We are all prone to developing dry eye disease (DED). As our population ages, there is an increase in co-existing systemic health issues and use of medications. In addition, the extended use of digital devices increase the incidence of dry eyes.¹ Adding to the prevalence of DED is the effect of ocular surgery on moderate to severe DED patients and the demand of more sharp, clear vision with premium technologies.

Historically, DED after ocular surgery was primarily attributed to laser refractive surgery. It became widely accepted that the cutting of the corneal nerves during laser refractive surgery with either a microkeratome or a laser ablation leads to an iatrogenic dry eye syndrome. These symptoms are generally transient and self-limiting, as the corneal plexus regenerates quickly after disruption² and the patients were typically in their 20s and 30s. However, we have found evidence that it’s not just laser refractive surgery patients who experience DED symptoms — it’s a variety of ocular surgery patients.

This article will discuss the surgical patients who are at risk of dry eye and how to effectively treat these patients.

TYPES OF SURGICAL PATIENTS EXPERIENCING DRY EYES

Cataract & refractive

Modern cataract surgery or clear lens exchange has now become a refractive procedure — with the same high patient expectations. The use of femtosecond lasers, toric lenses and multifocal lenses has led patients to achieve excellent uncorrected vision after surgery.

In general, patients undergoing cataract surgery tend to be older and at a higher risk for developing DED after surgery. However, as visual demands become more important for people of all ages, younger patients are undergoing these procedures as well.

Patients may experience worsening dryness after cataract surgery for several reasons. First, the incisions made can induce a neurotrophic effect — this includes the main incision and any arcuate or limbal relaxing incisions. Secondly, the postoperative medications may also exacerbate damage to the ocular surface.

Corneal refractive procedures are not immune to this corneal nerve disruption. Many patients complain of a fluctuation in vision because of the exacerbated dry eye from the surgery. Like with all premium patients, it is better to preemptively counsel and treat the patient for any underlying conditions like DED, as this will greatly enhance their visual outcomes.

Additional ocular surgery patients

Other surgical patients who experience DED include:

• Glaucoma. Modern glaucoma surgery is not without dry eye risk. Many glaucoma patients are on topical medications with and without benzalkonium chloride (BAK). BAK is a known irritant to the ocular surface.³ In addition, these patients may have concomitant meibomian gland dysfunction. Minimally invasive glaucoma surgery (MIGS) offers patients the ability to reduce or stop taking drops that are the culprit but, in some cases, still involves conjunctival tissue disruption and the ability to alter the ocular surface. Foreign body sensation associated with glaucoma procedures is typically associated with DED and should be treated alongside the glaucoma. Also, filtering blebs result in uneven lubrication of the ocular surface, which can lead to corneal issues as well.
• Retina. Vitreoretinal surgeries and multiple intravitreal injections also contribute to DED. These patients are also on many ocular medications and should be considered for DED treatment, even if it is just transient.
• Oculoplastics. Oculoplastic surgery has been known to contribute to the incidence of dry eyes in patients. Patients undergoing aesthetic blepharoplasty and lid repair are at a higher risk of developing DED.⁴ Many of these patients have had prior refractive surgery or have had multiple procedures that affect and compromise their lid function. Fortunately, many of these surgeries are performed by oculoplastic surgeons who understand the tear film and lid structure. In other cases, they are performed by general plastic surgeons, ear, nose and throat surgeons as well as maxillofacial surgeons who are not as familiar with the ocular structures as eye-care professionals. As a result, they may over-correct patients and induce an issue with their ocular surface

TREATING THE DED

Overview

The tear film provides the first refractive surface of the eye and contributes to the quality of our vision. The anterior surface of the pre-corneal tear film has the greatest optical power of any ocular surface. We have now learned that DED is aqueous deficient and evaporative. In fact, the purely aqueous-deficient dry eye (ADDE) subtype represents the smallest percentage of dry eye patients. Meibomian gland dysfunction (MGD) has been identified in 86% of patients with a classified DED.⁵ Many factors can alter the composition and structure of the meibomian glands; inflammation, hormone imbalance, diet, age, digital device use and decreased blinking all contribute to the inflammation of the lid margin and an altered ocular surface.

The diagnostic process

All eye-care professionals should be proactive in identifying patients at risk for dry eyes, diagnosing dry eyes and understanding the risk of dry eyes after ocular surgery. Surgeons differ widely on their dry eye preoperative regimen. Regardless of approach, conversations with the patient on the front end are crucial to surgical outcome and patient satisfaction.

