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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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.


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.


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.


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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: Accessed February 9, 2016
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