The Dry Eye

Dry eye, depression and LASIK: Serious thoughts about a serious issue

In the fall of 2018, there were two tragic suicides that were publicly linked to dry eye disease and LASIK. There are roughly 60,000 eye doctors in the United States. I cannot imagine that a single one of you did not hear about them.

As a LASIK surgeon (and patient) and a DED doc (and patient), I would like to offer my thoughts on this emotional and fraught aspect of these two medical worlds.

First, though, let me establish my standing to comment as well as set some guidelines. I am deeply embedded in all aspects of the dry eye world. If you have read my columns, you know that I have moderately severe DED and have had it since my teen years. Each day that I spend in the clinic, approximately one-third of my patients are DED sufferers. Because we are willing to do so, we see some of the most severe cases of DED in northeast Ohio, and therefore I interact with patients who border on despair every day. At the moment I am the longest-tenured LASIK surgeon in the greater Cleveland area. My own LASIK in 1999 was a success, albeit one that was somewhat delayed in coming due to what we now know as a temporary post-LASIK increase in the severity of my dry eye.

I do not have depression, nor to the best of my knowledge do I personally suffer from any form of mental illness. However, like most families, ours includes a number of relatives who do suffer from various types of mental illnesses, some of them severe. There have been suicides in the families of my friends and acquaintances. Blessedly, our family has thus far been spared this tragedy, although we came much too close to joining this sad fraternity one early summer evening in 2006. Just a glimpse of what life without this family member would mean changed me forever.

For all of the above, no one can reasonably nullify my standing in this discussion. Feel free to discuss my ideas and opinions.

As I write, there is a manuscript that has been accepted by Ophthalmology on my desktop that uses an app to examine the “risk factors” for dry eye in iPhone users. In addition to being female, excessive screen time and contact lens wear, depression is listed as a “risk factor” for Ocular Surface Disease Index-defined dry eye symptoms. This, of course, begs the obvious question: Does depression somehow cause dry eye symptoms, or does having dry eye symptoms cause or worsen depression? Having never seen a compelling theory on a possible mechanism of action for depression causing DED, it is probably more helpful for us to use the working hypothesis that DED symptoms can, at the least, contribute to depression.

Back in the earliest days of corneal refractive surgery, we would look for psychiatric medications, including antidepressants, and consider them as a possible exclusion for elective refractive surgery. Chalk this up to the fact that neither radial keratotomy nor first-generation LASIK or PRK was nearly as successful as modern varieties (including SMILE), as well as the general lack of understanding back then of what constituted disability due to mental illnesses. Suffice it to say that no one really does that anymore. Likewise, our understanding of the importance of diagnosing and treating any DED was in its infancy. Even the most average, middle-of-the-bell curve LASIK shop now screens for and treats DED as a part of the LASIK experience.

Let us agree on the fact that the overwhelming majority, approximately 97% or 98%, of LASIK patients are happy with their results and would do it again. LASIK (and PRK and SMILE) are not going to go away. There are tens of thousands of people in America who are killed by suicide* each year, only a few of which had LASIK (as an aside, no one knows what number of suicides is associated with DED). Let us agree that this particular statistic is not really meaningful because for each family that lost a loved one to suicide, that statistic is 100%. What is meaningful is that the above numbers indicate an opportunity and an obligation for us as a specialty to do whatever is humanly possible to identify any patient who might be at risk, even if we end up overcalling it sometimes.

What do we do then? What do we do when we have a desperate patient who has undergone LASIK and is suffering from what looks for all the world like DED postop? First, we must admit that a large part of what is necessary is totally beyond our ken. Treating the depression itself is way beyond our scope of practice as eye doctors. However, even though this is true, talking about how your patient is feeling and saying out loud that you are concerned is something we all need to do. It is important to state emphatically that the symptoms that your patient is suffering are not psychological. Although they may, indeed, be nerve-based, they are real. Encouraging the distressed patient to seek specific care for their depression from someone who is an expert is an essential part of the mission.

