Eyeworld

C ORNEA 10 | EYEWORLD BONUS ISSUE | OCTOBER 2025 Reference 1. Gouvea L, et al. Objective assessment of optical quality in dry eye disease using a double- pass imaging system. Clin Ophthalmol. 2019;13:1991–1996. Relevant disclosures Gouvea: None Waring: Johnson & Johnson Vision, Oculus, Tracey Technologies, Visiometrics said. If that's the case, understanding the con- tribution that the tear film is causing to optical quality issues is paramount, especially before proceeding with cataract or refractive surgery. To assess the impact the tear film might be having on a patient's optical quality, Dr. Gouvea said she starts with a targeted history and symp- tom scales, such as the SPEED questionnaire. "At the slit lamp, I always assess tear meniscus height and tear breakup time. Corneal staining and lid margin is extremely important as well. Lid margin disease is known to cause dry eye disease, and significant staining can impact quality of vision," she said. Dr. Gouvea will also conduct tear film analysis with the iTrace (Tracey Technologies) to determine tear film quality. "I think this is a good tool to show our patients how their vision is being affected. I have previously used the Keratograph 5M [Oculus], another comprehen- sive device that helps document non-invasive tear breakup time, and meibography. These are essential for patients' understanding of their dis- ease and can even improve adherence to treat- ment," Dr. Gouvea said. She has also previously used the HD Analyzer (Visiometrics). Dr. Waring said the HD Analyzer is more of a research tool and is currently not widely used, but he finds the iTrace ray tracing technology very effective in its ability to objectively eval- uate dry eye. He also uses the Pentacam AXL Wave (Oculus) for high-resolution tomography pattern analysis, which can be "highly sugges- tive of dry eye objectively," and meibography with LipiFlow (Johnson & Johnson Vision) to evaluate structural changes in the meibomian glands. Like Dr. Gouvea, Dr. Waring looks for signs of chronicity at the slit lamp. Even if a practice doesn't invest in all of these diagnostic technologies, Dr. Waring con- siders tomography a must-have. He said Placido topography is also underutilized for dry eye evaluation and diagnosis. "Most ophthalmolo- gists have access to either Placido-based topog- raphy or Scheimpflug tomography of some sort. … These can be very useful diagnostic devices for dry eye. They do not provide functional in- formation, but they give objective information." Once it is determined the patient has tear film quality issues that are impacting their optical quality, Dr. Gouvea said she recommends several things—first, improved diet and water intake, warm compresses, and lid hygiene. For drops, she'll start preservative-free tears. If those don't work, she'll prescribe a short-course of steroid and cyclosporine. "I also consider in-office therapies such as thermal pulsation, IPL, or BlephEx. For refractory or very severe patients, I add autologous serum tears or plate- let rich plasma," she said. Dr. Gouvea said she sees tear film insta- bility as chronic and likely to relapse, so she rarely considers patients "done" with treat- ment. If patients are not having cataract or refractive surgery, she de-escalates therapy to maintenance mode where their symptoms are controlled and the surface is stable. "I explain they will always need to do something to make sure their symptoms are under control—warm compresses/lid hygiene at least once a day and some sort of artificial tears," she said, noting that some patients will require ongoing anti-in- flammatories. If she is planning for surgery, Dr. Gouvea sees a patient as accomplishing control when their metrics are stable on at least two visits. The approach to tear film instability in Dr. Waring's practice is two-fold. He said there is an emphasis on addressing the underlying root cause, such as contact lens overuse, Demodex, or rosacea blepharitis. Then the focus shifts to ocular surface optimization. "If [the ocular sur- face is] more severe, we'll work on it in advance of vision correction, but it's part of a holistic program that we outline in our preoperative consultation." Dr. Waring also said that maintaining the tear film is an enduring process. He said it's important to address the root cause of the prob- lem, particularly if the dry eye may be affecting their preoperative measurements. However, maintaining a healthy ocular surface is not one and done—it's ongoing. "The tear film's contribution to the opti- cal system is not only important, it's the most important of the optical surfaces of the human eye," Dr. Waring said. "We are vision correction specialists on all optical surfaces. Whether it's the front of the cornea, the back of the cornea, crystalline lens, at every surface, we have a solution. But we can't disregard the most im- portant surface, which is the ocular surface. We have recently described this as improving 'visual performance,' and we think this is the true op- portunity to optimize visual performance." continued from page 9 Contact Gouvea: gouvea@musc.edu Waring: georgewaringiv@gmail.com

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