Eyeworld

EW CATARACT 41 February 2015 by Maxine Lipner EyeWorld Senior Contributing Writer For cataract patients who have mild to moderate dry eye, William B. Trattler, MD, Center for Excellence in Eye Care, Miami, initiates a course of topical steroids for 2–3 weeks, and has the patient return for repeat IOLMaster (Carl Zeiss Meditec, Jena, Germany) and topography. "We also consider add- ing topical cyclosporine preopera- tively and extending postoperatively for 3–6 months or longer," he said, adding that those who have pre-ex- isting dry eye beforehand are more likely to have it afterward. When the ocular surface is exceptionally dry and the tear film is low, he discusses placement of punctal plugs to increase tear film a day for the first 2 weeks postop- eratively, then dropping this back to twice a day for an additional 2 weeks. He also starts Restasis (cyclo- sporine, Allergan) as soon as possible preoperatively and continues it for a minimum of 3 months postopera- tively. Depending on the severity of the disease, other measures may still be needed. "For more severe meibomian gland disease, we might add oral doxycycline, and if patients have more severe aqueous deficiency dry eye, we'll very often place punctal plugs before surgery as well," he said. Depending on the severity of the dry eye, sometimes he will recommend the use of transiently preserved tears and minimize use of nonsteroidal medication, with once-a-day drops. diagnosed with dry eye preoperative- ly who has worsening dry eye tends to be among the most disgruntled patients in our practice," he said. "We need to diagnose it accurately and treat appropriately." "To diagnose dry eye, we routinely perform point-of-service testing on patients who come in for cataract surgery," he said. "We perform tear osmolarity and MMP9 testing with InflammaDry [Rapid Pathogen Screening, Sarasota, Fla.]." He said the test helps to max- imize outcomes and ensure that potential dry eye patients are not overlooked. Tapping into treatment Once dry eye is diagnosed, Dr. Donnenfeld institutes therapy based on the root cause of the disease, starting with the eyelids. "If the patient has markedly blocked meibomian glands, we squeeze the lids and look for the excretions," he said. "If it's turbid or toothpaste-like material, our therapy starts with hot compresses and lid hygiene." Dr. Donnenfeld adds an oral omega-3 supplement to the mix. He stressed that this should be re-esterified omega-3, which offers better absorption. Companies in the U.S. that offer this include Carlson Laboratories (Arlington Heights, Ill.), Nordic Naturals (Watsonville, Calif.), and PRN (Physician Recommended Nutriceuticals/Alphaeon Corpo- ration, Irvine, Calif.). He also uses artificial tears to lubricate the eye. Artificial tears on the market include Systane Ultra (Alcon, Fort Worth, Texas), Refresh Classic (Allergan, Irvine, Calif.), and Retaine MGD (OCuSOFT, Rosenberg, Texas). If the patient has more moderate disease or wants more aggressive therapy, Dr. Donnenfeld recommends instituting LipiFlow (TearScience, Morrisville, N.C.). "It's a device that not only heats the lids up from the inside where the meibomian glands are, but it also massages out the blocked oil glands," he explained. For patients who have aqueous deficiency dry eye or disease originating from mixed causes, he also recommends the use of fish oil. In addition, he uses anti-inflam- matory therapy, commonly recom- mending use of loteprednol 4 times Staving off dry eye throughout the procedure W hen it comes to cata- ract surgery, dry eye is more than just a nuisance; it can affect surgical outcomes, according to Eric D. Donnenfeld, MD, clinical professor of ophthal- mology, New York University Medical Center, New York. "Surgeons have to be aware that the corneal surface plays an integral role not only in the postoperative comfort and vision but also in the preoperative keratometry and IOL selection, so at every stage of cata- ract surgery the ocular surface has to be maximized to achieve optimal results," Dr. Donnenfeld said. An irregular topography from dry eye is going to have a significant impact not only on IOL selection, but also on the treatment of astig- matism. "We look to optimize the ocular surface before we do the preopera- tive evaluation. When patients come in and have irregular topography or any overt staining with fluores- cein of the corneal surface, we treat them before surgery and continue the treatment through the surgical postoperative period," he said. A critical concern Uday Devgan, MD, chief of ophthalmology, Olive View-UCLA Medical Center, and Devgan Eye Surgery, Los Angeles, concurs. "The tear film is the first refract- ing or focusing structure of the eye," he said. "If you fail to account for this, your focus will be off." The tear film can not only potentially affect measurements but also patient satisfaction with the procedure, he has found. Dr. Devgan stressed the importance of telling patients about dry eye from the start. "They could have borderline dry eye and all they need is the surgery to push them into really dry eye," he said. "If you tell them ahead of time, 'Your eyes are dry and may get worse after surgery,' you're a genius for predicting it, but if you don't tell them ahead of time and it happens, you're a bad guy for causing it." Dr. Donnenfeld also finds this to be true. "The patient who is not Optimizing the cataract surface for a smooth landing continued on page 42 Pharmaceutical focus Preop ocular surface disease, resulting in irregular astigmatism Patient placed on topical steroid QID for 2 weeks for treatment of ocular surface disease Source: William Trattler, MD

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