Case report

Management of dry-eye syndrome after laser in situ keratomileusis with a vectored thermal pulsation system

Petzold, Gernot MD*; Bedi, Raman MD; Blackie, Caroline A. OD, PhD

Author Information
Journal of Cataract and Refractive Surgery Online Case Reports: April 2016 - Volume 4 - Issue 2 - p 34-37
doi: 10.1016/j.jcro.2016.02.005
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Abstract

Laser in situ keratomileusis (LASIK) is the most common refractive surgical procedure. The efficiency rate is high, with more than 90% of patients achieving 20/25 or better corrected distance visual acuity (CDVA) without glasses.1 The procedure is documented to be safe, but several post-LASIK complications may occur; dry-eye syndrome is the most frequent.2,3 Although 95% of patients may experience dry-eye symptoms immediately after LASIK,4 approximately 20% develop chronic dry-eye symptoms that persist beyond 6 months.3 Despite the identification of several risk factors for post-LASIK dry eye5,6 and attempts to mitigate some of them, post-LASIK dry eye continues to be a major challenge of LASIK.

Multiple theories about the pathophysiology of post-LASIK dry eye have been proposed.1,4 Corneal nerve damage with resultant loss of corneal sensation7–9 is probably the most important. Loss of corneal sensation has been associated with reduced blinking rate, leading to evaporative stress and lipid-deficiency dry eye secondary to meibomian gland dysfunction.10–12 Additionally, LASIK-induced change in corneal shape may affect the relationship between the eyelids and the ocular surface and lead to abnormal tear distribution during blinking.4,13,14

The conventional therapy for post-LASIK dry eye is lubricating the ocular surface adequately with artificial tears, preserving tears using punctual plugs, and treating ocular surface inflammation. However, lubricants offer only temporary relief,15,16 punctual plugs are not without complications,16,17 and long-term use of topical steroids is not sustainable.4

Recently, a new treatment device, the Lipiflow vectored thermal pulsation system (Tearscience), has been reported to be safe and effective for treating evaporative dry eye with meibomian gland dysfunction.18–22 We describe a case of post-LASIK dry eye with severe symptoms recalcitrant to conventional post-LASIK dry-eye therapy that was successfully treated using vectored thermal pulsation therapy.

CASE REPORT

A 43-year-old woman presented to the author (G.P.) with severe dry-eye symptoms, which she reportedly had developed after bilateral LASIK 4 years earlier. Concomitantly, the patient had Hashimoto thyroiditis. A careful ophthalmic examination was done to look for ocular involvement of Hashimoto thyroiditis: signs of proptosis, soft tissue swelling, decreased eye muscle function, lagophthalmos or upper eyelid retraction; however, the patient had none of these signs. Therefore, post-LASIK dry eye was diagnosed.

The symptoms of dry eye included discomfort, irritation, foreign-body sensation, dryness and severe pain in both eyes. The symptoms negatively affected the patient's daily activities. Her treatment included instillation of hydroxypropyl methylcellulose (Artelac 3.2 mg/mL, eyedrop solution) every 15 minutes (up to 64 times a day), warm compresses once a day during waking hours, and carbomers 0.2% gel (Artelac nighttime gel) at night. The patient did not report using other therapies during the 4 years prior to seeking treatment.

The CDVA (decimal) was 0.63 in the right eye and 0.8 in the left eye. The ocular surface examination showed a corneal fluorescein staining grade of 2 to 3 in the right eye and 1 in the left eye (National Eye Institute/Industry Workshop scoring system); the tear breakup time (TBUT) was less than 5 seconds in both eyes. Meibomian gland function was evaluated using standardized diagnostic meibomian gland expression across the entire lower eyelid; only 8 meibomian glands in the right lower lid and 10 in the left lower lid yielded liquid secretions. The score of the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire was 20. The tear-film lipid layer thickness was measured using the ocular surface interferometer. Prior to vectored thermal pulsation therapy, it was 33 nm ± 5 (SD) in the right eye (Figure 1) and 31 ± 5 nm in the left eye.

Figure 1.
Figure 1.:
Improvement in the lipid layer thickness shown in pretreatment (left) and posttreatment (right) tear-film interferometry of the right eye.

Each eye was treated once for 12 minutes with vectored thermal pulsation therapy. The key clinical findings for all visits are shown in Table 1. One month after treatment, there was improvement in the number of meibomian glands yielding liquid secretions, the TBUT, the lipid layer thickness, and the SPEED score. At the last follow-up visit (18 months), the lipid layer thickness had increased further in both eyes (Figure 1).

Table 1
Table 1:
Clinical results from the pretreatment visit to the 18-month posttreatment visit.

DISCUSSION

The treatment of post-LASIK dry eye includes adequate lubrication of the ocular surface with artificial tears and/or cyclosporine eyedrops to treat the inflammatory component of dry eyes.4 However, despite the aggressive use of lubricants (instilled several times an hour) in our case, there was limited improvement in the dry-eye signs and symptoms.

