Address dry eye preoperatively and postoperatively to improve surgical outcomes

A healthy ocular surface helps both cataract, refractive surgery patients achieve optimal visual outcomes.

Issue: March 2010

ByY. Ralph Chu, MD

Y. Ralph Chu

Establishing a healthy ocular surface preoperatively is important because ocular surface issues, such as dry eye, can affect visual outcomes after cataract and refractive surgery and can increase the need for enhancement procedures.

Understanding dry eye

Many patients presenting for cataract or refractive surgery suffer from dry eye. In fact, approximately 7 million Americans have dry eye, and the prevalence of dry eye increases with age, so it is especially common in cataract surgery patients.

In addition, both cataract and refractive surgery negatively affect the ocular surface. In both types of surgery, the corneal nerves are cut, and the use of topical medications that contain preservatives can cause dry eye or exacerbate pre-existing dry eye. Studies have shown that preoperative tear volume may affect recovery of the ocular surface after LASIK and may increase the risk for chronic dry eye.

Preoperative and postoperative treatment

It is important to keep the ocular surface healthy both preoperatively and postoperatively. During the preoperative examination, refractive surgery patients and premium IOL patients undergo both tear breakup time testing as well as Schirmer testing. This is the beginning of the patient education process, and these numbers can help ophthalmologists develop a plan for therapy. After the

preoperative exam, patients are typically started on topical anti-inflammatories, topical antibiotics, Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), and tears for at least 1 week before surgery. Patients continue using topical cyclosporine for at least 6 weeks postoperatively. For patients with moderate to severe dry eye, the cyclosporine is continued for 4 to 6 months postoperatively.

During the preoperative and postoperative periods, Blink Tears (Abbott Medical Optics) can help provide a stable tear film. These tears thicken and stabilize the tear film through their unique visco-adaptive mechanism of action on the eye. The formula thickens every time the patient blinks, resulting in longer tear film stability and moisture retention on the eye.

Dryness after refractive surgery is common. This dryness can last more than 6 months postoperatively, so patients should continue using lubricating eye drops and cyclosporine until vision stabilizes. Studies have shown that treating dry eye can reduce the need for enhancements and also provide better visual outcomes faster. Patients who need an enhancement will likely still be experiencing dryness, so continuation of dry eye therapy is essential.

Patients with blepharitis and meibomitis are prescribed topical AzaSite (azithromycin ophthalmic solution 1%, Inspire Pharmaceuticals) once a day for 1 week before surgery. This helps to minimize some of the oily tear film that can disrupt the surface at the time of surgery. Azithromycin is not used postoperatively.

Topical antibiotics and nonsteroidals are used routinely both preoperatively and postoperatively. Pulsing steroids preoperatively reduces the risk of corneal edema and boosts ocular surface health as well.

We also routinely suggest omega-3 fatty acids. Patients use these preoperatively and continue them for at least 3 months after surgery. Many patients decide to continue using omega-3 fatty acids because they have systemic benefits.

My preoperative and postoperative regimen has evolved over time as new products have become available, and I have seen a noticeable improvement in visual outcomes with the use of this regimen.

Y. Ralph Chu, MD, can be reached at Chu Vision Institute, 9117 Lyndale Ave. South, Bloomington, MN 55420, U.S.A.; +1-952-835-1235; fax: +1-952-835-0534; e-mail: yrchu@chuvision.com. Dr. Chu is a paid consultant for Abbott Medical Optics and Allergan.