The Correlation between POSTLASIK and Dry Eye Syndrome

Ibrahim Achmad 030.09.117

FACULTY MEDICINE OF TRISAKTI UNIVERSITY 2012

BACKGROUND
Young people

Nowadays eye surgeries are very often

The most commonly

LASIK
(Laser-Assisted In situ Keratomileusis)

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 Produce component of tear film via Goblet cell

refraction media

Etc.

sensory media for the eye

LASIK
Definition:
LASIK is a refractive surgery procedure that involves the use of a microkeratome astigmatism changes the curvature of the central part of the cornea correct the refractive errors

How it works?
LASIK

hyperopia

mild to high myopia

LASIK(2)
Procedure
Anesthesia

Open the external of cornea

Re-Shaped internal cornea(correc t the refraction)

LASIK(3)
Procedure(2)

Make a cornea flap with a blade

The Laser correct the refraction error

DRY EYE SYNDROME

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

Multifactorial
Dry eye syndrome

Disturbances

DRY EYE SYNDROME(2)

Produce water/aqueous layer Produce Oil/Lipid layer

Produce(Goblet cell) Mucin layer/Mucus

DRY EYE SYNDROME(3)

Classification
conditions affecting sensory innervations
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

Secondary Lacrimal Gland Deficiencies Primary Lacrimal Gland Deficiencies

age related dry eye conditions with lacrimal gland infiltration, e.g. sarcoidosis ,lymphoma, acquired immunodeficiency syndrome (AIDS), or graft versus host disease

Conditions associated with obstruction of lacrimal gland ducts

trachoma, cicatrical pemphigoid, erythema multiform, and chemical and thermal burns

CORRELATION
The Neurogenic Theory

The Mechanism for the Dry Eye Syndrome Post LASIK Theory 4, 5, 6, 7, 8, 9, 10, 11

The Risk Factors

The inflammatory theory

Sensory-Stimulated Reflex Cornea Decreased

Production of proinflammatory cytokines

Decrease Blink Rate

Decrease tear production

Induced neurotrophic epitheliopathy

Stromal Nerve Fibers Decreases With 90%

Other

Anatomy

Trauma

Dry Eye Syndrome

Changes in corneal curvature

Decrease limbal Goblet cells

Abnormalities in the distribution of tears

CORRELATION(2)
Neurogenic Theory
Sub basal nerve bundles and superficial stromal nerve bundles in the flap interface are cut by the microkeratome The Neurogenic Theory Sensory-Stimulated Reflex Cornea Decreased Decrease Blink Rate
*only nerves entering the flap through the hinge region being spared

Decrease tear production Stimulation of the lacrimal gland and secretion :

the cornea trigeminal nerve brainstem facial nerve lacrimal gland reflex arc

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

Dry Eye Syndrome

CORRELATION(3)
Inflammatory Theory
The inflammatory theory

Production of proinflammatory cytokines

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

Induced neurotrophic epitheliopathy

Stromal Nerve Fibers Decreases With 90%

Dry Eye Syndrome

CORRELATION(4)
Others
Other

Anatomy

Trauma

Dry Eye Syndrome

Changes in corneal curvature

Decrease limbal Goblet cells

Abnormalities in the distribution of tears

CORRELATION(5)
Risk Factors
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

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)

CORRELATION(6)
Risk Factors
Surgical risk factors

Other risk factors

the greater the myopic correction, the greater the dry eye symptoms evaluated 28 eyes of 18 patients (range1.5011.25 D) who underwent LASIK
GQ Guilherme, Camacho W ,Behrens A. Postrefractive surgery dry eye. Current Opinion in Ophthalmology 2008; 19: 33541

1. Female sex 2. Smoking 3. Moderate or large refractive errors/ the size of the ablation 4. Low corneal sensibility 5. Diseases of the ocular 6. Environmental factors(air conditioning, pollution, wind) 7. The use of computers(long periods of watching the computer)

INCIDENT
Japan (Hickichi)

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

Canadians (Caffery)

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

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

*women reported severe symptoms more often than men at a ratio of 46:1. Half (50.1%) of the contact lens wearing group reported dry eye symptoms

INCIDENT(2)
Asian(Julie and colleagues) reported that the incidence of chronic dry eye after LASIK in Asian eyes was 28 percent

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
3 months 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

5 months after LASIK

12 months after LASIK

2 years after LASIK

*patients who seek refractive surgery are often

contact lens intolerant and may have preclinical dry eye before surgery

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.

THANKYOU