Cyclosporine relieves dry eye, ameliorates visual quality after IOL implantation

Cyclosporine 0.05% minimized dry eye signs and improved visual quality after bilateral multifocal IOL implantation, a study showed.

Study results showed that Restasis (cyclosporine 0.05% ophthalmic emulsion, Allergan) significantly improved tear production, tear breakup time and visual quality, the study authors said.

“Our conclusion was that cyclosporine reduced dry eye signs and symptoms, and improved visual quality and patient satisfaction following multifocal IOL implantation,” Eric D. Donnenfeld, MD, lead author and OSN Cornea/External Disease Board Member, said in an interview.

The results highlighted the importance of a healthy tear film to overall ocular surface health in eyes undergoing any cataract or refractive procedure, particularly cataract surgery with multifocal IOL implantation, Dr. Donnenfeld said.

“I think it’s fairly clear that the tear film is really the lynchpin to good surgical outcomes with cataract and refractive surgery, and it becomes of even more importance with multifocal IOL implantation,” he said. “[The study] suggests that for patients having cataract surgery in general, the patient should be evaluated for ocular surface disease and treated when appropriate. But for patients having presbyopic IOLs, unless they have absolutely no signs or symptoms of dry eye, I would treat almost all of these patients, as it dramatically improves outcomes and reduces the risk of having an unsatisfied patient.”

Study results were published in the Journal of Cataract and Refractive Surgery.

Patients and procedures

Dr. Donnenfeld and colleagues set out to assess the efficacy of topical cyclosporine in reducing glare and halo commonly associated with multifocal IOL implantation.

“Our premise was that the ocular surface, while important for all surgical patients, becomes of paramount importance in patients having multifocal IOL implantation, because any disruption of the tear film will increase glare and halo, which is already increased in patients having multifocal IOLs,” Dr. Donnenfeld said.

The prospective, randomized, contralaterally controlled, double-masked trial included 28 eyes of 14 patients with bilateral cataracts scheduled to undergo phacoemulsification and multifocal IOL implantation. Mean patient age was 65.9 years. Nine patients were women and five were men. Three patients had mild preoperative dry eye.

Patients received cyclosporine 0.05% in one eye and artificial tears in the other eye twice daily, from 1 month before first-eye surgery to 2 months after second-eye surgery. Eyes treated with cyclosporine and those treated with artificial tears were randomly selected to undergo first-eye surgery, the authors said.

Investigators evaluated outcomes at baseline (time of randomization, 1 month before surgery) and at 2 months after surgery in the second eye.

Data showed no statistically significant between-group differences in outcome measures at baseline, Dr. Donnenfeld and colleagues reported.

All patients underwent phacoemulsification through a sub-3-mm clear corneal incision with a 5.5-mm capsulorrhexis. Patients received a ReZoom refractive multifocal IOL (Abbott Medical Optics) centered in the capsular bag.

Surgery in the second eye was performed 1 to 2 weeks after surgery in the first eye.

Primary outcome measures were uncorrected distance visual acuity, corrected distance visual acuity with and without glare under mesopic and photopic conditions, and ocular surface staining with fluorescein and lissamine green. Secondary outcome measures were tear breakup time and Schirmer test scores.

Results and conclusions

“Two months postoperatively, the patients who received cyclosporine had significantly better uncorrected visual acuity than the control group that did not receive cyclosporine,” Dr. Donnenfeld said. “And, as you would expect, there was less corneal staining and less dry eye symptoms in the patients who received cyclosporine.”

Study results showed that at 2 months after surgery, the cyclosporine group had a mean logMAR uncorrected distance visual acuity of 0.11 (Snellen equivalent: 20/25); the artificial tears group had a mean logMAR uncorrected distance visual acuity of 0.19 (Snellen equivalent: 20/30). The between-group difference was statistically significant (P = .045).

Also at 2 months, the cyclosporine eyes had a mean logMAR corrected distance visual acuity of 0 (Snellen equivalent: 20/20); the artificial tears eyes had a mean logMAR corrected distance visual acuity of 0.1 (Snellen equivalent: 20/25). The difference between groups was statistically significant (P = .005).

“Treatment with cyclosporine also improved contrast sensitivity and tear breakup time,” Dr. Donnenfeld said.

However, the between-group difference in contrast sensitivity with glare was statistically insignificant under mesopic conditions with glare, Dr. Donnenfeld and colleagues said.

At 2 months, mean tear breakup time was 7.8 seconds in eyes treated with cyclosporine and 6.2 seconds in eyes treated with artificial tears; the difference was statistically insignificant.

“The most important parameter, really, was that patients preferred their cyclosporine-treated eye to their artificial tear-treated eye by a ratio of almost 4:1.” – by Matt Hasson

• Eric D. Donnenfeld, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 N. Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld consults with Allergan and Abbott Medical Optics.

This timely study evaluates the importance of improvement of the tear film on the results after presbyopic IOL surgery. We know that with presbyopic IOL implantation, patients are very sensitive to many issues that can cause subtle vision loss, such as mild cystoid macular edema, mild capsular opacity and especially tear film abnormalities. This study shows how important improvement in dry eye through the use of cyclosporine topically can be in increasing patient satisfaction with presbyopic IOL surgery, a rapidly growing and important group of patients.

– David R. Hardten, MD
OSN Cornea/External Disease Section Editor