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Ocular surface disease needs to be managed before and after surgery
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Ocular surface disease, including dry eye disease, blepharitis and ocular allergy, is a common comorbidity in the surgical patient. As many as 50% of seniors presenting for cataract surgery and 30% of younger patients presenting for LASIK, when evaluated carefully, demonstrate some degree of ocular surface disease.
 Richard L. Lindstrom |
Select chart reviews of patients presenting for cataract surgery suggest that we are significantly underdiagnosing dry eye, blepharitis and ocular allergy. In the era of premium “lifestyle-enhancing” IOLs, it is time for all of us to pay more attention to ocular surface disease in our surgical patients.
A new, easy-to-perform test for tear film osmolarity (TearLab), which can be done by a technician, should enhance our ability to screen for aqueous deficient or evaporative dry eye.
Once recognized, I believe we have four stages of treatment that can enhance our patients’ surgical outcomes: ocular surface preparation before surgery; ocular surface protection during surgery; ocular surface rehabilitation after surgery; ocular surface maintenance long term after surgery.
A few thoughts on each from my perspective. Once I make the diagnosis of ocular surface disease, I treat it before surgery. Because I want a rapid response, I find myself using a topical steroid routinely, often four times a day for 1 to 2 weeks preoperatively. This is an effective regimen for all forms of ocular surface disease and can be combined with other appropriate therapies, including artificial tears, punctal occlusion, lid hygiene, topical antibiotics, oral doxycycline, nutritional supplements and topical cyclosporine as indicated.
Second, in the patient with significant ocular surface disease, I take special care to protect the cornea and conjunctiva from surgical trauma. I have found the most effective tool here is to coat the ocular surface with a dispersive viscoelastic such as Viscoat (chondroitin sulfate, sodium hyaluronate, Alcon) or OcuCoat (hydroxypropyl methylcellulose, Bausch & Lomb). This enhances the surgeon’s view during surgery, eliminates the need for the assistant to constantly squirt balanced salt solution on the eye, and results in a much healthier ocular surface postoperative, with better day 1 visual acuities. We almost all routinely use an ophthalmic viscosurgical device to protect the endothelium. I suggest we consider doing the same to protect the corneal and conjunctival epithelium. In addition, surgery is a good time to consider placing a punctal plug when appropriate.
Third, we need to rehabilitate the ocular surface postoperatively. In the LASIK patient, this can take months, and data is accumulating that a combination of long-term topical lubricants and low-dose cyclosporine is quite effective, positively affecting patient comfort and quality of vision.
Finally, the patient with ocular surface disease before surgery will still have ocular surface disease after surgery. We need to educate the patient regarding their disease and the need for long-term treatment.
I find it interesting that a surgical procedure often gets my patients started on a lifetime regimen for their ocular surface disease that positively affects their quality of life and captures them and their family for a lifetime of care in our practice. So, look for ocular surface disease in your surgical patients, then prepare, protect, rehabilitate and maintain a healthy surface, and your outcomes will improve and your practice will grow.