Ocular Surface Diseases and Corneal Refractive Surgery

Debora Garcia-Zalisnak; David Nash; Elizabeth Yeu


Curr Opin Ophthalmol. 2014;25(4):264-269. 

In This Article

Abstract and Introduction


Purpose of Review. The purpose of this article is to provide an overview and update on recent literature regarding ocular surface disease and corneal refractive surgery.

Recent Findings. Studies involving ocular surface disease and/or keratorefractive (corneal) surgery published found on the Medline database were included in the report. Studies focused on mechanisms of refractive surgery induced dry eye disease, surgical options, including modification of technique, to prevent dry eye, and postoperative dry eye prevention and management by way of both established and novel therapies.

Summary. By understanding the mechanisms of postoperative dry eye as well as patient risk factors for dry eye, patient satisfaction and surgical outcomes can be maximized. Patients identified as having an increased risk for postoperative dry eye may benefit from surgical techniques such as small-incision lenticule extraction (SMILE) and femtosecond laser-assisted in-situ keratomileusis (LASIK). Employing well known therapies such as preserved and nonpreserved artificial tears, nutritional supplements, topical cyclosporins, punctal plugs and autologus serum as well as novel therapies such as insulin-like growth factor 1, neuropeptides and acupuncture could provide improve outcomes and, if started early, could allow more patients to be candidates for corneal refractive surgery.


Dry eye disease is the popular broad name for a common risk factor and complication after corneal refractive laser surgery. More appropriate is the term ocular surface disease. This encompasses aqueous deficiency, meibomian gland dysfunction, blepharitis, rosacea, allergies, medication-induced scarring and chemical or thermal burns.

Any preoperative ocular surface conditions can affect patient outcomes after corneal refractive surgery and therefore all patients considering refractive surgery should be thoroughly evaluated for ocular surface disease. A history of irritation, tearing, burning, stinging, foreign body sensation, mild itching, photophobia, contact lens intolerance, redness, mucous or watery discharge, increased frequency of blinking, eye fatigue and diurnal fluctuation of symptoms usually worse later in the day should be solicited. Patients with ocular surface disease usually endorse exacerbating factors such as wind, air, travel, decreased humidity and/or prolonged visual efforts leading to a decreased blink rate. Topical medications such as glaucoma drops, vasoconstrictors, corticosteroids, antihistamines and some homeopathic preparations, as well as the preservative such as benzalkonium chloride, can exacerbate symptoms as well.

It is also important to note any prior ocular disease that could predispose to surface conditions such as herpes simplex virus (HSV), herpes zoster virus, mucous membrane pemphigoid, Stevens–Johnson syndrome, Bell's palsy with resultant orbicularis weakness or graft-versus-host disease as well as any ocular or eyelid surgery.

Pertinent past medical history to obtain when evaluating a patient for ocular surface disease includes history of dermatological diseases such as rosacea, psoriasis, atopy, systemic rheumatologic or autoimmune diseases such as Sjogren's syndrome, rheumatoid arthritis, systemic lupus erythematous, scleroderma and sarcoidosis. Inquiring about menopause is also pertinent, as postmenopausal women are at an increased risk of developing ocular surface disease. History of eye or facial trauma, chronic infections such as hepatitis C or HIV, radiation to the orbit, neurologic diseases, dry mouth, dental cavities and/or oral ulcers are all important information to include in the patient's history.

Physical examination should include a visual acuity, examination of the skin, eyelids and adnexa, evaluation for proptosis, cranial nerve function and a slit lamp examination focused on tear film integrity, eyelashes, anterior and posterior eyelid margins, puncta, fornix, bulbar and tarsal conjunctiva, and a detailed examination of the cornea to assess for localized areas of dryness, epithelial erosions, punctate staining, filaments, epithelial defects, basement membrane irregularities, mucous plaques, keratinization, pannus formation, thinning, infiltrates, ulceration, scarring, neovascularization or any evidence of prior refractive surgery.[1]