Eyeworld

DECEMBER 2020 | EYEWORLD | 99 C Contact Matossian: cmatossian@cmassociatesllc.net Pflugfelder: stevenp@bcm.edu Sheppard: docshep@hotmail.com or via an intracanalicular dexamethasone-im- pregnated hydrogel insert (Dextenza, Ocular Therapeutix) placed in the inferior punctum preop, periop, or postop. Both are viable alter- natives to the tapering steroid drop burden, Dr. Matossian said. Generally, there is minimal short-term exac- erbation of dry eye from modern phaco surgery, Dr. Pflugfelder said, except in patients with severe aqueous tear deficiency. Cataract surgery will exacerbate dry eye, Dr. Sheppard said. "You're putting a lot of drops in and adding preservatives after holding the eye wide open with a speculum, thereby prohibiting blinking and desiccating the corneal epithelium with high intensity focal illumination." Dr. Sheppard said he likes to use a non-ste- roidal and a steroid for all cataract patients. There's a lot of clinical research and several FDA-approved products that can reduce that dosage, he added. Dexycu and Dextenza reduce the need for topical steroids. Physicians can use continuous intraopera- tive irrigation of Omidria (phenylephrine and ketorolac, Omeros), which circulates ketorolac in the eye throughout the surgical case and reduces pain and inflammation after cataract surgery, he said, adding that he thinks this significantly reduces the need for subsequent non-steroidal drops. LayerBio is developing a biodegradable NSAID ring attached to the IOL haptic that can provide weeks of intracameral anti-inflammatory therapy without drops. Minimizing dry eye issues There are other ways physicians can try to min- imize ocular surface issues, Dr. Sheppard said. For example, during surgery, physicians can minimize the amount of light blast as well as the amount of exposure created by the specu- lum by opening it just enough to access the eye safely. Physicians can also train staff to irrigate the eye frequently, protecting the ocular surface. Many will put a small layer of viscoelastic on the cornea, Dr. Sheppard said. He concluded with the following caveats: Don't forget the patient's environment, occupa- tion, and avocations; don't forget the systemic medications your patients are taking; and don't forget nutrition, both diet and supplementation, for surface control before, during, and after cataract surgery. lies, he added. LASIK is the next worst par- ticularly in light of a high incidence of ocular surface disease, Dr. Sheppard said, and PRK is also notorious for causing dry eyes. Even SMILE can cause dry eye but seems to be the least offensive. His strategy gears the timing and intensity of therapy to the underlying conditions. If someone had myopic refractive surgery, their corneal curvatures will change, Dr. Shep- pard said. This not only makes it more difficult to come up with precise sphere and cylinder calculations, but it also affects the type of lens you select. Patients lose positive asphericity of the cornea and may become flat or negatively aspheric, and you must choose the type of IOL appropriate for that corneal curvature. Dr. Pflugfelder added that some of these patients have a mild component of kerato- neuralgia that can be worsened with cataract surgery. "They can be identified as pain out of proportion to signs," he said. "Some post-LASIK patients may also have dry eye that should be treated as noted above." Dr. Sheppard added that toric IOLs can limit the use of LRIs, which further disturb corneal nociceptor architecture despite advances in femtosecond laser cataract surgery. Can cataract surgery aggravate dry eye? Ocular surgery causes an inflammatory insult to the eye leading to exacerbation of pre-existing dry eye disease, Dr. Matossian said. The preser- vatives in the eye medications prescribed pre- and post-surgery may have a toxic effect on the corneal epithelium. "Typically, three medication categories are used: an antibiotic, an NSAID, and a steroid," she said. "Each is used with a different frequency over a varying number of days or weeks." Dr. Matossian added that these medication schedules not only lead to a perceived burden by patients and their caregivers but also are wrought with non-compliance. "Patients either forget to use their drops or inadvertently miss their eye altogether, leading to a less than ideal postoperative course." Two recently FDA-approved steroids can be used either intracamerally at the conclusion of cataract surgery by placing a tiny spherule of dexamethasone under the iris or inside the cap- sular bag (Dexycu, EyePoint Pharmaceuticals) Relevant disclosures Matossian: Quidel, TearLab, BlephEx, NuSight, Olympic Ophthalmics, Physician Recommended Nutriceuticals, Allergan, Novartis, Sun, Bruder, Alcon, Johnson & Johnson Vision, Sight Sciences, Kala, Lumenis, Bausch + Lomb, EyePoint, Ocular Therapeutix Pflugfelder: Kala, Novartis, Senju, Kowa, Dompe Sheppard: Allergan, AbbVie, Alcon, Novartis, Bausch + Lomb, LayerBio, Omeros, EyePoint, Oc- ular Therapeutix, Sun, Novaliq, Quidel, Johnson & Johnson Vision, TearLab, LacriScience

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