Joel Hunter, MD Refractive Surgeon, Hunter Vision Updated 11/24/20 2:02 PM
One of the most common questions I get when someone is deciding on whether or not they want to get LASIK is whether or not they will get dry eyes afterward. I’m always glad when someone asks me because it means they’ve been doing some research on the idea, and more research is always better when people are feeling stressed about whether or not laser vision correction will be safe and/or effective.
There’s a reason that “dry eyes” (known in medical circles as "keratoconjunctivitis sicca" but I’ll stick to "dry eyes" to avoid being called a nerd) comes up as a result when searching for LASIK complications. Namely, it’s one of the known complications. But in a larger sense, that’s not as accurate as we can be about it with the current information available to us. Because it’s also true that infection is a known complication of ear piercing, but in that example, most people already know it’s a much different level of risk to get your ears pierced by a professional in a controlled environment vs. doing it yourself with a staple in middle school.
Incidentally, I know someone who did that and while I won’t give his name, I will say he works here and his office is by mine and his name is Josh Hunter.
What causes dry eyes after LASIK surgery
We know a lot about dry eyes after LASIK at this point—tons more than we knew about it in the 1990s. I actually attended lectures at conferences while theories were still being posited on what caused dry eyes.
It turns out almost all of the answer is nerves. The corneal nerves send information saying the eyes need more tears, and then you make more tears. When you do LASIK, a percentage of those nerves are shut down from sending that information, and then your eyes get dry.
Another (exceptionally rare) cause would be severe inflammation of the eyes from the surgery. For example, diffuse lamellar keratitis (DLK) or what we often call as "Sands of the Sahara" occurs when there is inflammation between the flap and corneal stroma that was created in the surgery. Any pre-existing dry eye state can be made chronic by DLK.
We learned some of that from good, old-fashioned, bench-in-a-lab research, and we learned more and confirmed more about it with the ever-vanishing incidence of dry eyes with modern LASIK. It’s a rare problem these days and one that I’ve always been able to fix when it happens, because of the big leaps in technology—both laser and pharmacologic —that have occurred in recent years.
What happens when you have dry eyes after LASIK surgery?
Post-LASIK surgery patients with dry eyes experience difficulty in focusing when there is light inside a room or outside when the sun's out. Another common complaint is having a sand-like material seemingly inside the eye. Others suffer from blurred vision, burning sensation, itchiness, and heavy eyes.
However, if there is severe pain that has taken its toll on your daily activities, consult your doctor immediately to assess your condition.
Is "dry eyes" after LASIK normal?
Following the LASIK procedure, it is common for most patients to experience dry eyes. Dry eyes were a relatively common complication of LASIK, and that we rarely see it now. Since “rare” is vague, I’ll be more specific with a semi-specific educated guess of a number. At Hunter Vision, probably 1 in 50 people who are good LASIK candidates and take the prescribed drops still need to be cured of dry eyes after the three month LASIK post-op visit.
Several studies have documented the high occurrence of dry eyes among LASIK patients. In 2014, it was found out by medical researchers from Harvard Medical School that 95 percent of LASIK patients experienced dry eyes right after their surgery while 60 percent still had the condition after a month.
In another study, the Food and Drug Administration (FDA) discovered in its Patient-Related Outcomes With Lasik (PROWL) reports that about 28 percent of more than 500 patients experienced dry eyes within 3 months. This ranged from mild to severe symptoms.
Furthermore, research from Japan revealed that post-LASIK dry eye syndrome is common but does not last too long. Neuron damage, goblet cells (those that contribute to mucus secretion) dysfunction, and disfigured corneal shape are severe (and, thank God, super rare) complications. I have never witnessed any of these complications and I’m very glad.
So if you’re wondering if dry eyes may develop after your LASIK surgery, there’s a chance that it can happen but it’s almost certainly temporary as long as you follow your eye doctor’s recommendations including regular post-surgery consultations.
Who is at risk of dry eyes after LASIK?
Another common question that I receive is, "Will I have a dry eye after LASIK?" What comes as a surprise to them is that some LASIK patients already have dry eyes even before undergoing LASIK.
Research from the Chinese University of Hong Kong revealed that many patients (estimated to be 50 percent) already have dry eye symptoms prior to their refractive surgery. Some patients, according to the study, with preexisting dry eye symptoms have abnormal tear flow condition.
