Eyeworld

this to twice a day for an addition- al 2 weeks. He recommends use of Restasis, as well as artificial tears. "We're also much more aggressive with punctal plugs with LASIK," Dr. Donnenfeld said. "A lot of the dry eye with LASIK is not inflammato- ry—it is actually mechanical due to the severing of the corneal nerves." This makes preserving the patient's own tears effective, he said, so he uses the collagen plugs from Odyssey Medical (Waltham, Mass.) in this situation. "The recent [FDA] PROWL studies showed that dry eye is very common for at least 3 months after surgery, and these plugs last 3 to 6 months," Dr. Donnenfeld said. "So while the dry eye is resolving, the plugs are there, and when the corneal sensation returns, the plugs are gone." For more on the PROWL studies and results, see the "Refractive edi- tor's corner of the world" column on page 96. Intraoperatively in LASIK cases involving dry eye disease, Dr. Donnenfeld will make flaps as small as possible and is cognizant of hinge placement. "We know, for example, that a nasal hinge is a bit better than a superior hinge," he said, adding that it is even more important to increase the width of the hinge and make them thin. In addition, he pointed out that a reverse side cut provides better nerve apposition. Dr. Trattler stressed the im- portance of being mindful not to induce a corneal abrasion intraoper- atively. "Patients with dry eye who experience a corneal abrasion may require a few days for the abrasion to completely heal," Dr. Trattler said. Postop treatment With prompt healing in mind in PRK cases, Dr. Donnenfeld moves aggressively postoperatively. "I want to optimize healing as quickly as possible, and non-healing PRK is a refractive emergency because it in- creases the risk of not only infection but also of haze," he said. "Sometimes for a short time I'll use amniotic grafts to promote healing," Dr. Donnenfeld said. He also relies on medications postop. "We go with a transiently preserved tear using unit doses for the first 2 weeks," he said. He gives the patient a regimen of tears every 3 hours. He will commonly continue Restasis on these patients for 3 months and sometimes will continue the steroids postoperatively as well. Dr. Devgan also emphasized the need for punctal plugs in these pa- tients and the need to use preserva- tive-free artificial tears. Some of the possibilities Dr. Devgan considers include Systane (Alcon, Fort Worth, Texas), Soothe (Bausch + Lomb, B+L, Bridgewater, N.J.), Refresh (Allergan), and Optive (Allergan). For those with severe dry eye, he finds that typical tears may not be sufficient. "Sometimes you get to the point where you have to put in even thicker agents—some of these more viscous tears, gel-type tears, or even ointments," Dr. Devgan said. Likewise, Dr. Trattler recom- mended the use of punctal plugs to maximize tear film quantity. His patients also receive a course of topical steroids. In addition, he said Restasis use is key because over time it increases tear production and goblet cell density. Overall, Dr. Donnenfeld finds that aggressive management of dry eye, especially the preoperative man- agement and treatment, improves refractive results. "In my personal view, one of the hallmarks of a good refractive surgeon is the appropriate manage- ment of dry eye," he said. EW Editors' note: Dr. Devgan has finan- cial interests with Alcon and B+L. Dr. Donnenfeld has financial interests with Allergan, Alcon, TearScience, TearLab, Rapid Pathogen Screening (RPS, Saraso- ta, Fla.), Abbott Medical Optics (Abbott Park, Ill.), and B+L. Dr. Trattler has financial interests with Abbott Medical Optics, Alcon, Allergan, B+L, and RPS. Contact information Devgan: Devgan@gmail.com Donnenfeld: ericdonnenfeld@gmail.com Trattler: wtrattler@gmail.com Uniform epithelium removal in only 5 - 7 seconds Corneal Xlinking, PRK Advanced Surface Ablation Improved clinical outcomes of CXL and PRK with Amoils Epithelial Scrubber T. 800.461.1200 | www.innovativexcimer.com Minimize total procedure time Avoid alcohol damage to surrounding tissue No need for subsequent scraping ASCRS, booth 3037 visit us at

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