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LASIK & Dry Eyes
Optimizing Eye Comfort
by Craig S. Bindi, MD

Being bothered by “Dry Eyes” is one the most common problems that I treat in my ophthalmology
practice. Luckily, when managed systematically and proactively, these symptoms should be very
treatable and temporary. Whether you have already had Laser Vision Correction or are considering
it in the future, this article explains the simple steps for optimizing eye comfort and teaches the
scientific rationale behind these tips.

Dry Eye SyndromeSummary of the Problem
Symptoms of “Dry Eyes” include foreign body sensation, burning
sensation, fluctuating vision clarity, and light sensitivity. Any
corneal surgery has the potential to affect corneal nerves and
decrease tear production. A recent very large scientific review
(based on 32,000 LASIK procedures from 46 independently
published studies from 13 countries) evaluated the frequency,
duration and cause of dry eyes after laser vision correction. The
study found that 35% of patients reported they noticed some
dry eye symptoms after LASIK surgery, yet, 32% of patients also
had these same symptoms PRIOR to surgery with glasses or
contacts. Most patients reported returning to “normal or baseline”
by 6 weeks after LASIK, but it can last for several months. Having
dry eyes before LASIK was the best predictor of postoperative dry eye and severe dry eye problems were very rare. Also, thinner LASIK flaps, Intralase-based LASIK flaps, “nasal-hinged” LASIK flaps and Epi-LASIK/PRK have been associated with less dry eye symptoms. With scientific advancements and a better understanding of the ocular surface, various treatments have limited the severity of this problem.

How Can LASIK Cause Eyes To Feel Dry?
If you have ever scratched your cornea or had a corneal infection, you already know that the corneal
surface is very sensitive to touch or injury. A vast network of sensory nerves provides this sensitivity.
In LASIK, creation of the corneal flap decreases the function of these nerves, which temporarily
diminishes corneal sensitivity. Subsequently, the eye cannot effectively send nerve impulses to the
tear gland for additional moisture. After these nerves grow back, sensitivity returns to normal levels
within a couple months after treatment.

The corneal nerves enter the cornea along the horizontal axis at the 3 o’clock and 9 o’clock position.
Older microkeratomes used to make the LASIK flap hinge on the top (superior-based hinge), so both
branches of these nerves were incised. Newer LASIK technologies, such as Intralase, have evolved to
create a nasal-based hinge, which preserves the entire nasal branch of the corneal nerve and reduces
the number of corneal nerves affected by the flap creation by about 50%. LASIK flaps with a nasal-based
hinge have shown to have a lower incidence of dry eye related problems. Until normal tear function
returns, Dry eye can be the source of sub-optimal vision, fluctuating vision and eye discomfort
until it resolves.

Basic Physiology of the Human Tear Film
The normal human tear film is about 98% water, 1% oil and 1% mucous. These three components
work together to hydrate the cornea, stabilize the tear film and prevent evaporation. The lacrimal
gland and other ocular surface glands create all three essential parts of the human tear film. If any
of these components are missing or out of proportion, the surface of the eye will “dry out”. When
the ocular surface senses irritation, it sends a nerve impulse for the tear glands to produce tears
(reflex tears). Other ocular surface glands consistently produce baseline tears are less dependent
on nerve impulses (basal tears). In the postoperative period, simple measures can be taken to keep
the cornea hydrated, stabilize the tear film and prevent tear evaporation.

The Primary Dry Eye Remedy
With any corneal surgery, the ability to efficiently produce tears is temporarily affected. For this
reason, it is very important to use preservative-free artificial tear eye drops at least 4 times per day
for the first month after LASIK (whether one feels dryness or not), and longer if desired to maintain
comfort. If used in a diligent manner for the recommended interval, this single remedy is effective
for the vast majority of patients in keeping “dry eye” symptoms to a minimum. If preservative-free
tears are used, there is no hazard preservative-induced irritation from over-use. There are many
brands of preservative-free artificial tears available at the pharmacy or grocery store (i.e. Systane,
Blink, Optive, Refresh Plus, Thera-Tears, and GenTeal). Some over-the-counter lubrication drops
that come in a large bottle contain a “preservative”. Eye drop preservatives, such as benzalkonium
chloride (BAK), tend to accumulate in the tear film and irritate the ocular surface. “Disappearing
Preservative” artificial tears are expensive, but are safe to use if desired. Artificial tears WITH a
preservative should be avoided right after surgery and are better tolerated when only used once
or twice per day.

Checklist of Over-the-Counter Remedies to Alleviate Dry Eyes:

• Use over-the-counter preservative-free lubricating artificial tears at least 4 times per day or more
if desired, especially following LASIK

• Avoid dehydration by drinking plenty of water. Staying hydrated helps produce natural tears
more effectively

• Avoid “too much” caffeine, which has a drying/diuretic effect

• Use gel lubrication at night. The thicker forms of over-the-counter lubrication, such as GenTeal
Gel, are more viscous and last longer. They tend to blur the vision more, so they are most useful
while sleeping.

• Add dietary omega-3 fatty acids, such as 1000mg molecularly distilled fish oil oral soft gels, to
optimize the oily portion of the tear film and prevent tear evaporation

• Baby shampoo eyelid scrubs can remove certain irritating oils that accumulate on the eyelids
and restore the balance between the three tear film components. (Do not attempt this or rubbing
eyes for one month after having LASIK) Some inflammatory skin conditions, such as ocular rosacea
and seborrheic dermatitis or blepharitis, are associated with problems with the lipid component
of the tear film. If the lipid component breaks down, no amount of supplemental artificial tears will
solve the problem because the tear film will evaporate too quickly. Daily baby shampoo eyelid
hygiene is gentle on the eyes and can inexpensively control the problem

• Use emollient eye drops, such as Soothe or Endura, which contain lipid emollient lubricants to
“stabilize the lipid layer of the tears and promote overall tear stability.

• Use a room humidifier to humidify environmental air. This can make a very big difference.

• By putting the humidifier in the bedroom or office, moist air can actually keep the eye surface
hydrated, instead of dry air depleting moisture out of the eyes.