Eyeworld

78 | EYEWORLD | SEPTEMBER 2022 G UCOMA Contact Singh: ipsingh@amazingeye.com Wu: pwu@saceye.com Relevant disclosures Singh: Allergan, Alcon, Bausch + Lomb, Glaukos, New World Medical, Nova Eye, Novartis, Sight Sciences Wu: None or amniotic membranes to optimize the ocular surface as much as possible." The majority of MIGS procedures are done at the same time as cataract surgery, Dr. Singh said, and many of these patients are paying extra money for premium lens options; they expect and deserve good outcomes. If the ocular surface is not healthy, outcomes may not be optimal and recovery may take longer. Dr. Wu said he talks to his glaucoma pa- tients with significant ocular surface disease and stresses that the surface of the eye needs to be optimized before proceeding with cataract surgery. "This is important to get the best result possible with their cataract surgery," he said. "This can sometimes take months, especially with patients with advanced ocular surface disease." Prior to doing cataract surgery on his glau- coma patients, Dr. Wu makes sure the topogra- phy is regular with minimal to no signs of ocular surface disease on exam. "I like to make sure that my intraocular lens biometry correlates with my topography as well," he said. "If there is an issue with the ocular surface, I will repeat the biometry after treating the ocular surface until I see consistency in the readings, especially if I'm planning to implant a toric lens." The time for ocular surface optimization preop depends on how bad it is, but Dr. Singh estimates about a month. He will usually put patients on lifitegrast or cyclosporine, and some type of MGD treatment option. He also will use steroids like loteprednol to calm the surface. "If they need an urgent subconjunctival surgery like trabeculectomy or the XEN Gel Stent [Allergan], you might not want to wait that long," he said; even 1–2 weeks could be enough time to calm the inflammatory cascade. Dr. Singh said Durysta (bimatoprost intra- cameral implant, Allergan) can help get patients off drops a few months before surgery to im- prove the surface. Even for patients not having surgery, Dr. Singh has used Durysta for a drug holiday. It releases bimatoprost for a period of 4 months, but the duration can be longer—6 months to 2 years with one implant. Overall, Dr. Singh said he's had positive patient experi- ences with this approach. Though it doesn't last forever, it does get patients off their medications for a few months and gives the surface time to heal. "I think Durysta is a great alternative and a stopgap solution for those patients who are having dry eye issues," Dr. Singh said. Dr. Singh said there are many treatments like intense pulsed light (IPL) therapy, TearCare (Sight Sciences), LipiFlow (Johnson & Johnson Vision), BlephEx, and more that can be useful for MGD treatment, Dr. Singh said. Dr. Singh stressed that even glaucoma-fo- cused surgeons can help patients with ocular surface problems by identifying the problem and educating patients about why they have symptoms. That's half of the battle, he said; don't minimize the impact dry eye can have on patients' quality of life and ability to stay compliant. continued from page 77 "When we tell patients, 'Here's a drop' and don't address or acknowledge dry eye, patients often blame the glaucoma drops for their ocular surface symptoms, which in turn leads to less compliance, more side effects, and the potential for fluctuating pressure." —Inder Paul Singh, MD

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