Eyeworld

5 Supported by unrestricted educational grants from TearLab, TearScience, and RPS Proactive ocular surface management: tools for success by Marjan Farid, MD Surgeons need to aggressively seek out dry eye before cataract surgery T he most significant change in refractive index occurs between the air and tear film, and the tear film and ocular surface play a major role in high- er-order aberrations and visual dysfunction. Therefore, surgeons need to pay close attention to the ocular surface and particularly the tear film before cataract surgery. Diagnostic tools Ophthalmologists tradition- ally wait for patients to complain of dry eye symptoms before diag- nosing ocular surface dysfunction (OSD); however, we will miss many cases using this approach. Symptoms and signs of dry eye disease do not always correlate. Using patient questionnaires and testing, William Trattler, MD, found that more than 62% of patients scheduled for surgery had an abnormal tear break-up time of 5 seconds or less. 1 This highlights that we have a large population of patients with dry eye disease (DED) and visual dysfunction from OSD who have no symptoms. Therefore, we need to be very proactive, asking Marjan Farid, MD patients key questions and testing them before refractive cataract surgery. In our practice, we ask patients to complete the SPEED questionnaire, which helps iden- tify patients at risk and guides diagnostic testing. We perform tear film anal- ysis on all patients with dry eye symptoms as well as all potential cataract and refractive patients. I use the test for MMP-9, a marker for inflammation, and osmolarity testing to identify tear film abnor- malities. To differentiate whether it is the cataract or the tear film that is affecting visual quality, I perform corneal topography on all cataract patients to identify corneal and tear film irregularities. If astigma- tism on topography is very differ- ent from biometry measurements, for example, this is a clue that there is some variance and the tear film may be a problem. Role of patient counseling Patient education is essential in this process. We explain to pa- tients that both the cataract and OSD may be blurring their vision. We tell patients that we need to postpone surgery to properly treat OSD and repeat preoperative mea- surements so we can achieve the best possible visual results from surgery. They are more willing to continued on page 6 Figure 1. Respondents to the 2015 ASCRS Clinical Survey reported their primary therapies in treating mild dry eye. Primary therapy: mild DED (Aqueous deficient or unspecified) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Any artificial tear/lubricant Customized artificial tear/ lubricant Cyclosporine Omega-3 Thermal lid expression Punctal occlusion Topical steroid Azithromycin 87% 80% 42% 29% 10% 8% 37% 16% 7% 9% 14% 3% 7% 9% 3% 3% U.S. Non U.S. Figure 2. Survey respondents reported additional information on their treatment approaches for moderate DED. 80% 70% 60% 50% 40% 30% 20% 10% 0% Any artificial tear/ lubricant Customized artificial tear/ lubricant Cyclosporine Omega-3 Thermal lid expression Punctal occlusion Topical steroid Azithromycin 67% 53% 71% 70% 70% 36% 52% 36% 17% 19% 66% 26% 43% 38% 18% 15% U.S. Non U.S. Primary therapy: moderate DED (Aqueous deficient or unspecified)

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