Premier Surgeon: Managing the ocular surface

Sixth in a series of the top 10 reasons for poor premium IOL outcomes and how to remedy them.

Issue: February 10, 2012

ByMitchell A. Jackson, MD

Mitchell A. Jackson

Managing patient expectations, conducting the preoperative evaluation and addressing cystoid macular edema are all critical aspects in making the premium IOL patient happy and ensuring a premium outcome. However, ignoring the ocular surface, one of the remaining reasons for poor premium IOL outcomes, can lead to a dissatisfied patient from a preoperative, intraoperative or postoperative perspective.

Common ocular surface issues

Dry eye syndrome, blepharitis and meibomian gland dysfunction, allergy, and epithelial basement membrane dystrophy are the most common causes of poor ocular surface function in the premium IOL patient. Approaching the ocular surface from a tear layer perspective will help manage and prevent many of the problems associated with these issues.

Recently, the international Delphi panel and the Dry Eye Workshop redefined dry eye as being a multifactorial disease of the ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface. Furthermore, dry eye is accompanied by an increase in tear film osmolarity and inflammation of the ocular surface. Dry eye affects approximately 20.7 million people in the United States and is most commonly observed in women older than 50 years. Other common causes of dry eye are the American fast food diet, high in bad omega-6 and low in good omega-3 fatty acids; LASIK and other corneal refractive surgery procedures; diabetes mellitus; vitamin A deficiency; hepatitis C infection; low blink rate caused by factors such as Parkinson’s disease and computer vision syndrome; cosmetic blepharoplasty; contact lenses; and medications such as diuretics, antihistamines, birth control pills, tricyclic antidepressants, anticholinergics, antispasmodics and hormone replacement therapy.

The preoperative evaluation must include a global evaluation of the patient, because a poor ocular surface can affect the accuracy of preoperative critical measurements such as keratometry, corneal topography and axial biometry. The PHACO study (Prospective health assessment of cataract patients’ ocular surface) led by William B. Trattler, MD, and colleagues confirmed that most patients who undergo cataract surgery are asymptomatic, but 62% have a tear breakup time of less than 5 seconds, 50% have central corneal staining, and 21% have abnormal Schirmer test scores of less than 5 mm. As much as 1 D to 2 D of error in IOL power calculations as a result of such poor data acquisition can definitely hinder the ideal outcome, especially in premium IOL patients.

Management

My approach to the ocular surface focuses on tear layer etiology and management, which typically overlap, requiring multiple treatment modalities to achieve an improved ocular surface. The lipid layer is most commonly affected in patients with acne rosacea or an ocular variant of this condition, creating what we refer to as blepharitis, meibomitis, meibomian gland dysfunction or simply lid margin disease. Management options include warm compresses, lid massage, lid scrubs, AzaSite Plus (ISV-502, InSite Vision) and/or Tobradex ST (tobramycin/dexamethasone ophthalmic suspension 0.3%/0.05%, Alcon) or Zylet (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension, Bausch + Lomb), artificial tears that replace the oily layer (eg, Alcon’s Systane Balance and OcuSoft’s Retaine), low-dose doxycycline (50 mg per day), the Maskin meibomian gland intraductal probe (Rhein Medical), and/or the potentially curative new LipiFlow thermal pulsation system (TearScience).

The aqueous layer is typically affected by autoimmune diseases such as lupus, rheumatoid arthritis, ulcerative colitis, diabetes and thyroid disease. Management options include concomitant care administered by an internist, rheumatologist or endocrinologist; Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan); punctal plugs; topical steroids such as Lotemax (loteprednol etabonate ophthalmic ointment 0.5%, Bausch + Lomb); and fish oil nutritional supplements. Tear film osmolarity is now easily detected with the TearLab Osmolarity System, which is no more difficult to perform than a Tono-Pen (Reichert Technologies) IOP measurement. If osmolarity is elevated, I may customize my artificial tear regimen to include Blink Tears (Abbott Medical Optics) because they have a beneficial effect on tear osmolarity.

Mucin layer insult is usually seen with vitamin A deficiency, Stevens-Johnson syndrome, graft-versus-host disease and ocular cicatricial pemphigoid conditions. For treating the underlying condition, topical cyclosporine, due to its enhanced goblet cell density effect, and topical FreshKote (polyvinyl pyrrolidone 2%/polyvinyl alcohol 0.9%/polyvinyl alcohol 1.8%, Focus Laboratories) are my treatments of choice in these circumstances. The latter also aids those with epithelial basement membrane dystrophy because of an enhanced oncotic pressure gradient effect at this level. Blink Tears mimic the mucin layer in its structural property as well and will provide benefits in these patients.

Lastly, although fairly easy to treat, ocular allergy will always aggravate dry eye, and selecting a more specific H-1 receptor antihistamine or mast cell-stabilizing pharmaceutical such as Lastacaft (alcaftadine ophthalmic solution 0.25%, Allergan) or Bepreve (bepotastine besilate ophthalmic solution 1.5%, Ista Pharmaceuticals) will limit such side effects in the dry eye patient.

In the end, managing the ocular surface is crucial in not only obtaining accurate diagnostic data preoperatively but improving visual quality postoperatively by managing each patient based on a tear layer etiologic approach.

Stay tuned for my next remedy for the premium IOL problem patient: managing IOL calculations with special attention to the post-refractive surgery patient.

References:

Lemp M, Baudouin C, Baum J, et al. The definition and classification of dry eye disease: Report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):75-92.

Market Scope. Report on the Global Dry Eye Market. St. Louis, MO: Market Scope; July 2004.

Montani G. Length of the effect of Blink Intensive on reduction of tear osmolarity. Presentation at: British Contact Lens Association Annual Clinical Conference; 2009; Manchester, U.K.

Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003;136(2):318-326.

Trattler W, Goldberg D, Reilly C. Incidence of concomitant cataract and dry eye prospective health assessment of cataract patients. Paper presented at: World Cornea Congress; April 8, 2010; Boston, MA.

Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; 847-356-0700; fax: 847-589-0609; email: mjlaserdoc@msn.com.

Disclosure: Dr. Jackson is on the speakers bureau for Alcon, Allergan, Ista Pharmaceuticals, Abbott Medical Optics, Inspire and Bausch + Lomb.