Eyeworld

59 EW FEATURE February 2016 • Ocular surface disease by EyeWorld staff molecules such as lifitegrast. For meibomian gland dysfunction, his primary therapy is omega-3 sup- plementation with a re-esterified supplement such as from Physi- cian Recommended Nutriceuticals (Plymouth Meeting, Pa.) or Nordic Natural (Watsonville, Calif.) that has markedly better bioavailability, he said. EW Editors' note: Dr. Donnenfeld has financial interests with Physician Recommended Nutriceuticals. Contact information Donnenfeld: ericdonnenfeld@gmail.com ASCRS members weigh in O cular surface health is important for all patients, especially those preparing to undergo surgery. "Our most unhappy patients following cataract surgery are the ones that have relatively asymp- tomatic dry eye prior to surgery and have overt dry eye postoperatively," said Eric Donnenfeld, MD, clinical professor of ophthalmology, New York University, New York. "For this reason, we are aggressive with screening all of our cataract surgery patients for dry eye disease. In addi- tion to a physical evaluation of the lids, tear film, and ocular surface, we believe point-of-service dry eye testing is the key to diagnosing and appropriately treating patients prior to cataract surgery. Tear osmolarity, MMP-9 testing, and meibomian gland imaging are all helpful, time saving, and accurate tests for diag- nosing dry eye disease." In the 2015 ASCRS Clinical Sur- vey, ASCRS members were surveyed about the incidence and treatment of ocular surface conditions in their practices. Here are the results. Ophthalmologists were asked, "On average, how many dry eye patients do you see per month who are on a prescription medication for dry eye therapy or have had punctal occlusion?" The average number of patients seen per month who have ocular surface disease requiring treatment beyond artificial tears is 31. Most U.S. and non-U.S. sur- geons reported that they see be- tween 11 and 25 patients per month with this severity of dry eye, while just over 5% reported that they see 100 or more patients per month (Figure 1). "This survey revealed that ASCRS members see 31 patients per month who are on a prescription medication or have had punctal oc- clusion. In my practice, this number is much higher," Dr. Donnenfeld said. "I believe in being proactive in treating dry eye disease before it progresses. I am not surprised by these findings. I think there is great variability among ophthalmologists in how aggressively they treat dry eye. However, I think the trend is that most ASCRS members are more attuned to the management of dry eye disease, and this number will increase greatly over the coming years." When asked what percentage of their cataract patients present as asymptomatic of any ocular surface disease prior to surgery but develop symptoms postop, the average was 20% (19% for U.S. surgeons and 22% for non-U.S. surgeons). More than one-third of respondents (34%) think that 21% or more of their patients present as asymptomatic (Figure 2). "Dry eye disease is endemic among our cataract population, and many of these patients are margin- ally compensated and relatively asymptomatic. Cataract surgery involves primary incisions and astig- matic incisions that reduce corneal sensation and the dry eye neural pathways. In addition, the medica- tions used in cataract surgery induce dry eye disease. I would suggest that more than 20% of cataract surgery patients develop symptoms postop- eratively," Dr. Donnenfeld said. Surgeons were then asked what tests they use to evaluate the ocular surface. Non-U.S. surgeons (31%) were more than twice as likely as U.S. surgeons (13%) to use Schirm- er's testing at the initial point of care. Overall, 21% said that they see no value in Schirmer's testing. Most surgeons (55%) use corneal and con- junctival staining at the initial point of care, and 52% use tear break-up time at the initial point of care. The majority of surgeons don't see any value in using tear osmolarity. Seventy-five percent said that they don't see any value in lipid layer interferometry, although non-U.S. surgeons are more likely to use this test than U.S. surgeons. Sixty-nine percent said that they don't see any value in MMP-9 markers, and 82% use blood work for systemic inflam- matory conditions such as Sjögren's syndrome and thyroid disease on a case-by-case basis. Twenty-eight per- cent said that they use meibomian gland expression at the initial point of care. "Historically, dry eye disease has been one of the most difficult diag- noses to make because the symp- toms are so variable and the physical findings may be subtle. Therapy can also be frustrating as there is variable response to treatment, and it may be slow to respond," Dr. Donnenfeld said. He is currently relying on tear osmolarity, MMP-9 testing, and meibomian gland imaging to supplement physical findings to diagnose dry eye disease. "Artificial tears continue to improve and play a role in treatment, but treating the underlying etiology rather than the symptoms makes better sense. For this reason, we rely on immuno- modulation for inflammatory dry eye and omega-3 nutritional supple- ments," he said. For aqueous deficiency dry eye, he uses cyclosporine and looks forward to the FDA approval of new Preparing the ocular surface for surgery Figure 2. Percentage of cataract patients who present as asymptomatic of any ocular surface disease prior to surgery but develop symptoms postop Source: ASCRS 0% 1–20% 21–40% 41–60% 61–80% 81–99% 100% All U.S. Non U.S. 70% 60% 50% 40% 30% 20% 10% 0 Figure 1. Patients seen per month with ocular surface disease requiring treatment beyond artificial tears 30% 25% 20% 15% 10% 5% 0% None 1–5 6–10 11–25 26–50 51–99 100 or more All U.S. Non U.S. ASCRS Clinical Survey

• Cover