Welcome to the first issue of Refractive Surgery Outlook! -- Chief Medical Editor, Marguerite B. McDonald, MD, FACS

CLINICAL UPDATES
- Eric Donnenfeld, MD, offers a primer on LASIK-associated dry eye
- WaveLight excimer laser appears safe, effective for hyperopia
- Intraoperative epithelial defects on the LASIK flap should be considered a severe complication
- Physicians may need to manage refractive expectations of some patients prior to cataract surgery
- Artificial tears provide temporary but significant improvement in visual acuity in dry eye patients
- Cytochrome c peroxidase significantly accelerates epithelial healing after PRK
- Excimer laser refractive surgery appears effective in treating fully refractive accommodative esotropia
- Large pupil decentration and iris tilting angle may be risk factors for reduced visual outcomes following refractive surgery
- LASIK safe, effective following other corneal surgical procedures

ISRS/AAO INFORMATION
- Abstract deadline for the 2006 ISRS/AAO meeting in Istanbul is Feb. 1
- Registration for the 2006 ISRS/AAO meeting in Istanbul is now open
- Review the latest news on the business side of refractive surgery
- Upcoming Meetings

INDUSTRY NEWS
- Academy now accepting nomination forms for its highest honor, the Laureate Award
- FDA approves foldable collamer lens for the correction of myopia in adults
- American surgeon has reportedly performed the first all-laser “top hat” cornea transplant
- Accommodating IOL approved for sale in Europe

CLINICAL UPDATES

Eric Donnenfeld, MD, offers a primer on LASIK-associated dry eye
In this feature article, Dr. Donnenfeld reviews the latest thinking on the causes of this condition, how to screen patients for dry eye and/or associated risk factors and how to treat dry eye before and during surgery.

WaveLight excimer laser appears safe, effective for hyperopia
This prospective study included 120 patients treated for hyperopia with or without astigmatism with the ALLEGRETTO WAVE excimer laser. At 12 months follow-up, 92 percent of eyes with low hyperopia were within ±0.50 D of the refractive goal. Among the moderate and the high hyperopia/toric groups, 79 percent and 71 percent of eyes, respectively, were within ±0.50 D of the refractive goal. No eye lost more than two lines of BSCVA. An increase in higher order aberrations was noted in the high hyperopia/toric group from 0.47 µm (±0.096) to 0.94 µm (±0.167) (P<.001). No significant changes in higher order aberrations were noted among the low or moderate hyperopia groups. Journal of Refractive Surgery, January/February 2006

Intraoperative epithelial defects on the LASIK flap should be considered a severe complication
This study included 26 patients with epithelial defects on the LASIK flap in one eye and no defects in the contralateral eye. Pre- and post-operative data were compared between the two groups at three, six and 12 months. Diffuse lamellar keratitis was observed in 58 percent of eyes in the epithelial defect group. These eyes also had more under-corrections at six and 12 months and a higher corneal irregularity index at six and 12 months compared with controls. The epithelial defect group took longer to recover visual acuity, showing more under-correction at three and six months postoperatively. By month 12, there was no statistically significant difference. Also, 76 percent lost best spectacle-corrected visual acuity at three months, compared to just 7 percent in the control group. By month 12; however, only 7 percent of the epithelial defect group and no eyes in the control group lost more than one line of BSCVA. Journal of Refractive Surgery, January/February 2006

Physicians may need to manage refractive expectations of some patients prior to cataract surgery
This prospective questionnaire study of 189 patients attending a preoperative assessment clinic for elective cataract surgery finds patients already wearing distance correction thought it significantly more likely that they would need distance glasses postoperatively than those who did not. The authors conclude this latter group is at particular risk for refractive disappointment and complaint. Similar differences in expectations were demonstrated for near correction. Median score of the importance of being free of spectacles was eight for both distance and near. Men scored this higher than women, but only for distance. There was a weak negative correlation between the importance of spectacle independence and patient age. Journal of Cataract & Refractive Surgery, October 2005

