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Journal of Medicine and Life Vol. 5, Issue 1, January‐March 2012, pp.

82‐84  

Dry eye disease after LASIK


Ţuru L*, Alexandrescu C**, Stana D***, Tudosescu R***
* VISIONCLINIC, Bucharest
**’’Carol Davila’’ University of Medicine and Pharmacy, Bucharest
***Scientific Resercher, Ophtalmology Clinic, University Emergency Hospital Bucharest

Correspondence to: Laura Ţuru, Attending physician


Visionclinic, 2B Marasesti Street, Carol Park Residence Complex, District 4, Bucharest
Phone: (021)-413.11.35; E-mail: info@visionclinic.ro

Received: November 19th, 2011 – Accepted: January 14th, 2012

Abstract
LASIK is a surgical tehnique for the correction of refractive errors (myopia, hyperopia, astygmatism). It results in a reshape of the
cornea with ocular surface and especially tear film disease. It is a cause for a iatrogenic dry eye syndrome. Neurogenic and
inflamatory theory explain this disease. The main therapy of dry eye is the replacement with artificial tears.

Keywords: LASIK, lacrimal film, dry eye disease, artificial tears

The refractive surgery became more important in quantity or quality of the tears [3]. The tear film has a
the last years also in our country. This type of surgery defensive role (the protection of the ocular surface) and a
aimes especially young people, fully active who want to refractive role (the first ocular diopter at the air – cornea
improve their quality of life and through this procedure not surface). It has 3 layers: lipid, aqueous and mucuous. Any
to depend on glasses or contact lenses. One technique disturbance in the composition of one of the layers can
used in refractive surgery on the cornea is the LASIK lead to ocular dryness.
procedure. In order to have postoperative results satisfying
But any action on the body results in a reaction for the physician and for the pacient, it is required to have
on its part, meaning that the „polishing” of the cornea will a good selection of the cases which can benefit from this
determine a local complex ocular response - the dry eye. procedure and to perform tests and preoperative specific
measurements.
The LASIK surgery (laser in situ keratomileusis)
represents the use of a special type of laser (excimer  Slit-lamp examination of the ocular surface with
laser) under a corneal flap (in situ) in order to reshape the the assesment of the lacrimal meniscus,
cornea (keratomileusis) [1]. The surgical procedure LIPCOF(Lid Parallel Conjunctival Folds), a
begins with the creation of a thin flap with a nasal or careful examination of the eyelid margin and of
superior hinge using a microkeratome. After the reflection
the meibomian glands [4]
of the flap, the corneal tissue will be ablated with the
excimer laser using a protocol specific for each pacient.  Schirmer test
The flap is repositioned and a contact lens can be used  TFBUT (Tear Fluorescein Breakup Time)
24 hours postoperatively for protection. Through this  The corneal map using the corneal topography
technique refractive errors( myopia – 8 D, hyperopia +5 D, (the follow-up of the tear film in dynamics)
astigmatism 5 D) can be corrected depending on the  Corneal sensibility Analysis (Ocular Response
thickness of the cornea(pachymetry) [2]. The pacients Analyzer - ORA)
older than 21 years with a stable refraction (the same
values of the diopters) in the last 2 years may benefit from The ocular surface and the lacrimal gland work
this procedure. together as a functional unit for the production and
This type of surgery influences the ocular distribution of the tears. The sensitive nerves from the
surface and the tear film. corneal epithelium and stroma are the triggers for blinking
through which the tears are spread on the ocular surface
The dry eye syndrome is a multifactorial and after that the used tears are pumped in the
disease of the ocular surface caused by an inadequate nasolacrimal duct.
Journal of Medicine and Life Vol. 5, Issue 1, January‐March 2012 

