Healthy ocular surface maximizes outcomes after IOL implantation

Dry eye, lid infections and epithelial defects can be managed preoperatively to help improve success with cataract removal and IOL insertion.

Edward J. Holland

KIAWAH ISLAND, S.C. — Preoperative recognition and management of ocular surface disorders may help maximize surgical outcomes and increase patient satisfaction.

The advent of premium IOLs has increased the number of indications for cataract removal, especially given that these lenses also help patients cope with presbyopia or refractive errors.

However, premium lenses have also brought cataract surgery and IOL implantation into the realm of refractive surgery. Increasingly, patients are expecting high-quality results, whether from refractive lens exchange or from cataract removal.

For these reasons, ensuring a healthy ocular surface before surgery increases the odds of improved outcomes after surgery, according to OSN Cornea/External Disease Board Member Edward J. Holland, MD. The degree of benefit from cataract surgery or refractive lens exchange may be inhibited by the presence of ocular surface disease, which can affect healing or cause a defect in the visual axis.

“Quality of vision starts with a healthy ocular surface, and the tear film is the most important surface of the eye,” Dr. Holland said at Kiawah Eye 2009.

Dry eye

Cataract surgery is known to induce or exacerbate dry eye symptoms. Dry eye, especially secondary to an inflammatory response, can abate the healing process after cataract removal, and surgically induced trauma can further worsen the inflammatory response.

“If we add two paired [limbal relaxing] incisions, we have significantly increased the amount of trauma to the nerves of the cornea and increased the problem of neurotrophic disease,” Dr. Holland said. “In your cataract and your refractive patients, it is the unstable tear film that I think is probably the most common cause of visual loss in your patients postoperatively. If you manage that preoperatively, you are going to have more happy patients.”

In patients who are diagnosed with significant dry eye syndrome, in that there is conjunctival staining with a lissamine green stain, or corneal staining, Dr. Holland said he delays surgery until after symptoms can be controlled and the staining resolves. Artificial tears are effective in restoring function, and topical immunosuppressive agents may have a role in more severe disease.

“I advocate pretreating cyclosporine patients with a topical corticosteroid,” Dr. Holland said. “If you pretreat a patient for 2 weeks with a steroid, you won’t get the red eye and the irritation that about 17% of patients encounter with cyclosporine. My steroid of choice is loteprednol because of its efficacy and safety profile.”

Healthy lids, healthy cornea

Another common condition that can affect postsurgical outcomes is blepharitis, which is often confused for dry eye, according to Dr. Holland. Blepharitis can lead to evaporative dry eye among other complications, but “many of these patients are treated for simple dry eye or aqueous tear deficiency when it’s really evaporative dry eye from lid disease,” he said.

Management of blepharitis starts with lid hygiene and hypothermia therapy, Dr. Holland said. Nutritional supplements, topical steroids and azithromycin — because it is known to have anti-inflammatory properties, broad anti-infective coverage, and excellent tissue penetration — may also be warranted.

“I think it is extremely important — and not just in your premium IOL patients, but all your cataract patients — to look carefully at the lid function,” he said.

Irregularities of the corneal epithelium and stroma may also limit the success of cataract surgery. Specifically, epithelial basement membrane dystrophy and Salzmann’s nodular degeneration can both cause changes within the visual axis that will limit the extent to which cataract removal aids in visual recovery.

“If there are epithelial changes in the visual axis, this patient will have decreased vision or fluctuating vision and be unhappy with their outcome. These patients also can get pain from spontaneous corneal erosion,” Dr. Holland said. “If the opacities from [epithelial basement membrane dystrophy] or [Salzmann’s nodular degeneration] are significant, then superficial keratectomy and possibly phototherapeutic keratectomy may be warranted.”

Endophthalmitis and cystoid macular edema

Endophthalmitis is a potential cause of severe, even sight-threatening inflammation and is of particular concern given the emergence of antibiotic-resistant pathogens. The greatest risk occurs in patients with a preoperative ocular surface disease, such as blepharitis, as well as dry eye. Proper preoperative management will reduce that risk, Dr. Holland said.

Intraoperative hygiene protocols — povidone-iodine preparations, lid draping that covers the lid margin and lashes, careful wound construction and suturing of leaking wounds — as well as postoperative antibiotics will also lower risk.

“For any patient postoperatively who is at risk for [methicillin-resistant Staphylococcus aureus] that you think there is signs of intraocular or a corneal infection, think about vancomycin as the treatment of choice,” he said.

Cystoid macular edema (CME) is the most common cause of visual loss after cataract extraction. About 12% of patients with routine cataract surgery have subclinical or clinical CME. However, postoperative management may be insufficient.

“Treating CME does not give the same visual acuity as preventing CME,” Dr. Holland said. “Even though some patients will get back to 20/20, they have decreased contrast sensitivity and decreased quality of vision. And I think as cataract surgeons, our goal should be preventing — not treating — CME.” – by Bryan Bechtel

• Edward J. Holland, MD, can be reached at Cincinnati Eye Institute, 580 South Loop Road, Edgewood, KY 41017; 859-331-9000; e-mail: eholland@fuse.net.