Artificial tears provide temporary but significant improvement in visual acuity in dry eye patients
This prospective, nonrandomized study treated 40 patients, half with symptomatic dry eye and half with asymptomatic dry eye, with Allergan’s Refresh Plus (carboxymethylcellulose 0.5 percent). All patients were 40 and older and were recruited from a clinic setting over a one-month period. A statistically significant improvement in uncorrected and corrected near and distance vision was observed in both groups of patients (P < .05). The mean duration of improvement of vision was 2.93 minutes in the symptomatic group and 3.70 minutes in the asymptomatic group (P = .036). The authors conclude this finding may be of diagnostic value in detecting ocular surface abnormality in symptomatic and asymptomatic patients. American Journal of Ophthalmology, November 2005

Foldable iris-fixated phakic intraocular lens shows promise in treating myopia
Twenty-two myopic patients (41 eyes) age 18 to 56 with an average sphere of -8.2±2.01 D and average preoperative cylinder of -0.90±0.62 D underwent implantation of a foldable iris-fixated PIOL with an optical zone of 6.0 mm. At six months follow-up, uncorrected visual acuity was significantly improved, with 82 percent of eyes reaching 20/25 or better. No eye experienced a loss in BSCVA, while 78 percent gained one or more lines of their preoperative BSCVA. There was a significant reduction in spherical errors in all patients after surgery. Ninety-one percent of eyes were within ±0.50 D of target refraction. A slight loss of endothelial cells (2.3 percent) was observed six months after surgery. No intraoperative complications occurred, but pigment precipitates were noted in four patients (five eyes) postoperatively. Ophthalmology, December 2005

Cytochrome c peroxidase significantly accelerates epithelial healing after PRK
After uneventful bilateral photorefractive keratectomy for low to moderate myopia and myopic astigmatism, 36 patients (72 eyes) received the standard postoperative therapy plus cytochrome c peroxidase eyedrops in one eye (three times a day for one week or until corneal re-epithelialization was completed, corresponding to 15 000). The other eye received standard postoperative therapy plus placebo. All the eyes treated with cytochrome c peroxidase eyedrops healed completely before day 5 postop, with a mean re-epithelialization time of 91 hours ± 14 (SD), compared to 154 ± 9 in eyes receiving placebo. There were no statistically significant differences between the two groups in corneal haze presentation during follow-up (P =.70), which the authors conclude might be due to the short time period (seven days). But the authors note that corneal clarity on slitlamp biomicroscopy was greater in the study group than in the control group. No side effects or toxic effects were documented. Journal of Cataract & Refractive Surgery, October 2005

Excimer laser refractive surgery appears effective in treating fully refractive accommodative esotropia
After a simulation of the cycloplegic correction with contact lenses over a 30-day period, 18 patients affected by fully refractive accommodative esotropia underwent refractive surgery (eight patients had PRK, 10 had LASIK). All but one patient experienced a reduction of the angle of deviation. This patient also presented with a regression of refractive error and of the angle of deviation at two years postop. The two-year follow-up showed that the mean angle of deviation in PRK was 2 esophoria at near and 0.4 esophoria at distance (P<.06); in LASIK, it was 1.7 esophoria at near and 0.2 esophoria at distance (P<.06). The difference between the two groups was statistically insignificant at near and distance and for spherical equivalent. Journal of Cataract & Refractive Surgery, October 2005

Large pupil decentration and iris tilting angle may be risk factors for reduced visual outcomes following refractive surgery
Orbscan was used to assess the degree of pupil decentration and tilting angle of the iris in 1,144 myopic patients (2,280 eyes) without abnormal findings. The mean pupil decentration in all eyes was 0.19 mm ± 0.11 (SD) (range 0 to 0.9 mm), and the mean tilting angle of the iris was 4.06 ± 1.41 degrees (range 0.19 to 12.69 degrees). By multiple analyses of variance (ANOVA), refractive power, pupil decentration and tilting angle of the iris were significant for the reduction of BSCVA. Journal of Cataract & Refractive Surgery, October 2005

