dry eyes 2.5 years after Lasik

[SAAG]

Hi!

First, I apologize for the length of my post...but I wanted to make sure you had enough info. to answer my questions. I am hoping that by providing you with all of this detail, that you may be able to help me... I've been trying for over 2 years to get help for my lasik-induced dry eyes, and have not found much in the way of improvement.

I had my original lasik procedure in Sept. 2005, then an enhancement in January 2006.

Even though it has been almost 2.5 years since the enhancement, I still need to use artificial tears once per hour (a huge improvement over every 15 minutes like it was for about 3mo. after surgery). To rule out the preservatives in the drops as a contributing factor to any irritation etc., I used Bion Tears exclusively for over 6 months, and noted no improvement. (I had also tried other brands of preservative-free drops, but Bion Tears worked the best for me.)

Regarding the use of low dose steroids for the dryness: I have asked TWO ophthamologist about this:

One of them just thinks it's environmental allergies causing the irritation, yet this explanation does not make sense to me since the dryness began after Lasik, and all allergy tests came back negative.... it seems like a bit much of a coincidence to have allergies cause all of this right after Lasik. This doctor does not feel steroid drops are warranted.

The Lasik doctor did not feel plain steroid drops were warranted, but thought that I might have a mild staphylococcal infection causing the discomfort in my eyes (which I'd been attributing to dryness). The Lasik doctor prescribed Blephamide drops and instructed me to use 1 drop twice daily for 3 days, then 1 drop in each eye every third bedtime thereafter. This did not seem to help very much, so I went back to the doctor... he said to just continue using 1 drop every third bedtime. As an experiment, I tried using it QID for 5 days during which time my eyes felt FABULOUS (dryness MUCH improved). I didn't want to use them too much longer than that for fear of doing more harm than good (especially since this was much more than the doctor's suggested dose.) Since that time, I've stuck with the every third night routine, although about once per month in winter (when the air is dryer), I've needed to bump up the dose again to QID (for 2-3 days) to regain control of my dryness. To give you an idea of my average usage, a 10ml bottle lasts me 6 months. Note, even when using the Blephamide q 3 nights, I still require artificial tears every hour. The main benefit that I get from the Blephamide: during those unbearable winter flareups where my eyes get so dry that I need artificial tears every 15 minutes again, use of the Blephamide qid for 2-3 days regains control of it. I suspect that the improvement is just due to the steroid in the drop. Prior to going to the doctor for the Blephamide, I had been using the leftover prednisolone drops from the surgery for this purpose and they worked just as well (better, actually, but that's no surprise since they were stronger than the steroid in the Blephamide). Would it not be worth a trial of plain steroid drops to see if they work just as well as the Blephamide? I'm thinking if the plain steroid drops would work just as well, then why use the antibiotic chronically and risk causing bacterial resistance over time?

I'm considering asking for a referral to yet another ophthamologist, but I don't want to waste their time (or mine) if there is nothing they can do for me... I'm still unsure as to why plain low dose steroids have not been considered as a treatment... OR is using Blephamide every third night the kind of low dose that's used for dry eye treatment? I'm a pharmacist, but I have not been able to find any information specifically regarding dosing of steroid drops for dry eyes to ask the doctor about... I've seen the side effect of corneal thinning mentioned in the monographs for the steroid drops - is that a likely outcome from using them in low doses for treatment of dry eye (this caught my attention particularly because my corneas are now thinner from the Lasik itself!)? I've contacted the manufacturers for more information on this (ie incidence, case reports, or anything!), and they had none.

Being a pharmacist, I'm used to being able to understand WHY something should or should not be used, and I feel frustrated by the lack of detailed information I've been able to find about the use of low-dose steroids for treatment of dry eye. Can you help me gain a clearer understanding of this issue?

What are the typical steroid doses used for treatment of dry eye?
What is the incidence of adverse effects (particularly any irreversible ones) with these treatment regimens?
What factors would cause you NOT to consider a patient for low-dose steroid treatent of dry eye?

Hopefully getting answers to the above questions will help me to
a) better understand the responses of the above ophthamologists and
b) help me to decide if I should seek another opinion.

Lastly, I have not asked you about Restasis, because it is not available here in Canada.

