The Dry Eye Zone

Rebecca's Blog

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Drying Surgeries

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#1. LASIK: Psst... It's the surgery. Not the surgeon.

One of the most enduring myths of elective vision correction surgery is that as long as you go to the type of surgeon whose name bestows sufficient bragging rights, you'll be fine.

It's a comforting idea.

Feels empowering.

Just not... true.

According to TFOS DEWS II - a massive bible of dry eye created by a 150-strong team of international experts over a three-year period - dry eye from LASIK is intrinsic to the procedure. That means that no matter who you go to, and no matter how good they are; no matter how much you paid, and no matter how many surgeries they have performed; in fact, no matter what claims to fame your surgeon may have, you are still at risk of dry eye just by choosing to do it at all:

However, one of the most emblematic situations is DED [dry eye disease] caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. 
 
TFOS DEWS II Iatrogenic Dry Eye Report (2017, The Ocular Surface)

So take what you want... but be prepared to pay for it. 

Screening, of course, matters too. It's something they didn't do at all in the old days, but learned to incorporate over time. They're doing a better job of it now, though to what end, I don't really know. If screening is cursory, you conveniently don't have dry eye. If screening is average, you might be a little dry but you can use drops after surgery if you have dryness longer than the first few weeks, and plugs and even Restasis if necessary! If you go to a dry eye savvy hotshot, where they tell you your osmolarity and TBUT, they will ply you with drugs before surgery.  The recurring theme is, you are unlikely to be ruled out as a candidate unless you're pretty extreme. Because everyone deserves to have refractive surgery if they so choose.

LASIK is on the wane.

Did you know? This has been going on for well over a decade. But quietly. You don’t see it in the news. The industry certainly don’t want you to know it’s slowly falling out of favor. It's been gradual, and they mostly blame it on our post-recession lack of discretionary income. (That's strange. We can cough up $1600 for Lipiflow and $400-500 a month for Restasis, but they think we can't cough up a few thou for a surgery?)  But for many, many years, many reputable surgeons have been growing disenchanted with LASIK because of dry eye and corneal ectasia - two complications of LASIK that surgical skill does not seem to prevent.

Picture this from the surgeon's perspective: You invest years of training and experience in a specialty field, only to find that no matter how good you get, a certain percentage of your patients will experience a certain set of problems that you cannot prevent. Period.

Surgeons don't like it when they can't improve on a thing. And that’s why many have moved on, or are considering it.

If you're going to do LASIK, or any other eye surgery, or any surgery at all, of course you should go to a good surgeon. That goes without saying. But do not buy into the myth. There is a grand total of zero published studies, to my knowledge, comparing dry eye outcomes between Joe/Josephina Hotshot LASIK Surgeon and Joe/Jo Cheap Local Schmo LASIK surgeons. On the other hand, there’s ample anecdotal evidence amongst the large body of intelligent consumers who got dry eye after having expensive, brag-able LASIK. LASIK dry eye is about the intersection of the nature of what the procedure does the your corneas; your personal risk factors; the idiosyncrasies of your “individual response”; a host of other factors unrelated to the credentials of your own personal particular fellowship-trained, world-famous hotshot LASIK surgeon. From Beverly Hills to Manhattan, there are simply no LASIK surgeons left that have not left a trail of unhappy dry-eyed patients in their wake. You just don't see them. They are not counted in the statistics, because they left their surgeon and found someone who does a better dry job of treating dry eye before the time came for the 6- or 12-month exam and/or follow-up survey.

LASIK predecessors and successors

The funny thing is, one of the first procedures disenchanted surgeons started moving TO is actually a LASIK predecessor: PRK. They packaged it up in more marketing-friendly names, such as LASEK and Epi-LASIK, but it’s still all about surface ablation - that is, no flap. The differences are simply in the details of what they do with the outermost layer of the cornea before and after they do the actual lasering part. And the fact is, PRK had good visual results before LASIK came along, and while it had some issues of its own (such as haze, a euphemism for scarring), complication-wise, none of them were so bad as the worst that LASIK can bring.

So when wavefront technology came along, allowing laser ablations to be customized, the marriage of PRK and wavefront technology started producing results that made many wonder why they were doing LASIK at all, if they could do something where they felt like they had more control over the results. Hence the trend. (Don't get my wrong. I'm really not a fan, except in a lesser-of-evils kind of way.)