LASIK safe, effective following other corneal surgical procedures
This retrospective review included 71 eyes (57 patients) undergoing LASIK for refractive errors following radial keratotomy (22), astigmatic keratotomy (13), photorefractive keratectomy (18) and penetrating keratoplasty (18). The mean preoperative manifest refractive spherical equivalent (MRSE) was -3.93 diopters (D) ± 2.83 (SD) in myopic eyes and +1.43 ± 1.79 D in hyperopic eyes. The mean time from the initial corneal surgical procedure to LASIK was 65.0 months. The mean post-LASIK follow-up was 9.40 months. Postoperatively, the mean MRSE was -0.85 ± 1.42 D in myopic eyes (P<.0001) and -0.16 ± 1.09 D in hyperopic eyes (P<.0001). Enhancement by LASIK was required in 14 percent of eyes. Journal of Cataract & Refractive Surgery, November 2005

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ISRS/AAO INFORMATION

Abstract deadline for the 2006 ISRS/AAO meeting in Istanbul is Feb. 1
The ISRS/AAO Grading Committee will review all proposals submitted by Feb. 1, 2006 and make its decision no later than Feb. 27. Acceptance notices will be e-mailed.

Registration for the 2006 ISRS/AAO meeting in Istanbul is now open
Register today and save on registration fees. Early registration ends March 1. The program schedule is also live on our Web site. ISRS/AAO is sponsoring the meeting, International Refractive Surgery: Art and Science, in partnership with the Turkish Cataract and Refractive Division of the Turkish Ophthalmological Society. It’s scheduled for May 26 to 28.

Review the latest news on the business side of refractive surgery
Read the December issue of Irving Aron’s Refractive Highlights, now live on the ISRS/AAO Web site.

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INDUSTRY NEWS

Academy now accepting nomination forms for its highest honor, the Laureate Award
The Laureate Recognition Award recognizes individuals from around the world who have made exceptional scientific contributions to the betterment of eye care, leading to the prevention of blindness and restoration of sight worldwide. Deadline for submissions is March 31, 2006.

FDA approves foldable collamer lens for the correction of myopia in adults
STAAR Surgical reports that its Visian ICL “allows an incision up to 50 percent smaller than competing technology, and its placement in the eye behind the iris provides a more aesthetically pleasing outcome.” STAAR said it will begin shipping the phakic IOL to “trained doctors” in six to eight weeks. The lens is already approved for sale in 41 countries, including those in the European Union. STAAR said the lens has been implanted in more than 40,000 eyes worldwide.

American surgeon has reportedly performed the first all-laser “top hat” cornea transplant
The Corneal Research Foundation of America reports that Francis W. Price, Jr., MD, has used the IntraLase FS laser to precisely cut a graft designed to provide faster and stronger healing compared with traditional transplant methods. The high-speed femtosecond laser allows the surgeon to produce “complex contours and custom designs” for each transplant patient, Price said. It's called the top-hat procedure because the donor button is shaped with a lip of tissue, like the brim of a top hat. The recipient bed is also shaped by the laser to accommodate the lip, which helps hold the graft in place.

Accommodating IOL approved for sale in Europe
Tekia, Inc., a privately owned medical device company, reports that it has received a CE Mark approval from the European Union for its Tek-Clear accommodating IOL. The CE Mark approval allows Tekia to market its lens throughout the European Union as a treatment for presbyopia. The company plans to initiate clinical studies in the United States later this year in a first step to obtaining FDA approval.

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FEATURE

LASIK-Associated Dry Eye: Causes and Management

Eric Donnenfeld, MD

Dry eye associated with LASIK and other refractive surgery procedures is the most common problem associated with refractive surgery.¹ Dry eye has been reported in 60% of patients at 1 month² and 50% at 6 months following LASIK.³ In addition, another study showed that 15% of patients experienced moderate dry eye for at least 3 months, and 5% experience severe dry eye for at least 6 months.⁴ In general, patients who had dry eye or borderline dry eye before surgery will have dry eye symptoms afterwards.

