Dry eyes after laser presbyopia surgery: what to know

A gritty feeling, stinging, vision that blurs from time to time: after laser corneal surgery, these signs of dry eye are common. They deserve particular attention in presbyopia surgery, which concerns people over 45, an age at which dry eye becomes more frequent. Here is why it occurs, what studies say about how long it lasts, how the pre-operative assessment takes it into account and what helps day to day. The data cited come mainly from LASIK studies; answers specific to your eyes are given at the assessment.

Why eyes can become dry after laser surgery

The surface of the eye is protected by a tear film, renewed with each blink. This film depends partly on the corneal nerves: they tell the brain that the eye needs moistening, which triggers blinking and tear secretion.

Laser corneal surgery, such as LASIK, is a recognised cause of dry eye, in particular because it cuts some of these small nerves [2]. After LASIK, creating the corneal flap is considered the main cause: corneal sensitivity decreases, and with it the reflexes that maintain tears and blinking [3]. The shape of the cornea, changed by the treatment, may also affect how the tear film spreads [5].

These mechanisms also apply to presbyopia surgery: Presby-LASIK and Presby-PRK treat the cornea with a laser, with or without a flap. Dry eye can occur after both techniques, with somewhat different features [7]. The principles of each are explained on the Techniques page.

After 45, an eye surface to examine carefully

Dry eye is common in the general population, and it becomes more frequent with age. An analysis of all epidemiological studies by the international TFOS DEWS II group confirms this increase with age, and shows that it is more frequent in women, especially from a certain age [8].

Yet dry eye present before surgery is a major risk factor for more marked dry eye after surgery [5]. Other factors can weaken the eye surface: wearing contact lenses, some eye drops, especially those containing preservatives, and some medicines taken by mouth [2]. This is one reason why age alone is not enough to say whether surgery is possible (see Presbyopia surgery after 60: Is it too late?).

What you may feel after surgery

The signs of dry eye can vary:

• a gritty feeling or foreign-body sensation, stinging or burning;
• red or tired eyes, especially at the end of the day;
• paradoxically, watery eyes: the irritated eye produces reflex tears, which protect less;
• fluctuating vision or vision that blurs at times, often improving after a blink [1];
• more noticeable discomfort in front of screens, during long reading, in the car or in air-conditioned places.

Dry eye does not only cause discomfort: it can also reduce the quality of vision through intermittent blurring [1]. It is one of the topics to discuss in order to have realistic expectations, just like halos at night (see Night driving after Presby-LASIK).

How long does dry eye last?

Just after LASIK, almost all patients have some degree of dryness [4]. A review published in 2018 states that signs and symptoms usually last about one month, and that a small number of patients still have them more than a year after surgery [3].

In the PROWL studies, conducted with the FDA in adults aged 21 to 57 who had LASIK for myopia, hyperopia or astigmatism, the frequency of dry eye symptoms had decreased overall after surgery. But among participants who had none before, about 28% reported mild, moderate or severe dry eye symptoms at 3 months [6]. In another study, in U.S. military personnel with a mean age of 30 operated on for myopia, chronic dry eye was present 12 months after surgery in 5.0% of PRK patients and 0.8% of LASIK patients [7].

These figures come from populations younger than people having presbyopia surgery: they cannot be transposed as such. The FDA points out that some patients may develop severe dry eye, sometimes permanent, requiring prolonged treatment [1]. Recovery as a whole is described in the article Recovery after Presby-LASIK.

Dry eye or something else?

Eye-surface pain that persists after LASIK is considered a different condition from dry eye, linked to the way the nerves grow back [3]. Any significant pain, marked redness or drop in vision after surgery should be reported promptly to the practice, without waiting for the next check-up.

Before surgery: the role of the pre-operative assessment

Authors agree on one point: detecting dry eye before surgery and managing it improves comfort afterwards [3, 4, 5]. The pre-operative assessment therefore includes examination of the eye surface, eyelids and tears, in addition to measurements of the cornea and vision.

• significant dry eye must be managed before any decision;
• severe dry eye is one of the situations in which laser corneal surgery is not performed (see Am I a candidate for laser presbyopia surgery?);
• the results of the examination are among the elements on which the surgeon bases whether or not to propose a technique suited to your eyes.

