Eyeworld

C OCTOBER 2025 | EYEWORLD BONUS ISSUE | 23 Relevant disclosures Beckman: AbbVie, Alcon, Amgen, Bausch + Lomb, Théa, Viatris Garg: AbbVie, Glaukos Kim: None Kugler: None Li: None Meghpara: None Shukla: AbbVie, Alcon, Théa Contact Beckman: kenbeckman22@aol.com Garg: ragarg927@gmail.com Kim: sk5624@cumc.columbia.edu Kugler: lkugler@kuglervision.com Li: lucysfmatch@gmail.com Meghpara: bmeghpara@willseye.org Shukla: ag2965@cumc.columbia.edu In the clinic, Dr. Garg's first step is to ask patients how their eyes are feeling and how their drops are treating them. Then she follows up based on their complaints and how compli- ant they seem to be. "In the past it used to be a pressure threshold. It used to be a visual dete- rioration threshold for intervention or advance- ment of your treatment, but now it's not so. Now it's even if the patient is stable, if they're miserable, we have options to offer them." Dr. Garg said the safety profile of minimally invasive procedures are such that if a patient has great pressure and a stable field, stable optic nerve but they're miserable, they can be offered SLT, iDose TR (travoprost intracameral implant, Glaukos), and other things to help get them off the medications and keep them stable. The refractive perspective The ocular surface is incredibly important for success with refractive surgery, said Lance Kugler, MD. "What I tell patients is that 100% of the light that enters the eye travels through the tear film first," he said. He explains to patients that as one of the most important refractive elements of the eye, the tear film and ocular surface have to be in good shape, or no procedure will produce the results they're hoping for. Dr. Kugler evaluates the ocular surface preop, looking at the slit lamp, tear breakup time, tear film index with the HD Analyzer (Visiometrics), interferometry with the TearScience LipiView (Johnson & Johnson Vision), meibomian glands, and epithelial mapping. Dr. Kugler said he thinks epithelial mapping is the most important thing to evaluate the ocular surface. "[It] shows us what's actually happening physiologically to the ocular surface that's dry," he said. "It's pretty rare to see an eye with significant tear film abnormality that has a normal epithelial map, so it's a very good test." If there is irregularity on the epithelial map, if the meibomian glands are in poor shape, if the tear film aberrometry is low, if any of these things are significant, Dr. Kugler said the ocular surface should be rehabilitated as much as possible before proceeding with surgery. In his practice, a procedural recommendation is not even made until the ocular surface is in good shape. If the ocular surface is inconsistent, could an IOL or ICL-based refractive procedure be considered instead? Dr. Kugler said, in some cases, yes, because these have less of an impact on the ocular surface in the short term. Howev- er, repeatability in measurements for these pro- cedures continues to be important for positive outcomes. When it comes to ocular surface reha- bilitation, Dr. Kugler said his practice has a comprehensive dry eye service that has many treatments and modalities available, including medications, drops, nutritional supplements, autologous serum tears (which he noted is "probably the most powerful tool we have for the ocular surface"), and devices, which include intense pulsed light therapy and BlephEx. "We treat blepharitis and Demodex very aggressive- ly," he said. Once the patient has been through an oc- ular surface rehabilitation program, Dr. Kugler said he wants to see any tests that were abnor- mal prior stabilize as much as possible before proceeding. "If the ocular surface is irregular, you want to make it as regular as possible. If there are objective findings of Demodex, you want to make sure those have resolved," he said. Dr. Kugler acknowledged that some things won't resolve with treatment, such as meibo- mian gland atrophy, but optimize the surface as much as possible. Dr. Kugler's ocular surface management doesn't stop after the procedure is complete. He said it's important to pay close attention to these patients postoperatively and continue optimizing the surface as much as possible. He said it's important to document and discuss sur- face irregularities preop so the patient can un- derstand these are chronic problems that were not caused by surgery and that they require management before and after surgery. "Patients understand that you're going to have periocular irritation and ocular surface irregularity around refractive surgery. What they're comforted by is knowing that you have a plan for it. If you see them and say, 'Your surface is drier than average right now, but that's OK. Here's the plan where we're going to prevent it from getting worse,' they're usually very receptive to that," Dr. Kugler said. He also said these patients are usually very compliant with postop ocular surface therapies. "They're thrilled with their new refractive sur- gery eyes, and they want to keep them healthy," Dr. Kugler said.

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