What Causes Post-Refractive Surgery Dry Eye?
All refractive procedures impact tear film dynamics because they affect the ocular surface, corneal sensation, aqueous tear production, wound healing, and can cause epithelial defects.

Because corneal sensation drives tear production, corneal denervation associated with refractive procedures is the most significant cause of post-procedure dry eye. In LASIK, the microkeratome severs the corneal nerve trunks, and photoablation disrupts the anterior stromal nerves. The resulting reduced corneal nerve feedback to the brain stem reduces efferent signaling to the lacrimal glands, diminishing tear production. This can lead to a vicious cycle, because reduced aqueous tear production and clearance further decrease ocular sensitivity and diminish sensory-reflex tearing, thus exacerbating dry eye. However, as the nerves regenerate postoperatively, corneal sensation and, as a result, tear function, returns in about 6 months.⁵

Inflammation, particularly postoperative, plays an important role in the pathogenesis of dry eye. Decreased tear production and clearance result in chronic inflammation of the ocular surface. This inflammatory response involves activated T-lymphocytes infiltrating the ocular surface with increased expression of adhesion molecules and inflammatory cytokines, elevated concentrations of inflammatory cytokines in the tear fluid, and heightened activity of matrix-degrading enzymes in the tear fluid.⁶ The clinical efficacy of anti-inflammatory therapies proves that inflammation is an important cause of dry eye.^7,8,9

LASIK also changes the interaction of the eyelid with the ocular surface because the excimer laser removes stromal tissue, altering the anterior curvature of the cornea. In addition, after the procedure, the cornea overlying the flap is largely anesthetic for 3 to 6 months, which causes a decrease in tear production.^10,11,12,13

Other potential causes of LASIK-associated dry eye include high pressure from the suction ring during flap creation, which may damage conjunctival goblet cells and compromise the mucin layer of the tear film;¹⁴ and the use of certain medications following the procedure, including epithelial-toxic antibiotics, nonsteroidal anti-inflammatory (NSAID) drops, and preservatives such as benzalkonium chloride (BAK).

Dry Eye Severity “Hinges” on Corneal Flaps
Sensation in the cornea, one of the most densely innervated and sensitive tissues in the body, is vital to corneal epithelial integrity and tear film function. Innervation is provided by the long ciliary nerves of the ophthalmic division of the 5th (trigeminal) cranial nerve. This nerve travels and branches in the suprachoroidal space; enters the cornea at the limbus; branches anteriorly and forms a plexus in the sub-Bowman's layer, densely innervating the central cornea; penetrates Bowman's membrane; and finally terminates in the epithelium at the wing cell layer.

LASIK-induced alterations in the sub-Bowman's nerve plexus decrease corneal sensation. After LASIK, corneal sensation is greatest near the hinge and diminishes toward the central cornea and the peripheral cornea away from the hinge.¹⁵ Because corneal nerves predominantly enter the cornea at the 9 and 3 o'clock positions, a vertical flap (superior hinge) will transect the two main areas of corneal innervation, whereas a horizontal corneal flap (nasal hinge) will transect only one.^16,17 In a self-controlled, masked clinical study, eyes with a large nasal-hinge flap had significantly greater sensation and decreased corneal and conjunctival lissamine staining at all time intervals compared to eyes that have a large superior-hinge flap.¹⁸ Another study showed that loss of corneal sensation and dry eye were less pronounced in corneas with a wide nasal-hinge flap than in those with a narrow nasal-hinge flap.¹⁹

The Importance of Preoperative Screening and Treatment
Screening patients before refractive surgery for dry eye and/or associated risk factors permits appropriate treatment to prevent symptomatic dry eye postoperatively. The dry eye history is especially important to assess. Some signs and risks of dry eye include:

• Contact-lens discomfort or intolerance, since these can be caused by underlying dry eye.
• Long-term contact-lens wear, especially hard-lenses, because this can further reduce the decreased corneal sensation associated with LASIK surgery and contribute to decreased tear production.²⁰
• Eye irritation, including sandy-gritty irritation, dryness, burning, or foreign body sensation. Look for signs of meibomitis on the lids of patients who report eye irritation when they wake up from sleeping. In patients who report their symptoms worsen as the day goes on, examine for stenosis and closure of the meibomian glands, large palpebral fissure width, and decreased tear production, all of which increase tear film osmolarity and cause dry eye.

