Eyeworld

54 The X Factors: Three areas that will improve refractive cataract surgery outcomes by Preeya K. Gupta, MD Dry eye disease too important to ignore in surgical practice and a foamy tear film, not all cases are obvious (Figure 2). Dry eye treatment does not need to be difficult. Topical therapies such as artificial tears, hot compresses, lid scrubs, ointments, and gels can be offered for any level of ocular surface inflammation. I reserve cyclosporine and prednisolone or loteprednol for patients with elevated MMP-9 or osmolarity levels, but any inflamma- tion must be addressed. Disease-modifying procedures such as thermal pulsation and intense pulsed light therapy have revolutionized dry eye care, relieving symptoms and enabling patients to have surgery more quickly. We should not reserve disease- modifying procedures for end-stage disease; we should offer them early to all patients with MGD. Conclusion We need to identify dry eye and ocular surface inflammation before surgery to avoid refractive surprises and unhappy patients. Treatment is not difficult. By intervening early with disease-modifying procedures, we can help patients achieve their goals more quickly. Dr. Gupta is assistant professor of ophthalmology, cornea and refractive surgery, Duke University Eye Center, and clinical medical director of the Duke Eye Center at Page Road in Durham, N.C. She can be contacted at preeya.gupta@duke.edu. Minimizing higher-order aberrations is especially critical in taking full advantage of advanced IOLs. Furthermore, if we do not identify ocular surface inflammation and dry eye preoperatively, patients believe we created these conditions. When we identify the problem early, patients recognize they may have 2 disease processes and their expecta- tions are more accurate. A 68-year-old patient who had femtosecond laser cataract surgery came to us for a second opinion because she couldn't see well with her multifocal IOL. Her uncorrected vision was 20/25+1 OU, J1 (manifest refraction: plano-0.25 x 180). Her records were unremark- able, but during the examination we identified 2+ meibomian gland dysfunction (MGD) on both lids and multiple punctate epithelial erosions. She had a 5-second tear breakup time, osmolarity was 308 and 310 mOsms/l, and she had positive MMP-9 results. This illustrates that we cannot take advantage of advanced technol- ogy if we ignore the ocular surface. Diagnostic options To quickly diagnose ocular surface disease, we need to apply pressure to the eyelids and examine the margins and gland openings carefully for secretions. Without digital examina- tion, we may miss gland disease. Point-of-care testing is import- ant and may include osmolarity, MMP-9 levels, non-contact tear breakup time, and lipid layer thick- ness assessment. Technicians can perform these tests and provide data to clinicians. MGD is the most common cause of dry eye. Although it produces thick gland secretions, poor oil flow, Surgeons need to identify and manage dry eye early to improve refractive outcomes C ataract surgery has evolved into refractive surgery, en- abling us to deliver visual outcomes our patients desire. To make the most of advanced laser and intraocular lens (IOL) tech- nologies, we need to identify and manage ocular surface disease—a potential source of postoperative refractive error. Dry eye impact Dry eye disease is one of the most common reasons to seek eyecare and impairs refractive outcomes in a number of ways. It creates a poor tear film, leading to unreliable preoperative measurements (e.g., biometry, keratometry, topography) (Figure 1). Postoperatively, ocular surface inflammation adversely affects vision quality. Patients report image quality degradation and increased higher-order aberrations. Figure 1. Dry eye has numerous consequences. Figure 2. MGD may cause thick gland secretions, poor oil flow, or a foamy tear film (top). However, not all cases are obvious (bottom). Preeya K. Gupta, MD DRY EYE SYMPTOMATIC UNHAPPY PATIENTS OCULAR SURFACE DAMAGE INCREASED OSMOLARITY INFLAMMATION TEAR FILM INSTABILITY POOR VISUAL OUTCOMES Meibomian gland dysfunction (MGD) " Disease-modifying procedures such as thermal pulsation and intense pulsed light therapy have revolutionized dry eye care. "

• Cover