Eyeworld

EW FEATURE 42 Improving the ocular surface for cataract and refractive surgeons • November 2018 AT A GLANCE • In patients with limbal stem cell deficiency, it's possible to choose a refractive procedure, but you should wait until the limbal stem cell defi- ciency is resolved, or as optimized as possible, before proceeding with a refractive procedure. • In graft-versus-host disease, a multifocal or toric IOL should generally be avoided. A scleral lens, however, may work well for these patients. • In atopic keratoconjunctivitis, eyelid disease should be addressed prior to surgery. by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor Dr. Daluvoy said she would aggressively treat the surface disease. "To start, I would try petroleum jelly or a mild hydrocortisone ointment to the lids and treat the surface with a course of mild topical steroid and preservative-free tears," she said. "I would also reiterate the importance of not rubbing the eyes." Other treatments might include oral doxy- cycline or prescription-strength dry eye medications. In terms of residual corneal staining, Dr. Daluvoy said she would tolerate only a mild amount because of concern about poor healing after epithelial debridement. Dr. Jacobs said she is not cur- rently doing crosslinking. "I think that the goal, as far as the ocular surface [is concerned], is to optimize healing—especially if the proce- dure is to be epi-off—to reduce the likelihood of persistent epi defect or residual haze. You would want to have the surface at a plateau, and if there is some staining, so be it." Experts discuss how to handle a variety of scenarios O ptimizing the ocular sur- face is an important step for treatment of patients with dry eye. Depending on the patient and co-ex- isting conditions, full optimization may prove particularly challeng- ing for ophthalmologists. Melissa Daluvoy, MD, assistant professor of ophthalmology, Duke University Eye Center, Durham, North Caroli- na, Deborah Jacobs, MD, associate professor of ophthalmology, Harvard Medical School, Boston, and Bennie Jeng, MD, professor and chair of the Department of Ophthalmology and Visual Sciences, University of Mary- land School of Medicine, Baltimore, weighed in on a variety of scenarios and how they would approach these patients. Scenario 1: Progressive keratoconus The first scenario involves a patient with progressive keratoconus and severe atopic keratoconjunctivitis with diffuse corneal and conjuncti- val staining and active lid eczema. EyeWorld asked Drs. Daluvoy, Jacobs, and Jeng about their protocol to settle the ocular surface prior to crosslinking in such cases. Dr. Jacobs is a "huge fan" of soft steroid ointment (loteprednol or fluorometholone) at bedtime for treatment and suppression of atopic blepharoconjunctivitis. Some patients benefit from tacrolimus ointment as a steroid suppressing strategy, she added. "I would contin- ue this through the post-crosslink- ing period in addition to protocol topical steroid drops." Dr. Jeng said that before any ocular surgery or procedure, eyelid disease needs to be addressed. Atop- ic keratoconjunctivitis is especially difficult for a lot of ophthalmolo- gists, he said. Treating it systemical- ly is the only way to address it, he added. Dr. Jeng noted that he tries not to use steroids on the eyelid because the eyelid skin is so thin, and it can cause depigmentation. Since this is a systemic disease, Dr. Jeng said it's important to "buddy up with an allergist." When considering residual cor- neal staining, Dr. Jeng stressed again that the systemic disease has to be under good control, and you need to make sure the body and eyelids are "as optimized as possible." In- variably, these patients will still get staining, he said. If a patient has atopic disease and keratoconus and you want to crosslink them, you need to realize they could end up with slow-heal- ing epithelium. For these patients, Dr. Jeng suggested considering an epi-on protocol so you don't destroy the epithelium. Or, if you do epi-off (the current FDA-approved proto- col), he said a contact lens or am- niotic membrane could help them epithelialize again after. "In terms of giving them better vision, these patients do well with a scleral lens," Dr. Jeng said. "It not only gives them better vision by giv- ing a new surface to see out of but also keeps them more comfortable." Challenging dry eye cases An example of graft-versus-host disease. These cases may be challenging to treat, and surgeons may want to avoid using premium lenses in these patients. Source: Melissa Daluvoy, MD

• Blank Page
• Blank Page (1)