Eyeworld

EW FEATURE 58 Treating the cornea before cataract surgery • May 2017 staining, and is receiving a monofo- cal IOL, Dr. Yeu may still go ahead and schedule surgery with a normal timeframe. Counseling the patient on their diagnosis, and the poten- tial implications of worse dry eye in the post-operative period should be discussed with the patient. Such patients should be offered dry eye therapies pre-operatively, to be used indefinitely in some cases. Treatment for preop OSD Treatment for dry eye and OSD in patients scheduled for cataract surgery will vary depending on the type found. Many dry eye patients will have a meibomian gland dysfunction (MGD) component, which is espe- cially common in an aging popu- lation, Dr. Holland said. In these patients, he favors omega-3 therapy and is aggressive about recommend- ing thermal pulsation therapy with LipiFlow (TearScience, Morrisville, North Carolina). "It heats the lids, pulsates the glands, and evacuates the old meibum. Lipiflow is the most effective therapy to relieve the MG obstruction and restore MG function. I don't think anything else jumpstarts therapy as much," Dr. Holland said. Depending on the patient, Dr. Holland may add oral doxycycline or consider topical azithromycin as well as a lipid-based tear. For MGD, Dr. Hovanesian recommends the use of warm compresses and Avenova (NovaBay Pharmaceuticals, Emeryville, Cali- fornia) or OcuSoft scrubs (OCuSOFT, Richmond, Texas). Patients with inflammatory dry eye often will need a short course of ocular steroids. Generic steroids can contain preservatives that are harsh, so Dr. Hovanesian favors Lotemax gel (loteprednol etabonate oph- thalmic gel 0.5%, Bausch + Lomb, Bridgewater, New Jersey). "It's very gentle on the surface, and there's a low risk of pressure spikes," he said. For aqueous-deficient dry eye, lifitegrast (Xiidra, Shire, Lexington, Massachusetts) or Restasis (cyclospo- rine ophthalmic emulsion 0.05%, Allergan, Dublin, Ireland) are often used. "In the context of cataract surgery, lifitegrast may be better be- cause it has a faster onset of action," Dr. Hovanesian said. Dr. de Luise has found that cyclosporine works best in his aqueous-deficient patients. In addition to medications, Dr. de Luise will address environmental changes patients can make, such as using a humidifier. The coupling of various ther- apies does a more effective job at improving the ocular surface, Dr. Yeu said. When she sees intense staining even after treatment, Dr. Yeu will use the PROKERA amniotic membrane (AM; Bio-Tissue, Doral, Florida) or amniotic membrane drops (Ocular Science, Manhattan Beach, California) used off-label. "AM therapy can provide a relatively rapid turnaround on their surface, enough to capture accurate diagnos- tic measurements for them [after that]," Dr. Yeu said. Many patients with aqueous tear deficiency dry eye will require therapy with an agent like lifitegrast indefinitely because of the chronic progressive nature of dry eye disease, Dr. Holland said. Prior to surgery, dry eye is usu- ally treated for 2 to 4 weeks before patients are reevaluated. "If every- thing is good, we're good to go. If not, we need to delay the surgery, which happens rarely," Dr. Trattler said. Occasionally, a patient's vision improves so much with the thera- pies for dry eye that cataract surgery is not necessary at that time, Dr. Trattler said. Still, there are situations where the patient's ocular surface is not yet ready for surgery upon reevaluation. These patients might have been incompliant with drops or could require punctal plugs or additional therapy, Dr. Trattler said. There are also situations where a patient may want a premium IOL, but the reevaluation reveals they just aren't a good candidate, Dr. Hovanesian said. "You have to judge if a patient can sustain a good ocular surface before you choose a multifo- cal IOL for them," he said. When Dr. Hovanesian has any doubts, he will use a Crystalens (Bausch + Lomb) instead of a mutifocal IOL, as the former tends to be better tolerated. "If dry eye is severe, I'll consid- er a toric IOL if we have consistent preoperative measurements for the magnitude and axis of astigmatism. However, I am reluctant to recom- mend a multifocal IOL in dry eye patients especially if there is an unstable tear film and corneal stain- ing. Dry eye is the most common cause of unhappy multifocal IOL patients," Dr. Holland said. Because dry eye is a chronic condition, Dr. Hovanesian encour- ages surgeons to partner with a cli- nician who has a clinical interest in dry eye management to meet with the patient over time and consis- tently reevaluate for problems. EW Editors' note: Dr. Holland has finan- cial interests with Allergan, Shire, and TearScience. Dr. Hovanesian has finan- cial interests with Allergan, Bausch + Lomb, Katena (Denville, New Jersey), and Shire. Dr. Trattler has financial in- terests with Allergan, Bausch + Lomb, Johnson & Johnson (Santa Ana, Cali- fornia), and Shire. Dr. Yeu has financial interests with Allergan, BioTissue, Ocular Science, Shire, and TearScience. Dr. de Luise has no financial interests related to this article. Contact information de Luise: vdeluisemd@gmail.com Holland: eholland@holprovision.com Hovanesian: johnhova@gmail.com Trattler: wtrattler@gmail.com Yeu: eyeulin@gmail.com readings out of the gate, but it's frus- trating because they often have dry eye, making these tests inaccurate," Dr. Trattler said. The first thing Dr. Yeu does at this point is spend some time asking patients about symptoms such as intermittent blurred vision. She points out that intermittent blurred vision is a sign of dry eye, not their cataracts. Creating awareness of the problem helps to establish common ground, so patients recognize the importance of dry eye treatment, Dr. Yeu said. Dr. Hovanesian emphasizes to patients that dry eye is a chronic issue that will require their help to manage. "I tell the patient, 'You have two diseases. We can fix the cataract, but we can't cure the other. Dry eye is a lifelong issue and it will affect your vision even after cataract surgery.' I also tell patients, 'I can't treat your dry eye, you have to treat it.' They understand that they bear responsibility for success," he said. Explaining the role that patients have in dry eye treatment helps boost compliance. Although every practice is a little different, the surgeons inter- viewed for this article generally still schedule surgery in patients with dry eye, but they may slightly alter the surgery schedule. This allows patients to use their treatments and then come in for a reevaluation. "They're coming in expecting to have cataract surgery scheduled, and it's disappointing to leave with- out a date," Dr. Yeu said. "I generally have a 2- to 4-week turnaround time for surgery. If it's mild to moder- ate, I'll push those dates out 6 to 8 weeks. If they're really unstable, maybe with a history of Bell's palsy, exposure keratopathy, or other extraneous issues, then I'll give dates that are 2 or 3 months out but have them come back in at 2 to 3 weeks to repeat measurements." If a patient has only mild dry eye disease, without any corneal Primer continued from page 57 annualmeeting.ascrs.org/education/yes-young-eye-surgeons

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