OSN round table, part 2: Optimization of the ocular surface

Dry eye is a multifactorial progressive disease that worsens with time. At the European Society of Cataract and Refractive Surgeons meeting in Barcelona, Ocular Surgery News convened anterior segment surgeons from both sides of the Atlantic to address the challenges of diagnosing and treating ocular surface disease, particularly before and after ophthalmic procedures. In this second of two parts led by OSN Technology Section Editor William B. Trattler, MD, the round table participants delve into their suggested regimens for optimizing the ocular surface with respect to dry eye, giving their thoughts on eyelid hygiene, use of punctal plugs, pterygium surgery and consequences of cross-linking for keratoconus.

Lid hygiene

William B. Trattler, MD: There have been a number of innovations in diagnostics as well as therapies for lid margin disease. What new technologies have you incorporated into your practice to improve care for your patients?

Jennifer Loh, MD: When assessing eyelid disease in terms of treating dry eye, we know that eyelids are a big foci for inflammation that contributes to decreased lipid layer and poor tear film, and so we want to treat the blepharitis and inflammation of the eyelids. A popular eyelid treatment now is something called Avenova (hypochlorous acid, NovaBay). It works well for cleaning the eyelids and getting rid of debris and inflammatory markers. If a patient cannot afford that, I often will use a product in the United States called OcuSoft, which is a pre-moistened towelette with lid cleanser.

Image: Trattler WB

Béatrice Cochener, MD, PhD: Do they need to warm it?

Loh: Yes. They should warm the eyelids first and then do the cleansing. Another point is that, sometimes, if someone has severe telangiectasias or redness, I will use oral doxycycline temporarily to help decrease the inflammation. I do not use it in all patients, but if they have severe rosacea or signs of that, I will. Sometimes I even give erythromycin ointment after the cleansing to keep the bacterial load at a minimum.

Trattler: What products or technologies do you use in Europe?

Cochener: The strategy is according to the compliance of the patients. Sometimes people forget or do not do the routine every day. So we start always with a simple and cheap process, just using warm and moist towelettes in the morning. Then we go for a warming mask that is put in the microwave or more sophisticated electric warming glasses. Patients do that every day and then two or three times per week. Of course, it needs to be associated with perfect cleaning of the eyes right after.

You may also use LipiFlow (TearScience), which is a therapeutic step that uses a thermopneumatic eyecup that gets warm and that works on just the lids. It is popular in the States because American patients are ready to pay. In Europe, it is more of the last choice when people get tired of the repeated treatment and/or still feel uncomfortable with their eyes, and they make then the decision to pay for one single treatment. But based on the media, some even come to the office and ask for it specifically. The key advantage is that it should work on average for 3 to 6 months. That is the average, 3 to 6 months. In between treatments, the patient does not have to do all this repetitive treatment.

Trattler: Educating patients on what to expect with LipiFlow is important. As part of a multicenter study, we found that patients experience some mild improvement in their lid margin disease 1 month after the procedure. However, there is continued improvement, with patients experiencing improved lid margin disease findings at 3 months and even further improvements at 6 months following the procedure. I expected the exact opposite to occur before personally working with LipiFlow. Patients just seem to experience more improvement with time, which is helping the underlying eyelid disease get better with just one treatment.

Cochener: This is a key issue because patients pay for the treatment, so they expect the results but need to be prepared. They have to know that it is not the end of the story and they need to be patient for the full outcome.

Aylin Kiliç, MD: It is important to do treatments like this before surgery because after surgery, it is not easy to manage.

Patient expectations

Wolfgang Riha, MD: In my experience, it is hard to drive awareness for those problem patients. One of the most important points in my informed consent process is talking about dry eye, either in cataract or in corneal procedures. When patients do not have any symptoms, it is extremely difficult because you tell them that they have an issue they are not aware of.

Kiliç: Before surgery.

Riha: Yes, before surgery, and afterward it is even worse.

Kiliç: Absolutely.