The use of vectored thermal pulsation therapy for meibomian gland dysfunction in this patient was effective in increasing the number of functional meibomian glands, with a corresponding increase in lipid layer thickness, an increase in TBUT time, and a decrease in symptoms. At the 1-month visit, there was improvement in the patient's symptoms, with a decrease in the pretreatment SPEED score from 20 to 7. Although the SPEED score increased by a couple of points in subsequent follow-up visits, overall the patient was satisfied with the treatment and did not feel the need for retreatment. Continued improvement in the ocular surface health was also apparent from the increased TBUT and absence of corneal staining at 6 and 18 months.

The safety of the vectored thermal pulsation device is well established19–22; however, there may be apprehension regarding flap dislocation with the use of the vectored thermal pulsation device in post-LASIK eyes. It is important to note that the device contains a scleral shell and thus is structured to vault the cornea, resting on the scleral portion of the eye only. The cornea remains untouched by the device even with rotation of the eye; therefore, the risk for flap dislocation with the use of the vectored thermal pulsation device would be minimal to none. However, inserting and removing the device should be done carefully to prevent contact of the device with the cornea.

Laser in situ keratomileusis may be the tipping point for subclinical forms of dry eye that become manifest after LASIK, highlighting the need for a thorough pre-LASIK ocular surface evaluation.23 Contact lens users electing to have LASIK may not present with significant dry eye but may have diagnosable and treatable nonobvious meibomian gland dysfunction.24,25 Because meibomian gland dysfunction is understood to be the leading cause of dry eye,26 detailed evaluation of meibomian gland function and structure during any pre-LASIK workup is arguably advisable. As it is known that aggressive pre-LASIK treatment of dry-eye syndrome reduces the frequency and severity of post-LASIK dry eye,16,27 comprehensive treatment of meibomian gland dysfunction,28 the leading cause of dry eye, should also be considered. Treatment of meibomian gland dysfunction before cataract surgery has been shown to improve ocular comfort after cataract refractive surgery relative to untreated controls.A

The increase in meibomian gland function after treatment was sufficient to reduce dry-eye symptoms, stabilize the tear film, improve visual acuity, and reduce the ocular surface staining to zero in this patient with severe refractory post-LASIK dry eye. The improvement was maintained, and no retreatment was needed up to 18 months after vectored thermal pulsation therapy. Future studies involving a series of patients with post-LASIK dry eye may validate the efficacy of vectored thermal pulsation therapy.

