Severe Dry Eye Surgical Treatment | PristynCare

Risk Factors

Patients most at risk for severe dry eye requiring surgery include those with:

• Sjogren syndrome with marked lacrimal gland dysfunction
• Stevens-Johnson syndrome or ocular cicatricial pemphigoid
• Neurotrophic keratopathy from herpes virus or previous surgery
• Prior radiation to the head and neck region
• Post-LASIK dry eye with persistent neuropathic component
• Longstanding contact lens use with limbal damage

Who is a Candidate

Patients with severe aqueous deficient dry eye or evaporative dry eye who have not responded to topical cyclosporine, punctal plugs, and lubricating drops are candidates for surgical intervention. Candidates must have adequate eyelid anatomy and no active ocular infection. Neurotrophic keratopathy with persistent corneal defects is a strong indication for early surgical management.

Diagnosis

Evaluation before surgical dry eye management includes:

• Schirmer test and tear break-up time (TBUT) measurement
• Ocular surface staining with fluorescein, rose bengal, or lissamine green
• Meibomian gland imaging and function assessment
• Tear osmolarity and MMP-9 inflammatory marker testing
• Corneal sensation testing for neurotrophic keratopathy
• Anterior segment OCT for epithelial thickness mapping

Treatment Plan

Treatment is staged from least to most invasive. Surgical punctal occlusion is performed first if punctal plugs have provided partial relief. Tarsorrhaphy is used for neurotrophic or exposure keratopathy. Amniotic membrane transplantation is used for acute surface decompensation. Salivary gland transplantation is considered for end-stage aqueous deficient dry eye in select patients.

Dry Eye Surgical Treatment Steps

Surgical procedures for severe dry eye are performed based on the underlying cause:

• Surgical punctal occlusion: The lacrimal puncta are cauterized or plugged with a permanent occlusive material under local anesthesia
• Tarsorrhaphy: The upper and lower eyelid margins are sutured together partially to reduce corneal exposure; performed under local anesthesia
• Amniotic membrane grafting: Dehydrated or fresh amniotic membrane is placed on the cornea and sutured or fixed with a ring device under topical anesthesia
• Salivary gland transplantation: The submandibular gland with its duct is dissected and transferred to the periorbital region to drain onto the eye surface; performed under general anesthesia

Recovery After Surgery

Recovery after surgical dry eye procedures involves:

• Continued use of lubricating and anti-inflammatory eye drops post-operatively
• Avoid rubbing or touching the surgical site
• Attend follow-up visits every 2 to 4 weeks in the first 3 months
• Tarsorrhaphy sutures may be adjusted or reopened as the cornea heals
• Amniotic membrane may dissolve over 2 to 4 weeks; monitor the underlying surface
• Salivary gland transplant patients require dietary adjustments and gland massage

Risks and Complications of Dry Eye Surgery

Potential complications of dry eye surgical procedures include:

• Punctal occlusion complications: Epiphora (excessive tearing) if aqueous production improves
• Tarsorrhaphy complications: Lagophthalmos, cosmetic concerns, and suture complications
• Amniotic membrane failure: Inadequate healing of the underlying epithelial defect
• Salivary gland complications: Crocodile tears phenomenon, mucus secretion, and gland malfunction
• Infection: Post-operative bacterial or fungal keratitis
• Disease progression: Despite surgical intervention, severe autoimmune dry eye may continue to worsen

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