In terms of successors, there's not a whole lot out there... really just SMILE (what a name!) and the jury is still out on that one, at least in terms of dry eye. Do you have any idea how many years it was after LASIK became popular before any useful information about dry eye emerged at all? Why should we trust that those promoting a new refractive procedure will go out of their way to figure out the dry eye piece? Their job is to promote, not distract people with pesky complications.

Are you considering LASIK?

Or know someone who is? Here are a few need-to-knows:

  1. Consider a LASIK alternative. No, I’m not going to suggest one. My conscience, LOL! But,,, honestly, if you're hell-bent on surgery, at least consider surface ablation of some kind, if your prescription is within the range of reasonably predictable outcomes. Just remember there's no free lunch. We’re talking, probably better than LASIK in dry eye terms, but not risk free - not by a long shot. 
  2. Don't pin your hopes on the surgeon's reputation, for reasons I explained above.
  3. Ocular surface savvy is the new brag factor. if you are hellbent on having LASIK, be smart about dry eye, not your surgeon's resume. Where they did their fellowship or when they performed their 20,000th procedure is just so stale. It's about YOU and YOUR NEEDS, not the surgeon and his/her ego!
  4. Contact lens intolerant? Start investigating scleral lenses.

About that last... Sclerals is the ULTRA SMART thing to consider before laser eye surgery. If it had been an option back in 2001, I would not have had LASIK and would not be writing this blog post today. I’m glad I’m here, and I have worn scleral lenses for 12 years, and I want to encourage you to consider them as an alternative to surgery.

My generation (I'm 49) have worn soft contacts for decades and become increasingly intolerant - in large part, due to dryness. That makes us extremely vulnerable to the promise of refractive surgery, LASIK or otherwise. Many of us rarely wore glasses, and don’t necessarily have anything against glasses. It’s just that we’re so… used to contacts. 

Scleral lenses are totally different from any other type of contact. No, they are not like a “dry eye friendly” soft contact, or a high water content lens. Scleral lenses are high-tech and hard, but instead of sitting on the cornea (like soft lenses, which suck up moisture, and RGPs, which rub uncomfortably), scleral lenses are BIG. They are shaped like a bowl. You fill them with a preservative free saline and put them on and… they keep the entire covered with that saline all day! The edges go way out on the white of the eye (hence the name, scleral). A wet cornea is a happy, happy cornea.

If you want to learn more about scleral lenses, you might visit the professional body’s website (sclerallens.org) or for a more user-friendly experience, join our Facebook group, My Big Fat Scleral Lens or better yet, one of our regional scleral lens Facebook groups. 

Have you had LASIK, and are considering an “enhancement”?

Please know that lifting your flap to do more lasering could put you at just as much dry eye risk, and quite possibly more, than your original LASIK.

Maybe you didn’t have any significant dry eye issues after your original surgery. But… maybe that was before you went on an antidepressant, or HRT, or beta blocker, or any of the myriad of drug types that make you higher risk for dry eye. The simple fact of aging may be putting you at higher risk. Don’t be lulled by marketing language into taking a “touch-up” surgery for less than it is: invasive eye surgery.

If you’re getting older, bear in mind that the average age for cataract surgery in the US is about 65. When (since these days, it really is more of a "when" than an "if") you have cataract surgery, they will remove and replace your lens, which completely changes the vision equation. Any refractive surgery you undergo between now and then will serve you at most for your distance vision for that gap period. If you’re getting close to the cataract years, it might make more sense to put on some glasses or contacts and just wait awhile. It is also worth considering that refactive eye surgeries make it more difficult for them to accurately calculate the power of the lens implant for cataract surgery, lessening the likelihood of glasses-free vision after cataract surgery unless you get, yes, more cornea surgery on top - like LASIK or "limbal relaxing incisions".

#2 Cataract surgery: the new LASIK?

As far as dry eye goes, that’s definitely what I’ve been feeling the last couple of years.

It used to be an occasional thing. Now it’s a routine. At least every week, a new call from someone whose cataract surgery pushed them over the edge from “a little dry eye” to “DRY EYE”. 

