because they are hypersensitive to ocular surface irregularities. Although the use of LALs enables postoperative refractive fine-tuning, the success of this process is dependent upon a stable and well-lubricated ocular surface. This patient had islands of dryness as seen in Figure 1 and had not previously been on any dry eye regimen. A confirmatory slit-lamp exam was done at the visit. Cataract surgery was uneventful in both eyes, and the LALs were implanted successfully. Postoperatively, standard LAL adjustment protocols were followed, beginning at her 1-month visit to allow for keratometric stabilization in the post-RK eyes. At her postoperative 1 month visit, UCDVA was 20/50 OD and slit-lamp exam demonstrated posterior capsular opacification. She was treated with a YAG laser. At her first LAL adjustment (two weeks after her YAG procedure), she presented with UCDVA 20/25 OD. However, at her second LAL adjustment visit, which was 2 months from cataract extraction, the patient’s visual acuity was significantly reduced, with UCDVA measuring 20/80 OD (Figure 1). The patient reported fluctuating vision, which is not an uncommon side effect in eyes with unstable tear film, and predominantly in post-RK eyes. Fluctuating vision impedes the precise refraction and light adjustment of the LALs.
Figure 1. The patient’s Pentacam (left) and HOA (right) values before LACRIFILL Canalicular Gel placement.
Treatment and Outcomes
To stabilize the patient’s tear film and improve her visual quality, LACRIFILL Canalicular Gel was administered by occluding both the upper and lower puncta in each eye at her second LAL adjustment visit. Within 15 minutes, the patient reported improved vision, which measured uncorrected 20/40 in both eyes. A Pentacam (OCULUS) evaluation was then performed, which demonstrated a significant reduction in higher-order aberrations (HOAs) within the central 4-mm zone. While LACRIFILL Canalicular Gel does not reverse the keratometric instability from the RK incisions, it helps by masking the irregularity, leading to improved functional vision. Repeat topography, while showing minimal to no significant change in keratometric indices, did demonstrate a clinically and visually significant 55% reduction in HOA in the central 4-mm optical zone (Figure 2). When the patient returned for her second LAL adjustment, she was correctable to 20/25.
Figure 2. The patient’s Pentacam (left) and HOA (right) values after LACRIFILL Canalicular Gel placement.
Conclusion
Eyes with prior RK are especially susceptible to ocular surface irregularities. In this patient’s case, her fluctuating vision and increased HOAs, as demonstrated by the Pentacam, were likely due to tear film instability and keratometric changes from the initial RK incisions. LACRIFILL Canalicular Gel, which can temporarily occlude lacrimal outflow, reduces tear drainage and enhances tear film stability. The effects of LACRIFILL Canalicular Gel can last up to 6 months. The rapid improvement in the patient’s UCVA from 20/80 to 20/40, in addition to the objective reduction in HOAs, supports the conclusion that tear film optimization can have an immediate and profound impact on postoperative visual outcomes.
This case also underscores that, among patients who have had prior refractive surgery, corneal irregularities, and advanced lens implants, it is important to address ocular surface abnormalities. Treatment of the ocular surface should be considered an integral component of pre-, peri-, and postoperative management. Further studies could aid in determining the long-term efficacy and optimal timing of such treatment interventions.
