Eyeworld

2 | SUPPLEMENT TO EYEWORLD | DECEMBER 2019 Performing the clinical exam T he ASCRS Preoperative OSD Algorithm breaks down the clinical exam for a preoperative cataract and refractive surgery patient into four steps: look, lift, pull, and push (LLPP). Look The look starts before getting un- der the microscope, by listening to the patient and watching them. Macroscopically, I look for rhinophyma, a ruddy complex- ion, or telangiectasis across the cheeks. I look for an erythem- atous lid margin suggestive of rosacea or a primary posterior blepharitis. I watch how many blinks are occurring, and if they are full blinks. Much of MGD is primarily due to not enough complete blinks, resulting in less than desired egress of meibum, which leads to congestion, pres- sure within the glands, and then the atrophy. We sometimes rush to look at their OSDI score or SPEED score and get a very brief history. I intentionally stop and really take a good listen and look. Under the microscope, I look first at the architecture of the lid margin to see if it's well opposed to the globe and if there is evidence of exposure. I then look for evidence of Demodex or anterior blepharitis, and as I go from the front to the back By Elizabeth Yeu, MD of the lid margin, I look for telangiectasis and for any capped meibomian glands. Furthermore, I'm evaluating for any pitting or primary notching of the lid margins. Correlating that area to meibography usually shows a good amount of atrophy or a completely missing gland. Finally, I look at where the tear film is, how thick it is, and what's in it. If it's soapy, there are bacterial lipases in action and some form of an anterior bleph- aritis. I also want to see if the tear film is going straight across from the temporal aspect to the nasal aspect. If it's being cut off anatomically, that's generally due to conjunctival redundancy. And I want to see if the puncta are tight or loose, if they're everted, and/or making contact with the globe. Lift Lifting means the upper lid, assessing for lid floppiness or tightness, and everting the lids. If there is concern that there may be an allergic component, I am concerned about the palpebral conjunctival surface of the actual lids. Pull and push As I pull the lower lid to lower it, I'm also everting it, so I can see the inner palpebral conjunctival surface of the lower lid. I use a cotton swab to push on the lower lids, pushing on the medial aspect, the central, and then the temporal, examining how easy it Right lower lid of 59-year-old female: Exam reveals moderate telangiectasis of lower lid margin, without notching, and meibography demonstrates very advanced meibomian gland loss throughout the lower lid. is to get the meibum to express and evaluating the quality of the meibum. Treatment regimens For active lid margin disease, reducing inflammation is key to management. I always rec- ommend oral omega-3s as a baseline. Oral MMP-9 inhibitors like doxycycline can be helpful, particularly in those with rosacea or significant telangiectasis of their lids as a core issue. An anti-inflammatory (cyclosporin-A or lifitegrast) can be useful as an adjunctive therapy down the line. A major part of MGD management is cleansing and getting the meibum back to health, evacuating the meibum and keeping the margin orifice open. Emollient-based tears, warm compresses, thermal therapies, intense pulsed light and neuro-stimulation all make sense. Microblepharoexfoliation can be helpful, particularly combined with a thermal therapy. I add blinking exercises to the lid hygiene regimen, a close and squeeze of the back surface of the lid which will help express the glands, once a night, 5 times for 5 seconds each. n Benefits of proper surgical preparation Dry eye disease and MGD, with or without architectural damage, can worsen following cataract surgery. By managing ocular surface disease prior to surgery, we are protecting our patients for functional success. Dr. Yeu is a partner at Virginia Eye Consultants and assistant professor of ophthalmology at Eastern Virginia Medical School. She can be contacted at eyeu@vec2020.com. Managing ocular surface disease in a preoperative cataract or refractive surgery patient Elizabeth Yeu, MD

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