The mechanism for the dry eye syndrome post The symptoms vary from discreet ocular
LASIK can be explained by 2 theories : neurogenic and discomfort, foreign body sensation, burning sensation.
inflamatory, chained in a vicious circle [5]. They tend to apear towards the end of the day and are
The neurogenic theory The surgical destruction emphasized by the environmental factors, requiring the
(microkeratome, stromal ablation) of the nerve enndings frequent use of ocular lubricants. What is typical is the
from the subepithelial plexus produces hypoaestesia with need to blink more often in ordet to clarify the image, the
a decrease in the stimulation of the lacrimal gland pacients feeling a real discomfort impairing the quality of
secretion, thus a aqueous lacrimal deficiency. Also a vision.
denervated cornea determines a drop in the blink rate.
Thereby the ocular surface is exposed for a longer period The treatment after LASIK surgery consists of
of time increasing the evaporation of the tears. All of 2 types of eye drops adminstered topically: a set
these lead to a low lacrimal clearance. combination between an antibiotic and cortisone for 2
The inflamatory theory A corneal aggression, weeks and preservative – free artificial tears for minimum
even iatrogenic (LASIK surgery) increases the production 1 month.
of pro-inflammatory citokines leading to the release of When the pacients suffer from ocular dryness,
inflammatory mediators which will exacerbate the corneal the treatment with lacrimal replacement therapy is
nerves lesions. It is described a neurotrophic extended even up to 1 year, avoiding formulas containing
epitheliopathy with an incidence of approximately 4% preservatives (cumulative toxic effect).
between 1 and 3 months postoperatively [6]. Through The perfect artificial tear does not exist because
confocal microscopy determinations, it was established it does not have all the ingredients which can be found in
that post LASIK the number of stromal nerve fibers the natural tears. There is not a type of product that can
decreases with 90%. One year after the surgery , the treat all the persons. The ideal formula should fulfill
measurements have reached 50% nerve fibers compared requirements such as:
with the preoperative ones.  A composition similar to that of the natural
However there are studies showing corneal tears(helps with tha healing process)
sensibility comeback at 6 months after the surgery by  No preservatives(minimal toxic effect)
comparing preoperatory and postoperatory corneal  To be stable on the ocular surface (fewer
histeresis (CH) measured with ORA(Ocular Response adminstrations)
Analyser Reichert) [7].  Not to cloud the vision (not to disrupt the daily
Most of the pacients will develop ocular dryness activity)
in the first 3-6 months after the surgery, considered The artificial tears [9] may contain:
„transient”.  high viscosity agents
Surgical risk factors involved in the development  electrolites
of the postoperative dry eye syndrome are related to:  solutions to maintain the ocular tonicity(NaCl,
 Hinge (smaller width, superior position – KCl)
sectioning of the nerve fibers from the nasal and  agents for adjusting pH, ideally 7.3
temporal subepithelial plexus )
 agents which lenghten the retention time on the
 Flap (a large diameter, thicker, done eye
mechanically or with the femtosecond laser [8])
 preservatives for maintaining the solution’s
 Larger ablation ( for the pacients with higher sterility (preferably without)
diopters) The preservatives are used to prevent the bacterial
Other risk factors for the development of dry eye contamination of the eye drops, thus having sterile
syndrome post LASIK are: products. The most widely used is Benzalkonium Chloride
 Female sex BAK. The presevatives’ side effects on the ocular surface
 Smoking are visible on the tear film, conjunctiva and cornea.
 Moderate or large refractive errors/ the size of Because of their detergent properties, they dissolve the
the ablation tear film’s lipids which leads to its instability, to increased
 Low corneal sensibility evaporation, thus ocular dryness. On the conjunctiva, the
 Diseases of the ocular surface(chronic preservatives cause the goblet cells’ destruction, altering
seborrheic blepharitis) the tear film’s composition. They induce the microvili
 Preoperative dry eye symptoms subjectively destruction on the cornea and ruptures in the tight
described by the pacients jonctions, thus the tearing of the epithelial barrier. This
 Environmental factors(air conditioning, pollution, increases the cornea’s permeability, but it also slows the
wind) healing process. Therefore, the polytherapy often does
 The use of computers(long periods of watching more harm than good.
the computer) If the simptoms do not improve with lacrimal
substitutes and their frequent adminstration becomes a
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Journal of Medicine and Life Vol. 5, Issue 1, January‐March 2012 

discomfort, the lacrimal puncta may be temporarily detailed consultaltion, an accurate information of the
occluded with devices called „plugs”. patient who will undergo refractive surgery. Most of the
pacients have ocular dryness in the first months after the
surgery, but that can be managed through treatment and
Conclusions the education of the patient. But sometimes it can create
a genuine ocular discomfort with a decrease in the quality
The dry eye syndrome after LASIK surgery is a
of life, requiring a replacement therapy with artificial tears
reality, a consequence of the direct damage on the ocular
for a longer period of time (months, 1 year).
surface, with the disturbance on the tear film forming
mechanisms. That is why it is necessary to have a

References

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ophthalmology. Marieta Dumitrache; 6. Tseng SCG. Does Post-LASIK Dry realizat mecanic. J Cataract Refract.
2008, 1-35 Eye Syndrome Really Exist?. Journal Surg. 2009.
3. The Ocular Surface Journal, Report Refractive Surgery. 2004; 82-84. 9. Frank J. Holly, The Preocular tear
of the International Dry Eye 7. Chen S, Wang J. Changes in ocular Film in Health, Disease and Contact
Workshop (DEWS), aprilie 2007. response analyzer parameters after Lense Wear, 1986.
4. American Academy of LASIK. Journal Refractive Surgery.
Ophthalmology, External Disease 2010 Apr;26(4):279-88.
and Cornea, 2009.

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