DRY EYES & MGD

I would like to second the admin's comment.
I welcome the comments from In the Business Not OE.
He appears to be fairly and squarely on our side and is in isolation about being prepared to speak out openly against "other providers".
I personally appreciate that Laser Surgery is acceptable in the right circumstances, with the right provider and the right information for the patient before surgery. Unfortunately for us OE failed us every step of the way. I believe it is the provider at fault not the procedure itself. I know that if I been assessed accurarately I should have been declined for surgery.
I would like to say a thank you to InTheBus.
Poppy

InthebusinessnotOE wrote: ... if you and others feel that I bring little or no value to the forum, I am happy to bow out - I don't usually have much time and can use it elsewhere.

Understandably there is lot of justifiable anger against this industry and I'm sure comments are not directed at you personally.

It would be good to have other surgeons raise their heads above the parapet and one can only guess at the reasons for their reluctance to do so.

Your time and input is appreciated so please don't take offence and stay with us

Below is a quote from a post under on this thread from InthebusinessnotOE.

"A small but significant fraction have had problems and usually as a result of poor choice of provider".

With all due respect, people should not be able to make a poor choice of provider, as those clinics that are a poor choice shouldn't be allowed anywhere near patients eyes and stopped from trading as businesses that ruin peoples lives.

This is why strict regulation needs to be imposed on this industry to get rid of those not fit to perform this type of surgery, which can have life ruining consequences for many patients who put their trust in clinics/clinicians which are in fact completely incompetent.

Actually I do mean to scare - this surgery is in the incorrect hands just like the cosmetic industry. I might profit from laser eye surgery but actually more profitable doing other procedures. Laser eye surgery is only one arm of activity and not the dominant. What I most definitely do not do is push, mislead, upsell, have competitions, ebay ads, 2 for 1 pricing, family and friends offers. I make sure I evaluate patients carefully. I do not have the problems that seem so common elsewhere.

Did someone at Moorfields actually state that you did not have MGD ? At Moorfields were you seen by a corneal service consultant ? Did you have a Tear break up time measured along with a Schirmers to evaluate your tear film stability ? Did the doctor push on your eyelids to check the quality of your lipids to find out if they were present and if so, clear or turbid ?

We (eye doctors) see MGD all the time in varying degrees but do not always mention this to patients unless they are symptomatic or about to undergo a procedure that might result in a problem e.g. lid surgery to correct droopy eyelids or laser eye surgery. MGD correlates directly with age. The older we are the more chances we have of having MGD. Some have suggested there is a direct correlation: 50% of 50 year olds will have the condition and 80% of 80 year olds etc. I believe this is probably about right. We even see this in children.

The courtesy requested: For example the flippant comments made about being a surgeon and protecting my own interests - others on the lines of not responding - speculating why I was not responding:

-" It seems the good doctor has answered the question by not answering it, leaving us to conclude that the answer is far higher than he would want advertised.

Assuming Dr InthebusinessnotOE performs laser surgery then it would not be in his interests to admit the numbers suffering MGD after surgery who did not before!

Which is why there are NO ACTUAL STATISTICS for prevalent problems caused by this industry!"

This is a site that seems to be to be quite constructive in terms of bringing to the attention problems with certain providers. In the spirit of being constructive for the greater good and for this forum to accomplish its goals, it is sensible to encourage discourse amongst all in the business and not just amongst victims. Victims are justifiably angry - however to dismiss the science and to suggest that we as doctors are not being objective is not helpful. If there are alternate scientific studies out there to dispute what is being stated, please provide the references. Dry eye is a bigger industry than Lasik and there are several groups who are actively working on some pretty high tech medical solutions to the problem. There is a lot of science already out there - as a point of disclosure, I am a consultant for several of these pharmaceutical companies and start-ups working on solutions and so very familiar with current science. LASIK does not cause MGD. Patients undergoing regular cataract surgery sometimes get an exacerbation of MGD symptoms - does that mean cataract surgery also causes MGD ? Similar issues occur following Lasik and cataract surgery including reduced corneal sensitivity, toxicity from medications and their preservatives. What we do know is MGD when inflammatory combines very badly with neurotrophia and toxic medications including glaucoma drops, antibiotics, steroids etc..

Finally if you and others feel that I bring little or no value to the forum, I am happy to bow out - I don't usually have much time and can use it elsewhere.

With respect, I would like to point out that as a surgeon profiting from this business you do not want to scare people with the realities of this surgery and will of course sing its praises and play down the risks.

Those of us damaged by this industry want to warn others & do our utmost to stop them risking their eyesight the way we did ours.

I don't care who performs it, the risks are too high & full disclosure of statistics etc... essential.

I underwent eye tests @ Moorfields a few years before surgery (unrelated) and DID NOT HAVE ANY SIGN OF MGD !!

Re "I am happy to be challenged but would appreciate some courtesy too."

Am I missing something because I don't see absence of courtesy from Tom or myself?

Seems you have your mind made up.

No it is not my "opinion". Not too much has changed since 2007 except a number of new drugs in the pipeline.

