Laser-Assisted In Situ Keratomileusis (LASIK) is a widely performed refractive procedure designed to correct vision errors. Dry eye syndrome (DES) is a common condition characterized by insufficient tear production or poor-quality tears that evaporate too quickly, leading to ocular discomfort. For individuals with DES considering LASIK, the interaction between the surgery and the compromised tear film is a major concern. Whether a person with dry eyes can have LASIK depends entirely on the severity of the pre-existing condition and the ability to manage it before and after the procedure.
Why LASIK Interacts with Tear Production
The reason dry eye is a significant concern in the context of LASIK lies in the procedure’s mechanical impact on the corneal nerves. During surgery, a hinged flap is created on the cornea’s surface to allow the underlying tissue to be reshaped by the laser. This process temporarily severs thousands of tiny corneal nerves responsible for signaling the brain to produce tears.
The resulting decrease in corneal sensation is a temporary condition known as neurotrophic dry eye, which significantly reduces the reflex tearing response. Because the eye surface feels less irritation, it does not prompt the necessary tear production to maintain a stable tear film. While this effect is temporary for most patients, lasting a few weeks to months as the nerves regenerate, those with pre-existing dry eye are at a higher risk for prolonged or more severe symptoms.
Preoperative Evaluation and Qualification Criteria
A thorough preoperative evaluation is paramount for determining candidacy and mitigating the risk of long-term postoperative dry eye. Surgeons employ several diagnostic tools to measure the quality and quantity of the patient’s tear film. The Schirmer’s test, for instance, measures the volume of tear production by placing a small strip of filter paper inside the lower eyelid to check wetting length over a set period.
Another standard measurement is the tear film breakup time (TBUT), which determines the stability of the tear film by observing how quickly the tears evaporate between blinks after a dye is applied. Corneal staining is also performed using specialized dyes to identify any existing damage or dry spots on the corneal surface caused by insufficient lubrication. Patients presenting with mild dry eye are often considered candidates, provided their condition can be managed and optimized before surgery. However, severe or unmanageable dry eye disease is considered a definitive contraindication for LASIK, as the procedure would likely worsen the symptoms.
Preparing Borderline Patients for Surgery
For patients who are otherwise good candidates but present with mild or moderate dry eye, a period of aggressive pre-surgical treatment is required to optimize ocular surface health. This preparatory phase aims to stabilize the tear film and ensure the cornea is in the best condition for healing. One common approach involves prescription anti-inflammatory eye drops, such as cyclosporine or lifitegrast, which reduce surface inflammation and promote natural tear production.
Other treatments focus on improving tear retention and quality. These methods include:
- Tiny devices called punctal plugs may be temporarily inserted into the tear ducts to slow tear drainage, keeping the eye surface moist for longer periods.
- Nutritional supplements containing Omega-3 fatty acids, like fish or flaxseed oil, are recommended to improve the quality of the tear film’s oily layer.
- In-office procedures, such as Intense Pulsed Light (IPL) therapy, may be used to address meibomian gland dysfunction, a common cause of evaporative dry eye, by clearing blockages and improving oil secretion.
Vision Correction Alternatives for Severe Dry Eye
When a patient’s dry eye is severe or cannot be adequately controlled through pre-treatment, LASIK is ruled out, but other surgical options remain available. Photorefractive Keratectomy (PRK) is a common alternative that is safer for patients with pre-existing dry eye. Unlike LASIK, PRK does not involve creating a corneal flap; instead, the outer layer of the cornea is removed before the laser reshapes the underlying tissue.
Since PRK is a surface ablation procedure, it disrupts fewer corneal nerves than LASIK, leading to a lower risk of long-term neurotrophic dry eye. Another option is the Implantable Collamer Lens (ICL), an intraocular procedure where a biocompatible lens is placed inside the eye, behind the iris, without altering the cornea’s structure. ICLs are an excellent choice for those with significant dry eye because they do not affect the corneal nerves or the tear film, making them effective.