Eyeworld

EW FEATURE 50 Dry eye disease update • November 2017 AT A GLANCE • Ocular surface disease can produce both objective and subjective disappointments in cataract surgery. • Frequent lubrication and topical steroids provide acute normalization of the ocular surface. • Consider the entire presentation before using premium lens implants in patients with ocular surface disease. by Rich Daly EyeWorld Contributing Writer gland probing has been of limited use and usually only lasts a few weeks, in Dr. Davidson's experience. "Intense pulsed light has re- ceived attention recently, and while there is some published evidence of its efficacy, the literature is sparse, and I would like to see a prospective randomized controlled study," said Dr. Davidson, who has not tried the therapy. Implant concerns For patients with ocular surface disease who want premium lens implants, Dr. Yeu said it is import- ant to step back and take the entire presentation into consideration. "What comorbidities exist? What DED treatments have been utilized? Is the patient willing to maintain chronic DED treatment in order to optimize the vision after the surgery? These questions are import- ant to consider because while I can often improve the ocular surface enough for cataract surgery, the pa- tient may not want to keep up with the maintenance necessary to keep the vision optimized for a presby- opia-correcting IOL, for example," Dr. Yeu said. Equally as important, Dr. Yeu said, is how well the patient re- sponds to treatment with acute therapies, like topical steroids. "If the DED is recalcitrant to aggressive therapy, this is a patient in whom certain ATIOLs would be contraindicated," Dr. Yeu said. "Also, Dr. Glasser uses a combination of artificial tears, hot compresses, oral omega-3 supplements, and environmental modifications. Dr. Glasser agreed topical cyclosporine and lifitegrast may be helpful in those who respond poorly to initial therapy but noted those medications take a substantial amount of time to work. "Topical steroids rapidly address any inflammatory component but are generally not good long-term solutions for most patients," Dr. Glasser said. "Punctal plugs are often helpful in those with a significant component of aqueous deficiency and minimal or no inflammatory component." For patients with a significant blepharitis component that fails to respond to conservative therapy, Dr. Glasser considers trials of topical an- tibiotic ointment to the lid margins, pulsed topical azithromycin and topical tacrolimus, in that order. Preop MGD Hot compresses, lid hygiene, and oral omega-3 supplements may be sufficient preop cataract surgery treatments for some patients with MGD, Dr. Davidson said. Those with rosacea respond well to oral doxycycline or minocycline. Other treatments, such as LipiFlow (TearScience, Morrisville, North Car- olina) can be beneficial to "reset" the meibomian glands and stabilize the tear film prior to surgery. Meibomian thoroughly evaluate the patient for dry eye disease (DED) and meibo- mian glad dysfunction (MGD) prior to cataract surgery. "I practice in Colorado so most patients already have some element of DED and MGD," Dr. Davidson said. Dr. Davidson recommended performing a detailed slit lamp examination, paying attention to lid position, presence of conjunctivo- chalasis, and tear meniscus. Addi- tionally, he urged meibomian gland imaging and tear film lipid layer analysis. Expensive equipment is not nec- essary to diagnose DED, Dr. Glasser said about the use of a good clinical history or a dry eye questionnaire, a slit lamp, and fluorescein and lissa- mine green or rose bengal dye. "Clinical evaluation of the mei- bomian gland orifices and quality of the meibum by gentle pressure on the lids, and assessment of the tear meniscus and tear film breakup time can all be performed without the need for adjunctive testing," Dr. Glasser said. "Evaluation of lid position and function are critical components of the exam. Evaluation of the corneal mires for shifting ir- regularity with a simple keratometer is an unheralded but sensitive test for the presence of an unstable tear film." Medical therapies Acute normalization of the ocular surface can readily occur by using frequent lubrication and a short course of topical steroids, as needed, Dr. Yeu said. "I'm a huge advocate of hypo- chlorous acid spray in preparation for surgery, particularly in the presence of anterior blepharitis," Dr. Yeu said. Dr. Yeu recommends oral omegas, and if MGD is present, she routinely recommends thermal pulsation therapy, particularly if the patient has symptomatic disease or if he or she is leaning toward a refractive cataract surgery option. Although Dr. Davidson views artificial tears as a reasonable first line therapy, in patients with any- thing worse than mild dry eye he recommends topical lifitegrast or cyclosporine. To establish a stable ocular surface in the cataract patient, Surgeons identify key approaches U nstable ocular surface disease can produce both objective and subjective disappointments if not managed preoperatively. "Objectively, cataract surgery diagnostics will provide inaccurate corneal power and astigmatism measurements," said Elizabeth Yeu, MD, assistant professor, Eastern Vir- ginia Medical School, and partner, Virginia Eye Consultants, Norfolk, Virginia. "Subjectively, patients' dry eye disease can worsen after cataract surgery, often resulting in irritation or suboptimal quality of vision." Dry eye disease impacts cataract surgery patients by reducing preop visual acuity due to an irregular tear film or an irregular corneal surface, said David Glasser, MD, assistant professor of ophthalmology, Johns Hopkins University School of Medi- cine, Baltimore. "This can interfere with the as- sessment of the contribution of the cataract to the visual disability," Dr. Glasser said. Additionally, an irregular tear film or cornea surface will render keratometry and corneal topography measurements inaccurate, which will in turn reduce the accuracy of IOL calculations. Postop visual acuity can be reduced, especially since the use of topical medications in the periop period may contribute to further sur- face irregularity, Dr. Glasser noted. Exam critical Richard Davidson, MD, professor, UCHealth Eye Center, University of Colorado School of Medicine, Auro- ra, Colorado, said it is important to Identifying and treating ocular surface disease before cataract surgery Meibum being expressed from the inferior MG Source: Elizabeth Yeu, MD

• Blank Page
• Blank Page (1)