Eyeworld

JUL 2019

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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JULY 2019 | SUPPLEMENT TO EYEWORLD | 7 problems—such as ocular fatigue and difficulty reading for long periods of time—re- sult from OSD, not cataracts. I explain to patients that the more effectively we treat OSD before surgery, the better their recovery will be after surgery, and patients understand that. Treating OSD Clinicians often are uncertain about where to begin when treating OSD. Unlike the gradual step-by-step approach used for standard dry eye, our goal for preoperative patients is to improve the ocular sur- face rapidly. Two major areas should be treated aggressively from the beginning—tear film inflammation and lid margin disease. We need to quickly im- prove tear quality to improve the ocular surface. If patients have even a slightly positive matrix metalloproteinase-9 (MMP-9) response, I begin with a topical anti-inflamma- tory that has a rapid onset of action such as loteprednol or lifitegrast. 2,3 Cyclosporine also is an option, from proven formulations we have used for several years to newer formulations, such as cyclo- sporine 0.09% in a nanomicel- lar formulation that gets the drug to the ocular tissue in a high concentration and more rapidly. 4 If significant inflamma- tion is present in lid margin disease, I may also use an oral anti-inflammatory, such as doxycycline or minocycline, which can reduce concomitant rosacea and inflammation of the lid margin. 5 Meibomian gland disease is often the root of tear film problems and OSD. We can reduce punctate keratitis with aggressive lubrication, but we need to address the source— the obstructed glands and lack of a good-quality lipid layer in the tear film. We have many procedur- al interventions that we can offer. I usually offer thermal pulsation in the preoperative setting to clear the meibomian glands. 6 A single treatment helps clear the meibomian glands and prepare them for surgery. Warm compresses at home can be somewhat effective to maintain the lids, but we need something more aggressive when glands are chronically obstructed. The heat needs to penetrate multiple layers of the lid, and thermal pulsation provides heat where it needs to be. Blepharoexfoliation can remove bacteria and debris from the lid margins of pa- tients with blepharitis, which is important to reduce the risk of infection. 7 The biofilm that forms in chronic bleph- aritis along the lid margin is a major culprit for obstruction of the meibum flow. Addi- tional heating devices have become available that heat the oil glands and mechanically debride the glands. Pinpointing potential risks The ASCRS SPEED II ques- tionnaire recommended in the algorithm guides surgeons in diagnosing OSD and pro- vides additional information to guide treatment. It covers topics such as IOL selection and risk factors for OSD. Patients receiving multifocal or extended depth of focus IOLs may have a lower toler- ance for tear film irregularities. This is where we need to be most aggressive and identify patients who may not be good candidates for these lenses. Conclusion Using the ASCRS Preopera- tive OSD Algorithm, surgeons can methodically identify OSD subtypes and develop aggressive treatment strategies to optimize the ocular surface before surgery. n References 1. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669–684. 2. Sheppard JD, et al. Effect of lotepre- dnol etabonate 0.5% on initiation of dry eye treatment with topical cyclosporine 0.05%. Eye Contact Lens. 2014;40:289–296. 3. Tauber J, et al. Lifitegrast ophthalmic solution 5.0% versus placebo for treat- ment of dry eye disease: results of the randomized Phase III OPUS-2 study. Ophthalmology. 2015;122:2423–2431. 4. Mandal A, et al. Ocular pharma- cokinetics of a topical ophthalmic nanomicellar solution of cyclosporine (Cequa) for dry eye disease. Pharm Res. 2019;36:36. 5. Doughty MJ. On the prescribing of oral doxycycline or minocycline by UK optometrists as part of management of chronic meibomian gland dysfunc- tion (MGD). Cont Lens Anterior Eye. 2016;39:2–8. 6. Blackie CA, et al. The sustained effect (12 months) of a single-dose vectored thermal pulsation procedure for meibomian gland dysfunction and evaporative dry eye. Clin Ophthalmol. 2016;10:1385–1396. 7. Murphy O, et al. The efficacy of tea tree face wash, 1, 2-Octanediol and microblepharoexfoliation in treating Demodex folliculorum blepharitis. Cont Lens Anterior Eye. 2018;41:77–82. Dr. Farid is director of cornea, cataract, and refractive surgery, vice chair of ophthalmic faculty, and associate professor of oph- thalmology, Gavin Herbert Eye Institute, University of California, Irvine. She can be contacted at mfarid@uci.edu.

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