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Ocular surface management critical to patient satisfaction
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Proper management of the ocular surface is now recognized as a critical factor in surgical outcomes and patient satisfaction, especially in the refractive corneal and refractive cataract surgery setting. I am a strong advocate of recognition and treatment of dry eye disease in the surgical patient.
The Dry Eye Workshop report defined dry eye disease, whether aqueous deficient or evaporative, as being associated with elevated tear film osmolarity and inflammation. Many patients with mild to moderate dry eye are asymptomatic, and studies suggest that most of us do not diagnose this problem as frequently as we should.
For me, the recently approved TearLab device for measuring tear film osmolarity has been extremely useful in screening the preoperative surgical patient for dry eye. It is simple, easily done by an office assistant or technician, and now reimbursed in most parts of the country. I have learned that both eyes should be tested. A reading of 308 or higher, a significant difference in tear film osmolarity from one eye to the other, and variable readings in one day to the other are all suggestive of dry eye disease. To me, this is much the same as IOP as a screening tool for glaucoma, in which an elevated IOP, a significant difference in IOP from one eye to the other, and variable IOP from one visit to another are red flags that encourage further diagnostic tests. In studies led by Michael Lemp, MD, tear film osmolarity demonstrated higher sensitivity and specificity in diagnosing dry eye disease than our classical tests, including Schirmer’s, tear meniscus measurement, tear breakup time, and even corneal and conjunctival staining.
In the elderly cataract patient, meibomian gland dysfunction (MGD) with tear film instability and evaporative dry eye is more frequent than aqueous-deficient dry eye, representing as much as 80% of patients. Tear film osmolarity is a good screen in these patients, and a careful look at the meibomian glands with gentle gland expression can usually confirm the diagnosis. In the near future, I also expect a screening test for ocular surface inflammation, which measures MMP-9 levels in the tears, to become available (RPS, Nicox).
Once dry eye is diagnosed, an appropriate treatment plan can be formulated. I break treatment of the surgical patient into four stages. First is ocular surface preparation before surgery, then ocular surface protection during surgery, then ocular surface restoration after surgery, and finally long-term ocular surface maintenance for a lifetime. A few thoughts on these four treatment plans.
For ocular surface preparation, I want something that works fast because most patients do not want to wait more than a week or two for their surgery. The magic treatment for me is a topical steroid in drop and/or ointment form. Because most of these patients have some MGD, I add lid hygiene and prefer the commercial lid scrubs because they contain antiseptics that lower bacterial colony count. Frank Bucci, MD, one of my former fellows, has shown that lid hygiene alone in the preoperative eye increases surface bacterial colony count, but that lid hygiene combined with a topical antibiotic reduces bacteria on the surface. For that reason, I favor an antibiotic-steroid combination.
Stephen Lane, MD, another former fellow, has shown that a 1- to 2-week course of a tobramycin/dexamethasone drop combined with lid hygiene results in an extremely successful and rapid remission of ocular surface disease signs and symptoms. I have been very happy with this approach. As I look more carefully for any level of ocular surface disease, I find it to be extremely common, and I now treat all my surgical patients with this regimen for 1 week preoperative. A topical lubricant and 2 g of an omega-3 are added in patients with signs or symptoms of dry eye. The choice of omega-3 is important because some are not well absorbed and serve better as a laxative than a treatment for dry eye disease. I am happy with Nordic Naturals, PRN and Biosyntrx brands in my practice.
During surgery I coat the ocular surface with a dispersive viscoelastic, which is highly protective and enhances visibility in the dry eye during surgery. OcuCoat (2% hydroxypropyl methylcellulose, Bausch + Lomb), Viscoat (4% chondroitin sulfate, 3% sodium hyaluronate, Alcon) and Healon EndoCoat (sodium hyaluronate 3%, Abbott Medical Optics) work well, as does Goniosol (hydroxypropyl methylcellulose, Novartis). With Viscoat, I warm it slightly before surgery and place it on a surface moistened with a squirt of balanced salt solution to enhance its optics.
In the postoperative period, attention to the toxicity of the postop drops is important. In managed-care Minnesota, many prescriptions for once- or twice-daily less-toxic NSAIDs are substituted by the pharmacist for more toxic, preserved, four-times-a-day generic alternatives. In patients with significant dry eye, I encourage them to ask the pharmacist to dispense the drops I have recommended.
The basics of postoperative surface restoration and long-term surface health maintenance are already in place in the patient in whom I have started omega-3s and appropriate topical lubricants before surgery. These are simply continued in the postoperative period. I like the lipomimetic drops such as Systane Balance (Alcon) and Soothe (Bausch + Lomb) in the MGD patient and the hyaluronate-containing drops such as Blink (AMO) or those available from Oasis for aqueous-deficient dry eye. In the moderate to severe dry eye, I like Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), and in patients with acne rosacea, long-term use of an optical macrolide such as AzaSite (azithromycin, InSite Vision) or erythromycin ophthalmic ointment and low-dose tetracycline, doxycycline or minocycline is indicated.
I find careful screening for ocular surface disease before surgery combined with an appropriate medical regimen for ocular surface preparation preoperatively, ocular surface protection with a dispersive viscoelastic intraoperatively, combined with ocular surface restoration and maintenance postoperatively have enhanced my patients’ outcomes and satisfaction. As mentioned before: happy patient, happy surgeon.