A little anatomy lesson. Meibomian glands are located on the eyelids. Lasik is performed on the Cornea. The two besides being distant neighbours are not related.

Again for the purposes of clarity - those with pre-existing Meibomian gland disease are very likely to develop symptoms following Lasik if this has not been treated preoperatively. This is not an opinion. The DEWS report is pretty clear in that Laser eye surgery causes temporary neurotrophia resulting in a change in equilibrium on the ocular surface.

Page 111
"An example would be those refractive surgery patients with reduced tear stability (eg, as assessed by the tear stability analysis system [TSAS]), who have greater risk of post-LASIK symptomatic keratitis and have a slower recovery time than those without a preoperative tear film instability.

I have already answered the question about those with MGD from other laser providers: yes I do see them and they clearly had MGD prior to surgery with chronic features (also described in the DEWS report). THey were unstable prior to surgery and pushed over the edge following surgery.

Laser optometrists unfortunately are just not surgeons and the majority are a bit dismissive of the ocular surface. A lot of patients wind up getting treated without being recognized as high risk for dry eye.

Can dry eye patients undergo Lasik - answer is absolutely YES - as long as they are pre-treated and stabilised. Last month I did Lasik on a doctor who travelled from a long way away. She had been under my care for 6 months sorting out her dry eye - she is now one month following surgery with no dry eye symptoms.

Summary - this is SURGERY - pick SURGEONS well versed with the area to look after you. The advertising of laser eye surgery is a real pity and makes the surgery sound like it is common place. Price shoppers seem to ignore risk and forget about doing due diligence prior to signing the dotted line.

For my part and a few colleagues whom I admire and respect, we are happy to look after problem patients but do resent being tarnished with the same brush as the very commercial operatives.

I contribute to this site as I fully appreciate the frustration and sense of regret many victims have and try to provide some decent advice on how to move forward and remedy problems where possible. I am happy to be challenged but would appreciate some courtesy too.

MGD is a problem that can be remedied - although may take some time.

Inthebusiness – Thank you for that DEWs link.

It is very useful information but with new medical information coming to surface continuously perhaps this maybe a little out of date as it was written in 2007, anything in current times?

Can you direct me on the DEWS report to indicate your opinion to suggest that LASER does not cause MGD please?

As your answer seems more opinion rather than scientific fact?

Or maybe a link/information sources to suggest elsewhere perhaps, as you seem very passionate to believe Laser does not cause MGD.

I have read the report and it is indicating towards the theory it is linked.

Please refer to page 83, 97 (LASIK and refractive excimer laser surgery) and pages 99.

Reports of the prevalence of dry eye in LASIK patients without a prior history of dry eye vary according to the definition of dry eye are up to 48%.

In my opinion and theoretically the connection of MGD to laser seems logical.

Laser cut the nerves, damages cells, and causes inflammation which mutates the mebioman glands oils which changes and modifies the oils which affects the ocular suface.

How many patients suffered MGD/ blepharitis from other laser providers?

Yes sadly I do see patients with MGD, who are symptomatic following Laser eye surgery. Examination in almost all cases demonstrates the presence of CHRONIC disease with permanent lid changes indicating the disease had been present for years.

In answer to Tom - NO laser eye surgery does not cause MGD, It definitely exacerbates symptoms of MGD.

Since you wish to learn more about dry eye, suggest you look and read the following report:
DEWS report

www.tearfilm.org/dewsreport/pdfs/TOS-0502-DEWS-noAds.pdf

This illustrates the complexity of dry eye and is the result of a phenomenal amount of work from a large group of illustrious dry eye experts.

In a nutshell, the ocular surface is quite delicately balanced. An imbalance of a few components can lead to dry eye symptoms.

Laser causes dry eyes including blepharitis, which leads to the blocking of the mebioman glands, resulting to MGD.

It's that simple and logical which links laser to MGD.

Even the FDA website has stated the potential risk of blepharitis resulting from laser surgery, and even the manufacturer of the laser machine has indicated the risks of nerve and cells damage during the cutting of the flap, not to mention the radiation of the UV lasers slicing the cornea.

Plus I don't get some laser places, OE has cocked up, and another laser place says they can fix the problem after treating the problem of MGD and carry out another laser surgery, but after further researching and words of advice from another specialist states no more further laser due to the thin cornea, anymore could lead to a cornea transplant in the future! Who wants that? So why am I offered enhanced surgery in both places?!

There is a big difference between someone showing clinical signs of dry eyes symptom prior to pre op laser surgery due to medicine, contact lens wearer, staring at a computer screen for prolong periods and more.....but thats all it is dry eye symptoms.

Laser causes permenant damage to the nerve, which might take up to 6 months to 12 months or it may never restore to normal levels!

Laser causes blephartitis, laser damages key components linked to the lacimal function unit .

Laser causes MGD.

Mr Inthebusiness would this be correct ?

InthebusinessnotOE wrote: In answer to your question, I hardly see any patients with an exacerbation of MGD symptoms on whom I have operated.

Thank you for your response but you have misunderstood my question, or perhaps I didn't make it clear enough.

How many post operative patients suffering with MGD referred to you from other providers tell you they did not have this problem before surgery?