I realize that you cannot answer me as well as you would be able to if you could personally examine my eyes, but I am hoping that you can provide me with some guidance based on the information I've provided you with above. If you would like any further information from me, please let me know.

Thank-you!

[William Trattler MD]

Thank you so much for your very detailed question on dry eye and LASIK. I think I will have to make you an honorary dry eye specialist - because you have discovered something that is well-know to dry eye specialists. That topical steroids are a wonderful treatment for dry eye.
Dry eye has inflammation as an underlying cause. That is why restasis works - as Restasis suppresses inflammation. Topical steroids work even faster than restasis - but there are risks with long term use of topical steroids. So typically we will use a burst of topical steroids along with long term restasis.
But there are many more things that you need to look into.

1. Punctal plugs. You should look into having plugs placed. There are 2 ducts per eye. If after plugging 1 per eye - your eyes are still dry - then you should discuss with your doctor about closing the second duct in each eye. Although this may be too much,. and may lead to tear overflow (which means that your eyes would always feel wet and an occasional tear would run down). Of course - after sufferring from dry eyes - a week or two of tear overflow is not much of an issue - so the downside is low.

2. Punctal plugs will not work perfectly if there is still lots of inflammation. You should inquire about topical FML drops 0.1%. These are low dose steroids, that you could potentially use BID for 2 to 3 weeks at a time. The biggest side effects of topical steroids is eye pressure elevation and cataracts. Because eye pressure elevation does not have any symptoms - you must have your eye pressure checked every 6 to 8 weeks while using topical steroids. cataracts are treatable with surgery - and in my opinion - since cataract surgery is so safe and effective - the successful treatment of severe dry eyes outweighs the risk of cataracts. Just my opinion - with the point being that you need to conquer your dry eye so that you can function normally.

3. You should talk to your doctor about oral omega 3 fatty acids (fish oil). These supplements are quite effective for dry eye. Lifeguard health is a company that makes a very pure form of oral omega 3's that does not have any fishy after taste.

4. Warm compresses - 10 minutes once or twice a day - can also be quite effective in helping patients with dry eye. It is hard to find the time - but this type of therapy is quite effective. The challenge is finding a good solution to maintaining 10 minutes of heat that is hot but not too hot. You should look into heating pads, etc. But obviously you have to be careful and not make things too hot.

5. I have found that many patients with post-LASIK dry eyes have clogged oil glands in their eyelids. This is called meibomian gland dysfunction. Oral Omega 3's and warm compresses help this condition. But some patients may also require oral tetracyclines (doxy or minocycline). As well, compounding pharmacies can create topical docycycline, which can also be effective, and avoids the systemic side effects. Lastly, Azasite (topical azithromycine), a new medication here in the US, is very effective in my experience for meibomian gland dysfunction.

So - this is just the start. Dry eyes can always be treated in my experience. If these suggestions do not work - there are still many more things to look into.

I hope this helps. Don't forget to check back in a month or so to share your progress.

Bill Trattler, MD

[SAAG]

Thank-you very much for your detailed reply Dr. Trattler. It is appreciated more than you know.

If you have the time, could you expand upon the following:

1) Regarding the use of low dose steroids to treat dry eye:

What is the incidence of cataract formation? Is is pretty much 100%
guaranteed that eventually you'll develop cataracts? or is it much lower?

How many years of chronic low dose steroid use does it normally take for one to develop cataracts?

I realize there will not be any firm guaranteed-accurate numbers for the above questions, but I'd love to hear your best guess based on your experience and any literature out there on the subject. This will help me to decide if the risk of cataracts is worth it for me personally... the idea of getting cataracts freaks me out a bit... my father-in-law had them, and the wait for surgery was so long that he went over a year unable drive, or enjoy simple things like reading or watching TV. It was such a waste of precious time, since once he finally got the surgery, his vision was fantastic!


2) What is the usual therapeutic dose of omega 3 fatty acids that you recommend for the treatment of dry eye?


3) Regarding meibomian gland dysfunction and treatment with tetracyclines:
How does one know if they will benefit from tetracycline treatment? or is it just a "try it and see" type of thing?
What is a typical therapeutic dose of oral tetracycline for this purpose?
For topical doxy or tetracycline, what is the usual % concentration that you recommend? what is the usual dosing interval/frequency?


