Eyeworld

I OCUR SURFACE CONSIDERATIONS FOR SURGERY N FOCUS 42 | EYEWORLD | JUNE/JULY 2020 Contact Epitropoulos: eyesmd33@gmail.com Matossian: cmatossian@matossianeye.com Starr: cestarr@med.cornell.edu Trattler: wtrattler@gmail.com continued from page 41 References 1. Gupta PK, et al. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Re- fract Surg. 2018;44:1090–1096. 2. Trattler WB, et al. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423–1430. 3. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669–684. Relevant disclosures Epitropoulos: Novartis, Allergan, Sun, Johnson & Johnson Vision, PRN, BlephEx Matossian: Johnson & Johnson Vision, Quidel, TearLab, Bruder, PRN, BlephEx Starr: Allergan, Novartis, Alcon, Johnson & Johnson Vision, Dompe, BlephEx, Bruder, TearLab, Quidel, Sun, Kala, Eyevance Trattler: Allergan, Novartis, Sun, Sight Sciences, Johnson & Johnson Vision, Bausch + Lomb, NovaBay, Alcon Visually significant corneal staining is common prior to cataract surgery, but patients are often asymptomatic. Source: Christopher Starr, MD term and often starts long-term therapy with Restasis (cyclosporine, Allergan), Xiidra (lifite- grast, Novartis), or Cequa (cyclosporine, Sun Pharma). He also considers whether a punctal plug might be helpful to raise the tear film. Dr. Trattler said that if the patient has blepharitis, he would treat with topical steroids to help quiet inflammation, along with hypo- chlorous acid spray and warm compresses. If patients aren't responding well, he discusses ad- ditional therapies with them including LipiFlow or TearCare (Sight Sciences). While there is no rigid standard of care for treatment, Dr. Starr said there are a lot of treatment recommendations based on severity and subtype. Treatment recommendations put forth by the ASCRS Cornea Clinical Committee largely follow the TFOS DEWS II treatment recommendations, with the difference being that you may have to act a bit more aggressively in a pre-surgical patient. Dr. Starr noted the identification of both visually significant ocular surface disease and non-visually significant ocular surface disease. Many will have non-visually significant ocular surface disease, he said, which doesn't necessar- ily require you to cancel surgery and do aggres- sive treatment. However, it's important for the patient to be aware of this prior to surgery. If you don't tell them prior to surgery and it gets worse afterward, it's considered a complication, he said. Meanwhile, visually significant ocular surface disease needs to be treated and reversed prior to surgery, Dr. Starr said, which can delay the surgery. Dr. Epitropoulos said she's had excellent re- sults reducing inflammation with immunomod- ulators, often in conjunction with a short course of a steroid and high-quality omega-3 supple- ments. It's important to unblock the glands, especially prior to cataract or refractive surgery, and this can be done by heating and evacuating the glands with thermal pulsation treatment or using a handheld instrument that delivers light energy to soften blockages of the meibomian glands. Results are maximized when combined with microblepharoexfoliation, she said. Dry eye and premium lenses Dr. Trattler said that premium lenses, especially presbyopia-correcting lenses, can be sensitive to residual astigmatism. Physicians have to be sure that they are getting accurate measurements so that the optimal lens power is selected, he said. This typically requires aggressive treatment of MGD and dry eye first to obtain good measure- ments. Dr. Trattler also mentioned the Light Adjustable Lens (RxSight), where the mea- surements and in-lens refractive treatments are done 3–4 weeks after surgery. For patients that receive these lenses, it's important to pretreat and optimize their ocular surface and continue this treatment until the lens power is locked in. "Especially for patients who are paying out of pocket for a premium lens, we need to nail that refractive outcome, otherwise we're going to have an unhappy patient," Dr. Matos- sian said. Their expectation is beyond perfect because they're paying thousands of dollars, she added, so tuning up the surface to get more reliable information is important, especially in a subset of patients seeking less dependence on spectacles. If they have very severe dry eye disease with an underlying chronic medical condition, they may not be a candidate for a presbyopia-correcting implant, and they would have to be educated as to why they're not a good candidate, Dr. Matossian said.

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