In 2015, approximately 600,000 people underwent Laser-Assisted In Situ Keratomileusis (LASIK) or other types of laser eye surgery to improve their vision. Whether suffering from nearsightedness, farsightedness or astigmatism, the lure of a life without glasses or contacts is understandable, especially when you consider the 95% success rate of refractive surgery¹.

However, LASIK and other like procedures are not without risk, and postoperative dry eye symptoms are quite common. While these symptoms are often temporary, patients have increasingly high expectations regarding the outcomes and effectiveness of these surgeries, and postoperative dry eye symptoms may reduce patient comfort and overall surgical satisfaction.

Why Do You Experience Dry Eye After LASIK?

Dry eye symptoms may start with the quantity and quality of tears. If communication between the lacrimal functional unit (which includes the lacrimal glands, conjunctival goblet cells and meibomian glands) and the ocular surface breaks down, the health of the tears and tear film can be compromised ². Beyond the presence of preexisting dry eye symptoms, studies have shown that refractive laser surgery can affect any, or all, of the components of tear production. During LASIK, corneal nerves can be cut and cause a loss of corneal sensitivity. Without that sensitivity, the lacrimal glands will lose the stimulation they need to secrete tear fluid and proteins. Most dry eye symptoms occur due to changes in the ocular surface that alter the clearance of tears, blinking rate and thus, distribution of the tears ³. The use of a suction device to stabilize the eye during LASIK has been associated with loss of goblet cells, which can lead to tear film instability and tear hyperosmolarity. This postoperative symptom is particularly prevalent in patients who have chronic dry eye prior to LASIK and it could take six months to return to pre-LASIK goblet cell levels. In addition, postoperative inflammation can lead to ocular surface dryness, and the change in corneal shape caused by the creation of the surgical flap could lead to abnormal lubrication during blinking ⁴.

Preoperative Dry Eye

Ideally, refractive surgeries would be performed on patients with optimal ocular surface health. However, many patients choosing to undergo LASIK may already be exhibiting symptoms associated with dry eye disease. In fact, it may have been those symptoms, especially in conjunction with the use of contact lenses, which led them to seek out the procedure in the first place. Screening patients for dry eye prior to surgery should be a routine part of pre-LASIK procedure. A growing number of studies have highlighted the importance of treating patients with dry eye symptoms in advance of any laser surgery, discovering that preoperative treatment guards against the development of postoperative dry eye symptoms and accelerates visual recovery ⁵. The importance of preoperative treatment of dry eye is especially pronounced when considered alongside the development of postoperative dry eye symptoms. Studies have shown that the vast majority of LASIK patients will experience such symptoms; in one study, approximately 95% of LASIK patients were affected immediately following surgery, with 60% still reporting symptoms one month post-surgery ². Preoperative management of dry eye symptoms in patients already experiencing them, as well as those with risk factors, should be similar to therapies for a dry eye patient not seeking refractive surgery. Depending on the severity of preoperative symptoms,  artificial tears, hot compresses and/or eyelid scrubs, nutritional supplements such as fish oil or Omega-3 fatty acids, cyclosporine and punctal plugs could all be considered ⁵. Even if a patient’s tear production is considered normal, treating dry eye symptoms proactively is an opportunity to prevent those symptoms from occurring or worsening post-surgery. By keeping the ocular surface lubricated, preoperative punctal occlusion therapy may reduce the dependency on artificial tears and actually facilitate epithelial wound healing after surgery. A 2012 study found that patients who received preoperative punctum plugs had milder ocular surface damage, better improved visual recovery, and less postoperative haze one week after LASIK surgery than those who did not ⁶.

Postoperative Dry Eye

As previously noted, post-LASIK dry eye symptoms may be caused by a variety of factors, including, but not limited to, corneal nerve damage, loss of goblet cells, inflammation, and surgically induced changes in corneal shape. Therefore, postoperative treatment typically focuses on maintaining eye moisture, improving the tear film, reducing inflammation and increasing the quality and quantity of tears produced in reaction to those potential surgical outcomes. Most postoperative dry eye symptoms can be properly treated using the same conventional therapies used to treat preoperative dry eye as discussed above. Focusing on anti-inflammation post-surgery with topical corticosteroids for short-term use or cyclosporine has been reported to be an effective treatment for inflammation in patients with chronic dry eyes. In fact, cyclosporine treatment has been shown to not only reduce inflammation, but also increase goblet cell numbers, tackling two postoperative symptoms at once ⁷. In addition to the deployment of these standard dry eye treatments, punctal plugs are considered a safe and effective short- to long-term option for LASIK patients. Postoperative punctal occlusion lengthens the amount of time that tears remain on the ocular surface and may eliminate the need for artificial tears. The use of punctum plugs—alone or in conjunction with cyclosporine—has shown an increase in tear volume and goblet cell density that may produce superior postoperative results. Studies have found that including punctal occlusion in postoperative dry eye treatments produced the most rapid improvements in ocular surface wetness ⁷.

Each part of the LASIK procedure can affect not only the visual result, but postoperative side effects. While dry eye symptoms are common in post-LASIK patients, the good news is that with conventional therapies, these symptoms typically improve as the eye heals—within 6 to 12 months after surgery—and don’t appear to effect refractive outcomes ².

Citations:

1. Brian S. Boxer Wachler, MD. ”LASIK Risks and Complications.” All About Vision. 2016.
2. RM Shtein. ”Post-LASIK dry eye.” Expert Rev Ophthalmol.. 2011.
3. Marcella Q. Salomão MD, Renato Ambrósio, Jr, MD, PhD, Steven E. Wilson, MD. ”Dry eye associate with laser in situ keratomileusis: Mechanical microkeratome versus femtosecond laser..” Journal of Cataract Refractive Surgery.. 2014.
4. Gregory R. Nettune, MD, MPH and Stephen C. Pflugfelder, MD. ”Post-LASIK Tear Dysfunction and Dysesthesia..” The Ocular Surface.. 2013.
5. Victor Y. Chang, MD, and Terry Kim, MD. ”Dry Eye Syndrome and Cataract and Refractive Surgery..” Advanced Ocular Care.. 2010.
6. Kojima T, Watabe T, Nakamura T, Ichikawa K, Satoh Y. ”Effects of preoperative punctal plug treatment on visual function and wound healing in laser epithelial keratomileusis..” J Refract Surg.. 2011;27(12):894-898.
7. Guilherme G. Quinto, MD, Walter Camacho, MD, and Ashley Behrens, MD. ”Postrefractive surgery dry eye.” Current Opinion in Ophthalmology.. 2008.