Eyeworld

69 EW REFRACTIVE September 2018 continued on page 70 obstructed. If there are abnormal- ities that might be associated with any form of blepharitis, he treats it preoperatively. Before proceeding with surgery If tear film abnormalities are ob- served, surgeons need to decide whether or not to proceed with surgery or to improve the tear film before continuing. "If the tear film is not normal on the front end, then we will have a discussion with the patient about optimizing the tear film before we proceed," Dr. Doane said. "We would optimize it preop- eratively, then proceed with sur- gery. However, there are situations postoperatively where you might do something from an iatrogenic stand- point and make things worse. For example, let's say you do refractive cataract surgery, and you make any type of corneal incision or perform laser vision correction. Especially in older patients, these procedures may affect corneal sensation, which will affect the tear film. Surgeons have to be ready for that and manage any issues that arise." When treating a patient for dry eye, Dr. Donnenfeld uses tear osmolarity and MMP-9 to provide a baseline of the disease and to provide information as to the cause of the disease. "I then develop a treatment protocol based on my physical findings that correlate with the point-of-service testing. I use the point-of-service testing with osmolarity and MMP-9 to follow the patient's response to therapy and to make sure he or she is responding in a good way. The point-of-service testing not only provides diagnostic information as far as the severity of dry eye, but it also provides me with good reproducible information about the patient's response to ther- apy," Dr. Donnenfeld said. Dr. Donnenfeld commonly treats patients who have good vi- sion with glasses and minimal or no corneal staining and minimal con- junctival staining. If a patient has physical findings of dry eye, such as lissamine green conjunctival stain- ing or some corneal staining, he will treat him or her with aggressive therapy to resolve the problem. "I never perform surgery on a patient with active dry eye if I can avoid it. I want to manage the disease before I go on to surgery," he said. The future According to Dr. Donnenfeld, MMP- 9, which has been a qualitative test, will shortly become a quantitative test. Surgeons will get a numeric value of the amount of MMP-9. "That will give us a lot of important information. This will hopefully be available later this year. Then a va- riety of other point-of-service tests will become available. I think in the near future, we will have a litany of tests that will allow us to provide specific therapy to patients that will optimize their response to therapy based on testing," he said. EW Editors' note: Dr. Donnenfeld has fi- nancial interests with Allergan (Dublin, Ireland), RPS Diagnostics (Sarasota, Florida), and Ocular Therapeutix (Bedford, Massachusetts). Dr. Koch has financial interests with Carl Zeiss Meditec. Dr. Doane has no financial interests related to his comments. Contact information Doane: jdoane@discovervision.com Donnenfeld: ericdonnenfeld@gmail.com Koch: dkoch@bcm.edu

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