It is my strongly held position that these patients do not suffer from regular, garden-variety DED, because if they did, they would all get better, right? You, or someone you know, are going to tune up the ocular surface on these patients so that it is as healthy as it was on the day they were born. These individuals have neurogenic pain, the so-called “phantom dry eye.” This is nerve pain caused by some sort of inappropriate peripheral nerve signaling that results in aberrant central pain processing. Chronic pain of any type is a well-known cause of depression and can lead to death by suicide.

These are chronic pain patients and should be treated as such.

I very much like how Dr. Deborah Jacobs of Harvard addresses this type of pain, and she shared her strategy at ASCRS Cornea Day in April. If she determines that there is ongoing peripheral signaling (ie, symptoms are relieved with topical anesthetic), she increases the aggressiveness of her ocular surface treatments. Simultaneously, she enlists the help of other physicians including the patient’s family doctor, neurologists and other pain specialists. We should not discount the work that Drs. Vance Thompson and Michael Colvard have done regarding eye pain caused by imbalances between central and peripheral fixation. I am convinced that the aberrant peripheral signaling in at least some of these patients comes from the constant battle to realign these eyes and overcome the imbalance. Ask your patient to patch an eye; if their symptoms decrease, consider the possibility of treatment with a progressive base-in prism.

Elective medical procedures, such as LASIK, cosmetic surgery and back surgery, that have been associated with suicide, however rare, will continue to be performed. For the LASIK surgeon or the DED doctor, patients who live in desperation because of their symptoms are doubtless our most difficult patients to treat, but we must treat them to the limits of the resources that our entire community possesses. My family was spared the tragedy of death by suicide, so I cannot say what it feels like to have had that loss. But I came close enough to the edge of the abyss to have seen the void below, close enough to see what terrible pain lives there. Each day I awaken, joyful that for at least one more day that very special person in our family got the help they needed and is still here.

With the help of Drs. Jacobs, Thompson, Colvard and so many others, let us all work toward solving this problem of DED and chronic pain.

*Note the phrasing “killed by suicide.” For a thousand reasons, this is much more accurate and merciful to the survivors than “committed suicide.” I encourage you to adopt it instead.

Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.

In the fall of 2018, there were two tragic suicides that were publicly linked to dry eye disease and LASIK. There are roughly 60,000 eye doctors in the United States. I cannot imagine that a single one of you did not hear about them.

As a LASIK surgeon (and patient) and a DED doc (and patient), I would like to offer my thoughts on this emotional and fraught aspect of these two medical worlds.

First, though, let me establish my standing to comment as well as set some guidelines. I am deeply embedded in all aspects of the dry eye world. If you have read my columns, you know that I have moderately severe DED and have had it since my teen years. Each day that I spend in the clinic, approximately one-third of my patients are DED sufferers. Because we are willing to do so, we see some of the most severe cases of DED in northeast Ohio, and therefore I interact with patients who border on despair every day. At the moment I am the longest-tenured LASIK surgeon in the greater Cleveland area. My own LASIK in 1999 was a success, albeit one that was somewhat delayed in coming due to what we now know as a temporary post-LASIK increase in the severity of my dry eye.

I do not have depression, nor to the best of my knowledge do I personally suffer from any form of mental illness. However, like most families, ours includes a number of relatives who do suffer from various types of mental illnesses, some of them severe. There have been suicides in the families of my friends and acquaintances. Blessedly, our family has thus far been spared this tragedy, although we came much too close to joining this sad fraternity one early summer evening in 2006. Just a glimpse of what life without this family member would mean changed me forever.

For all of the above, no one can reasonably nullify my standing in this discussion. Feel free to discuss my ideas and opinions.

As I write, there is a manuscript that has been accepted by Ophthalmology on my desktop that uses an app to examine the “risk factors” for dry eye in iPhone users. In addition to being female, excessive screen time and contact lens wear, depression is listed as a “risk factor” for Ocular Surface Disease Index-defined dry eye symptoms. This, of course, begs the obvious question: Does depression somehow cause dry eye symptoms, or does having dry eye symptoms cause or worsen depression? Having never seen a compelling theory on a possible mechanism of action for depression causing DED, it is probably more helpful for us to use the working hypothesis that DED symptoms can, at the least, contribute to depression.

