Thinking of Having LASIK? Be Clear with your Doctor on WHY

20 03 2013

“Have you considered having LASIK because you’re tired of your contact lenses?”  Think about what this popular marketing question is asking.  Are you tired of the inconvenience of taking proper care of your contact lenses or are your eyes tired and fatigued from wearing them all day long?  Are you tired of the discomfort that contact lenses cause you?  These are very different questions and can be the difference of being a good candidate or a poor candidate for surgery.  Let’s look at a patient case after having LASIK over a year ago complaining of significant discomfort which is preventing her from an increasing number of the routines in her daily life.lasik

Lasik 1 year ago.  Current presentation:

Almost a year after having LASIK (she self referred to a local center), this 40+ female was referred to me for complaints related to dry eye.  Her LASIK surgeon had prescribed all forms of over-the-counter eye drops and finally treated her dry eye with Restasis (cyclosporine 0.05%) for 90 days with no improvement in her symptoms in that time.  Her vision was corrected to 20/20 in each eye so what’s the problem right?  I’ve heard many times over the years from various ‘experts’ that developing dry eye after LASIK as being a mild problem and that having to use eye drops for the rest of your life is a small price to pay for 20/20 vision.  This patient would vehemently disagree.

During her consultation with me, it came out that she suffers with atopic dermatitis (eczema) and has since a child.  She is a caucasian female with northern European descent and has auburn hair.  This combination of demographic information and her dermatological history are pearls for why this patient should have been screened more thoroughly prior to having LASIK.  In further discussion as to her motivation for LASIK, she mentioned never being comfortable with any contact lens which caused fatigue and frustration.  Another pearl!

For the doctors reading this article, do you have a differential diagnosis in mind?

On clinical examination, she presented with bilateral epithelial basement membrane dystrophy (EBMD) with right eye being more severe clinically and symptomatically.  Symptom scores using SPEED evaluation were 19 (normal is under 6) and lipid thickness from interferometry was 50 in her right and 75 in her left (normal being above 80).  Eyelid evaluation revealed moderate meibomian gland stasis and anteriorly thickened Marx’s line, which is indicative of progressive lid disease causing evaporative dry eye.  Her tear volume 5mm in the right and 7mm in the left by Schirmer indicating an aqueous component to her dry eye.  She also exhibited mild ocular rosacea with some facial pattern acne.

MDF_LASIKOS

MMP-9 is a particular matrix metalloproteinase  found in high concentrations on  diseased ocular surfaces.  MMP-9 is known to be a catalyzing agent (among others) in ocular inflammation and corneal erosions ( Dursun D, Kim MC, Solomon A, et al, Am J Oph 2001).  At present in Canada, we can’t test for its presence, however it is becoming widely claimed as a hallmark protein  in patients with dry eye disease.  There is some correlation between patients with atopic disease and higher concentrations of MMP-9 on the ocular surface.

From this information, this patient having had symptoms of dry eye without obvious clinical signs of EBMD pre-surgery was convinced that contact lenses were her problem, however the current clinical picture suggests that she was exhibiting symptoms of ocular surface inflammation due to a mixed component dry eye combined with contact lens use.  This patient was better suited for photorefractive keratectomy (PRK) or no surgery at all given the strong likelihood of underlying corneal disease.  A key pearl in her history is the discomfort due to contact lens wear.  She was lead, like a moth to a flame, by clever marketing suggesting that being ‘tired of contact lenses’ made her an excellent LASIK candidate but in fact it was quite the opposite.

All patients considering LASIK should be properly evaluated for the presence of underlying lid disease in addition to seemingly unrelated medical conditions.  Without assessing meibomian gland depth, expression, quality of secretions in addition to anatomical indicators of progressive lid disease like Marx’s line, an important aspect was missing in determining this patients candidacy for LASIK.  It is true, that the body of science pointing to a direct correlation between eczema and corneal dystrophy is small, in my clinical experience I have seen this correlation to be strong.  Add to that an ocular surface with increasing inflammatory proteins due to poor aqueous and lipid content and a traumatic event like LASIK, her present clinical picture now makes sense.

So what can be done? Treatment:

She is currently being treated to minimize MMP-9 with a combination of low-dose doxycycline 50 mg po in addition to topical loteprednol bid 1 month. Oncotic pressure reduction with hypertonic sodium ointment applied at night ( Muro 128 5% Bausch & Lomb) will help on more chronic basis .  Treating the mgd  will have the biggest impact on her symptoms so this patient will undergo LipiFlow OU as manual expression and lid debridement has already been performed with mild improvements to her symptomology.  Maintenance of the lid surface with Cliradex eye wipes has also been added to manage the external inflammation (rosacea) with its active component  4-Terpineol, an organic compound that has demonstrated good efficacy at eradicating demodex as it relates to blepharitis and mgd.  PTK ( phototherapeutic keratectomy) is a more invasive option here which is very effective at recalcitrant erosion cases but our patient opted for more conservative therapies (Sridhar MS, Rapuano CJ, Cosar CB, et al Ophthalmology 2002).

Take home:

So what can be learned from this lesson?  History is key and marketing is clever.  If you’re a patient considering LASIK, do speak with your eye doctor about your reason for wanting surgery and be thorough because buried within your rationale may be a very clear reason as to why you shouldn’t have it done.  If you’re a doctor, be sure to assess for non-obvious MGD or accessories to dry eye and consider that even mild cases will advance given the perfect sequence of events like my patient above.

LASIK is an amazing life changing procedure that is absolutely the right choice for the right patient.  I spent a major part of my career specifically managing complex LASIK cases so by no means am I commenting on the effectiveness of the procedure or on the millions of lives that have been changed for the better from having it done.

Minimizing the impact that dry eye disease can have is, for me, like trivializing depression and the importance of mental health.  Too often are these patients told that ‘it’s in your head’ or to ‘live with it,’ when we know that when left untreated this condition doesn’t get better.  When eye care providers put value in our patients’ symptoms and consider the impact of what many of us take for granted like walking through a mall without your eyes burning, or not being  woke up in the middle of the night with extreme discomfort, we empower them to be honest to take control of their ocular health.  This will inevitably create happier patients.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca

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