Eyeworld

Supported by unrestricted educational grants from Allergan, Shire, TearLab, and TearScience 8. Holland EJ, et al. Lifitegrast for the treatment of dry eye disease: Results of a Phase III, randomized, double-masked, placebo-controlled trial (OPUS-3). Ophthal- mology. 2017;124:53–60. Dr. Donnenfeld practices with Ophthalmic Consultants of Long Island and Connecticut and is a clinical professor of ophthalmology, New York University, and trustee, Dartmouth Medical School. He can be contacted at ericdonnenfeld@ gmail.com. the OCEAN group meeting. Ocul Surf. 2017;15:179–192. 5. Epitropoulos AT, et al. Effect of oral re-esterified omega-3 nutritional supplementation on dry eyes. Cornea. 2016;35:1185–1191. 6. Blackie CA, et al. Treatment for meibo- mian gland dysfunction and dry eye symp- toms with a single-dose vectored thermal pulsation: a review. Curr Opin Ophthalmol. 2015;26:306–313. 7. Boynton GE, et al. Prospective randomized trial comparing efficacy of topical loteprednol etabonate 0.5% versus cyclosporine-A 0.05% for treatment of dry eye syndrome following hematopoi- etic stem cell transplantation. Cornea. 2015;34:725–732. The patient's vision im- proved to 20/20. Valuable assessments If we had not identified MGD as the source of this patient's dry eye and treated her aggressively, her refractive outcome would not have been as successful. Tear osmolarity testing and corneal topography were essen- tial. Irregular mires on corneal topography are a key sign of dry eye disease. Contact lens intol- erance is almost pathognomonic of dry eye disease, so every LASIK candidate with such a history should be considered to have dry eye until proven otherwise. However, the most import- ant tests were the physical ex- amination and inspection of the patient's lid margins, as well as documenting MGD with dynamic meibomian imaging. The short- ened tear breakup time and ocular scatter index evaluation readings supported a diagnosis of MGD. Conclusion Before considering surgical intervention, surgeons must use objective testing to determine whether the patient's ocular sur- face is healthy. It also enables us to establish the cause of OSD and develop a more focused therapy. Dry eye disease must be treated before surgery. If it is not, it significantly decreases the like- lihood of achieving the desired refractive outcome. References 1. Donnenfeld D, et al. Measurement of refractive surgery induced dry eye using tear osmolarity testing. ESCRS Congress, September 2011. 2. Sambursky R. Presence or absence of ocular surface inflammation directs clinical and therapeutic management of dry eye. Clin Ophthalmol. 2016;10:2337–2343. 3. Torricelli AA, et al. Screening of refrac- tive surgery candidates for LASIK and PRK. Cornea. 2014;33:1051–1055. 4. Geerling G, et al. Emerging strategies for the diagnosis and treatment of meibo- mian gland dysfunction: Proceedings of Dynamic meibography of both eyes revealed moderately in- spissated meibomian glands with dropout of one or two glands, as well as dilated meibomian glands (Figure 2). 4 She had a very short tear breakup time as proven by the ocular scatter index evaluation. The remainder of the examina- tion indicated a normal anterior segment with a normal posterior pole. Based on her clinical examination and contact lens intolerance, we diagnosed dry eye disease most likely related to mei- bomian gland disease (MGD). Treatment strategy We recommended hot compresses and prescribed re-esterified ome- ga-3 fish oil supplements. 5 This patient wanted rapid improvement, so we performed thermal pulsation on both eyes and prescribed topical lotepred- nol gel three times a day and a T-cell immunomodulator. 6,7 The combination of loteprednol and lifitegrast ophthalmic solution 5% is useful in patients who want re- sults quickly as lifitegrast has been reported to improve symptoms in as little as 2 weeks. 8 Two weeks later, lissamine green staining had resolved and tear osmolarity improved to 298 and 307 mOsm, which was abnor- mal but significantly improved, and corneal topography showed significant normalization with more regular mires. Because her ocular surface improved dramatically, we per- formed a thin flap, large-hinge LASIK with a small diameter of 8.5 mm to reduce the risk of post- operative dry eye. Although her recovery was relatively uneventful, we pre- scribed non-preserved tears four times a day for the first month after surgery, as well as an ome- ga-3 supplement and the topical immunomodulator. Loteprednol gel was tapered during a 1-month period. Figure 1. Corneal topography revealing irregular mires consistent with dry eye disease Figure 2. Dynamic meibography showing thickened, irregular meibomian glands with dropout

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