REFERENCES

1. De Paiva CS, Chen Z, Koch DD, Hamill MB, Manuel FK, Hassan SS, Wilhelmus KR, Pflugfelder SC. The incidence and risk factors for developing dry eye after myopic LASIK. Am J Ophthalmol 2006; 141:438-445.
2. Melki SA, Azar DT. LASIK complications: etiology, management, and prevention. Surv Ophthalmol 2001; 46:95-116.
3. Shoja MR, Besharati MR. Dry eye after LASIK for myopia: incidence and risk factors. Eur J Ophthalmol 2007; 17:1-6. Available at: http://medlib.yu.ac.kr/eur_j_oph/ejo_pdf/2007_17_1-6.pdf. Accessed February 9, 2016.
4. Shtein RM. Post-LASIK dry eye. Expert Rev Ophthalmol 2011; 6:575-582. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235707/pdf/nihms337785.pdf. Accessed February 9, 2016.
5. Donnenfeld ED, Solomon K, Perry HD, Doshi SJ, Ehrenhaus M, Solomon R, Biser S. The effect of hinge position on corneal sensation and dry eye after LASIK. Ophthalmology 2003; 110:1023-1029. discussion by CJ Rapuano, 1029-1030.
6. Turu L, Alexandrescu C, Stana D, Tudosescu R. Dry eye disease after LASIK. J Med Life 2012; 5:82-84. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307085/pdf/JMedLife-05-82.pdf. Accessed February 9, 2016.
7. Benitez-del-Castillo JM, del Rio T, Iradier T, Hernández JL, Castillo A, Garcia-Sanchez J. Decrease in tear secretion and corneal sensitivity after laser in situ keratomileusis. Cornea 2001; 20:30-32.
8. Linna TU, Vesaluoma MH, Pérez-Santonja JJ, Petroll WM, Alió JL, Tervo TMT. Effect of myopic LASIK on corneal sensitivity and morphology of subbasal nerves. Invest Ophthalmol Vis Sci 2000; 41:393-397. Available at: http://iovs.arvojournals.org/article.aspx?articleid=2199874. Accessed February 9, 2016.
9. Nassaralla BA, McLeod SD, Nassaralla JJ Jr. Effect of myopic LASIK on human corneal sensitivity. Ophthalmology 2003; 110:497-502.
10. Kawashima M, Tsubota K. Tear lipid layer deficiency associated with incomplete blinking: a case report. BMC Ophthalmol 2013; 13:34. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3737109/pdf/1471-2415-13-34.pdf. Accessed February 9, 2016.
11. McMonnies CW. Incomplete blinking: exposure keratopathy, lid wiper epitheliopathy, dry eye, refractive surgery, and dry contact lenses. Cont Lens Anterior Eye 2007; 30:37-51.
12. Suhalim JL, Parfitt GJ, Xie Y, De Paiva CS, Pflugfelder SC, Shah TN, Potma EO, Brown DJ, Jester JV. Effect of desiccating stress on mouse meibomian gland function. Ocul Surf 2014; 12:59-68. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3896889/pdf/nihms533186.pdf. Accessed February 9, 2016.
13. Lee JB, Ryu CH, Kim J-H, Kim EK, Kim HB. Comparison of tear secretion and tear film instability after photorefractive keratectomy and laser in situ keratomileusis. J Cataract Refract Surg 2000; 26:1326-1331.
14. Yu EYW, Leung A, Rao S, Lam DSC. Effect of laser in situ keratomileusis on tear stability. Ophthalmology 2000; 107:2131-2135.
15. Stern ME, Beuerman RW, Pflugfelder SC. The normal tear film and ocular surface. In: Pflugfelder SC, Beuerman RW, Stern ME, eds, Dry Eye and Ocular Surface Disorders. Boca Raton, FL, CRC Press, 2004; 41-62.
16. Salib GM, McDonald MB, Smolek M. Safety and efficacy of cyclosporine 0.05% drops versus unpreserved artificial tears in dry-eye patients having laser in situ keratomileusis. J Cataract Refract Surg 2006; 32:772-778.
17. Balaram M, Schaumberg DA, Dana MR. Efficacy and tolerability outcomes after punctal occlusion with silicone plugs in dry eye syndrome. Am J Ophthalmol 2001; 131:30-36.
18. Blackie CA, Carlson AN, Korb DR. Treatment for meibomian gland dysfunction and dry eye symptoms with a single-dose vectored thermal pulsation: a review. Curr Opin Ophthalmol 2015; 26:306-313.
19. Friedland BR, Fleming CP, Blackie CA, Korb DR. A novel thermodynamic treatment for meibomian gland dysfunction. Curr Eye Res 2011; 36:79-87.
20. Greiner JV. A single LipiFlow® thermal pulsation system treatment improves meibomian gland function and reduces dry eye symptoms for 9 months. Curr Eye Res 2012; 37:272-278.
21. Greiner JV. Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment. Clin Experiment Ophthalmol 2013; 41:524-530.
22. Lane SS, DuBiner HB, Epstein RJ, Ernest PH, Greiner JV, Hardten DR, Holland EJ, Lemp MA, McDonald JE II, Silbert DI, Blackie CA, Stevens CA, Bedi R. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea 2012; 31:396-404.
23. Durrie D, Stahl J. A randomized clinical evaluation of the safety of Systane® Lubricant Eye Drops for the relief of dry eye symptoms following LASIK refractive surgery. Clin Ophthalmol 2008; 2:973-979. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699815/pdf/co-2-973.pdf. Accessed February 9, 2016.
24. Blackie CA, Korb DR, Knop E, Bedi R, Knop N, Holland EJ. Nonobvious obstructive meibomian gland dysfunction. Cornea 2010; 29:1333-1345.
25. Korb DR, Henriquez AS. Meibomian gland dysfunction and contact lens intolerance. J Am Optom Assoc 1980; 51:243-251.
26. Nichols KK, Foulks GN, Bron AJ, Glasgow BJ, Dogru M, Tsubota K, Lemp MA, Sullivan DA. The international workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci 2011; 52:1922-1929. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072157/pdf/z7g1922.pdf. Accessed February 9, 2016.
27. Rosenfeld SI. Evaluation and management of post-LASIK dry eye syndrome. Int Ophthalmol Clin 2010; 50:191-199.
28. Geerling G, Tauber J, Baudouin C, Goto E, Matsumoto Y, O'Brien T, Rolando M, Tsubota K, Nichols KK. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci 2011; 52:2050-2064. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072163/pdf/z7g2050.pdf. Accessed February 9, 2016.

OTHER CITED MATERIAL

A. Jackson MA, “Evaluation of Thermal Pulsation System Treatment for Meibomian Gland Dysfunction in Cataract Surgery Patients,” presented at the ASCRS Symposium on Cataract, IOL, and Refractive Surgery, San Diego, California, USA, April 2015. Abstract available at: https://ascrs.confex.com/ascrs/15am/webprogram/Paper14760.html. Accessed February 9, 2016
© 2016 by Lippincott Williams & Wilkins, Inc.
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