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Scrutinize use of perioperative medications to help eliminate dry eye after surgery
Dry eye has always been a big nuisance for surgeons. Most of the time we are dealing with fast, straightforward decisions and with procedures that lead to an immediate result, usually positive. Complications may eventually develop, but most of them are acute and short term. Dry eye is just the opposite of this. It is a disease that may require long-term treatment, may respond poorly to medications, takes up a lot of our time and, most importantly, can make the patient extremely dissatisfied with even the most successful surgery.
The problem is that dry eye is multifactorial and can happen frequently and unexpectedly. Many times borderline ocular surfaces in middle-aged or elderly people, especially women, are decompensated after surgery due to the abuse of topical medications (anesthetics, mydriatics and antiseptics), the surgical action and the postoperative treatment. So, there is a general basis for dry eye development, which, associated with factors of local toxicity, creates a problem that can decompensate the ocular surface for a long time. These patients come to our office complaining about symptoms, in some cases associated with loss of best corrected vision for months. This happens especially after cataract surgery and refractive surgery, but also glaucoma surgery and most intraocular procedures, including vitreoretinal procedures.
So, what to do in these surgically induced or decompensated so-called “dry eye” syndromes? First of all, go to the etiology. It is essential to pay attention to the preoperative diagnosis of borderline cases and to prepare them with adequate topical medications, avoiding the toxicity of perioperative topical drops. At the time of surgery, I strongly believe that the less topical medication used, the better. Topical anesthetics are highly toxic because of both the toxicity of the specific drops and the preservatives. Even preservative-free medications might be toxic. Repeated administration leads to adverse cumulative effects. Mydriatics, topical nonsteroidals and other medications create a perfect environment for toxicity even in normal patients. It is essential to avoid this perioperative toxicity.
In the postoperative period, the use of topical medications is another problem. The drops are necessary, but most of the time the modern evolution of surgery makes the use of medications up to 1 month unnecessary. I am a strong advocate of limiting the use of topical medication in the postoperative period to the minimum time necessary.
There is no evidence of the usefulness of preoperative topical medication such as antibiotics. NSAIDs might prevent the development of myosis during surgery, but intraocular mydriatics used at the moment of surgery can handle this properly. At the time of surgery, most topical medications can be avoided. Only antiseptics might be necessary. Intraoperative use of intraocular preservative-free lidocaine in combination with mydriatic drops is enough to control all the surgical steps, which depend on the surgeon and not on the operating room staff, which is usually very busy and may overuse medications.
Postoperatively, abolishing the use of topical medications should be a goal. The use of short-duration intraoperative steroids and even NSAIDs will soon become a feasible practice, and then patients will not need to use drops. This will avoid the well-known problems of poor compliance, difficulties with self-instillation and contamination of the eye drops.
Adequate preoperative examination, prevention of toxicity and efficacious substitutes of postoperative medication are the main challenges for the ophthalmic surgeon today. The joint efforts of physicians and industry will lead to a better life for our patients.
- References:
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- For more information:
- Jorge L. Alió, MD, PhD, is an OSN Europe Edition Board Member and a professor and the chairman of ophthalmology, Miguel Hernandez University, Alicante, Spain. He can be reached at Vissum Corporation, Avenida de Denia, s/n, 03016 Alicante, Spain; email: jlalio@vissum.com.
Disclosure: Alió reports he is an investigator for Novagali.