Riha: In our everyday routine in a high-volume cataract and refractive center, it is critical to show patients that the ocular surface is so important for their quality of vision. Any objective testing can help tremendously. Today we are dealing with high patient expectations. We are doing refractive premium lens procedures in 70- and 80-year-old patients. To deliver 20/20 vision is often not enough. If there are conditions after the surgery that were not there before, it is a big thing for them, and I see anything connected with the ocular surface as the most common issue.

Kiliç: I think also patients do not think it is a disease. They think, “Yes, I received treatments — warm compress and drops — and it was finished.” It is not like that. We have to inform patients that this is something they will have all of their life. So they go from doctor to doctor looking for one treatment, and it does not solve the problem.

Trattler: When a patient is not satisfied with their vision after cataract surgery, my first treatment step, after ruling out other potential causes of reduced vision such as posterior capsular opacity or macular disease, is to initiate treatment for ocular surface disease, even if there is minimal corneal staining. I start patients on topical cyclosporine, a short course of topical steroids and lid cleansers. Over a couple of months, the quality of vision will often improve. So, before I ever consider a PRK or LASIK procedure to enhance vision after cataract surgery, I give these patients a course of treatment for potential ocular surface disease, and most of the time this works, so that I do not have to perform laser vision correction.

Cochener: I agree. First, educate the doctors. They need to think about the corneal surface, particularly before, during and after the surgery. That is the whole point. That is why we are here, to underline the role of the ocular surface. But patient education is another deal because patients do not understand or accept that you would give them drops when their eyes are already tearing.

Cross-linking, keratoconus and dry eye

Trattler: I want to switch our discussion to cross-linking, keratoconus and dry eye.

Cochener: I am taking great care in keratoconus, and I guess that you are doing the same. I have noticed that in older keratoconic patients, they have rosacea, like if long-term allergy could lead to this evolution, related probably to the chronic inflammation process. And you know the meibomian glands are most of the time terrible, especially at the age of 40 years. We have older keratoconus patients now and know how much itching is an increased factor of ectasia.

Kiliç: Especially after intracorneal ring implantation, dry eye is more important in cross-linking for keratoconus than for other refractive procedures, especially because there is a relationship between change in corneal shape and dry eye. The dry eye can be dangerous in this group.

Cochener: It is so true. I used to do a combination of cross-linking and rings, but I stopped because in my experience the risk for infection is a huge problem with this combination. You have risks with the incision and the channel, and in addition to that, you are removing the epithelium. This should be taken into consideration. In 2014 at ESCRS Cornea Day, we did recommend not to do them both at the same time if the ocular surface is not good enough.

Trattler: This is an interesting topic because in the U.S., we do not have topography-guided PRK that can effectively reshape keratoconus, so I have to send my patients to Canada or other countries. I have helped 10 patients with keratoconus make arrangements to travel to Canada for topo-guided PRK, and surprisingly, two of the 10 patients experienced corneal ulcers during their re-epithelization stage. Dr. Cochener, I think you are right, there is probably a predisposition. They may have ocular surface disease or rosacea that increased their risk for infection.

Another point to mention is that patients want to know after cross-linking or Intacs (Addition Technology), “Did my corneal shape improve?” And the way we assess it is to evaluate the corneal shape via topography and/or tomography. But if the patient has dry eye, it can be hard to determine if their corneal shape is improving.

Cochener: Even with the rings, it is difficult to interpret the topography. Since using the femto laser, it is a little easier, because before, doing the mechanical cut, we had the tendency to make the channel too superficial, making the ring jut out of the anterior face of the cornea and inducing the interruption of the tear film.

Kiliç: I have no experience with manual.

Cochener: You are too young. We were using this mechanical method from around 1996 to 2000, before the great event of the femtosecond laser.

Omega-3

Trattler: Is anyone using oral omega-3s for the treatment of ocular surface disease?

Kiliç: I have used it, but not in all cases.

Cochener: I think that for omega-3 we do not have enough evidence. The fact is that dry eye is a multifactorial disease, and it is difficult to understand. An oral prescription would take at least 1 month to act, and the key issue, again in our country [France], is that patients must pay for it.

Kiliç: Yes, but patients also buy vitamins.

