What is the best approach for a dry eye sufferer approaching an operation under general anesthesia?
Thanks to a patient of mine who is soon approaching a very substantial set of abdominal surgeries, I reviewed and can now share a severe dry eye patient’s protocol for eye care when undergoing significant surgical procedures (particularly if unrelated to the eyes).
In preparation for the upcoming surgery:
- Have a thorough dry eye exam by an experienced dry eye specialist (preferably one you’ve had a good experience with and who knows your conditions). If you routinely require “maintenance” treatments (IPL, RF, BlephEx, ZEST or other lid hygiene treatments, etc…) then such care may be advised in preparation of the upcoming surgery to help with any related extra stresses from the surgery and recovery. Pulses of topical steroids or punctal plugging treatments are sometimes employed for those with anticipated extra levels of inflammation and/or dryness.
- If using Autologous Serum Tears (ASTs) or Platelet Rich Plasma Drops (PRP), get enough put aside for several weeks of use every up to 2 hours. If obtained frozen, then keep frozen and arrange for transport to the hospital in a frozen state. (Many commercial freezer packages exist for this purpose and your tears may commonly arrive this way).
- If using prescription or over the counter drops or ointments, nasal sprays or other renewable eyecare related prescriptions and products, obtain enough for several weeks use.
- If possible, meet with the anesthesia team prior to the surgery and advise them of your eye issues (and any other medical issues). Review all your medications including any and all supplements and eye-related prescriptions.
- If possible, meet with your surgical team and review the same information as the anesthesia team got.
- If using Omega Oil supplements, check with these teams as to when to best stop and then restart them, as they can have mild blood thinning side effects/benefits (a benefit if you want thinner blood for better circulation, but a negative side effect if the surgery could involve extensive bleeding).
- If you have a history of uveitis (iritis) or any herpetic eye diseases (HSV, HZV), then get extra advice on use of antiviral and anti-inflammatory medications, immunomodulators, etc, from your eye specialist prescribing those medications. (Many will require higher doses during their recovery from surgeries due to the extra stress on their immune system, but over-aggressive anti-inflammatory medications taken orally may also slow recovery/healing from surgery – so this complex balance is usually a question for the prescribing physicians and the surgical team).
- If you are on Biologics for your inflammation, or autoimmune disease, you might coordinate with your Rheumatologist and Surgeon so that (if possible) the Surgery will take place so that the biologic (if dosed periodically) dose is strategically planned prior to Surgery, so that when the date for the Surgery occurs, the effect of the biologic is at - or is approaching - it’s anticipated highest level of effect.
For hospital staff involved in your dry eye care:
- During the actual surgery and as long as you may be on assisted ventilation or be kept in an unconscious state, extra eye protection is warranted. Most anesthesiologists are aware of the risk to overexposure of eyes if they are inadvertently allowed to stay open during active general anesthesia and will commonly use tape to close the eyes completely. This is of a higher risk in patients with active ocular surface disease and worth reiterating to the anesthesia staff and those directly involved with your after care in the ICU and for general postoperative care.
- If you are sensitive to tape, or if you commonly use an eye sealing mask or special tape at home, check with the staff if you can have them use the same care while in the hospital. Anti-evaporative glasses have special seals around them and may prove useful during the recovery phase when you are interested in using your eyes for reading, texting, watching TV but are still having post-op difficulty keeping eyes from drying out. (They are also helpful for routine non-postoperative use).
- Most patients will benefit from use of an occlusive ointment in their eyes while undergoing their anesthesia/surgery. This also can be useful when sleeping/resting postoperatively and if you have a preferred ointment, see if they will let you bring it to the hospital for them to apply it for you. Common over the counter ointments include Retaine, Hylo and Systane brands. Prescription ointments like Lotemax (a steroid for those with active inflammation) and some with antibiotics (erythromycin) and steroids (Tobradex, Maxitrol, and a number of generic equivalents).
- Staying well hydrated is important to post-op dry eye recovery (as well as all aspects in healing and dry eye life). Please ask how soon you can begin drinking water and in what quantity after your surgery. When you can’t drink, ask that they pay special attention to running enough iv fluids to keep you well hydrated. They may wish to monitor your input and output so your task is to be faithful to recording the amount you take in and the amount you pee out (they have measuring devices for both measurements).
- If you wear contact lenses, it is likely you won’t be able to wear them until you are more fully recovered and should have appropriate spectacles to wear in place of the contacts. Swelling of the conjunctiva (the clear membrane on the surface of the white of the eyes) is fairly common in the immediate post-op timeline and may persist for some time afterwards, so contact lenses that fit well before, might not until this settles down. If you wear scleral contacts for dry eye, once you are fully conscious and able to take care of insertion and removal, it may be prudent to resume, but ask the team how soon they will let you resume them to be sure.
- Once you are out of the OR, the task of daily eye care needs to resume. Your lid hygiene continues to be important and you should review with the nursing staff In advance, what you routinely do (i.e. Hypochlorous Acid spray over lids and lashes twice daily, Zocuwipes or other approved lid wipes to clean lids, lashes and face at least once daily vs a botanical oil-based skin and face cleaner like Stone Crop Gel twice daily). If warm moist compresses are a routine part of your care, check to see how soon that might be available (and do you “lid crunches” after 3-4 minutes of moist heat to help express those lid oils).
- If you use ASTs or PRP, that can start after your exit from the OR and can be administered by the nursing staff until you are able to do it yourself. If you routinely rely on artificial tears, then use only preservative free versions and they may also be administered (preferably chilled) every hour as needed. Keeping them on ice at your bedside is a convenient way to keep up with a every 1-2 hour treatment for the first few days and then weaned to your comfort level once you are back in control, thereafter.
- If despite all the above and best laid plans, there appears to be extra dryness or damage, then an in-hospital consult may be required from an on-call eye doctor. Though they may not necessarily be a dry eye expert, they should be capable of diagnosing and treating abrasions, erosions, flare ups of HSV, HZV infections, inflammations and other potentially sight threatening issues. Don’t be afraid to advocate for yourself!
- Once you are sufficiently recovered and sent home, it should be fairly easy to resume your “normal” care. If normal doesn’t seem to suit your post-op needs, reach out to your dry eye specialist for additional recommendations.
Once recovered, it is appropriate to check in with your dry eye specialist to let them know how you made out and if you are experiencing any additional dry eye or vision problems. Follow up can be adjusted according to these conversations.
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463