Comparison Between Botulinum Toxin A Injection and Lacrimal Punctal Plugs for the Control of Post-LASIK Dry Eye Manifestations: A Prospective Study

Abstract

IntroductionLaser in situ keratomelieusis (LASIK) is one of the commonest refractive procedures performed nowadays. The dry eye problem is nearly universal in all patients after LASIK and it can be so annoying that the post-operative patient satisfaction is sometimes precluded. Conventional treatment includes the use of artificial tears. Alternative methods such as punctal plugs and botulinum toxin injection can be used for the management of post-LASIK dry eye. The aim of this study is to compare botulinum toxin injection in the orbicularis muscle to lacrimal punctal plugs for the control of post-LASIK dry eye manifestations.MethodsThis is a prospective study that included 60 patients who had LASIK eye surgery for correction of refractive errors. Patients were randomly assigned to one of three methods of dry eye management; the first method was conventional medical treatment with preservative-free tear substitutes only (group A: 20 patients = 40 eyes); the second method was intraoperative injection of botulinum toxin A (BTA) in the orbicularis muscle below the lower punctum of both eyes (group B: 20 patients = 40 eyes) and the third method was intraoperative insertion of temporary extended duration silicone punctal plugs in the lower punctum of both eyes (group C: 20 patients = 40 eyes).ResultsIn the first follow-up visit after 2 weeks, the two test groups (B, C) showed a statistically significant increase in both tear film break up time (TBUT) and Schirmer test score with a decrease in the OSDI score and daily frequency of lubricants used in comparison to the control group A. These differences were maintained in the next follow-up visit but they became statistically insignificant at the 3rd and 6th post-operative months. Complications were encountered more in the punctal plug patients (60%) than in BTA patients (25%) and this difference was statistically significant.ConclusionThe use of BTA injection to control dry eye symptoms by inducing temporary punctal ectropion is an effective method to improve patient satisfaction after LASIK eye surgery. It has higher level of patient satisfaction and fewer complications in comparison to punctal plugs or topical standard dry eye treatment.

A Review of Periocular Botulinum Neurotoxin on the Tear Film Homeostasis and the Ocular Surface Change

“…Compared to the punctal plug group, patients receiving 3.3 U of Botox ® injected into the medial lower eyelids had higher overall satisfaction (100%) and a lower complication rate (16.7%). Following this study, Fouda et al [ 57 ] demonstrated similar findings for the treatment of patients with dry eye after laser in situ keratomileusis (LASIK) surgery. Sixty patients were randomly and equally assigned to one of three groups comprising the control (i.e., topical lubricants only), BoNT, and punctal plug (i.e., temporary silicone plugs in the lower puncta) groups.…”

“…Subsequently, a few researchers have studied the efficacy and safety of BoNT-A injection into the medial eyelids [ 53 , 54 , 55 , 56 , 57 , 58 ]. Sahlin et al [ 53 ] found the injection of BoNT-A into the medial lower eyelid reduced lacrimal pump and decreased ocular discomfort in a patient with Sjogren’s syndrome.…”

Botulinum Toxin A Injection for the Treatment of Intractable Dry Eye Disease

“…As mentioned above, previous studies have shown inconsistent results of the Schirmer test [ 5 , 8 , 9 , 10 , 15 , 16 , 17 ]. The studies in which the injection sites were limited to the medial side of lower and upper eyelids have shown increased Schirmer test values [ 8 , 9 ].…”

Plasma Rich in Growth Factors for the Treatment of Dry Eye after LASIK Surgery

“…Several treatments, such as artificial tears, punctal plugs, and botulinum toxin, have been used to treat dry eye syndrome after LASIK surgery. However, these therapies are associated with some complications, including eye irritation, extrusion, or decreasing blinking power [24]. …”