Loh: I think omega-3s are beneficial. I often recommend the PRN omega-3s that are available in the States. I am not sure if they are available in Europe. But I agree with Dr. Kiliç; it is not my first-line treatment usually. Usually I start with topical eyelid hygiene, topical steroids, topical Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), and even punctal plugs and go from there. If the patient still does not seem to be responding, or if there is meibomian gland disease and inspissation of the glands, then I will recommend omega-3.

Cochener: It works well in your experience?

Loh: It is additional. I do not have any personal proof yet that it works, but the data from a recent study by Donnenfeld and colleagues on the effects of oral re-esterified omega-3 supplements seem convincing.

Cochener: It takes time to see the effect.

Trattler: I believe the specific formulation can make a difference.

Loh: That is why I have been using the PRN. I have learned recently that there are many different formulations of omega-3. The ethyl ester form, which is the more popular, cheaper-to-produce kind you find widely available, is not absorbed as well. It is not as bioavailable and has lots of side effects. The re-esterified triglyceride form is a more bioavailable form. So that may play a role in that we have so many patients on the ethyl ester form and they are not receiving good results so they give it up. It is a little hard to convince them to pay more to get the special kind, but I think it would help. Again, I do not have a lot of personal experience with it, but I have begun to recommend it. Some patients also love the idea of taking vitamins. They feel like it is something extra they can do to help their condition, and it also has other beneficial systemic effects.

Cochener: The American people are so familiar with taking vitamins, which is not the case in many countries in Europe. Even in macular degeneration, it is difficult to convince them.

Loh: Really? It is the opposite in the United States.

Cochener: No, people assume, “If I have good food, well-balanced food, a good diet, it is good enough.” In a certain way, they may be right.

Riha: Don’t forget the red wine.

Dry eye in retina

Trattler: I do not know everyone’s practice, but I do know Dr. Loh’s practice has some retina people who are seeing dry eye in their retina patients as well. Can you comment on that?

Loh: I practice with a physician who treats medical retina who does a lot of injections for macular degeneration. Every month patients are receiving injections. What I have noticed is that the preparations for performing the injections include a lid speculum, holding the eye open for several minutes, dousing the eye with Betadine, and doing the injection. Then he will send the patients to me for cataract surgery after they have been receiving months of treatment, so I have to be aware of the fact that they likely have dry eye.

Cochener: There are many, many ways of getting a dry eye, according to the well-known vicious circle in which neurogenic, mechanical and inflammation processes can be combined.

Loh: As anterior segment surgeons, we are focused on it and aware, but we can help our ophthalmology colleagues also be aware of it because they are eventually sending the patients to us.

Cochener: It is common to have keratitis right after intravitreous injections.

Loh: It is the most common call I get from patients: “My eye hurts; I just had an injection.” And the patient is worried that the pain is from an infection from the injection.

Pterygium, punctal plugs

Trattler: Any comments on pterygium surgery and dry eye?

Cochener: Pterygium is obvious inflammation of the corneal surface that increases with the mechanical irritation process, such as sun and wind. As soon as we detect any progressive pterygium, we start to use steroids or nonsteroidal anti-inflammatory drops. And then when you go to surgery, that is an obvious source of keratitis induced by the surface irregularities. It takes a long time to get rid of that.

Kiliç: Pterygium surgery affects not only the cornea but also the sclera. So this is dangerous.

Trattler: When I perform pterygium surgery, I always place a silicone punctal plug in every patient because I worry about dry eye postoperatively. By raising the tear film, patients can also feel better, and this may reduce ocular surface inflammation. Because the risk of recurrence of pterygium is related to inflammation, aggressively treating dry eye and ocular surface disease postoperatively may play a role in reducing the chance of recurrence.

Cochener: I have a question about the punctal plug. You know, we have so many different modern concepts available, do you choose a permanent plug or a temporary one?

Kiliç: I choose short term usually, which resolves in 3 weeks. But if I want a permanent plug, a silicone plug can be put inside quickly and easily. I do not like the plug to be outside at all; I put it completely inside the channel. So, I choose a silicone and collagen plug for this purpose.