In addition to the above screening, we do tear testing, including TBUT; examine for tear debris in the inferior cul-de-sac; perform Schirmer testing with anesthesia; and, most importantly, look for the staining pattern of dry eye through supravital staining of the conjunctiva with lissamine green or rose bengal (figure 1), and fluorescein staining of the cornea (figure 2).

Treating Dry Eye Before LASIK
While pre-existing dry eye doesn't necessarily affect LASIK efficacy and safety, it increases the risk for symptomatic post-LASIK dry eye.^{21,22,23,24,25} Preoperative conjunctival staining is a risk factor for postoperative dry eye, and corneal staining contraindicates surgery until the ocular surface has been stabilized. The risk for chronic dry eye after LASIK is also increased in females and with reduced preoperative tear film stability.²⁶

Patients with dry eye symptoms but no corneal or conjunctival staining are usually excellent candidates for LASIK. Patients with dry eye symptoms and mild conjunctival staining should be treated with artificial nonpreserved tears, to stabilize the ocular surface before surgery. Patients with corneal staining should also be treated with transiently preserved tears; lubricating ointment at night; cyclosporine ophthalmic emulsion (See Treating the Underlying Cause of Dry Eye below.); and, if necessary, punctal occlusion.

For patients with meibomian gland disease (figure 3), we add oral doxycycline 100 mg b.i.d. for 2 weeks and then daily for an additional month.  Nutritional supplements containing flax seed oil and fish oils are also helpful for treating Meibomian gland dysfunction.  Recently, Restasis has also been shown to be effective again Meibomian gland dysfunction and rosacea.  Patients with chronic meibomian gland dysfunction may also be at increased risk for sterile corneal infiltrates after LASIK.²⁷ We have found these patients benefit from a lipid emulsion tear such as Refresh Endura or Systane.

Intraoperative Management of Dry Eye
The risk of dry eye from LASIK can be minimized through efforts to preserve the corneal epithelium and prevent corneal abrasions just before and following the procedure. We have found the following measures and approaches useful:

• Minimize topical anesthetic use by giving the first dose when the patient enters the laser suite and a second dose before surgery.
• Reduce corneal abrasion risk by lubricating the ocular surface with proparacaine prior to the keratome pass.
• After replacing the flap, place a small amount of carboxymethylcellulose 1% (Celluvisc) on the corneal surface to prevent surface desiccation.
• Apply a nonpreserved NSAID, a fluoroquinolone, and prednisolone acetate 1% intraoperatively before removing the lid speculum; postoperatively, the patient should use a fluoroquinolone and prednisolone acetate 1% 4 times a day for 5 days. 
• Artificial tear use on the first postoperative day, and a viscous tear every 2 hours thereafter for the rest of the first postoperative week, either nonpreserved or transiently preserved tears.
• If the patient has dry eye symptoms following LASIK, insert inferior punctal plugs to stabilize the ocular surface; if this isn't successful, add oral doxycycline

We have found that many patients with meibomian gland disease also benefit from a lipid emulsion applied b.i.d. and nutritional supplements containing omega-3 fatty acids, including eicosapentaenoic acid (EPA). For patients with recalcitrant, long-term dry eye problems, Restasis b.i.d. for 6 months provides significant benefit.

