Eyeworld

Supported by unrestricted educational grants from Allergan, Shire, TearLab, and TearScience and cataract surgery with a multi- focal implant in each eye. Essential diagnostics The most important diagnostic in this case was meibography. As the old adage says, a picture is worth a thousand words. Meibography images showed significant gland dropout, helping the patient un- derstand that he required lifelong treatment. Conclusion I would not have suspected such advanced meibomian gland drop- out in a patient in his mid-50s. Without meibography, I probably would not have treated him as lipid reserve before the mechan- ical expression of the impacted meibomian glands. I think having a healthy lipid reserve on hand has improved my success rate with this technology by minimiz- ing the dry eye feeling that some patients experience 1 to 2 days post-procedure. Thermal pulsation improved but did not eliminate his ocular symptoms. He was now motivat- ed to continue with the omega-3 supplements and the microwave- able mask. At this point, I ex- plained that his disease required prescription eye drops, which he finally accepted. I prescribed cyc- losporine drops because lifitegrast had not yet been approved. 6 Weeks later, when the ocular surface was optimized, we pro- ceeded with preop measurements technician performed tear osmo- larity and MMP-9 testing. These two procedures must be per- formed before drops are instilled in the eye. 1,2 Next, we imaged his meibomian glands while the patient's pupils were dilating. 3 By the time I examined the patient, I had his questionnaire responses and test data. I proceed- ed with the fundus examination and a thorough slit lamp exam- ination with both lissamine green and fluorescein staining, inspect- ing the lid margins, conjunctiva, and lens. He had marked meibomian gland dysfunction with gland dropout, as well as a visually significant cataract. Figures 1 and 2 illustrate meibomian gland dropout in other cases. I explained that we needed to optimize and treat his ocular surface before addressing the cataract. He was unhappy to hear that his cataract surgery had to be delayed; I explained to him that even with flawless surgery, we might not reach our intended re- fractive target if the ocular surface is not pretreated properly. I custom-tailored his treat- ment protocol to include oral omega-3 supplements to stabilize his lipid layer, a heated microwav- able mask to keep the meibum more liquefied and the orifices of the glands open, as well as preservative-free artificial tears. 4 He preferred to avoid prescription medications. Repeat testing in 4 weeks showed that his ocular surface had improved, but not enough. Therefore, I offered him the option of prescription eye drops or thermal pulsation therapy. He chose the latter. 5 It was important to engage him in the decision- making process because he is accustomed to making import- ant decisions all day long in his career. I usually treat patients with oral omega-3 supplements for at least 4 weeks before thermal pulsation. This helps increase the Diagnostic technologies help clinicians detect and treat source of dry eye to improve refractive surgery outcomes T o optimize vision with premium intraocular lenses, clinicians need to perform a comprehensive ocular surface exam- ination to uncover conditions that may impact the accuracy of preoperative measurements. Unreliable measurements can lead to refractive surprises. Suboptimal visual results cause dissatisfaction, particularly if patients have paid out of pocket. Case report A man in his mid-50s came to our office for a cataract consul- tation because he had difficulty seeing. He worked in the financial market and explained that he was surrounded by multiple computer displays and his "whole world depended on decimal points." As with all of our intake interviews, the technician began with a SPEED questionnaire that is incorporated into our electronic medical records as a drop-down menu that cannot be skipped. The patient's responses triggered the next step, where the by Cynthia Matossian, MD Case report: Advanced diagnostics pinpoint severe MGD in cataract patient Figure 1. Meibomian imaging showing meibomian gland dropout in right eye Figure 2. Meibomian imaging showing meibomian gland dropout in left eye Cynthia Matossian, MD continued on page 4

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