Cochener: There is a silicone model called the Painless Plug (FCI), which is a nice compromise. You can see the plug and assume that the patient will not eliminate it. It is specifically for refractive surgery. (I have no financial interest in the product.)

Loh: I have been using a 3-month absorbable collagen plug from Beaver-Visitec/Odyssey to give the patient a little longer occlusion than a few weeks. Some of my patients get nervous when I discuss the more permanent silicone, so I tell them, “Let’s just try this one.” They can get used to it, and then they know it dissolves and that there is no risk of pain.

Trattler: My challenge is, if you put the resorbable in and the patient comes back a week later, is it still present or not? You never know. So I actually do not use temporary plugs. I only use silicone plugs because I want to know the plug is still present.

Kiliç: But if you perform a permanent plug, there is a possibility for too much lacrimation.

Trattler: There are pluses and minuses to everything. Dr. Kiliç, you mentioned that you do not like plugs that are elevated above the surface, and this may be because there is a risk that patients may experience foreign body sensation from the plug. One thing that seems to help is that when I place a plug, I always initiate a topical steroid for a week, and that will typically avoid redness and irritation of the conjunctiva in the corner where the plug is located. So the success rate with plugs is high when using a short course of topical steroids, in my experience.

Kiliç: One of our patients with this plug had infection. Maybe the infection was not related to the plug, but I needed to remove any foreign body from the eye, and so it was not a good experience for me.

Corneal transplant

Trattler: I have a final topic, which is corneal transplant surgery and ocular surface disease. When you perform a full corneal transplant, do your patients experience more dry eye with the full transplant vs. DSEK, and do you handle those patients differently?

Riha: I see some patients but not enough to draw conclusions.

Cochener: For PK, it is not the procedure itself that is so difficult, but as soon as you have any kind of irregularities, the keratitis is much more frequent than any rejection.

For DMEK or DSEK, I think that most of the keratitis is related to the stromal edema. It is more a consequence of what is occurring underneath the epithelium, so we are interested in adding to lubricant some new therapies focused on corneal edema and consider the ocular surface as a consequence of the endothelial dysfunction.

I do not see much difference between a deep lamellar anterior graft and a penetrative one in terms of ocular surface disease. We are just avoiding potentially the rejection of the graft. Nothing else is different. You have the same issue with the suture and with induced astigmatism, so there is not so much of a difference considering the visual and ocular surface recovery.

And the final category is a superficial anterior graft, which is like LASIK. You keep the suture for 1 or 2 months under the same regimen as for any kind of keratoplasty, but the flap is 150 µm to 180 µm, so it is the same story as for LASIK, in which optical interface and ocular surface play a crucial role.

Trattler: You all have some fantastic points. Thank you for sharing.

• For more information:
• Béatrice Cochener, MD, PhD, can be reached at Department of Ophthalmology, University of Brest, CHU Morvan - 5, Av. Foch, 29609 Brest Cedex, France; email: beatrice.cochener-lamard@chu-brest.fr.
• Aylin Kiliç, MD, can be reached at Dunyagoz Eye Hospital, Istanbul, Turkey; email: aylinkilicdr@gmail.com.
• Jennifer Loh, MD, can be reached at South Florida Vision Associates, 2900 Cypress Creek Road, Suite 1, Fort Lauderdale, FL 33309; email: jenniferlohmd@gmail.com.
• Wolfgang Riha, MD, can be reached at Sehkraft Augenzentrum Maus, Wolfsstraße 16, 50667 Köln, Germany; email: riha@sehkraft.de.
• William B. Trattler, MD, can be reached at Baptist Medical Arts Building, 8940 N. Kendall Drive, Suite 400-E, Miami, FL 33176; email: wtrattler@gmail.com.

Disclosures: Cochener reports she is a consultant to Abbott Medical Optics, Alcon, Bausch + Lomb, ReVision Optics, Santen and Thea. Kiliç reports no relevant financial disclosures. Loh reports she is a paid consultant to Allergan, Abbott Medical Optics, Bausch + Lomb and TearScience. Riha reports he is a consultant to AcuFocus. Trattler reports he is a consultant and/or speaker for Abbott Medical Optics, Alcon, Allergan, Oculus and Shire.

