Eyeworld

6 OSD: Honing diagnostic protocols to pinpoint disease, enhance surgical outcomes by Preeya Gupta, MD Investigating the ocular surface in various types of patients By starting patients on a topical steroid at the same time as lifitegrast or cyclospo- rine, patients not only get a rapid improvement but also may tolerate initial side effects of the medication better. Disease-modifying ther- apies such as thermal pulsa- tion or intense pulsed light therapy also can be useful. In patients who primarily have MGD, thermal pulsation re- stores the ocular surface fairly quickly so they don't need to delay surgery for a prolonged time. This patient's initial cal- culation called for a T5 toric lens, but after thermal pulsa- tion treatment was performed and remeasurement 3 to 4 weeks later, it was determined that the appropriate toric lens was a T3 implant (Figure 1). The decision was made to perform thermal pulsation treatment as the patient had a significant component of MGD. If we had not optimized her ocular surface and re- peated the measurements, we would have implanted a toric IOL with the incorrect power, significantly overcorrecting astigmatism. Case 2 A 42-year-old woman had increasing ocular redness, irritation, and light sensitiv- ity, which worsened later in the day (Figure 2). She used preservative-free artificial tears almost every 2 to 3 hours and ointment at night. She had a family history of rheumatoid arthritis but had not received a diagnosis of the condition. She reported Case 1 A 55-year-old woman with glare and blurred vision while reading was evaluat- ed for cataract surgery. She took amitriptyline and used artificial tears occasionally. She stated she did not want to wear glasses after surgery for distance vision. On examination, she had a tear break-up time of 3 to 4 seconds; there was 2+ meibomian gland dysfunction (MGD), inferior corneal stain- ing of 1+, osmolarity of 330 and 320 mOsm/L, and weakly positive results for MMP-9. Her biometry revealed 1.6 D of corneal astigmatism, which would require a toric implant to correct. To treat dry eye initially, surgeons can use artificial tears, gels, compresses, lid scrubs, and oral omega-3 cap- sules. These treatments, while helpful, often take many weeks to improve the corneal surface. I generally prescribe a topical steroid to treat the inflammation more rapidly, especially in those with a positive MMP-9 test. Because we cannot continue steroids indefinitely, given the risk of glaucoma and cataracts, I pair the steroid with an anti-in- flammatory medication, such as lifitegrast or cyclosporine. Lifitegrast was approved in 2016, and my patients gen- erally have tolerated it well. 4 The most common side effects are burning, blurred vision, and dysgeusia. Patients have noticed improved symptoms as early as 2 to 3 weeks after initiating treatment. I now intervene earlier with this medication because of its rapid onset of action. examination for dry eye is essential. Preop assessments During cataract evaluations, we administer patient ques- tionnaires and I perform a full standard examination with staining. Point-of-care tests such as osmolarity and MMP- 9 facilitate diagnosis and guide management; because technicians usually perform these tests, they are easy to integrate into a practice. Foulks et al. described a sensitivity of 75% and spec- ificity of 88% for osmolarity testing in mild to moderate cases, whereas sensitivity was 95% in severe cases. 2 Sambursky et al. reported that MMP-9 testing had a sensitiv- ity of 85% and specificity of 95% for dry eye. 3 I routinely use corneal topography during cataract evaluations, which provides information about the health of the ocular surface. Patient complaints of blurred vision with specific activities trigger additional questioning. All blurry vision does not result from cataracts, so it is important to identify all distinct causes. Cases demonstrate the importance of preop dry eye assessments I t is crucial to pinpoint dry eye before cataract surgery, but the con- dition often remains undiagnosed. 1 Based on data from numerous studies, it has been estimated that the prevalence of dry eye ranges from 5 to 30% among those older than 50. 2 The ocular surface is less stable in patients with dry eye, affecting the accu- racy of preop measurements and, consequently, surgical outcomes. A thorough preop Preeya Gupta, MD Figure 1. Case 1: Preop and postop corneal topography; the image on the left is before treatment, and the image on the right is after treatment

• Cover