Eyeworld

This CME supplement is supported by unrestricted educational grants from Alcon and Bausch + Lomb. performed a mini-monovision procedure, targeting –1 D in his left eye in view of his residual cylinder. His outcome was successful and the patient is incredibly satisfi ed. Dry eye also may infl uence decisions when planning a lens exchange or enhancement. A patient relied on a single contact lens for her near vision needs. Another ophthalmology offi ce performed her preoperative measurements immediately after she removed her contact lens, and the ophthalmologist chose a toric IOL for a pseudoastigmatism pattern created by her contact lens. When she presented at my of- fi ce, the patient was very dissatisfi ed with her outcome, which prevented her from driving or seeing clearly. I explanted her toric lens and implanted a monofocal IOL since she had less than 0.5 D of cylinder. Engaging the patient When ocular surface disease is diagnosed, cataract surgeons should show patients evidence of their dry eye disease so patients understand that they have a pre-existing con- dition that needs to be treated not only before surgery but may require ongoing treatment post surgery. If you engage patients and help them see that they're improving by showing them sequential images, they are more likely to adhere to their prescribed regimen. They may achieve their optimal state more quickly by being encouraged with their progress. One of our patients had no complaints of dry eye, but his Placido disk image with OPD3 showed a very erratic surface and irregular mires. I showed him the results of his ocular surface testing. If explanation of pre-existing ocular surface disease is unclear, patients may mistakenly blame their surgeon or procedure for causing their dry eye. In addition, it is important to set patients' expectations. We told a patient with Salzmann's corneal dystrophy that the cornea should be treated before we could calculate her IOL power. However, the patient declined additional surgery, even after I explained that her refractive outcome would be less predictable. This unpredictability made her a poor candidate for an advanced technology implant. Conclusion For the best refractive outcomes, it is important to optimize the patient's ocular surface before performing preoperative measurements and calculations, separating the surgical testing appointment from the cataract consult. A good quality tear fi lm is critical for accurate measurements and more predictable refractive outcomes. Dr. Matossian is the founder and chief executive offi cer of Matossian Eye Associates with offi ces in Pennsylvania and New Jersey. She can be contacted at Cmatossian@matossianeye.com Thorough assessment of the tear fi lm is necessary before proceeding with preoperative calculations. To evaluate the ocular surface, we begin with the OSDI questionnaire. I perform tear osmolarity on all of my patients, and we recently began using the Infl ammaDry test, which detects MMP-9, a marker of infl ammation. In addition, we use the Sjö Test, a blood test used to detect Sjögren's disease if warranted. I also use lissamine green dye to examine the uptake on the eyelid margin, the conjunctiva and cornea. (Before preoperative testing, contact lenses must be discontinued for 2 to 4 weeks.) In a patient with abnormal mires on her Placido disk (left), 1 month after I began treatment with cyclosporine ophthalmic emulsion 0.05%, her results were greatly improved (right). Therefore, I was confi dent the IOL calculations would bring her much closer to my refractive target. I personalize ocular surface treatment to each patient, depending upon severity. In addition to preservative-free artifi cial tears 4 times a day, I may prescribe oral omega-3 supplements. I prescribe the triglyceride form, which is absorbed more readily. I also may prescribe cyclosporine ophthalmic emulsion 0.05%, azithromycin ophthalmic solution 1.5%, and loteprednol 0.5% (gel or ointment), and warm compresses as often as possible. Assessing and treating the ocular surface preoperatively Supported by an unrestricted educational grant from Allergan

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