Treating the Underlying Cause of Dry Eye
Restasis is the first medication approved by the FDA that treats the underlying cause of dry eye disease rather than just the symptoms. Recent studies have shown Restasis improves LASIK outcomes in patients with dry eye:

• In a controlled study, patients with moderate to severe dry eye who underwent LASIK achieved a better visual outcome if they were pre-treated with Restasis 0.05% b.i.d. for 1 to 3 months and then reassessed before LASIK was performed.³²
• In a retrospective analysis of patients who underwent LASIK correction for different refractive errors, those who were treated post-operatively with Restasis in addition to the usual topical steroids and antibiotic drops were significantly more likely to have better visual acuity recovery than those who did not. Specifically, Restasis users were more likely to have 20/15 vision or 20/20 vision; nonusers were significantly more likely than Restasis users to have a visual outcome worse than 20/20.³³

We advise patients to use Restasis with transiently preserved tears, but not to use the tears for 30 minutes after the Restasis to avoid washing it out of the tear film. We don't use Refresh Endura with Restasis because the common vehicle can create an oily tear film and compromise vision.

While dry eye syndrome is a common sequelae to LASIK, with a thorough pre-operative screening exam risk factors for dry eye can often be identified.  Treating these risk factors such as dry eye and blepharitis prior to surgery can improve postoperative results with better visual acuity and a reduced risk of dry eye syndrome.  Most dry eye symptoms resolve by 6 months following LASIK but for the rare case when it continues there are a variety of new treatment modalities to improve patient outcomes.

Dr. Donnenfeld is co-director of the External Disease/Cornea Department, Manhattan Eye, Ear and Throat Hospital, New York, surgical director of the Lions Eye Bank for Long Island, North Shore University Hospital, and assistant clinical professor of ophthalmology, New York University Medical College. He is a founding partner at Ophthalmic Consultants of Long Island. He can be reached at eddoph@aol.com.

