Eyeworld

EW FEATURE 56 Treating the cornea before cataract surgery • May 2017 by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Dry eye is common in patients who require cataract surgery, but it is often underdiagnosed. • Surgeon should use a battery of diagnostic tests to evaluate for dry eye preoperatively. • When dry eye is diagnosed, explain to patients why treatment is so im- portant and how they have a crucial role in improving dry eye. • Treatments for dry eye vary depend- ing on the type that is seen. • Schedule surgery a few weeks out so there is time to reevaluate the patient and look for ocular surface improvement. Primer for dry eye diagnosis and treatment before cataract surgery Another test commonly used is the matrix metalloproteinase-9, which can help indicate if inflam- matory dry eye is present, Dr. Hova- nesian said. Tear film break-up (TBUT) time is another long-standing test used; in the PHACO study, TBUT was abnormal in about two-thirds of pa- tients scheduled for cataract surgery, said William Trattler, MD, Center for Excellence in Eyecare, Miami. Dr. Trattler was a lead investigator in the PHACO study, which was present- ed at several meetings but not yet published. Topography and keratometry are two revealing tests when eval- uating the ocular surface. "You can see the quality of the topography is related to the quality of tear film and the ocular surface," Dr. Trattler said. Although corneal staining has an important role in dry eye as- sessment, Dr. Holland shared this pearl: "Many times, you see charts where it says that corneal staining is a sign of moderate dry eye. If they put in fluorescein as the only stain and don't see staining, they think the patient doesn't have dry eye. I argue that corneal staining is a sign of severe dry eye. By the time there are multiple epithelial erosions, that patient has long-standing dry eye, not moderate dry eye," he said. Don't use staining as your main defining test for dry eye, Dr. Holland thinks dry eye is "one of the most underrecognized and neglected conditions." "There are an estimated 55 million people with dry eye, but only 16 million receive a diagnosis," he continued. "In cataract surgery, the busy comprehensive surgeon is not always looking out for dry eye." "With cataract surgery, it's our obligation to consider every patient as possibly having dry eye," said Vincent P. de Luise, MD, FACS, assistant clinical professor of oph- thalmology, Yale University School of Medicine, New Haven, Connecti- cut, and adjunct clinical professor of ophthalmology, Weill Cornell Medical College, New York. Dry eye left untreated before surgery can worsen postoperatively, potentially leading patients to think the surgery—and the surgeon—did something wrong. By evaluating and treating dry eye before a cataract procedure, you can stop patients from blaming you for less than stel- lar results. Although the diagnosis of dry eye before cataract surgery is im- portant in all patients, it's especially crucial in premium IOL recipients. Patients expect excellent outcomes with premium IOLs, and a problem- atic ocular surface can affect results. "You want a wow factor for them," Dr. de Luise said. "We have to do extra due dili- gence from a chair time standpoint and with appropriate diagnostics so we can achieve our refractive target and outcomes," said Elizabeth Yeu, MD, Virginia Eye Consultants, Nor- folk, Virginia. Here's a primer on how to evalu- ate and treat dry eye in your cataract surgery population. Evaluation, diagnosis Before you even see patients, ed- ucate technicians and other staff members about the prevalence of dry eye, Dr. Holland recommended. This prompts them to keep dry eye forefront in their mind as they eval- uate patients. Many dry eye-focused ophthal- mologists will use questionnaires such as the SPEED II questionnaire— available online—to assess patient perception of ocular surface prob- lems. However, because not all dry eye patients will have symptoms, your diagnostic testing needs to go beyond just the questionnaire, said John Hovanesian, MD, clinical instructor, Jules Stein Eye Institute, University of California, Los An- geles. Dr. Hovanesian, along with other dry eye experts, uses tests such as tear film osmolarity. "Tear film osmolarity is considered abnormal when it's greater than about 308 in either eye or there's a variability greater than 8 between eyes," he said. "That would usually indicate there's a component of aqueous deficiency." For better surgical outcomes, don't miss this all-too-common ocular surface problem D ry eye before cataract surgery is more common than you might think. Although estimates vary, a PHACO study which focused on the prevalence of dry eye in cataract surgery found that almost two-thirds of patients had clinical signs of dry eye. Even still, Edward Holland, MD, director of cornea, Cincinnati Eye Institute, Cincinnati, said he Monthly Pulse Treating the cornea before cataract surgery T he topic of this Monthly Pulse survey was "Treating the cornea before cataract surgery." We asked participants what they would most likely do in a patient with stable irregular corneal astigmatism from keratoconus and a visually significant cataract. The majority of respon- dents said they would use a monofocal intraocular lens. The second question asked survey participants which corneal lumps and bumps they would manage prior to intraocular lens calculations and cataract surgery. The majority of respondents selected "all of the above," which in- cluded central epithelial basement membrane dystrophy changes, peripheral Salzmann's nodules, and pterygium inducing astigmatism. In the third question, we asked participants to identify which sce- narios in clinical practice they have experience employing an amniotic membrane graft. The majority of respondents, at 45.8%, said in the case of a neurotrophic ulcer, followed by 40.5% responding in the case of a persistent epithelial defect. Finally, we asked participants to identify the approximate per- centage of patients undergoing cataract surgery who exhibit clinical signs of dry eye at their practice. The majority of respondents answered between 25–50%.

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