Eyeworld

DECEMBER 2020 | EYEWORLD | 97 C Dr. Matossian said that in order to optimize the ocular surface prior to cataract surgery, a more aggressive approach is required. She added that a short course of steroids such as loteprednol etabonate (Lotemax, Bausch + Lomb, or Inveltys, Kala) BID–QID is often necessary to control the surface inflammation. "The steroid is not refilled; it is used for acute inflammation control," she said. "Thereafter, therapy for chronic disease continues with various at-home remedies, including oral omega supplements, lid hygiene with scrubs (NuLids, NuSight) or lid cleansers, heated moisture masks, and prescription pharmaceuticals." She added that it's also important to make sure patients are using a good quality artificial tear or given the option to stimulate their own tear production with an FDA-cleared device such as iTEAR 100 (Olympic Ophthalmics). Dr. Matossian said that additional in-office treatments may be required to maintain tear film homeostasis. Microblepharoexfoliation (BlephEx) to remove the built-up biofilm on the she said. Vital dyes, such as fluorescein and lissamine green, are important to describe the level of ocular surface staining. Dr. Matossian said she employs all of these tests in her practice but noted that they have shortened the questionnaire to three ques- tions for efficiency. Her process includes the three-question questionnaire, tear osmolarity, MMP-9 testing, and meibography, followed by lissamine green and fluorescein staining at the slit lamp with grading and evaluation of the ocular surface and lid margins. Dr. Matossian said all patients get started on preservative-free artificial tears QID as a teach- ing tool on how to instill drops. Drop adminis- tration is not intuitive and is rather difficult to master by most patients, she explained. Additionally, Dr. Matossian said if the MMP-9 test is positive, indicating the presence of inflammation on the ocular surface, she will prescribe an immunomodulator such as Resta- sis, Xiidra, or Cequa and let the patient know that this treatment is ongoing and will continue indefinitely after the standard postop cataract surgery drops are completed. "I do not use punctal plugs as a first-line treatment," Dr. Matossian said. "I wait for the surface inflammation to subside before con- sidering plug placement." Often, with a com- bination of a re-esterified triglyceride omega-3 (Physician Recommended Nutriceuticals), a heated moisture mask (Bruder), and a prescrip- tion immunomodulator, the tear film stabilizes in most patients, she said. Optimizing before cataract surgery Dr. Pflugfelder said timing to optimize before cataract surgery is variable, but it usually takes 4–6 weeks. In explaining this process to patients, Dr. Pflugfelder tells patients that a smooth corneal surface is necessary for accurate IOL power calculations and the best outcome. Four to 6 weeks after beginning dry eye therapy is generally the best time to consider topography and biometry for IOL calculations. "We perform IOL calculations at that time if the corneal surface is healthy," he said. "Sometimes we'll repeat the calculations at the preop exam." continued on page 98 LipiFlow during COVID-19 Source: Cynthia Matossian, MD

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