Eyeworld

EW CATARACT 30 Device focus Screening, Sarasota, Florida), and looking at corneal topography, Dr. Epitropoulos said. The treatment regimen that she uses in mild to moderate and severe dry eye cases centers on reducing inflammation of the ocular surface. "I use topical cyclosporine perioper- atively, and that can be very helpful with increasing the natural tear production, reducing inflammation, and treating unstable hyperosmolar tear films," Dr. Epitropoulos said. "I also use a topical corticosteroid preparation that's friendly to the ocular surface and safe and effective to rapidly reduce inflammation; it works synergistically with cyclospo- rine." Dr. Epitropoulos routinely starts her dry eye patients on a re-esterified omega-3 nutritional supplement, which she pointed out has been proven to benefit patients with dry eye disease and improve tear osmolarity. "We did a multicenter trial that demonstrated a significant improvement in symptom scores, tear osmolarity, tear breakup time, omega-3 index scores, and a signifi- cant reduction in MMP-9 positivity. "In addition, I think an effective treatment for evaporative dry eye is the LipiFlow thermal pulsation sys- tem [TearScience, Morrisville, North Carolina]," Dr. Epitropoulos said. "It's the only FDA-cleared treatment for evaporative dry eye disease, and it helps to prevent progression of the disease." This can also help to sta- bilize the tear film prior to cataract surgery, she said. Following diagnosis and ag- gressive treatment of ocular surface disease, Dr. Epitropoulos finds her patients have less refractive surpris- es. "I'm able to achieve my target more consistently, with overall improved patient outcomes," she concluded. EW Reference Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672–1677. Editors' note: Dr. Epitropoulos has financial interests with Allergan (Dub- lin), Bausch + Lomb (Bridgewater, New Jersey), Imprimis (San Diego), Physician Recommended Nutriceuticals (Plymouth Meeting, Pennsylvania), Omeros (Seat- tle), Shire (Lexington, Massachusetts), TearLab (San Diego), and TearScience. Contact information Epitropoulos: aepitrop@columbus.rr.com Clinical perspective From a clinical perspective, Dr. Epitropoulos said that ocular surface disease is the root of what causes many patients to be unhappy or un- satisfied after cataract surgery. "It's critical that we evaluate and iden- tify dry eye patients preoperatively because I want to avoid unhappy patients after cataract surgery, and tear osmolarity helps me to identify this," she said. "It's so important to identify patients who may not be symptomatic with their dry eye and tell them that they're on the verge of moving from asymptomatic to symptomatic and that the surgery may be what puts them over the edge." If physicians don't identify this preoperatively, the patient may blame the physician when their dry eye becomes symptomatic after surgery, thinking that the cataract surgery caused their dry eye. "By recognizing and diagnosing dry eye disease before surgery, we can avoid unhappy patients by managing the disease before it becomes a prob- lem," Dr. Epitropoulos said. She pointed out that practi- tioners should also be aware that dry eye patients have large swings in the tear osmolarity between their 2 eyes. "Normal osmolarity patients don't have much fluctuation or variability in their osmolarity scores," Dr. Epitropoulos said. "But dry eye patients tend to have more variabili- ty—that's 1 of the diagnostic criteria that we look at." Practitioners can identify dry eye patients using osmolarity if the number is greater than 308 or if there is more than an 8 milliosmole difference between the 2 eyes. "There is increasing evidence that evaluating tear osmolarity provides crucial information about disease severity and therapeutic response," she said. "Physicians can use this point-of-care test to help diagnose and follow dry eye disease, educate patients about this condi- tion, and treat them; when patients come back for follow-up, they like to see if their 'number' has improved." This is something that can assist with compliance, helping to ensure that patients follow the prescribed treatment regimen. Tear osmolarity should be used as a tool, but in conjunction with other tests. There are other valuable ways of evaluating dry eye such as looking at tear breakup time and corneal staining, looking for the presence of meibomian gland dys- function (including meibography), using InflammaDry (Rapid Pathogen Keying continued from page 28

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