Eyeworld

I MANAGING IRREGUR CORNEAS PRIOR TO CATARACT SURGERY N FOCUS 48 | EYEWORLD | NOVEMBER 2019 Contact information Ayres: bayres@willseye.org Epitropoulos: eyesmd33@gmail.com Farid: mfarid@uci.edu Mah: mah.francis@scrippshealth.org Starr: cestarr@med.cornell.edu In severe dry eye, Dr. Farid will use serum eye drops or a PROKERA (Bio-Tissue), the latter of which provides a microenvironment for healing, she explained. Dr. Mah prefers to use serum or amniotic eye drops before using PROKERA. Ocular allergies sometimes are also a prob- lem to be addressed before surgery, Dr. Mah said. Patient education Patient education is a crucial part of any preop surgery prep, but it's especially important when explaining to asymptomatic patients with DED why the condition may become symptomatic after surgery. This could involve the continuous use of agents like cyclosporine or lifitegrast or working toward better lid management. "As a referral doctor, I see patients on a routine basis who complain about their quality of vision after surgery. They have good vision, but they are unhappy patients," Dr. Ayres said. "They don't understand how they went in feeling fine and then come out not feeling fine. Warning patients about the symptoms of dry eye will help them understand the problem." treatments at once is often the way to go, ac- cording to the surgeons. The ASCRS algorithm divides patients with OSD as having non-visually significant or visually significant OSD. The ones with visually significant OSD require more pre-treatment and may need to postpone their surgery. "Never hesitate to delay surgery until the ocular surface is healthy enough," Dr. Epi- tropoulos advised. Although the algorithm recommends waiting 2–4 weeks before starting treatment and repeating measurements, she will typically wait 4–6 weeks. Dr. Mah usually sched- ules surgery 6 weeks out. The algorithm suggests reworking your way through the beginning of the algorithm when a patient returns after treatment. The goal prior to surgery is to either eradicate OSD completely or convert it from visually-significant to non-vi- sually significant OSD via an aggressive treat- ment regimen targeting each OSD subtype. Some ocular surface problems such as EBMD, floppy eyelid syndrome, or Salzmann's nodules may require surgical interventions preoperatively when deemed visually-signifcant. However, if the patient has DED or MGD, more treatments are needed. For aqueous-deficient dry eye, preserva- tive-free artificial tears, over-the-counter gels and ointments, and an immunomodulator such as lifitegrast (Xiidra, Shire) or cyclosporine A (Restasis, Allergan) are often used, Dr. Mah said. Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharma), approved in the U.S. but not yet commercially available, may become a third possible option, he added. Some patients may require the immunomodulator chronically, even after surgery. A topical corticosteroid also may be used for a short time before surgery. For patients with MGD and blepharitis, treatments such as warm compresses, lid scrubs, thermal pulsation, blepharoexfoliation, oral doxycycline or minocycline, topical antibiotics, intense pulsed light therapy, and tea tree oil may be used, according to sources. In addition to those treatments, Dr. Epitropoulos will rec- ommend omega-3 supplements, particularly higher-quality ones that have been re-esterified and provide users with the full omega-3 dose available in the supplement, she said. continued from page 47 References 1. Jones L, et al. TFOS DEWS II management and therapy report. The Ocular Surface. 2017;15;3;575–628. 2. Milner MS, et al. Dysfunctional tear syndrome: Dry eye disease and associated tear film disorders — new strategies for diagnosis and treatment. Curr Opin Ophthal- mol. 2017;27:Suppl 1:3–47. 3. American Academy of Ophthal- mology Cornea/External Disease Committee. Dry Eye Syndrome PPO. 2018. Available at: https:// www.aao.org/preferred-prac- tice-pattern/dry-eye-syndrome- ppp-2018 4. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669–684. 5. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672–1677. Look-Lift-Pull-Push Here are some highlights of what is recommended in the LLPP mnemonic described in the paper by the ASCRS Cornea Clinical Committee. Find more details in the algorithm paper. 4 •Look at the blink quality and quantity, examine the eyelids, and look for signs of anterior and posterior blepharitis. •Lift and pull up the eyelid to rule out superior EBMD and identify floppy eyelid syndrome and eyelid laxity, because these are often missed in exams. •Push on the lower lid margin to express the meibum.

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