Low tear development may be a result of tear gland damage, aging (usually those older than 50 years), diabetes, thyroid issues, Sjogren's syndrome or Vitamin A-deficient diet. If you're taking medications such as antihistamines, antidepressants, decongestants and even medicines to control high blood pressure and acne, these can also contribute to dry eyes.
Some patients who blink less, who have eyelid issues, or who are exposed to environments with dry air or too much smoke may also develop faster tear evaporation. Finally, those who have inflammation around the eyelids can experience dry eyes. Usually, women who have hormonal changes as a result of taking birth control pills, going through menopause, or pregnancy may experience dry eyes more often.
Contact lenses also cause eyes to dry out, although I have to be clear about this: when contact lenses are the primary reason for the eyes to dry, we call it contact lens-induced dry eye (CLIDE) to be more precise. Nevertheless, the effects are the same, which include itchiness, fatigue, soreness coupled with a momentary stinging and burning feeling. This is brought about by the contact reducing the slickness or “wetability” (that’s the actual word for it) of the surface of the eye.
Studies by medical researchers from the University of Miami and Complutense University of Madrid in Spain discovered that those with a long history of wearing contact lenses prior to their LASIK treatment are more likely to have dry eyes after the surgery. More specifically, tear secretion and sensitivity of the cornea are the main causes of such condition.
Those who wear contact lenses are also prone to dry eyes because some patients prefer to prolong the use of contact lenses beyond their normal life. Allergens may also come in contact with the contact lenses when poor hygiene practices are observed. Finally, some people keep their contact lenses in long after the recommended time for removal, which causes their eyes to suffering from extra wear and tear (no pun intended here).
If you have myopia, then this can also be a contributing factor to dry eyes after your LASIK surgery. According to a medical study, patients who are myopic prior to their LASIK surgery had a higher incidence rate of dry eyes after six months of the treatment.
Your ancestry may also have to do with developing dry eyes. Researchers from Australia compared dry eye complications among LASIK surgery patients with Asian and Caucasian origins. They found out that the risk of post-LASIK dry eyes occurs higher among the former. The reason? The researchers attribute it to the anatomy of the Asian patients’ eyes having different eyelids, tear film parameters, and blinking frequency.
These pre-existing dry eye conditions should be evaluated by the eye doctor prior to the surgery. Sometimes dry eyes need to be resolved first before moving on with LASIK, but this should be handled on a case-by-case basis.
What tests can be done to determine the extent of dry eyes?
The success of LASIK surgery will also depend on the existing health of your eyes. Apart from determining your overall condition and any history or presence of eye-related disease, your eye doctor may require you to take a combination of different tests.
This may include the Schirmer test to measure your tear production, non-invasive tear breakout time (TBUT) to measure tear film stability, fluorescein clearance test to measure tear turnover rate or tear clearance, and meibography to measure tear film lipid layer, among others.
How long do dry eyes after LASIK last?
Dry eyes are likely to occur a few months after LASIK surgery. However, this is still a case-to-case basis. Some patients already experience it just a few weeks after the procedure, while some don't. Those with preexisting dry eye conditions are at a higher risk of prolonged dryness after the surgery as evidenced by a study although this may not always be the case as concluded by researchers at the Baylor College of Medicine who found out that patients with no history of dry eyes are most likely to develop such condition after LASIK treatment.
The good thing about this is that your eye condition should improve over the course of the healing period. But how long will the temporary dry eyes last? One study by ophthalmologists found out that among the patients they surveyed, 95 percent have complained about dry eyes a day after the surgery. This was reduced to 85 percent after a week and then declined to only 59 percent after a month.
This is supported by a study from the Cullen Eye Institute at Baylor College of Medicine in Houston when research results revealed that almost 40 percent of patients had dry eyes after LASIK after the first month then gradually dropped to only 20 percent after three months.
The speed of recovery from dry eyes still depends on the patient, the surrounding environment (if he is less exposed to sunlight, dust, and harmful particles), lifestyle, and faithfulness to observe self-care procedures prescribed by the doctor.
What can be done to prevent dry eyes before undergoing LASIK surgery?
There are plenty of ways on how you can prevent dry eyes. For instance, your environment can significantly contribute to your eye condition. Avoid, as much as possible, places where there are cigarette smoke and too much moisture in the air.
Your workplace can also contribute to dry eyes. Prolonged exposure in front of the computer screen can reduce your blinking. In addition, if you stare at the computer screen with your eyes wide open then tear evaporation will be much faster. For those working in places located in high altitudes or in airplanes, the air can be dry and thus impact your eyes. Make sure to take the necessary precautions to minimize the effect of your workplace environment.
