Eyeworld

2 Advanced diagnostics in action: Identifying ocular surface disease in cataract and refractive patients using a commercially available point- of-care immunoassay. Ophthalmology. 2016;123:2300–2308. 5. Sheppard JD. Effect of loteprednol etabonate 0.5% on initiation of dry eye treatment with topical cyclosporine 0.05%. Eye Contact Lens. 2014;40:289–296. 6. Holland EJ, et al. Lifitegrast clinical efficacy for treatment of signs and symptoms of dry eye disease across three randomized controlled trials. Curr Med Res Opin. 2016;1–7. 7. Salib GM, et al. Safety and efficacy of cyclosporine 0.05% drops versus unpreserved artificial tears in dry-eye patients having laser in situ keratomileusis. J Cataract Refract Surg. 2006;32:772–778. 8. Rynerson JM, et al. DEBS—a unification theory for dry eye and blepharitis. Clin Ophthalmol. 2016;10:2455–2467. Dr. Hovanesian is in private practice in Laguna Hills, California. He can be contacted at jhovanesian@ harvardeye.com. day. Although these diagnostic tests only take a minute or so, they will not become a perma- nent part of the process if they impede their work flow. Conclusion Because each case of dry eye is unique, it is important to make the most of available diagnostics to pinpoint and treat the cause of the disease. In this supplement, my colleagues will share how they use these diagnostics in specific cases. References 1. Trattler W, et al. Cataract and dry eye: prospective health assessment of cataract patients' ocular surface study. ASCRS•ASOA Symposium & Congress, March 2011. 2. Asiedu K, et al. Ocular surface disease index (OSDI) versus the standard patient evaluation of eye dryness (SPEED): a study of a nonclinical sample. Cornea. 2016;35:175–180. 3. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672–1677. 4. Messmer EM, et al. Matrix metallo- proteinase 9 testing in dry eye disease Treatment protocols I prefer using loteprednol gel or lifitegrast to rehabilitate the ocular surface. 5,6 After surgery, cli- nicians may continue treatment with lifitegrast or cyclosporine drops. 7 In addition, microbleph- aroexfoliation using a rotary device with a disposable sponge tip helps remove biofilms from the eyelid surface (Figure 1). 8 One month of dry eye treat- ment typically stabilizes the oc- ular surface so we can repeat tear osmolarity and MMP-9 testing along with the clinical examina- tion to confirm that preoperative measurements will be accurate (Figure 2). Introducing new protocols When implementing new pro- tocols, we cannot spend enough time educating and training staff. When we explain to staff why we are making these changes and how they will improve patient outcomes, they embrace them. As part of this process, we need to help our staff incorporate new tests into the flow of their Objective measures include tear film osmolarity, which gen- erally indicates aqueous deficien- cy, and MMP-9 markers, which show inflammation that often correlates with blepharitis and meibomian gland disease. 3,4 We also perform a compre- hensive examination including classic tests such as tear breakup time and staining with lissamine green or fluorescein. Patient education One of my mentors taught that if you caution patients about a complication before surgery, you are a genius; if you tell them after surgery, you are making excuses. Therefore, it is important to edu- cate patients before surgery. When we diagnose dry eye, we explain to patients we cannot achieve their desired visual result without treating ocular surface disease first and that it is the pa- tient's responsibility to treat dry eye with the tools we provide. Patients also need to under- stand that surgery will not cure their dry eye; therefore, they need to continue dry eye treatment indefinitely to have good vision. Figure 1. Microblepharoexfoliation removes from the eyelashes and eyelid margins the biofilms that contribute to chronic dry eye and a disrupted tear film. Source: James Rynerson, MD Figure 2. Dry eye can cause significant alteration of biometry measurements long before significant corneal staining appears. Source: AAO image collection continued from page 1

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