Dry Eyes and PRK

On August 30th I posted a question regarding my extreme dry eyes issue. On of the suggestions from Dr. James Salz of Medhelp was Lotemax for about 3 weeks, which I did  My tear ducts had been plugged but my dr. said he didn't recommend them to be closed with cautery.  I am also on Omega 3 and 6 as Dr. Salz recommended, also with no avail.  I am still using Restasis but I've developed an inflamaiton of the lids which prevents me from wearing contacts.  I cannot continue wearing glasses,  I have tried and just cannot see right, get headaches, just plain difficult for me, My dr. suggested PRK, althoug you agreed as well that LASIK would not be a good options for me.  It's been two months since I'm wearing the glasses and have noticed that my vision has deteriorated (right eye blurry).  I would like to know what would be my risks with PRK and dry eyes,  I was told that the LASIK w/the flap would not be a good option for me but what about the PRK?  

[John C Hagan III, MD, FACS, FAAO]

It depends on how dry your eyes are and how badly you want refractive surgery. Your dry eyes may well be made worse at least for 6 months or so by refractive surgery. Also some eye MDs feel PRK or mini-flap LASEK may be better than traditional LASIK for dry eyes.

Please read the information from a previous post on Dry eyes

JCH III MD
General Information on Dry Eyes

a Schirmer test of zero indicates that you have severe dry eyes. I'm assuming from your posting that you have tried both preserved and unpreserved artifical tears, gels or lubricating ointments at bedtime, environmental modification, etc. Don't discount eye drops. There are over a 100 different brands of artificial tears and they can't all be lumped together. Sometimes one will find the perfect drop. Because the problem is so prevalent the pharmaceutical compies are coming out with new products all the time. Some of the newest are Systane preserved and unpreserved drops and Optive drops.

If you took Restasis you have used the best prescription medication. A "trial" of Restasis is a minimum of 8 weeks of therapy using one drop in each eye twice/day. Because of the way Restasis works, it takes two months to "start working". I have found that many patients use it for a few weeks then conclude it won't help. The medication often stings when therapy is begun--it usually gets better by week three or your Ophthalmologist (EyeMD) can prescribe a mild steroid drop for a couple of weeks. If you did not take for 8 weeks you need to restart therapy. Improvement often continues for up to 6 months.

If you have tried tear duct plugs you should have had all for tear duct openings (puncta) plugged with a permanent plus (not a disolving one). Usually just the lower lids are done with mild dry eyes. If your problem is as bad as you say, you and your ophthalmologist should discuss permanent closure of some or all four of the tear duct openings with cautery.

Additional things that can help include a diet rich in fatty fish (eg salmon, sardines, etc). Fish oil taken by mouth usually 2 to 4/day has been show to help some patients. In addition there are non-prescription pills for dry eyes available at most major drug stores or by direct order from the companies. Thera-tears formula for dry eyes is probably the most widely used. You can use any search engine to pull up the websites of the companies that see these.

In dry eyes associated with corneal damage, moisture retaining goggles are used for sleeping. Be absolutely certain you do not sleep under a fan, heating outlet or situation where air moves over your face during sleep. Make certain you home is humidified in the winter, put a humidity gage in the bedroom. If you cannot maintain a 50-60% humidity put a room humidifier in the bedroom. Run the A/C or heater of your car through the vents on your feet not in your face. Long car or plane trips put your tears in every couple of hours.

If you are menopausal or post-menopausal be sure you and your gynecologist maintain optimal hormonal balance. (Many women with dry eyes have dry mouth and dry vaginal canal). If you have joint pain have that evaluated to be sure you don't have Sjorgren's syndrome. Many medications eg antihistamines can make dry eye worse. You might review your medications with your ophthalmologist.

If you reach a point of exhausting all the above see an ophthalmologist that specializes in "Cornea and External Disease". This is their special area of expertise. A final new treatment that they can often do is “Autologist Platelete-rich plasma” therapy. This uses eyedrops made out of your blood products. (reference Ocular Surgery News: November 1, 2007 page 46  lead author Jorge Alio MD.

Keep digging and moving forward. I suspect you have not exhausted all the ways you can be helped.

[Winikor]

Thank you for your reply and help in this matter.  I have tried most of the above and have also been on Restasis for about a year, having had used the Lotemax for 3 weeks as prescribed.  I will discuss with my opthalmologist the Autologist Platelete-rich plasma therapy.  For some reason, however, my opthalmologist did not want to do the cautery, he said that sometimes it works in reverse and said that since he did plug my bottom lids and that didn't help, that he felt the cautery would not help either in my case.  He has 3 different drs. in with us during the office visit.  He feels some of my problems now are caused by the use of contacts, that is the reason for my wanting to do the laser.  Thank you again for your help.

[Winikor]

I tried to find the article 'Ocular Surgery News: November 1, 2007 page 46  lead author Jorge Alio MD"  but could not find it.

[John C Hagan III, MD, FACS, FAAO]

I have tried to find that article on their website also but have not be able to find it. I don't think they post in their archives for about 3 months after publication.

Use Google and search the topic. There is a wealth of information to be had.

Anyone that has your problems that is wearing contacts and remains as symptomatic as your are I tell them in no uncertain terms to stop wearing contacts.

Also your Eye MD might put plugs in all 4 tear duct openings (puncta).

Long term the risk of continuing to wear contacts with very dry eyes is quite a bit higher than have a one time LASIK, LASEK or PPK.

Merry Christmas.
JCH III MD

[Winikor]

Thank you so much for your help.  I have been googling PRK and dry eyes and have found some information but not PRK related to dry eyes.  I do appreciate your advising me that contacts with very dry eyes is a higher risk than the PRK.  

Merry Chrismas to you, too and a very happy new year!

[John C Hagan III, MD, FACS, FAAO]

Christmas was merry with family here. Best of luck to you.

JCH III MD