Also, try to avoid air from being blown directly to your eyes. We often become unaware of how much air conditioners affect dryness when directed towards us while watching TV or working in front of the PC.
Modify your diet with the addition of food rich in omega-3 fatty acids. Your meals can be healthier with tuna, sardines, oysters, anchovies eggs, chia seeds, and ground flaxseed. Use palm, soybean and flaxseed oil often too. Now is also the best time to eat caviar.
What to do with dry eyes after LASIK surgery
The reason dry eyes are less common now is that we have access to the reason that dry eyes is common for the first three months. The corneal nerves need some time to recover, and once they do, all is well. We use that information in four actionable ways to limit the incidence of dry eyes:
1. Don’t do LASIK if someone already has a compromised level of tears.
This means saying “no” or “do this treatment first” to a lot of people, which is sad but still overall a very nice thing to do if you like people, which I do. I should point out, however, that difficulty with contacts because of dry eyes is a “no” but is very different from the much more common difficulty with dry eyes because of contacts. People in the second group are some of the happiest LASIK patients. I was one of them.
2. Recommend Restasis to every LASIK patient for the first eight weeks after laser.
It makes the corneal nerves heal faster during that initial period. It isn’t required for most people, but it is recommended for all of them.
3. Use artificial tears every two hours for two months.
While we are waiting for the tear film to return to normal, artificial tears do an honorable job keep the surface of the eye quiet and smooth, which keeps unnoticeable, low levels of inflammation away. That makes healing easier.
Researchers from the John Hopkins University School of Medicine also found out that patients with post-refractive surgery dry eyes improved their condition when administered with artificial tears. Another study by doctors on post-LASIK tear dysfunction revealed that artificial tears, particularly with no preservatives, work best when the patient blinks less often after the surgery.
4. When doing LASIK, take the extra time to perfectly, beautifully, symmetrically, obsessive-compulsively finish the procedure so precisely that it is difficult to impossible to tell that you just did LASIK.
It adds about one minute of operating time. And I can just feel the technicians around me rolling their eyes on around the 15th round of smoothing (they’re nice, so they probably aren’t). But if you want those nerves to heal perfectly, you’ve got to be the type of surgeon that feels physical pain and gets hives when watching a YouTube video of a LASIK surgery that was done competently but not perfectly.
When those four points are adhered to, we just don’t hear a lot about dry eyes anymore. It’s why I like when people do their research on this stuff. It usually leads to good questions, and good questions should either have good answers or if not, set off some alarm bells for the doctor and the patient to re-evaluate the path ahead.
Why you should not wait too long to get LASIK
If you’re still worried about the risks of LASIK treatment, even if you have read this lengthy and comprehensive discussion on dry eyes after LASIK, I see no reason why you have to delay your plans of getting a LASIK consultation where you’re qualified in the first place.
As I’ve mentioned in a previous post that has helped a lot of people make sense of it, “If there is a way to make your life easier or better, then it makes sense to do that sooner than later.”
But then, next comes the question of affordability. Can you pay for LASIK?
Is LASIK expensive or already affordable?
Here’s what I often ask my patients before they consider the total costs involved in LASIK: What’s your vision worth?
My patients who have successfully undergone refractive surgeries are always delighted by the results in terms of restoring their eyesight. There’s no denying that LASIK can be expensive but there is no better investment they’ve made in their lives – not even the new car they bought – than getting eyes that work perfectly without needing glasses or contacts. (As a side note, if you want to learn more about it, read about the top 8 reasons why people choose us for vision correction.)
But whoever thought that something that’s expensive can still be affordable? In all honesty, getting eye surgery won’t require you to burn a hole in your pocket these days.
We have payment plans available that make vision correction surgeries affordable for almost everyone. We know tight budgets make it tough to come up with a “chunk” of money rather than paying overtime in bite-sized bits.
Our affordable payment plans for vision correction surgeries including LASIK can fit your tight budget. That's why we offer payment plans for as low as $130 per month - yes, that's not a typo - so you can start and end your day without your eyeglasses.
Author:Joel Hunter, MD is an Ophthalmologist, Refractive Surgeon, and the Founder of Hunter Vision, a LASIK Clinic in Orlando, Florida. A recognized and respected specialist in vision correction who has performed a countless number of refractive surgeries, Joel gives lectures across the country and trains fellow doctors in the newest LASIK surgery techniques.