Eyeworld

EW REFRACTIVE SURGERY 108 September 2015 by Maxine Lipner EyeWorld Senior Contributing Writer "They actually had underlying dry eye disease but it was subclinical to the point that we didn't detect it prior to surgery," he said. "Having LASIK brings it out and tells us that these patients have an underlying dry eye that we want to treat." With such treatment, not only will their vision fluctuation and other symp- toms typically improve, but there is also evidence that treatment with medications like cyclosporine can halt disease progression and keep them from becoming worse later in life, Dr. Wilson said. "In some ways catching it after refractive surgery may be fortuitous for those patients because they'll get earlier treatment and I think are less likely to progress to more severe dry eye later in life," he said. Overall, Dr. Wilson said that dry eye isn't the barrier that it once was to refractive surgery. "Most patients with proper diagnosis and treatment can go on to become good candi- dates for the surgery," he said. EW Editors' note: Dr. Wilson has financial interests with Allergan. Contact information Wilson: WILSONS4@ccf.org underwent refractive surgery. Of these patients, 28 ultimately un- derwent LASIK, while 4 were slated for PRK, he reported. "I think the key result is that there is a large population of patients with dry eyes that can be successfully treated with LASIK or PRK if you pretreat them," Dr. Wilson said. However, it's important not to give up too early, he stressed, pointing out that in the Restasis phase 3 clinical trial, in many cases a significant effect was not seen until 3, 4, or 5 months after treatment was started. Treating preclinical patients Meanwhile, there were some pa- tients who showed no signs of dry eye preoperatively who went on to develop LASIK-induced neurotrophic epitheliopathy postoperatively. "Cy- closporine is again very successful in treating those patients and lessen- ing their symptoms and signs," Dr. Wilson said. Investigators found that just 5 eyes continued to be dry post- operatively after 12 months or more of cyclosporine treatment. "Cyclosporine is very success- ful in treating those patients and lessening their symptoms and signs." He said refractive surgery is a kind of stress test in these patients. Treating dry eye LASIK and PRK patients W hile patients with dry eye may not seem optimal for refractive surgery, with appro- priate pretreatment they may ultimately do well, accord- ing to Steven E. Wilson, MD, pro- fessor of ophthalmology, Cole Eye Institute, Cleveland Clinic. Study results published in the Journal of Cataract & Refractive Surgery indicat- ed that for such patients undergoing PRK and LASIK, topical cyclospo- rine treatment can help to improve the eye preoperatively so they can successfully undergo PRK or LASIK, he reported. Dr. Wilson said it's very com- mon for dry eye patients to appear for a screening, with many wanting to pursue refractive surgery because they can no longer comfortably Beyond untouchable refractive status D ry eye in refractive surgery is one of the few remaining enigmas that we still face on a daily basis. Not only is this the case for post-surgical management, but pre-surgical considerations abound. Should we treat patients with significant dry eye, and if so, how should we best prepare them for surgery? Steven E. Wilson, MD, and team have helped unravel some of the mystery in their study of more than 500 patients who underwent laser vision correc- tion. The use of topical cyclosporine before surgery in those patients with pre-existing dry eye and those with postoperative dry eye was found to be very effective. I completely agree with Dr. Wilson that there are many patients who could successfully undergo LASIK with the proper pretreat- ment, and he has demonstrated one such approach. The barriers to treating patients with significant dry eye are slowly coming down as we gain a better understanding of how to effectively manage them before surgery. Steven C. Schallhorn, MD, refractive editor Some patients who show no signs of dry eye preoperatively can develop LASIK-induced neurotrophic epitheliopathy postoperatively. Source: Steven E. Wilson, MD wear their contact lenses. "It's a much higher proportion of people in the refractive surgery screening population than in the population at large," he said. Considering surface optimization Armed with the idea that it might be possible to ready dry eye patients for refractive surgery with Restasis (cyclosporine, Allergan, Dublin, Ireland), investigators launched the study on this. "Our clinical impres- sion has always been that cyclospo- rine can help prepare patients for refractive surgery who didn't used to be candidates because their dry eye was to the point that we wouldn't consider them candidates," Dr. Wilson said. "Now that cyclosporine is available, many of those patients with pretreatment can become candidates at least for PRK if not LASIK." Of the 2 refractive procedures, Dr. Wilson finds LASIK can be less forgiving in dry eye patients. "The difference to me is that when you do LASIK, you cut the nerves that are involved in tear production and corneal sensation all the way out in the periphery, and it takes them 6 to 8 months to grow back; in PRK you just ablate the nerve endings, and I think they can regenerate much faster," he explained. He described the study as a large one that initially included 1,056 consecutive patients screened to undergo refractive surgery. Of these patients, 81 were diagnosed with dry eye, with 55 considered potential candidates for refractive surgery, Dr. Wilson reported. "Most of those we could effectively pretreat primar- ily with cyclosporine, but we also allowed them to use non-preserved artificial tears and ointments," he said, adding that on rare occasions punctal plugs were also used. Patients were followed for sever- al months and if all of their corneal staining cleared, typically as long as their Schirmer's reading was great- er than 5, they were deemed to be refractive surgery candidates. After surface optimization for a mean of 3.2 months, 32 patients who had previously been described as having moderate dry eyes Refractive editor's corner of the world

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