EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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20 EW CATARACT December 2012 Considering Sj��grens syndrome patients for cataract surgery by Vanessa Caceres EyeWorld Contributing Writer Take extra steps to ensure surgical success A bout 4 million Americans have the autoimmune disease Sj��grens syndrome (SS), according to the Sj��grens Syndrome Foundation. Some of them surely have come into your office for dry eye treatment or other ophthalmic is- sues. You���ve probably had to remove cataracts in some SS patients as well���in fact, because SS patients frequently use topical or system steroids, cataracts might be seen more often in this population than the general population, said Esen K. Akpek, M.D., associate professor of ophthalmology and rheumatology, and director, Ocular Surface Diseases and Dry Eye Clinic, Wilmer Eye Institute, Johns Hopkins University, Baltimore. Dr. Akpek is also associate director of the Johns Hopkins Jerome L. Greene Sj��gren���s Syndrome Center. Here are a few special concerns to consider with these patients because of their disease. To remove or not to remove? Sj��grens syndrome patients are notoriously dry���both in their eyes and their mouth. Because of their eye symptoms and vision that is slightly off, they may come to your office seeking help, said Robert Latkany, M.D., founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York. Upon dilation and an exam, you may see a small cataract. However, before you schedule that surgery, consider whether they might be served best first by aggressive dry eye treatment and then surgery once the cataract has grown larger. In the scenario outlined above, Dr. Latkany will perform a test he devised called the tear film normalization test, which involves artificial tears. If he finds the patient���s vision improves after use of the test, he���ll implement dry eye treatments before he recommends cataract surgery. ���There may be a small cataract, but it���s mostly the dryness that���s not managed that is the problem,��� he said. Calming the dry eye If the cataract is large enough that surgery is warranted, you still want to make their eyes as comfortable as possible. Treating the signs and symptoms of dry eye will not only help patients, it will also make it easier to perform IOL calculations. Just as dry eye treatment prior to cataract surgery is becoming more common in the general population, the same idea should hold true with SS patients. Assess their dry eye by testing. ���Tear film break-up time and ocular surface staining using lissamine green plus fluorescein should be performed to assess the tear film and damage to the ocular surface,��� Dr. Akpek said. Dr. Latkany will use the Schirmer���s test, his tear film normalization test, and lissamine green staining to gauge the severity of an SS patient���s dry eye. Both Drs. Akpek and Latkany use Restasis (cyclosporine ophthalmic emulsion, Allergan, Irvine, Calif.) in SS patients. Dr. Akpek will start if necessary at a dose of four times daily rather than the recommended twice-daily dose. She will also prescribe a topical steroid such as loteprednol etabonate 1% (Lotemax, Bausch + Lomb, Rochester, N.Y.) or fluorometholone in patients with high staining scores.