Eyeworld

emulsion 0.05%; however, negative results may mean the patient has a milder case that still may require cyclosporine treatment. Patients with Sjögren's syn- drome are most in need of inflam- matory therapy, but their cases often have been misdiagnosed or undi- agnosed for decades. We now use the Sjö blood test, which includes markers for Sjögren's syndrome, in patients younger than 50 with dry eye, those with significant dry eye at any age, or those with dry eye that does not respond to treatment. In my practice, 50% of results are posi- tive, in which case I refer the patient to a rheumatologist. I also explain to these patients that long-term ther- apy with cyclosporine is the only long-term therapy that will work. In addition, LipiView lipid layer interferometry helps identify meibomian gland disease. Treating dry eye preoperatively In many cases, artificial tears do not adequately treat dry eye. We accel- erate therapy in patients with signs or symptoms of dry eye, elevated osmolarity, positive MMP-9 results, a history of LASIK or PRK, collagen vascular or autoimmune disease, or a surgical plan including arcuate inci- sions or limbal relaxing incisions. My preoperative strategy includes preservative-free artifi- cial tears 4 times a day, as well as loteprednol twice a day and cyclo- sporine twice a day. Loteprednol reduces the sting from cyclosporine, and cyclosporine enhances corneal nerve regeneration. 1 In patients we studied, cyclosporine treatment for 1 month before and 2 months after cataract surgery with multifocal IOLs resulted in better visual acuity and contrast sensitivity after surgery. 2,3 Combination immunomodula- tion hastens the response to therapy, allowing patients to see results more quickly. I continue loteprednol for 1 month. (Because it is a steroid, long-term use is not recommended.) Patients may benefit from oral omega-3 supplements; however, in my experience, all omega 3 supple- ments are not equal. Some tricyclic forms absorb very well. Punctal occlusion also is effec- tive, but anti-inflammatory therapy should be initiated first so inflam- matory residue is not trapped in the eye. In addition, warm compresses and lid scrubs play a role. If the ocular surface has not been corrected after treatment, you will need to talk with the patient about alternatives. Intraoperative measures For patients with dry eye, I specifi- cally choose surgical techniques to reduce dry eye after surgery. 4 For example, in eyes with low amounts of cylinder, rather than penetrating incisions, I use intrastromal abla- tions, which are associated with a lower incidence of dry eye because they are below the neural plexus. In patients with moderate dry eye, I may implant a toric lens rather than creating arcuate or limbal relaxing incisions. In addition, I minimize drops containing benzalkonium chloride, reduce the amount of anesthetic drops, and use more viscoelastic or balanced salt solution. Postoperative strategies Everyone has dry eye after cata- ract surgery. Some patients may not notice it because severing the corneal nerves decreases pain and irritation. The most common symp- tom is visual fluctuation because of disruption of the corneal surface. When patients voice this complaint, we should consider treating dry eye more aggressively until it is proven otherwise. On postsurgical day 1, I pre- scribe preservative-free tears every 2 hours. I prescribe preservative-free tears during the first week, lubri- cating ointment at night as need- ed, and cyclosporine for at least 3 months after surgery, until the patient's eyes are fully healed. Conclusion As cataract surgeons, we all strive to provide the most favorable visual outcomes, and the most effective way to do that is to manage dry eye, which is very common and underdiagnosed. Dry eye adversely affects visual function—but it is reversible and we can prevent progression, ultimately improving the outcome of refractive cataract surgery. References 1. Peyman GA, Sanders DR, Batlle JF, et al. Cyclosporine 0.05% ophthalmic preparation to aid recovery from loss of corneal sensitivity after LASIK. J Refract Surg 2008;24:337–343. 2. Donnenfeld, Roberts, Perry et al. ARVO 2007 Poster B1041 3. Donnenfeld ED, Solomon R, Roberts CW et al. Cyclosporine 0.05% to improve visual outcomes after multifocal intraocular lens implantation. J Cataract Refract Surg 2010;36:1095–1100. 4. Albietz JM, Lenton LM. Management of the ocular surface and tear film before, during, and after laser in situ keratomileusis. J Refract Surg 2004;20:62–71. Dr. Donnenfeld is in private practice at Ophthalmic Consultants of Long Island and is clinical professor of ophthal- mology at New York University. He is a trustee of Dartmouth Medical School in Hanover, N.H. He can be contacted at ericdonnenfeld@gmail.com. Supported by an unrestricted educational grant from Allergan Cyclosporine improved contrast sensitivity under mesopic conditions without glare. Source: Donnenfeld, Roberts, Perry et al. ARVO 2007 Poster B1041

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