REFERENCES

1. Toda I, Asano-Kato N, Hori-Komai Y, et al. Dry eye after laser in situ keratomileusis. Am J Ophthalmol. 2001;132:1-7.
2. Yu EY, Leung A, Rao S, et al. Effect of laser in situ keratomileusis on tear stability. Ophthalmology. 2000;107:2131-5.
3. Hovanesian JA, Shah SS, Maloney RK. Symptoms of dry eye and recurrent erosion syndrome after refractive surgery. J Cataract Refract Surg. 2001;27:577-84.
4. Donnenfeld E, Solomon K, Perry H, et al. The effect of hinge position on corneal sensation and dry eye following LASIK. Ophthalmology. 2003;110:1023-9; discussion, 1029-30.
5. Linna TU, Vesaluoma MH, Perez-Santonja JJ, et al. Effect of myopic LASIK on corneal sensitivity and morphology of subbasal nerves. Invest Ophthalmol Vis Sci. 2000;41:393-7.
6. Pflugfelder SC, Jones D, Ji Z, et al. Altered cytokine balance in the tear fluid and conjunctiva of patients with Sjogren's syndrome keratoconjunctivitis sicca. Curr Eye Res. 1999;19:201-11.
7. Stern ME, Beuerman RW, Fox RI, et al. The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. Cornea. 1998;17:584-9.
8. Avunduk AM, Avunduk MC, Varnell Ed, et al. The comparison of efficacies of topical corticosteroids and nonsteroidal anti-inflammatory drops on dry eye patients: a clinical and immunocytochemical study. Am J Ophthalmol. 2003;136:593-602.
9. Lobefalo L, D'Antonio E, Colangelo L, et al. Dry eye in allergic conjunctivitis: role of inflammatory infiltrate. Int J Immunopathol Pharmacol. 1999;12:133-7.
10. Kanellopoulos AJ, Pallikaris IG, Donnenfeld ED, et al. Comparison of corneal sensation following photorefractive keratectomy and laser in situ keratomileusis. J Cataract Refract Surg. 1997;23:34-8.
11. Linna TU, Vesaluoma MH, Perez-Santonja JJ, et al. Effect of myopic LASIK on corneal sensitivity and morphology of subbasal nerves. Invest Ophthalmol Vis Sci. 2000;41:393-7.
12. Chuck RS, Quiros PA, Perez AC, et al. Corneal sensation after laser in situ keratomileusis. J Cataract Refract Surg. 2000;26:337-9.
13. Albietz JM, Lenton LM, McLennan SG. Effect of laser in situ keratomileusis for hyperopia on tear film and ocular surface. J Refract Surg. 2002;18:113-23.
14. Albietz JM, Lenton LM, McLennan SG. Effect of laser in situ keratomileusis for hyperopia on tear film and ocular surface. J Refract Surg. 2002;18:113-23.
15. Chuck RS, Quiros PA, Perez AC, et al. Corneal sensation after laser in situ keratomileusis. J Cataract Refract Surg. 2000;26:337-9.
16. Muller LJ, Pels L, Vrensen GF. Ultrastructural organization of human corneal nerves. Invest Ophthalmol Vis Sci.1996;37:476-88.
17. Muller LJ, Vrensen GF, Pels L, et al. Architecture of human corneal nerves. Invest Ophthalmol Vis Sci.1997;38:985-94.
18. Donnenfeld E, Solomon K, Perry H, et al. The effect of hinge position on corneal sensation and dry eye following LASIK. Ophthalmology. 2003;110:1023-9; discussion, 1029-30.
19. Donnenfeld E, Ehrenhaus M, Solomon R, et al. The effect of hinge width on corneal sensation and dry eye following LASIK. J Cataract Refract Surg. In Press.
20. Stern ME, Beuerman RW, Fox RI, et al. The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. Cornea. 1998;17:584-9.
21. Yu EY, Leung A, Rao S, et al. Effect of laser in situ keratomileusis on tear stability. Ophthalmology. 2000;107:2131-5.
22. Hovanesian JA, Shah SS, Maloney RK. Symptoms of dry eye and recurrent erosion syndrome after refractive surgery. J Cataract Refract Surg. 2001;27:577-84.
23. Donnenfeld E, Solomon K, Perry H, et al. The effect of hinge position on corneal sensation and dry eye following LASIK. Ophthalmology. 2003;110:1023-9; discussion, 1029-30.
24. Stern ME, Beuerman RW, Fox RI, et al. The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. Cornea. 1998;17:584-9.
25. Toda I, Asano-Kato N, Hori-Komai Y, et al. Laser-assisted in situ keratomileusis for patients with dry eye. Arch Ophthalmol. 2002;120:1024-8.
26. Albietz JM, Lenton LM, McLennan SG. Effect of laser in situ keratomileusis for hyperopia on tear film and ocular surface. J Refract Surg. 2002;18:113-23.
27. Donnenfeld E, Solomon K, Perry H, et al. The effect of hinge position on corneal sensation and dry eye following LASIK. Ophthalmology. 2003;110:1023-9; discussion, 1029-30.
28. Solomon R, Donnenfeld E, Bolder N, et al. Flap hydration with carboxymethylcellulose versus dehydration following laser in situ keratomileusis surgery (abstract). Invest Ophthalmol Vis Sci. 2000; 41suppl:S688.
29. Stroobants A, Fabre K, Maudgal PC. Effect of non-steroidal anti-inflammatory drugs (NSAID) on the rabbit corneal epithelium studied by scanning electron microscopy. Bull Soc Belge Ophthalmol. 2000; 276:73-81.
30. Lenton LM, Albietz JM. Effect of carmellose-based artificial tears on the ocular surface in eyes after laser in situ keratomileusis. J Refract Surg .1999; Apr 15(2 Suppl):S227-31.
31. Albietz JM, Lenton LM, McLennan SG, et al. A comparison of the effect of Refresh Plus and Bion tears on dry eye symptoms and ocular surface health in myopic LASIK patients. CLAO J. 2002;28:96-100.
32. Salib G, McDonald M. Use of cyclosporine 0.05% drops versus unpreserved artificial tears in dry eye patients having LASIK. Am Soc Cataract Refract Surg Symposium on Cataract, IOL, Refractive Surgery. Abstracts 2003; Abstract # 669.
33. Ursea R, Lovaton M, Ehrenhaus M, Tan B, Heichel C, Schanzlin DJ. The benefit of cyclosporine 0.05% in faster visual acuity recovery after refractive surgery. Poster B739 presented at: annual meeting of the Association for Research on Vision and Ophthalmology, Ft Lauderdale, Florida, May 1-5, 2005.

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