Eyeworld

By Kenneth A. Beckman, MD Supported by unrestricted educational grants from Shire, Johnson & Johnson Vision, Allergan, and Sun Ophthalmics DECEMBER 2019 | SUPPLEMENT TO EYEWORLD | 3 A patient is not ready for surgery until their ocular surface is optimized, and I want them to understand why this is important for their outcome. Patient education There are three major reasons to clean up the surface of the eye prior to surgery. I explain to patients that these are important to successfully choosing an IOL. 1. Reduced infection risk 2. An improperly prepared surface can lead to inaccurate K-readings and topography. 3. An unhealthy surface can lead to significant postoperative aberrations even with proper IOL choice. Be willing to wait When I start a patient on ste- roids, antibiotics, or whatever is needed, I explain that this will take weeks to months, but that they don't want to have surgery more than once. Most patients are comfortable with delaying surgery when they consider the alternative. I also tell them this will require maintenance or visual aberrations may return. If you identify ocular surface disease before surgery, the patient will understand that the problem exists prior to surgery. If it isn't detected until after surgery, the patient is likely to believe the surgery caused it. Setting expectations to achieve 20/happy There's more to vision than just visual acuity on the chart. Some patients who are 20/20 aren't satisfied, and some who are 20/40 are. The biggest thing is expectations, which are set by an explanation. You need to identify and explain to the patient everything they have and the limitations on improving their vision. I explain not just their disease but also about the lens, the process, and eye health in general. They need to know about and understand all pre-existing conditions and understand what we are and are not treating. I also explain that, especially with multifocal lenses, even an IOL with the correct power can cause aberrations such as rings and halos. I tell them if they won't want to live with that, don't get the lens. Once they under- stand that, when they notice aberrations, they're not worried by it and they tolerate it. n Dr. Beckman is the director of corneal surgery at Comprehensive Eyecare of Central Ohio and clinical assistant professor of ophthalmology at The Ohio State University. He can be contacted at kenbeckman22@aol.com. Discussing preoperative management Kenneth A. Beckman, MD developing symptoms, or that they already have signs, and that treating the condition now will help achieve better outcomes. It's important that the patient under- stand the process. Treatment regimens My decision for how to treat in- flammation depends on its sever- ity. If very severe, I give steroids to quickly reduce the inflamma- tion. When only cyclosporine was available, I would typically pre-treat with a mild steroid, like Lotemax or fluorometholone, while the patient was taking the cyclosporine, because it takes longer to take effect. Lifitegrast has a fairly rapid onset of action, as soon as 2 weeks. I will often prescribe it without a steroid and see how the patient does. Sometimes they'll report burning, in which case I'll start a steroid for a couple weeks before reinstating lifitegrast. n Dr. Chan is an assistant professor in the Department of Ophthalmology and Vision Sciences at the University of Toronto. She can be contacted at clarachanmd@gmail.com. Treating inflammation related to dry eye By Clara C. Chan, MD P atients arriving to our dry eye clinic receive osmolarity and MMP-9 testing. Follow- ing the ASCRS algorithm, a clinical exam is then performed. For the "Look" in the LLPP mnemonic, I look for signs of inflammation that I want to address prior to surgery. I look to see if the patient has rosacea, a red eye, or signs of allergic conjunctivitis, and ask their history of eye rubbing. On slit lamp exam, I look for epithelial basement membrane dystrophy, Salzmann's nodules, conjunctival chalasis, pterygi- um, or anything else that could contribute to irritation or DED symptoms. The last thing I look for is corneal fluorescein staining. Benefits of treating Cataract or refractive surgery can worsen dry eye conditions, so you want to treat any inflam- mation before surgery. Inflam- mation is part of the underlying process behind DED. I explain to patients they are at risk for Clara C. Chan, MD

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