SLK and dry eyes after Lasik

Hello,
I had Lasik in early 2006 and have suffered from extreme dry eyes and SLK ever since.  In January 2008, I had conjuntiva resection in both eyes in an effort to eliminate the SLK.  Although the resection helped considerably, I still must take steroid drops twice a day or the inflammation becomes severe.  My eye pressure climbs when on the drops - up to mid-30s when I was on Pred Forte.  I'm now on Alrex, which still elevates the pressure but keeps it in the low 20s.  I'm also on Restatis, Systane and must use Refresh Plus approximately every 15-20 minutes to have any degree of comfort.  

My ophthamologist says he cannot put in ductal plugs for the dry eyes until the SLK is under control and I'm off the steroid drops for a couple months.  I can't help but think the dry eyes contribute to the SLK, in that the dry scratching feeling makes my eyes feel inflamed.  

What are your thoughts?  Are dry eyes and SLK related?  Any suggestions on how to proceed?

Cindy

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

This is a recent answer concerning dry eyes: I don't know any reason why plugs shouldn't be put in right now.  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. Eye drops for dryness are classified as preserved drops (individual vials that must be used within 24 hrs), preserved drops, gels and ointments. The preserved drops are more expensive and usually only help the small percentage of people that are really allergic to preservatives. Gels and ointments are normally used at night since regular tears won’t last all night.   There is also an over the counter spray for dry eyes called “Tears Again”.  Tears may need to be used as often as 6 times/day.

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.

[AnnaE]

The doctor will answer you asap.

[Cindy103d]

Dr. Hagen,
I really appreciate your lengthy response regarding the dry eye treatments.  Yes, I've tried quite a few kinds of drops, gels and ointments.  I've found the kind with preservative to be problematic, so stay with the non-preservative types.  I've been on Restatis for two years solid now, so figure I'm getting as much benefit from that as I'll ever get.  I'm doing everything you've listed other than the goggles and "Autologist Platelete-rich plasma” therapy, and will definitely check into those options.  I'm also going to press my ophthamologist about the plug.  He is the fourth ophthamologist I've seen, is a corneal specialist at the university eye center and seems to be well-informed about treatments, but absolutely does not to insert the plugs at this time.

Do you believe there is a relationship between dry eyes and SLK or is it just coincidence that I have both?

Thank you,
Cindy

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

This is the latest work on SLK.

http://www.emedicine.com/OPH/topic103.htm

One other think you can talk to him about "moisture goggles at night".

Besure he uses a plug that is easy to take out.

JCH III MD