PAGE BREAK

Back in the earliest days of corneal refractive surgery, we would look for psychiatric medications, including antidepressants, and consider them as a possible exclusion for elective refractive surgery. Chalk this up to the fact that neither radial keratotomy nor first-generation LASIK or PRK was nearly as successful as modern varieties (including SMILE), as well as the general lack of understanding back then of what constituted disability due to mental illnesses. Suffice it to say that no one really does that anymore. Likewise, our understanding of the importance of diagnosing and treating any DED was in its infancy. Even the most average, middle-of-the-bell curve LASIK shop now screens for and treats DED as a part of the LASIK experience.

Let us agree on the fact that the overwhelming majority, approximately 97% or 98%, of LASIK patients are happy with their results and would do it again. LASIK (and PRK and SMILE) are not going to go away. There are tens of thousands of people in America who are killed by suicide* each year, only a few of which had LASIK (as an aside, no one knows what number of suicides is associated with DED). Let us agree that this particular statistic is not really meaningful because for each family that lost a loved one to suicide, that statistic is 100%. What is meaningful is that the above numbers indicate an opportunity and an obligation for us as a specialty to do whatever is humanly possible to identify any patient who might be at risk, even if we end up overcalling it sometimes.

What do we do then? What do we do when we have a desperate patient who has undergone LASIK and is suffering from what looks for all the world like DED postop? First, we must admit that a large part of what is necessary is totally beyond our ken. Treating the depression itself is way beyond our scope of practice as eye doctors. However, even though this is true, talking about how your patient is feeling and saying out loud that you are concerned is something we all need to do. It is important to state emphatically that the symptoms that your patient is suffering are not psychological. Although they may, indeed, be nerve-based, they are real. Encouraging the distressed patient to seek specific care for their depression from someone who is an expert is an essential part of the mission.

It is my strongly held position that these patients do not suffer from regular, garden-variety DED, because if they did, they would all get better, right? You, or someone you know, are going to tune up the ocular surface on these patients so that it is as healthy as it was on the day they were born. These individuals have neurogenic pain, the so-called “phantom dry eye.” This is nerve pain caused by some sort of inappropriate peripheral nerve signaling that results in aberrant central pain processing. Chronic pain of any type is a well-known cause of depression and can lead to death by suicide.

PAGE BREAK

These are chronic pain patients and should be treated as such.

I very much like how Dr. Deborah Jacobs of Harvard addresses this type of pain, and she shared her strategy at ASCRS Cornea Day in April. If she determines that there is ongoing peripheral signaling (ie, symptoms are relieved with topical anesthetic), she increases the aggressiveness of her ocular surface treatments. Simultaneously, she enlists the help of other physicians including the patient’s family doctor, neurologists and other pain specialists. We should not discount the work that Drs. Vance Thompson and Michael Colvard have done regarding eye pain caused by imbalances between central and peripheral fixation. I am convinced that the aberrant peripheral signaling in at least some of these patients comes from the constant battle to realign these eyes and overcome the imbalance. Ask your patient to patch an eye; if their symptoms decrease, consider the possibility of treatment with a progressive base-in prism.

Elective medical procedures, such as LASIK, cosmetic surgery and back surgery, that have been associated with suicide, however rare, will continue to be performed. For the LASIK surgeon or the DED doctor, patients who live in desperation because of their symptoms are doubtless our most difficult patients to treat, but we must treat them to the limits of the resources that our entire community possesses. My family was spared the tragedy of death by suicide, so I cannot say what it feels like to have had that loss. But I came close enough to the edge of the abyss to have seen the void below, close enough to see what terrible pain lives there. Each day I awaken, joyful that for at least one more day that very special person in our family got the help they needed and is still here.

With the help of Drs. Jacobs, Thompson, Colvard and so many others, let us all work toward solving this problem of DED and chronic pain.

*Note the phrasing “killed by suicide.” For a thousand reasons, this is much more accurate and merciful to the survivors than “committed suicide.” I encourage you to adopt it instead.

Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.