Eyeworld

EW REFRACTIVE 60 June 2017 by Eric Donnenfeld, MD LASIK patients benefit from plugs at the time of surgery Symptom questionnaire scores, corneal staining, and osmolarity improve with punctal occlusion W e know that LASIK causes transient, neurotrophic dry eye. This can result in superficial punctate keratitis and loss of visual quality during the first few months after surgery. This improves over time and by 3 to 6 months is generally completely resolved. Because of the accompanying loss of corneal sensation while the corneal nerves regenerate, patients may not com- plain of dryness, but fluctuating vision and symptoms like glare and halo that are related to the ocular surface problems may affect their satisfaction with the procedure and surgeon. Refractive surgeons should strive to improve the ocular surface before surgery to make sure the preopera- tive measurements are accurate and the eye will heal well. In addition, I think that placing a temporary punctal plug at the time of LASIK surgery could be an excellent solu- tion to this transient, neurotrophic dry eye. I set out to objectively test in a prospective study whether tem- porary punctal occlusion could im- prove the ocular surface quality and reduce symptoms following LASIK. Study design Forty patients undergoing bilateral simultaneous LASIK at my practice, Ophthalmic Consultants of Long Island, New York, were enrolled. Patients were not excluded for prior contact lens use or for prior history or treatment of dry eye or meibo- mian gland dysfunction (MGD). Exclusion criteria included those undergoing monocular LASIK and those with ocular surface irregu- larities such as pinguecula, current punctal occlusion, lacrimal drainage dysfunction, and use of any topical medications other than artificial tears or cyclosporine A (Restasis, Allergan, Dublin, Ireland). Subjects were randomized to the treatment group or the control group, with 20 patients in each. All eyes underwent femtosecond laser flap creation and wavefront-guided LASIK, with the same flap param- Figure 1: The Extend absorbable plug increased the odds of improving the OSDI score after surgery by nearly six-fold (p<0.001). Figure 2: Punctal occlusion significantly influenced ocular surface quality (p=0.005), increasing the odds of improved corneal staining by approximately three-fold. Source (all): Eric Donnenfeld, MD Table 1: Preoperative characteristics were equivalent in both groups except for MMP-9 tear testing, which was more likely to be positive in the control group. Punctal Occlusion Group (n=20) Control Group (n=20) p value Mean age (years) 31.7 33.8 0.467 Gender (male:female) 10:10 8:12 0.525 Median OSDI score 4.5 5.0 0.304 Values below are for right eyes only Mean UCVA 20/137 20/146 0.778 Mean BCVA 20/19 20/19 0.643 Ocular surface grade >0 (%) 15% 20% 0.677 Mean tear osmolarity (mOsmol/L) 292.4 ± 9.67 290.9 ± 8.52 0.606 Mean Schirmer value (mm) 16.75 ± 6.77 17.40 ± 6.19 0.753 Positive MMP-9 test (%) 0 15% 0.036

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