Management of ocular surface disease crucial before refractive surgery

Dry eye, blepharitis, allergic conjunctivitis and other conditions require aggressive treatment, three experts say.

Close scrutiny of ocular surface disease and appropriate treatment are critical for optimizing postoperative outcomes and preventing complications from refractive surgery, according to three surgeons.

Rigorous, targeted treatment of external disease can transform “poor” LASIK or PRK candidates into viable prospects, but only after aggressive treatment that may take a few weeks to several months, the experts said.

Common external diseases include dry eye, blepharitis, conjunctivitis and atopy. Systemic factors and attendant medication use may also contribute to ocular surface disorders, requiring even more aggressive treatment, they said.

In telephone interviews with Ocular Surgery News, OSN Cornea/External Disease Section Editor Eric D. Donnenfeld, MD, OSN Refractive Surgery Section Member Marguerite B. McDonald, MD, and surgeon William B. Trattler, MD, outlined strategies for identifying and managing ocular surface disease before proceeding with refractive surgery.

Eric D. Donnenfeld

“I rely upon physical findings to determine candidacy,” Dr. Donnenfeld said. “Any corneal staining is, to me, an absolute contraindication to surgery.”

Contact lens intolerance is a fairly reliable sign of external disease, Dr. McDonald said.

“The same conditions that make you a bad contact lens candidate make you a bad LASIK candidate,” she said.

Dr. Trattler said various symptoms of contact lens intolerance may point to dry eye and other conditions.

“[Patients] complain of foreign body sensation, burning, irritation, scratchiness, tearing,” he said. “All of the typical dry eye signs and dry eye symptoms can occur in contact lens patients, and these symptoms can lead to contact lens intolerance.”

Testing and assessment methods

“What we want to do is identify the cause of the dry eye,” Dr. Trattler said. “Is it medication? Is it meibomian gland dysfunction? Is it lack of tears? You figure out what the cause is.”

William B. Trattler

Dr. Donnenfeld described a systematic approach to weighing patients’ readiness for refractive surgery.

“I have two criteria for assessing candidacy for LASIK and PRK surgery, and that is based on signs and symptoms,” he said. “If a patient has no signs or symptoms, they’re generally good candidates. If they have symptoms of dry eye, say ocular surface disease, irritation, foreign body sensation, but they have no signs, no conjunctival staining and corneal staining, I treat them and they do well.”

The quality of the patient’s tear film is a primary concern, Dr. Donnenfeld said.

“Vision starts with the tear film. If you don’t have a good tear film, no matter what else you have, you can’t have good quality vision,” he said.

An unstable tear film may also cause fluctuations in vision, Dr. Trattler said.

“You can have a breakup of the tear film, which can result in little blank spots on the topography,” he said. “You may potentially see an abnormal topography, not because the cornea is abnormal but because the tear film is of poor quality.”

Patients wearing glasses or contacts may experience fluctuation in their vision, Dr. Trattler said.

Fluorescein staining is particularly useful in identifying dry eye, he said. However, the examiner should wait several minutes before studying the stained area because dry areas of the cornea absorb the dye slowly.

Preoperative dry eye is a relative contraindication to LASIK, Dr. Donnenfeld said. “The No. 1 reason is that usually the dry eye will be made worse following surgery.”

Dry eye slows postoperative healing, which may negatively affect refractive outcomes, he said.

Marguerite B. McDonald

“It’s been documented in the scientific literature that untreated dry eye and untreated allergic conjunctivitis increase your chances of a slow recovery and of needing an enhancement for undercorrection,” Dr. McDonald said. “But if you treat these patients, they have the same chance of obtaining a great outcome as those patients who do not have those conditions.”

Although fluorescein staining can detect chronic dry eye, lissamine green dye is recommended for patients who have a “suspicious history” and show no signs of dry eye with fluorescein staining, she said.

Schirmer’s testing is not the newest or most reproducible testing method, but it is the most widely accepted, Dr. McDonald said.

A thorough medical history will generally show factors that contribute to dry eye or any other condition that needs to be treated, regardless of the staining method used, she said.

“Before you even examine them, if you take a good history, you should know what you’re going to see,” Dr. McDonald said.

Systemic factors and medication use

The systemic conditions that most influence ocular surface health are diabetes, rheumatoid disease and hypertension, Dr. Donnenfeld said.

