Eyeworld

EW FEATURE 42 by Jena Passut EyeWorld Staff Writer Impact of dry eye on patient satisfaction I f conventional wisdom holds true, an unlucky post-op LASIK or refractive IOL patient who goes home with an irritating case of dry eye will complain to a dozen or so friends about the experience. That number probably increases tenfold with social media thrown into the mix—not a good scenario for surgeons who count on these pa- tients for their livelihood. Dry eye has quite an impact on a patient's satisfaction after one of these elective procedures. Experts now advise colleagues to treat the dry eye before even scheduling the surgery. A healthy ocular surface has become a pre-op must. Look for it Surgeons should first know the po- tential exacerbating factors for dry eye disease, including various sys- temic medications such as antihista- mines and antidiuretics and the presence of systemic diseases such as rheumatoid arthritis. Other oph- thalmic conditions that can accom- pany dry eye disease or make it worse are blepharitis, meibomian gland dysfunction, lagophthalmos, and ocular rosacea. Those may be treatable with warm compresses and lid hygiene scrubs, as well as artifi- cial tears, oral doxycycline, and pos- sibly topical antibiotics and steroids. "If patients have dry eye pre-op- eratively, they are at an increased risk of developing worsening signs and symptoms post-operatively," said William B. Trattler, M.D., cornea specialist, Center for Excellence in Eye Care, Miami. "Since dry eye is so common in patients, we have to be aggressive and look for it." In LASIK, an unhealthy ocular surface will affect wavefront and to- pography readings. For cataract sur- gery, it could affect IOL calculations and the axis and magnitude of astig- matism. "That can affect your planning for surgery," Dr. Trattler said. How to test Dr. Trattler said his preferred method of testing for dry eye is fluo- rescein straining and testing for tear break-up time (TBUT). Don't expect patients to come in complaining of the common symptoms, he warned, because a good portion of them could be asymptomatic. Dr. Trattler sited a prospective review of 272 eyes scheduled for cataract surgery. A majority of those patients were found to have dry eye and not even know it. Their history, which most surgeons are hard-wired to ask about, wasn't helpful. "We had them fill out a ques- tionnaire, but they didn't report any problems," he said. The testing told a different story, however. "We had about 62% of patients who had severely abnor- mal TBUT at 5 seconds or less," Dr. Trattler said. Most practitioners feel 7-8 seconds is abnormal. The study was presented at World Cornea Congress VI in Boston in 2010, and it is submitted for pub- lication. Although dry eye is prevalent in older populations, especially peri- and post-menopausal women, Dr. Trattler said younger patients are also at risk, and contact lenses may be to blame for masking the symp- toms. Doctors should test all patients for dry eye, even those without clear evidence of the disease, especially since it's better to treat the disease pre-op, Dr. Trattler said. "Everyone thinks about symp- toms of pain, irritation, and foreign body sensations, but in reality the more important issues are poor qual- ity of vision issues," he said. "With- out a good, healthy tear film, patients will complain of poor qual- ity of vision, maybe even fluctuation of vision, and that their visual re- sults after surgery are not what they expected. They may have paid a lot of money out of pocket and yet their quality of vision is less than satisfac- tory." Besides TBUT and fluorescein, Stephen C. Pflugfelder, M.D., pro- fessor of ophthalmology, Baylor Col- lege of Medicine, Houston, recommends testing with lissamine green staining and Schirmer's test, which might help the practitioner decide whether the dry eye is aque- ous deficient. "There are some new sophisti- cated tests that can measure the vol- ume of tears in the eye, like OCT [optical coherence tomography]," he said. "That's turning out to be a great test because we can see for the first time the area where tears accu- mulate along the lower lid." A tear osmolarity test can meas- ure the osmolarity and the tear film in a microdroplet, as well. "That hasn't gotten widespread acceptance yet, and neither has OCT, but both of them have the po- tential to identify dry eye," Dr. Pflugfelder said. Other risk factors for dry eye in- clude smoking, diet (lack of omega-3 and omega-6 fatty acids), and med- ications such as antidepressants and antispasmodics, like the ones that are used for bladder control. February 2011 OCULAR SURFACE April 2011 5+* +V_`J`JSPUL/`JSH[LTN*HWZ\SLZ<:7 )YPLM:\TTHY`VM7YLZJYPIPUN0UMVYTH[PVU AT A GLANCE • Dry eye will negatively affect patient satisfaction • Experts advise achieving a healthy ocular surface before performing LASIK • New, sophisticated tests can meas- ure the volume of tears in the eye • Smaller flaps and larger hinges may mitigate dry eye problems Post-LASIK dry eye with punctate epithelial erosions Source: William B. Trattler, M.D. 032-047 Feature_EW April 2011-DL_Layout 1 4/10/11 8:02 AM Page 42

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