I plan on printing all of this information and keeping it on file for future reference as I continue to consult with my doctor in efforts to get this dry eye issue under better control.

Again, I thank you for the detailed reply that you've already given - it was extremely helpful - I'll be certain to post with updates as I try the various strategies.

I intend to pursue the option of punctal plugs, although I'd like to try to find an ophthamologist like yourself who uses them regularly - hopefully that will make the whole experience go more smoothly.

[William Trattler MD]

Great questions.
There is no perfect answer for the risk of cataracts with steroids. Longterm use (years of use) can lead to cataract formation, but the rapidity is very variable. Of course - cataract surgery is an 8 minute procedure, very safe, etc. In general - steroid induced cataracts can occur - but they are not that common despite the amount of topical, oral and nasal-inhaled steroids that we use.

I do not know the dosage of oral omega 3's. Sorry. I just recommend following the labelled recommendation.


As far as the use of tetracyclines - it is like the use of other medications for dry eye. They work - but not in 100% of patients. So we try tetracyclines, or topical Azithromycin, and expect that it will work.

So - to answer your question - I prefer topical Azithromycin (Azasite) over oral tetracyclines.

I hope this helps

Bill Trattler, MD

[SAAG]

I know you must be very busy, so I am especially grateful that you have replied yet again!! Thank-you! This will most definitely be printed off and kept in my files for future reference.

It's wonderful to be able to fill in some of the extra details that I was after!

[SAAG]

Hello again!

Again, sorry this is so long, but I figure it's better not to leave anything out...

Well, here's where I'm at a year later:

In late April, my dry eyes flared up worse than ever - I've been back to needing artificial tears every 15 minutes - I've stopped watching TV, stopped reading books, and limited my computer time to a maximum of 30 minutes per day. I only go outdoors if I'm wearing sunglasses with a foam gasket to block the wind, and I wear onion goggles in my home to block the breeze created by walking around (I know... this must sound bizarre... but I'm desperate, and this provides a great deal of relief from the itching and burning sensation in my eyes.)

I've been taking 3 grams of fish oil daily, using cold compresses several times per day (this alleviates the burning sensation in my eyes, although only temporarily), and I even tried a couple of weeks of warm compresses (although this seemed to do nothing... perhaps I didn't stick with it long enough...)

My surgeon who performed my lasik continues to believe that all I should be doing is to continue on with artificial tears, and the Blephamide drops every 3rd night at bedtime.

I decided to see an optometrist, to see if I could be referred to an ophthamologist here who specializes in dry eye for a second opinion.

The optometrist put in extended wear (60-90 day) collagen plugs in my lower puncta 5 weeks ago. He does not expect me to get in to see the ophthamologist (this one is a corneal specialist) until sometime in October.

The plugs don't seem to be doing much... maybe there is too much inflammation for them to work??

Given what you've read so far... do you think it's worth considering permanent lower plugs at this time, even though the collagen ones don't seem to have made much difference? The reason I ask is because I've heard anecdotes from people saying the permanent ones helped more than the collagen ones did...if there is a chance the permanent ones might still help, then at least I could be doing something for my eyes while I wait to see the corneal specialist in October...

One new piece of news that may be helpful to any Canadians reading this:

Restasis IS available in Canada... but there's a catch.

It is only available through Health Canada's Special Access Program. To qualify for access to this medication, you must first try every other approved dry eye treatment in Canada. Lastly, only select ophthamologists are familiar with Restasis and able to get it for their patients via this program. It can take a lot of searching to find such a Dr. (at least that's been my experience thus far), and you need a referral from either an optometrist or an MD.

So... that's my update... I wish I could have reported more cheery news... maybe next time...

