Tear film stability crucial for reducing post-surgical dry eye incidence

ByEric D. Donnenfeld, MD

Reducing the incidence of post-surgical dry eye in patients undergoing cataract and refractory surgery is an important process. It begins with preoperative assessment of risk and symptom treatment and moves through the operation and into postoperative therapeutic interventions. This article discusses the best preoperative management procedures and methods for helping patients avoid post-surgical dry eye.

Minimize preoperative symptomatology

Preoperative evaluation and care is the first step toward preventing or reducing dry eye symptoms following surgery.

— Eric D. Donnenfeld, MD

Preoperative evaluation and care is the first step toward preventing or reducing dry eye symptoms following surgery. The main goal at this stage is to minimize dry eye symptoms and inflammation in the presurgical eye.

Supporting the tear film is crucial to this process. This begins with artificial tears, gels, ointments and punctal plugs. Any patient with substantial ocular surface disease should be treated with autologous serum eye drops.¹

Any lid disease, such as anterior or posterior blepharitis, should be treated as well (Table 1). The first step in this process is to use hot compresses and/or lid scrubs, as well as bacitracin ointment for pre-existing staphylococcal lid disease. Anti-inflammatory therapies should also be used, because they can improve tear production, corneal staining and visual acuity. Some of these include nutritional supplements, topical cyclosporine A (Restasis, Allergan) and topical corticosteroids. Preoperative use of cyclosporine A has been shown to improve postoperative visual acuity.²

Table 1
Table 1. Methods for treating lid disease preoperatively
Table 1: Methods for treating lid disease preoperatively.

Information courtesy of Ophthalmic Consultants of Long Island.

Topical corticosteroids

Topical corticosteroids have been shown to help stabilize the tear film (Figure 1) and improve tear production by controlling inflammation.³ A study showing that reduction in inflammation indicated that the optimal use of one such agent, loteprednol etabonate (Lotemax, Bausch & Lomb) involves the corticosteroid four times a day for 2 weeks, then initiation of cyclosporine A treatment along with twice daily loteprednol for 4 to 6 weeks. This study shows a decrease in the commonly felt irritation associated with the use of topical cyclosporine A⁴ by as much as 75%.⁵

Dry eye disease is not a stable condition, and many factors can influence it; these include hormonal fluctuations and medications, as well as environmental changes. For patients taking cyclosporine A, who experience short-term worsening of the ocular surface, a short course of topical corticosteroids can reduce the symptoms of dry eye.

Figure 1

Figure 1: Tear film reflection before and after application of cyclosporine and loteprednol.

Images courtesy of Ophthalmic Consultants of Long Island.

Summary

Optimizing the ocular surface preoperatively is particularly crucial in terms of modern cataract surgery, because biometry or surgical skill is no longer the rate-limiting factor for these operations. Instead, reliable keratometry is used forfor intraocular pressure selection. Improving the tear film preoperatively will allow for more reliable keratometry, as well as more accurate biometry and a more accurate postoperative result. Postoperative dry eye symptoms can also be reduced.⁶

When heading to the operating room, physicians should always have a clear and intelligent preoperative, intraoperative and postoperative plan of management for reducing the incidence and severity of surgery-related dry eye. Improvements in visual acuity and quality of vision start with stabilization of the tear film preoperatively, and some of the methods laid out in this article should help improve results of cataract and refractive surgery.

References

Toda I. LASIK and dry eye. Compr Ophthalmol Update. 2007;8:79-85.
Salib GM, McDonald MB, Smolek M. Safety and efficacy of cyclosporine 0.05% drops versus unpreserved artificial tears in dry-eye patients have laser in situ keratomileusis. J Cataract Refract Surg. 2006;32:772-778.
Marsh P, Pflugfelder SC. Topical nonpreserved methylprednisolone therapy for keratoconjunctivitis sicca in Sjögren syndrome. Ophthalmology. 1999;106:811-816.
Donnenfeld E, Sheppard JD, Holland EJ, et al. Prospective, multi-center, randomized controlled study on the effect of loteprednol etabonate on initiating therapy with cyclosporin A. Presented at the American Academy of Ophthalmology Annual Meeting. New Orleans. 2007.
Sheppard JD. Topical loteprednol pre-treatment reduces cyclosporine stinging. Presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery. Washington, DC. 2005.
Roberts CW, Elie ER. Dry eye symptoms following cataract surgery. Insight. 2007;32:14-21.