The Correlation between POST-LASIK and Dry Eye Syndrome

Ibrahim Achmad030.09.117

FACULTY MEDICINE OF TRISAKTI UNIVERSITY2012

BACKGROUND

Nowadays eye surgeries are

very often

LASIK(Laser-Assisted In situ

Keratomileusis)

The most commonly

Young people

fully active who want to improve their

quality of Life

Not to depend on glasses or contact

lenses

side effects /adverse effects

DRY EYE SYNDROME

ANATOMY OF CORNEA

FUNCTION OF CORNEA

a protective membrane

refraction media

sensory media for the eye

Produce component of tear film via Goblet cell

Etc.

LASIK

Definition:LASIK is a refractive surgery procedure that involves the use of a microkeratome

How it works?

LASIKchanges the curvature of the central part of

the cornea

correct the refractive errors

mild to high myopiahyperopia

astigmatism

LASIK(2)

Procedure

AnesthesiaOpen the external of cornea

Re-Shaped internal cornea(correct the refraction)

LASIK(3)

Procedure(2)

1 2

3 4

Make a cornea flap with a blade

The Laser correct the refraction error

DRY EYE SYNDROME

DefinitionDry eye syndromes or Keratoconjunctivitis Sicca is a multifactorial disease of the ocular surface caused by an inadequate quantity or quality of the tears

Disturbances

Multifactorial

Dry eye syndrome

DRY EYE SYNDROME(2)

Produce water/aqueous layer

ProduceOil/Lipid layer

Produce(Goblet cell)

Mucin layer/Mucus

DRY EYE SYNDROME(3)

Classification

Primary Lacrimal Gland Deficiencies

Secondary Lacrimal Gland Deficiencies

Conditions associated with obstruction of lacrimal gland ducts

conditions affecting sensory innervations

age related dry eye

conditions with lacrimal gland infiltration, e.g.

sarcoidosis ,lymphoma, acquired

immunodeficiency syndrome (AIDS), or graft

versus host disease

trachoma, cicatrical pemphigoid, erythema

multiform, and chemical and thermal burns

herpes simplex keratitis, herpes zoster ophthalmicus, penetrating keratoplasty, PRK, LASIK, diabetes

mellitus, and topical anesthetic abuse, as well as secretomotor innervation, e.g. damage to the VII

cranial nerve and certain systemic medications

CORRELATIONThe Mechanism for the Dry Eye Syndrome

Post LASIK Theory 4, 5, 6, 7, 8, 9, 10, 11

Other

Anatomy Trauma

Changes in corneal curvature

Decrease limbal Goblet cells

Abnormalities in the distribution of tears

Stromal Nerve Fibers Decreases With 90%

Dry Eye Syndrome

The Neurogenic Theory

The inflammatory theory

Sensory-Stimulated Reflex Cornea Decreased

Decrease tear

production

Decrease Blink Rate

Production of pro-inflammatory cytokines

Induced neurotrophic epitheliopathy

The Risk Factors

CORRELATION(2)

Dry Eye Syndrome

The Neurogenic Theory

Sensory-Stimulated Reflex Cornea Decreased

Decrease tear production

Decrease Blink Rate

Neurogenic Theory

Sub basal nerve bundles and superficial stromal nerve

bundles in the flap interface are cut by the microkeratome

*only nerves entering the flap through the hinge region being spared

Rapid and forceful blinking can increase the thickness of the lipid layer. A low blink rate can thin the lipid layer.4, 5, 9, 10

Stimulation of the lacrimal gland and secretion :the cornea → trigeminal nerve → brainstem → facial nerve → lacrimal gland reflex arc

CORRELATION(3)

Stromal Nerve Fibers Decreases With 90%

Dry Eye Syndrome

The inflammatory theory

Production of pro-inflammatory cytokines

Induced neurotrophic epitheliopathy

Inflammatory Theory

It is described a neurotrophic epitheliopathy, it was established that post LASIK the number of stromal nerve fibers decreases with 90%. 11

CORRELATION(4)

Other

Anatomy Trauma

Changes in corneal curvature

Decrease limbal Goblet cells

Abnormalities in the distribution of

tears

Dry Eye Syndrome

Others

CORRELATION(5)

Risk Factors

Hinge (smaller width, superior position – sectioning of the nerve fibers from the nasal and temporal sub epithelial plexus)

Flap (a large diameter, thicker, done mechanically or with the femtosecond laser )

Larger ablation ( for the patients with higher diopters)

Surgical risk factors Other risk factors

Preoperative and postoperative corneal sensation at the nasal flap hinge, at the central cornea and within the temporal flap edge was measured before and after LASIK for a 3-week period using the Cochet-Bonnet esthesiometer.

Corneal sensation initially decreased in all three positions of the flap measured after LASIK and the greatest decrease was in the central cornea. 5

CORRELATION(6)

Risk Factors

Surgical risk factors Other risk factors

1. Female sex2. Smoking3. Moderate or large refractive errors/ the size of the ablation4. Low corneal sensibility5. Diseases of the ocular6. Environmental factors(air conditioning, pollution, wind)7. The use of computers(long periods of watching the

computer)

the greater the myopic correction, the greater the dry eye symptoms evaluated 28 eyes of 18 patients (range1.50–11.25 D) who underwent LASIK

GQ Guilherme, Camacho W ,Behrens A. Postrefractive surgery dry eye.

Current Opinion in Ophthalmology 2008; 19: 335–41

INCIDENTJapan (Hickichi)

13,517, including all age groups, reported dry eye symptoms among 28.7% of respondents.

*women reported severe symptoms more often than men

2,127-person sample 17% suffered from dry eye symptoms

Canadians (Caffery)(The report included 60% women and 24% contact lens wearers)

at a ratio of 46:1. Half (50.1%) of the contact lens wearing group reported dry eye symptoms

INCIDENT(2)

reported that the incidence of chronic dry eye after LASIK in Asian eyes was 28 percentAsian(Julie and colleagues)

Asia has the highest incident of all three.

Julie MA, Lee ML, Suzanne G, Maclennan B (2005): Dry eye after LASIK Comparison of outcomes for Asian and Caucasian eyes. Clin Exp Optom; 88:2: 89-96.

Indonesia ?

REGENERATION

*patients who seek refractive surgery are often contact lens intolerant and may have preclinical dry eye before surgery

3 months after LASIK

5 months after LASIK

12 months after LASIK

2 years after LASIK

Regeneration of anterior stromal, subbasal, and epithelial nerve fibers

Deep stromal nerves may show abnormal morphology even 5 months after the procedure

Corneal sensitivity seems to be at its lowest 12 weeks after LASIK, and by 12 months sensitivity has recovered to normal levels

Corneal sensitivity was close to normal values by 2 years post LASIK

AW Micheal. Current Understanding of the Pathophysiology of Dry Eye Disease. Eyewitness Second Quarter. 2002

ST Ilpo.2008. Corneal Nerves In: Refractive Surgery and Dry Eye. thesis, department of ophthalmology university of helsinki

CONCLUTION

There is a correlation between Post-LASIK between dry eye syndrome. Many theories about the correlation. The mechanism for the dry eye syndrome post LASIK can be explained by neurogenic theory is theory of decreasing Sensory-Stimulated Reflex Cornea, Inflammatory theory, and others is about anatomy and trauma because of the LASIK. and from several sources is associated with risk factors such as during surgery and factors of the patients themselves such as a woman, smoking, and others.

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