Rheumatoid arthritis dramatically increases the risk of dry eye, he said. He also pointed out that treatment for hypertension currently leans toward diuretics, which can induce dry eye.

Medication use plays a prominent role in contributing to dry eye, Dr. McDonald said. Virtually every medication that lowers cholesterol, controls heartbeat, manages high blood pressure and treats depression is a factor, she said.

Dr. Trattler said antihistamines can also exacerbate dry eye. Additionally, patients who previously underwent cataract surgery are a more common group of patients undergoing refractive surgery in 2008. Most of this increase comes from presbyopic IOL patients who require laser vision correction to reach their refractive targets.

“These patients have a higher risk for ocular surface disease as compared to patients just out of college, so we have to carefully analyze their ocular surface preoperatively,” Dr. Trattler said.

Myriad treatment options

“The treatments for ocular surface disease are myriad,” Dr. Donnenfeld said.

The experts cited various current treatments, such as Restasis (cyclosporine ophthalmic emulsion, Allergan) for dry eye and Lotemax (loteprednol etabonate ophthalmic suspension, Bausch & Lomb) for inflammation.

“Those two therapies I find helpful to improve the ocular surface,” Dr. Donnenfeld said.

To treat pre-existing lid disease, he expressed a preference for topical azithromycin, which he said has “tremendous penetration into the lids to improve the quality of the tear film by reducing lid inflammation and improving the meibomian gland secretions.”

Dr. McDonald lauded form- fitting punctal plugs such as Form Fit plugs from Oasis Medical for dry eyes and eye lid scrubs such as those from OcuSoft.

“I’m pretty aggressive,” Dr. McDonald said. “I really ‘tune them up’ before laser vision correction because I know they will have a much reduced chance of complications or complaints.”

Nutritional supplements are also beneficial, Dr. Donnenfeld said.

“I’m a strong believer in nutritional supplementation, and I like to use fish oil and flaxseed oil combination,” he said.

One effective and popular preparation, Dr. McDonald said, is Thera-Tears Nutrition for Dry Eyes, which is available in most drug and grocery stores in the same aisle as the eyedrops.

Drs. Donnenfeld and McDonald also recommended the use of eye compresses.

Diligence pays dividends

Most patients, even those with preoperative ocular surface disease, can be molded into strong candidates for refractive surgery, Dr. Trattler said.

“I think the vast majority of dry eye patients can become excellent candidates for refractive surgery with treatment, but it may take some patients 2 or 3 weeks, while it may take other patients many months, depending on their underlying condition,” he said. “Most patients can typically have a healthy ocular surface within just a few weeks, as long as you avoid taking a staged approach of starting just one treatment at a time and move toward an approach of using a few treatments as initial therapy.”

“Bad” candidates for refractive surgery after treatment for external disease are rare, Dr. McDonald said.

“There are a few patients who have such severe external diseases that, even with the best that modern medicine has to offer, they aren’t good candidates, but those people are rare,” she said.

Extra attention to risk factors and treatment pays large dividends in patient satisfaction and low enhancement rates, she said.

“[Patients] appreciate how careful you are; you will never lose a patient because you detect a condition that needs treatment before surgery,” Dr. McDonald said. “I can honestly tell them, ‘We have a very low enhancement rate here because we first search for preoperative conditions that need treating, so that you will have a good experience and will sail through the postop period and have a great result.’”

Individualized treatment is a key to positive outcomes, Dr. Donnenfeld said.

“My feeling is that every person should be evaluated on a case-by-case basis,” he said. “With the advances in therapy, we find that patients who in the past were bad candidates have become good candidates. The important point is that the preoperative evaluation and treatment are absolutely imperative to ensure good outcomes.”

For more information:

• Eric D. Donnenfeld, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. He is a consultant for Allergan, Bausch & Lomb and Inspire.
• Marguerite B. McDonald, MD, can be reached at OCLI, 266 Merrick Road, Lynbrook, NY 11563; 516-593-7709; fax: 504-232-3641; e-mail: margueritemcdmd@aol.com.
• William B. Trattler, MD, can be reached at 8940 N. Kendall Drive, #400, Miami, FL 33176; 305-598-2020; fax: 305-274-0426; e-mail: wtrattler@gmail.com.

• Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses on regulatory, legislative and practice management topics.