[William Trattler MD]

I am so sorry to hear that your dry eye condition is not resolved. There are so many options for treatment for dry eye. In my practice - I no longer use temporary collagen plugs because they can not predict the beneficial effects of silicone external plugs. In a case like you are describing, I would place lower plugs, and if that is not enough, then place upper plugs so that all ducts are closed. This would lead to significantly more tears. Sometimes this is too much.
Other things to consider

1. Blepharitis may also be present - and you need to have your doctor determine the extent of blepharitis - and in particular Meibomian gland dysfunction (MGD). Here is an article to print out and bring to your doctor
http://www.optometric.com/article.aspx?article=102027

2. If blepharitis/MGD is present - you may want to consider sticking with warm compresses - which get the meibomian glands flowing better

3. Topical steroids. I personally use topical steroids all the time for dry eye. They work very well - although Restasis is better because there is less risk. Still - for severe dry eye to the level that you describe - the risk of low dose topical steroids is worth the benefit of making someone functional. The risks include the early development of cataracts (which is fixed with a straightforward surgery), elevated eye pressure (If this occurs, then one should discontinue steroid drops), or rarely, increased risk of infection. But overall - short courses of steroids are really helpful - especially for severe dry eye

4. I would work to get on the list for restasis. But - for severe dry eye - it is not enough. You need to have the dry eye under better control to be comfortable with Restasis (it can burn in severe dry eye). Once you start it - it can help prevent dry eye from worsening.


Here are some links about plugs and other dry eye treatments:
http://bmctoday.net/crstoday/pdfs/CRST0409_12.pdf


In summary - please see a specialist, and I hope these ideas prove to be helpful so that you can discuss them with your doctor.

Best regards

William Trattler, MD

[SAAG]

Thank-you so much for taking the time to respond yet again! I appreciate it so very much!

I broke my moratorium on reading to read those articles you posted links to. They were very informative, and I've printed them off to bring to future appointments.

If you don't mind, and if you have the time, I have a few other questions...

What is your opinion on intracanicular plugs such as the Smart Plugs?

The optometrist seems to favor those - he said that if he were to use the silicone plugs, I would feel them, hence, his preference for the Smart Plugs. But, now that I haven't seen much, if any, benefit from the collagen plugs, the optometrist does not want to put in permanent plugs at this time - he said he would prefer to wait and see what the corneal specialist advises.

Since it will likely be October before I am able to see the specialist, I'd like to better understand WHY the optometrist is now hesitant to try lower permanent plugs. I'm assuming it's not epiphora that he's concerned about, since with my need to use drops every 15 minutes, that is surely an unlikely outcome...

I've read that some negative aspects to intracanicular plugs include:

1) If they ever need to be removed, they sometimes are not able to be irrigated out, and therefore would need to be removed surgically.

Is this a likely problem?

2) Physician is unable to see them once they are inserted, therefore if dry eye worsens, he cannot tell if it's because the plugs have fallen out or not.

What are your thoughts on this?

Lastly, in case this would change your answers to any of my questions, I am currently breastfeeding my baby (The optometrist is aware of this). I don't think this flare-up is related to hormonal issues though, since the flare-up started shortly after I'd spent an entire day working on the computer back in April. (Plus, I noticed no difference in my dry eye when pregnant, or after my baby was born compared to pre-pregnancy... of course, I'm hardly an expert in dry eye, so if you have any comments on this, I'll gladly take them!) In regards to potential rx treatments, I'll of course be stopping breastfeeding if the specialist prescribes anything incompatible with breastfeeding. But, I'm wondering if the fact that I'm breastfeeding might influence what you think about my getting permanent plugs (mainly the intracanicular type due to the potential difficulty in removing them, should that ever become necessary.)

[William Trattler MD]

I am not a fan of intracanalicular plugs. It is true that you can not feel them - but you can also not tell if they are in place and even if they are in place, what percent of the duct are they clogging. 30%, 50%, 80%. Who knows - because we can't see them. They also can pose a risk - such as infection. If you are interested in silicone plugs - I first would recommend pushing up your appointment with your specialist. Otherwise, talk with your optometrist about the external plugs.
I don't have any answers to your breast feeding, hormonal issue. I would focus on treating the underlying cause with medications like I mentioned in the previous post. Some may not be suitable for use if you are still breast feeding - so please ask your doctor

best regards

Bill Trattler, MD

[SAAG]

Thank-you for taking the time to respond to my questions yet again! I appreciate it SO very much!

Well, my appointment with the corneal specialist is on Oct. 30 - I inquired about the possibility of getting in earlier, but his receptionist said they are totally over-booked already, and there's no hope of that.

