Eyeworld

by Eric D. Donnenfeld, MD Therapeutic protocols for the refractive cataract patient Eric D. Donnenfeld, MD To optimize refractive cataract surgery outcomes with the latest technologies, surgeons first need to address the tear film T his is in some ways the golden age of ophthalmology, presenting endless opportunities with extraordinary technology, including aspheric intraocular lenses (IOLs), multifocal and accommodating IOLs, custom ablations, femtosecond laser cataract surgery, and more. As a result, cataract surgery and refractive surgery are merging into a single entity. However, the benefits of these advances are lost without a normal ocular surface. The tear film is the most important refracting surface of the eye, and vision quality begins with a healthy tear film. Therefore, carefully examining and treating the tear film are key. By aggressively addressing dry eye before, during, and after surgery, cataract surgeons are not changing the focus of their practice but laying the groundwork to potentially opti- mize postoperative outcomes. Identifying dry eye Dry eye has become an epidemic as a result of medications, nutritional deficiencies, and other factors. Many of our patients have mar- ginal dry eye before cataract surgery, complaining of minor eye fatigue. Because they don't see any corneal staining, most surgeons aren't too concerned about these corneas. Although there is a myth that dry eye patients are unhappy after cataract surgery, unhappy patients are actually marginally compensat- ed before surgery. Cataract surgery, including necessary medications and incisions, increases corneal anesthe- sia—pushing the patient from being marginally compensated to having overt dry eye. In these cases, patients often attribute their postoperative dry eye symptoms to their surgeons. Furthermore, as we increasingly use femtosecond lasers to create arcuate incisions, many more of these patients will exhibit dry eye symptoms because it was not man- aged appropriately before surgery. We must diagnose dry eye before surgery, treat the patient appropriately, and develop a therapeutic plan to reduce postoperative dry eye and avoid postoperative dissatisfaction. Preoperative assessment to drive treatment To practice smarter, we need to rely on physician extenders who can help us manage patients compre- hensively, providing us with more time to speak with the patient about dry eye treatment for better clinical results. In our practice, we provide a dry eye questionnaire to our patients. If they affirmatively answer three of the questions, our technicians proceed with dry eye testing. Testing enables us to diagnose dry eye accurately the first time and select therapy effectively. I believe osmolarity testing is the lynchpin, but the InflammaDry MMP-9 test is also extraordinarily important. Pos- itive results definitively indicate in- flammatory dry eye, which we must treat with cyclosporine ophthalmic The neglected refractive interface: Impact of the tear film on refractive cataract surgery outcomes Use of cyclosporine versus artificial tears resulted in significantly better visual acuity. Source: Donnenfeld, Roberts, Perry et al. ARVO 2007 Poster B1041

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