In my opinion, dry eye after eye surgery in general has a lot to do with multiple risk factors, and a confluence of events. So many people go through life with no dry eye symptoms at all but… with issues quietly brewing. A little MGD. A slightly incomplete blink. Maybe a little reduced tear production. Then something happens. They go on a drug that’s new to them. They change jobs to one with more computer use, or they move to a different climate. They get addicted to a new phone. They go into menopause. 

Or they have cataract surgery. 

All of a sudden, the quiet chamber orchestra of easily overlooked signs of dry eye has swelled into a symphony of symptoms. If if you're sure it's the surgery that caused it. It’s not quite that simple, of course! Cataract surgery just pushed you ver the edge.

Preparing for cataract surgery?

If you have any dry eye symptoms, consider getting a referral to a corneal specialist before having cataract surgery. Get a detailed diagnosis. See what you need to do to get your eyes in the best possible shape before surgery. (Does that sound ironic after what I said about LASIK? Don't forget - that's an entirely elective procedure. People get cataract surgery when they're having too much trouble with their vision and no alternatives.

If you have no dry eye symptoms at all, make sure you read the list of symptoms carefully!

If you really have no dry eye symptoms, you should still be given a thorough workup for dry eye before surgery - because many people have clinical signs but don’t experience symptoms! And at cataract surgery "age", dry eye is statistically more likely overall. TFOS DEWS II recommends the usual suspects, getting thoroughly diagnosed and treated before and afterwards.

The bottom line if you already have dry eye and are considering cataract surgery:

  • Get your eyes in the best possible shape before surgery
  • Have a plan for managing discomfort afterwards

#3. Blepharoplasty (eyelid surgeries, including “lid lifts”)

The blepharoplasty facts

Dry eye after blepharoplasty is common. One large study (892 patients) found that 26.5% had dry eye. Why? Poor eyelid closure or altered eyelid function. Dry eye after blepharoplasty can result in the same kind of "disconnect" with your doctor that LASIK does. In LASIK, if your vision meets the mark, you're presumed happy. In blepharoplasty, if your results are good cosmetically, you're presumed happy. But chronic eye pain is a big deal

Blepharoplasty and pain

Among all the things I hear from people who are in extreme eye pain, some of those at the top of the list are blepharoplasty with lid retraction, acoustic neuroma surgery and post LASIK corneal neuropathy. It's not often that bad, thankfully. But serious dry eye after blepharoplasty - serious enough to induce you to travel to specialists and sink a ton of money into every treatment available, including scleral lenses, is for more common than people realize.

OCULOplastic surgeon, NOT plastic surgeon.

If you are having eyelid surgery of any kind, please o not go to a plastic surgeon, no matter how famous they are! Plastic surgeons may have a brilliant understanding of your cosmetic needs but they do NOT understand the lacrimal system and the complex functions of the eyelids. It’s not their specialty. If you are going to invest in your eyelids,  go to a specialist. Oculoplastic surgeons are ophthalmologists that specialize in eyelids. While going to an oculoplastic surgeon does not, of course, come with a guarantee, at least you will stand a much better chance.

As TFOS DEWS II Iatrogenic Dry Eye report says,

Close interaction of the eyelids, tear film and ocular surface makes effective lubrication susceptible to surgery-related changes. As a result, a thorough knowledge of the eyelids' complex anatomical structure and function is mandatory to prevent inadvertent injury and to ensure effective tear film function post-surgery

You will not get that kind of knowledge from a plastic surgeon. Get the right kind of surgeon. This is your eyes.

Tip #2: Got dry eye? Consult a corneal specialist first.

In an ideal world, your corneal specialist and your oculoplastic surgeon work in the same practice and talk to each other.

#4. Consider the mental health cost of complications from elective eye and eyelid surgeries.

It's very, very steep. It lasts a very, very long time.

#5. Other eye surgeries.

Okay, time for a list! That's easier. Eye surgeries that can produce dryness include:

  • Conjunctival
  • Glaucoma
  • Vitreoretinol
  • Strabismus
  • Intacs

#6. "Procedures" that may be drying

  • Botox

  • Corneal crosslinking

  • Eye makeup

  • Eyelash growth

  • Eye whitening

  • Eye tatooing

  • Eye jewelry / piercings