Eyeworld

The third refractive surface: Improving surgical outcomes with advanced diagnostics and therapeutics by Francis Mah, MD Establishing a system for approaching ocular surface disease therapy their full benefit. The entire ocular surface was not managed. Therefore, we needed to continue cyclosporine and/or lifitegrast and address MGD. Additional treatments may include warm compresses and lid hygiene, omega-3 fatty acids, an emulsion-type lubricant, antibiot- ic ointment, systemic tetracycline derivative, thermal pulsation, and steroids, as well as cyclosporine and lifitegrast. Punctal plugs may be considered when the eyes are quiet. Conclusion Optimizing the ocular surface can improve the patient experience and surgical outcomes. The ASCRS algorithm will guide the use of an increasing number of point-of- care ocular surface tests. Dr. Mah is director of the cornea ser- vice and co-director of the refractive surgery service, Scripps Clinic, La Jol- la, California. He can be contacted at Mah.Francis@Scrippshealth.org. After the testing, the clini- cian performs the examination, taking a careful history that will help determine whether the patient has MGD, blepharitis, or aqueous deficiency. Next, we perform a dry eye examination, with tear film break- up time, corneal and conjunctival staining with the aid of vital dyes such as fluorescein and/or lissamine green, and meibomian gland assessment by expression (Figure 1). Serum Sjögren's testing may be necessary if the patient has dry mouth or eyes. In addition to the aqueous component, we need to address the possible evaporative compo- nent based on the examination, history, and meibum. Case: Diagnosis The patient explained that ocular burning in the morning was very bothersome. On examination, she had very thick meibomian secre- tions, which is why cyclosporine and lifitegrast did not achieve surgical outcomes. We also need to educate our patients so they are aware that they have dry eye before surgery and continue treatment after surgery. Diagnostic process When a patient arrives in our practice, the first thing we need to do is to identify dry eye. Many cataract patients have no symp- toms. Therefore, we begin with the SPEED questionnaire after the technician speaks with them about their vision and symptoms. If a patient has blurred vision, we need to know if it is constant or fluctuates, which is almost pathognomonic for OSD. With fluctuating vision, we can skip the questionnaire and begin osmolarity testing and then inflammation testing. If osmolarity and inflamma- tion are positive, this indicates dry eye disease. Treatment may include lubrication, omega-3 fatty acids, steroids, and cyclosporine 0.05% and/or lifitegrast. This testing does not detect meibo- mian gland dysfunction (MGD), so it will be necessary to treat that if present. Serum tears may be considered, as well as amniotic membrane or extract. If osmolarity is positive and MMP-9 testing is negative, this might be considered dry eye without significant inflammation. Treatment may include cyclo- sporine 0.05% and/or lifitegrast, lubrication, and omega-3 fatty acids, as well as MGD treatment if necessary. If osmolarity is negative and MMP-9 testing is positive, the patient may not necessar- ily have dry eye but may have allergic conjunctivitis, conjunc- tival chalasis, anterior basement membrane disease, or another condition that would cause in- flammation of the ocular surface. New algorithm will guide ocular surface disease management T o help clinicians navi- gate the complex maze of diagnostics and treat- ments for ocular surface disease (OSD), the ASCRS Cornea Clinical Committee will soon provide a logical algorithm for guidance. This will be a revolutionary year, with the release of many different protocols. Dry eye management The following case illustrates how the algorithm will be used. A 55-year-old woman was referred to our practice who had small incision cataract surgery with a multifocal intraocular lens and astigmatism correction with limbal relaxing incisions. Although she had 20/20 vision, a month after surgery she was unhappy. She had blurring, vision fluctuation, and discomfort, as well as punctate epithelial kerati- tis. Several treatments were tried, including artificial tears, cyclospo- rine 0.05%, and lifitegrast, but she still had symptoms. Dry eye can impact contrast sensitivity because the tear film is the most important refractive surface. Many studies have shown the prevalence of postoperative dry eye in cataract and refractive surgery. However, because dry eye is common in cataract patients, it is essential that we diagnose and treat it before surgery, which optimizes the ocular surface and Francis Mah, MD Figure 1. Meibomian inspissation 6

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