Eyeworld

EW CORNEA 34 January 2017 by Maxine Lipner EyeWorld Senior Contributing Writer corneal staining, we're going to have unreliable test measures," he said. Dr. Epitropoulos takes into consideration that dry eye is a pro- gressive disease that becomes more difficult to manage as its severity worsens. "A combination of treat- ment modalities should be individu- alized for each patient based on the type and severity of the disease," she said. For evaporative dry eye, she finds that thermal pulsation treat- ment is one of the most effective ap- proaches. "The traditional methods of treating lid margin disease such as warm compresses and lid scrubs tend to work better once you address the obstruction of the meibomian glands," Dr. Epitropoulos said. She thinks that Lipiflow thermal pul- sation is more effective when used with BlephEx (Lake Worth, Florida) to exfoliate the lids and lashes. The next priority is to reduce ocular surface inflammation. "This is the primary goal of treating mod- erate to advanced dry eye disease," Dr. Epitropoulos said. Use of topical cyclosporine can increase produc- tion of the patient's own natural tears, reduce corneal staining, and increase goblet cell density, she said. However, this treatment can take 3 to 6 months to reach peak efficiency. "So a short course of topical steroids, such as loteprednol, can be started to rapidly reduce ocular surface inflammation, and it works syner- gistically with cyclosporine," Dr. Epitropoulos said. In addition, lifitegrast may work faster on the surface. Lifitegrast is a new integrin inhibitor that targets the inflammatory pathway of the dry eye cycle in multiple areas by preventing new T cells from be- coming activated and turning off T cells that are on the surface, Dr. Epitropoulos explained. She also finds re-esterified omega-3 supplements to be benefi- cial for improving the health of the ocular surface. There is a significant difference between an ethyl ester and re-esterified omega-3, she said. Alcohol is typically added to fish oil to extract toxins and mercury, but this changes the oil's natural triglycerides into an ethyl ester com- pound. "Humans have a difficult time processing this artificial com- pound because it is not naturally occurring," she said. "Patients could After screening, he assesses the severity of the disease and whether it is a result of aqueous tear deficien- cy, meibomian gland dysfunction, or a combination. "I think it's import- ant to diagnose the exact etiology of dry eye because the treatments are going to be different," Dr. Holland said. Treatment considerations Since the typical cataract patient must wait several weeks to get on the schedule, Dr. Holland puts the milder cases—patients who are symptomatic with conjunctival injection, rapid tear break-up time, and fluctuating vision, but with minimal or no corneal staining—on the surgical schedule and begins to tackle the ocular surface disease. "We typically manage those types of patients with an omega-3," he said, adding that he likes the re-esterified form of this since it is better ab- sorbed and has better efficacy. In ad- dition to 2 grams of omega-3 twice a day, Dr. Holland recommends that the patient use an artificial tear. "If we think the patient has aque- ous tear deficiency, we will initiate Xiidra [lifitegrast, Shire, Lexington, Massachusetts] because of the rapid onset of action and excellent effi- cacy. Many patients in the clinical trial had efficacy as early as 2 to 4 weeks," he said. 2 For patients with moderate to severe disease, in whom he sees corneal staining but who are getting fluctuations on various tests, he advises caution. "Those patients are at risk of getting the wrong IOL power," Dr. Holland said. "We wouldn't want to risk picking a toric lens because we can see a drastic change in the astigmatism measure- ments in these patients." Likewise, those with severe ocular surface disease will have trouble with visual satisfaction with multifocal lenses. "For those patients we will delay surgery and maximize the ocular surface." This includes considering LipiFlow treatments (TearScience) if the patient has meibomian gland disease, as well as topical cortico- steroids such as loteprednol, which Dr. Holland views as the best topical steroid for ocular surface disease. "I see the patient back in 4 to 6 weeks and repeat testing to see if we have a stable surface. With significant screen our preoperative cataract patients for dry eye disease." Dr. Epitropoulos starts out by asking patients to fill out a dry eye questionnaire, which she finds is an efficient method of documenting patient complaints prior to testing and receiving drops. After the questionnaire, if a patient is symptomatic, she empow- ers her technicians to proceed with point-of-care tests including the TearLab Osmolarity System (TearLab, San Diego), InflammaDry (Rapid Pathogen Screening, Sarasota, Flor- ida), and LipiView II (TearScience, Morrisville, North Carolina). "These are useful tools in evaluating dry eye but should not take the place of our actual exam," Dr. Epitropoulos said, adding that it's still important to look at the tear film, lid margins, and quality of the meibum. Likewise, Edward Holland, MD, professor of ophthalmology, University of Cincinnati, routinely questions patients about symptoms related to the ocular surface. "The typical symptoms of dry eye such as burning, irritation, and redness are important, but fluctuation in vision is also common, especially in older patients," Dr. Holland said, adding that if patients are symptomatic, he performs tear osmolarity testing, which he views as the best screening method. Improving the ocular surface before cataract surgery W hen a patient has dry eye, cataract surgery may need to wait a bit so physicians can address this. EyeWorld took a close look at how various pharmacologic treatments can make a difference for those with dry eye. Spotting surface issues It begins by identifying cataract patients who may have dry eye. Because of its potential to affect patients' quality of life, daily functioning, and cataract and refractive surgery outcomes, Alice Epitropoulos, MD, clinical assistant professor, Ohio State University Wexner Medical Center, Columbus, Ohio, recently led a study consid- ering the effect of tear osmolarity on keratometry. 1 This study showed that tear film hyperosmolarity was associated with an increased vari- ability of keratometry measurements used for determining IOL power and toric IOL planning, Dr. Epitropoulos said. "These findings confirm the importance of evaluating the surface in our cataract patients," she said. "Fortunately, newer technologies have emerged that are improving our ability to properly diagnose and Facing dryness MGD with meibomian gland dropout and abnormal meibum Source: Edward Holland, MD Pharmaceutical focus

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