Pre-operative tests take place at 4, rue Donizetti, 75016 Paris, Monday to Thursday from 9 am to 6 pm, at a time that suits you. The course of the procedure is described on the Day of surgery page, and fees and coverage on the Fees page.

After surgery: what helps eye comfort

The treatment prescribed after the procedure usually includes artificial tears. It is important to follow the prescription and the instructions given at the practice, and not to stop the drops on your own. If dry eye persists, the ophthalmologist has several options, chosen according to the examination: suitable artificial tears, anti-inflammatory treatments, care of the eyelid glands (meibomian glands), punctal plugs, or in some cases eye drops prepared from the patient's own serum [3, 11].

Screens and reading

In front of a screen, we blink much less: in an older study, blink rate was on average divided by five during screen work [10]. An international report published in 2023 mainly recommends, to limit discomfort, blinking fully, adjusting your workstation and taking regular breaks [9]. Screen use resumes after the procedure according to the surgeon's instructions.

Environment

• avoid air from air conditioning, a fan or the car heater blowing directly onto your face;
• think about dry places: planes, overheated rooms, wind;
• keep your artificial tears within reach during long periods of reading or screen use, as prescribed.

These measures do not replace the ophthalmologist's advice: if discomfort persists or worsens, mention it during follow-up.

What is worth asking at the consultation

• Do the surface of my eyes and my tears allow laser surgery?
• Should dry eye be treated before considering surgery?
• Can my contact lenses, eye drops or medicines play a role?
• Which technique do you propose, and did dry eye count in this proposal?
• What treatment is planned after surgery, and what should I do if discomfort persists?

FAQ: dry eyes after presbyopia surgery

Sources

1. U.S. Food and Drug Administration (FDA). LASIK: What are the risks and how can I find the right doctor for me? fda.gov. fda.gov
2. Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. The Ocular Surface. 2017;15(3):511-538. PubMed 28736341
3. Toda I. Dry eye after LASIK. Investigative Ophthalmology & Visual Science. 2018;59(14):DES109-DES115. PubMed 30481814
4. Shtein RM. Post-LASIK dry eye. Expert Review of Ophthalmology. 2011;6(5):575-582. PubMed 22174730
5. Ambrósio R Jr, Tervo T, Wilson SE. LASIK-associated dry eye and neurotrophic epitheliopathy: pathophysiology and strategies for prevention and treatment. Journal of Refractive Surgery. 2008;24(4):396-407. PubMed 18500091
6. Eydelman M, Hilmantel G, Tarver ME, et al. Symptoms and satisfaction of patients in the Patient-Reported Outcomes With Laser In Situ Keratomileusis (PROWL) studies. JAMA Ophthalmology. 2017;135(1):13-22. PubMed 27893066
7. Bower KS, Sia RK, Ryan DS, et al. Chronic dry eye in photorefractive keratectomy and laser in situ keratomileusis: manifestations, incidence, and predictive factors. Journal of Cataract and Refractive Surgery. 2015;41(12):2624-2634. PubMed 26796443
8. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. The Ocular Surface. 2017;15(3):334-365. PubMed 28736337
9. Wolffsohn JS, Lingham G, Downie LE, et al. TFOS Lifestyle: Impact of the digital environment on the ocular surface. The Ocular Surface. 2023;28:213-252. PubMed 37062428
10. Patel S, Henderson R, Bradley L, et al. Effect of visual display unit use on blink rate and tear stability. Optometry and Vision Science. 1991;68(11):888-892. PubMed 1766652
11. Amescua G, Ahmad S, Cheung AY, et al. Dry Eye Syndrome Preferred Practice Pattern®. American Academy of Ophthalmology. Ophthalmology. 2024;131(4):P1-P49. PubMed 38349301

Going further

• Techniques: Presby-LASIK and Presby-PRK, principle and procedure;
• Pre-operative assessment: what is examined before any proposal;
• Day of surgery: how the procedure takes place;
• Recovery after Presby-LASIK: stages and advice;
• Am I a candidate?: the criteria examined before presbyopia surgery;
• Fees: fees and coverage.