So... I've made another appointment with my optometrist on Sept. 3 to discuss the possibility of getting silicone external plugs put in. Your explanation of why you are not a fan of the intracanicular type made a lot of sense, and is similar to what I've read elsewhere. Although I'm scared that the silicone external plugs might be terribly uncomfortable, I won't know for sure unless I try them, right?

I'll also be asking the optometrist if he thinks I might have meibomian gland issues... if so, I might see if I can get in to see my Lasik surgeon in the next month, and ask for a trial of oral doxycycline (of course, I'd stop breastfeeding if I do this). I'm thinking the risks to me from trying doxy is low, so I hope he would feel comfortable in allowing me to try it.

I'll also re-start the warm-compresses to see if using them for a month or two gives better results this time.

Thanks again Dr. Trattler for all of your help to date!

[SAAG]

Well... here's yet another update... some good news this time!

Sorry about the length...

I went back to see my optometrist the first week of September. He didn't feel comfortable putting in permanent plugs until he hears what the corneal specialist has to say (my appt. is on Oct. 30). I asked him to take a look at my meibomian glands for me - he said that there is some mild capping, but he didn't think it was bad enough to account for my dry eye symptoms being so insanely bad.

I've been trying to taper back on my usage of artificial tears, as I'd heard via another dry eye forum that it is possible to over-use these, and cause even MORE problems with dry eye. I'd been skeptical of this until now, because my Lasik surgeon has always told me the opposite: to use them as often as I need (he's been told many times how often I use them), and that they cannot do any harm. I hadn't been having much luck with tapering back... so...

This past Sunday, I decided to just quit... cold turkey. (I still use drops before bedtime though... I'm scared my eyelids will stick too badly overnight if I don't...)

Sunday morning my eyes felt pretty lousy, but rather than use drops, I just closed my eyes and rested them. To my complete and utter SHOCK, this lousy feeling in my eyes passed, and by the afternoon, they felt no worse than they did when I was using drops all the time.

Monday, my eyes felt a bit better still... Tuesday, they felt even better... and today has been my best day yet.

Don't get me wrong, they are still dry... but it's tolerable. Also, my eyes are less pink than they were when using drops, and, overall, they are feeling a bit BETTER. I'm completely shocked!

So... I am now suspecting that perhaps my prolonged bout with dry eyes since Lasik is due to either irritation from using the drops for so long, OR perhaps due to my eyes always being wetted with drops, my eyes stopped making tears of their own... so I'd use more drops... my eyes would make even less tears... etc.

So... the big question is: IF it's overuse of artificial tears for four freaking YEARS that has caused my post-lasik dry eye to persist for so long, can my eyes recover from this??

Also, I went to my GP a couple of weeks ago, and she started me on oral tetracycline 250mg BID for my facial rosacea. Hopefully its anti-inflammatory effects will do my eyes some good also!

If you have any comments or suggestions for me, I'm all ears!

Thanks for reading!

[SAAG]

Hello again!

Well, the corneal specialist I've been seeing is excellent! It's nice to have finally found a doctor who is willing to treat my eyes with something other than artificial tears.

I started Restasis 3 times daily on Nov. 6, 2009 - I think it's helping, but not in a huge way...

As of last week, I now have permanent plugs in my lower puncta, and temps in my uppers. I am scheduled to have my uppers cauterized on Feb. 9.

After completing a 3 month course of tetracycline 250mg bid from my GP for my rosacea, my corneal specialist elected to continue systemic treatment, but switched me to 20mg per day of doxycycline.

I'm also still taking 3 grams per day of fish oil, and doing hot compresses with gland expression 2 times daily.

The 1 thing that has made the biggest difference in my symptoms is having all 4 ducts plugged. But, I am still quite dry... I presume that I must be insanely aqueous deficient since even with all 4 ducts plugged, I don't have even the smallest signs of overflowing tears. Even with all 4 ducts plugged, I still need to use artificial tears every 1.5-2 hours.

So... are there any other treatments out there that I can try? I have a few ideas that I'll be asking my doctor about, but I'd love it if you could throw a few suggestions my way too!

Thanks again for reading!