Most patients, fortunately, only experience dry eyes symptoms in the immediate postoperative period and resolve quickly. Their symptoms are transient and can range from itching, burning, tearing, vision fluctuations, photosensitivity and redness. Well-trained and educated staff can help patients get through this period with positivity and reassurance. Coach staff to respond to patient complaints on intake, like foreign body sensation, tired eyes or fluctuation in vision. Staff should ask patients if they are using their artificial tears and how often. Also, they should advise patients that they may have some dry eye, which is normal, but the doctor will look at their tear film during the exam. This helps patients realize their role in their dry eye treatment and that dry eye happens to many patients.

However, some patients need more than just coaching and artificial tears. It is imperative to identify these patients who may require additional treatments. These patients typically present with vision that has worsened after the first day or week of surgery or who complain of severe dry eye. Fortunately, we have seen an increase in therapeutic options for these patients.

Treatment options

The artificial tear drop market is booming, and it can be overwhelming for patients to go to their local pharmacy and choose the correct type of drop. Simple postoperative instructions with specific examples often help the patient in this process. Often times, patients are reluctant to use tears and may in fact fear that they can use them too much. Simple conversations can allow your patients to be more proactive in helping restore their tear film after surgery. For example, recommend artificial tears use a minimum of six times a day AND as needed for the first week to help rebuild the tear film. Alternatively, only suggesting drop use as needed tends to lead patients using fewer drops than they actually need. If you provide a minimum, patients can always exceed that number. If a patient does not respond to drops with preservatives used multiple times a day, try to move the patient to a preservative-free option.

Also, ask patients if they have been on the computer and how many breaks they take during the day. This approach allows the patient to be part of the recovery. Explain to them that prolonged digital device use or near work decreases blink rate and will make their eyes even drier.

Pharmaceutical options continue to play a role in ocular surface rehabilitation. Available options are Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), Xiidra (lifitegrast ophthalmic solution 5%, Novartis) and Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharma). Both Restasis and Cequa are cyclosporine-based pharmaceuticals that work by reducing the inflammation in the tear glands to help increase the production of tears. Xiidra is lifitegrast-based, which works by attaching to proteins in the body that help reduce inflammation in the tear glands. Oftentimes, cost and insurance coverage become issues for patients. Once again, proper patient communication and coaching allows patients to understand the benefits of these treatments and that their use is usually short-term.

Nutraceutical options to treat postoperative dry eyes includes the recommendation of omega supplementation. Studies have shown that high dose DHA/EPA can help stabilize the tear film and improve the subjective symptoms and signs of dry eyes. Once again, many products are available for these patients, who rely on the advice and expertise of their eye-care professional. Proper knowledge on the dosage of supplementation can help the patient not only during the postoperative period but can also benefit the patient systemically with continued use.

If a patient experiences continued dry eyes months after ocular surgery, other treatment modalities may need consideration. Examples include thermal treatments (LipiFlow [Johnson & Johnson Vision], iLux [Alcon], TearCare [Sight Sciences]), intense pulsed light (Lumenis), amniotic membrane and autologous serum tears.

CONCLUSION

All eye-care professionals should understand the theoretical and real risk of dry eyes after any type of ocular surgery. Appropriate counseling, consent and treatment can benefit a patient and help to provide the best post-operative result and satisfaction. Also, remember that this process requires effort from your entire team. It starts with the front desk staff who answer a patients’ first calls and continues with your team of scribes, technicians, surgical coordinators and doctors.

Dry eye symptoms are real, and it takes a team approach to coach surgical patients through positive encouragement and help them to understand why they may experience dry eye symptoms in the postoperative period. OM

REFERENCES

1. Sheppard AL, Wolffsohn JS. Digital eye strain: prevalence, measurement and amelioration. BMJ Open Ophthalmol. 2018;3:e000146.
2. Bandeira F, Yusoff NZ, Yam GH, Mehta JS. Corneal re-innervation following refractive surgery treatments. Neural Regen Res. 2019;14:557-565.
3. Coroi MC, Bungau S, Tit M. Preservatives from the eye drops and the ocular surface. Rom J Ophthalmol. 2015;59:2-5.
4. Watanabe A, Selva D, Kakizaki H, et al. Long-term tear volume changes after blepharoptosis surgery and blepharoplasty. Invest Ophthalmol Vis Sci. 2015;56:54-58.
5. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472-478.

About the Author

Shilpa Rose, MD, is in private practice at Whitten Laser Eye in Chevy Chase, Md.

Dr. Rose reports no relevant disclosures.