One on One with A. John Kanellopoulos, part 2

William B. Trattler, MD: Can you talk about managing the ocular surface with regard to your refractive surgery patients?

 

A. John Kanellopoulos, MD: Of course. Any cornea or any eye procedure is an ocular surface “hurricane.” It is amazing to me not how much ocular surface disturbance we get, but how most people can function with all these tremendous changes in the surface, which shows you how nature has compensatory mechanisms.

But I think that a lot of procedures that we currently use are No. 1 suspects in disturbing this balance. Hopefully, and thankfully, most of these symptoms are transient and affect the short term. LASIK is definitely one of them, in my opinion. We are hoping that SMILE will be far better regarding dry eye symptoms. Our initial experience with SMILE is indeed that: With regard to disturbing the ocular surface in the first 3 months, it appears far better than LASIK. We are currently investigating whether this difference is neurotrophic or inflammatory in origin. The difference is small the first 3 months but becomes significant after that.

Trattler: That is interesting. Here, again, it is helpful to set up expectations for patients and clinicians.

Kanellopoulos: And it does make sense that long-term SMILE would be better in dry eye vs. LASIK because of the less amount of nerve plexus injury. In my opinion, the initial year following LASIK or SMILE is significant not only for dry eye, but also in how this disturbance of the ocular surface will affect the quality of vision of these patients.

Combining cross-linking and laser is a double procedure, and they are both disturbing procedures for the surface. These unusual cases treated with combined PTK and cross-linking may be seen transiently as a serious ocular surface condition for 3 months. These are patients whom you cannot send away and see 3 months later. These are patients who, in my opinion, require a certain level of external disease management expertise to treat. Anywhere from the persistent epithelial defect, dry eye, hyaline keratopathy Salzmann’s nodule-type patients, superficial scarring — all of these are significant potential contributors to severe morbidity. We have reported that even so, these cases do very well long term. We nevertheless extensively consent our patients in that regard that they will have to suffer, if I may, for 3 months through a period when their vision will have a lot of fluctuation, and we may have to use some more involved measures besides tears, blepharitis management and topical cyclosporine. We may engage severe symptoms with platelet-rich plasma as an adjunct. And we are currently working with a novel protein, lacritin, which may hold significant promise in tear production and tear homeostasis.

Trattler: You do all types of corneal surgery. Grafts also?

Kanellopoulos: Transplants are probably the most invasive surgery for the ocular surface. You are not only doing a major incisional surgery, but you are also transplanting allograft tissue. So there is a lot of healing and inflammation there. The only fortunate thing is that most transplants are heavily treated with corticosteroids and other immunomodulating agents so that does help a lot with these patients.

I have treated end-spectrum extreme disease patients, and that is the most challenging part, having to bring allograft limbal stem cells or mucous autografts from the oral cavity or even sometimes employ keratoprosthesis. There is a wide spectrum of external disease. But I think that through the everyday routine we have to identify early patients who may in the future develop cicatricial changes from either autoimmune disease or physician-induced disease. We are almost instinctively prescribing preserved medications and preserved drops, and the impact of these is tremendous, especially when they are over-the-counter drops and drugs that patients may use for a lifetime without even seeing you again. That is a huge intervention in their lifetime, and it is important to convey that message to patients, that between preserved and unpreserved, there is a significant difference. We have found OCT epithelial maps as a brilliant adjunct metric in diagnosing and treating almost all aspects of external disease patients.

A. John Kanellopoulos, MD, director of the LaserVision Clinical and Research Institute in Athens, Greece, and Clinical Professor of Ophthalmology at NYU School of Medicine, can be reached at 115 E. 61st St., New York, NY 10065; email: ajk@brilliantvision.com. Disclosure: Kanellopoulos reports financial disclosures for Alcon, Allergan, Avedro, Optovue and Zeiss.

William B. Trattler, MD, can be reached at Baptist Medical Arts Building, 8940 N. Kendall Drive, Suite 400-E, Miami, FL 33176; email: wtrattler@gmail.com. Disclosure: Trattler reports no relevant financial disclosures.