What is your approach to identifying and managing ocular surface disease before ocular surgery?
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Treatment first is ‘critical’
Treating dry eye before cataract surgery or any refractive surgery is critically important. Typically in my practice we perform topographies and slit lamp examinations, including using fluorescein staining to screen for dry eye that could affect surgical outcomes.
We often distribute a dry eye questionnaire in the waiting room, but not always. These can be helpful, but what is more important is doing the exam and looking at their tests. I also look carefully at keratometry and biometry, and if there are any inconsistencies, I take time to discuss with the patient about their dry eye and possible treatments. One of the barriers when treating dry eye in a person who is coming in for a cataract consult is that it takes time. It may cause a delay in surgery. Patients usually come in excited about having cataract surgery and want to proceed as soon as possible, but first they need to understand their options and be on board with the treatment.
Once I have identified dry eye, the next step is to identify what type of dry eye they have and where the problem is coming from. I look closely at the eyelid and the eyelashes to determine if there is any meibomian gland disease or blepharitis that could be causing an evaporative disease. I look at the ocular surface and ask the patient about medications and systemic comorbidity. Regarding the treatment, oftentimes I will start with lid cleansers to treat blepharitis. I like hypochlorous acid products in order to clean the lids and lashes. Also, I will recommend a BlephEx microexfoliation procedure. As well, I will turn to topical steroid drops because they tend to work well and quickly when we are trying to get patients tuned up for surgery. We also recommend artificial tears and can place punctal plugs as well. I also use LipiFlow (Johnson & Johnson Vision) and TearCare (Sight Sciences) to help with evaporative dry eye.
Jennifer M. Loh, MD, is an OSN Technology Board Member. Disclosure: Loh reports she has relevant financial interests with Allergan, Johnson & Johnson, Kala, Novartis, Sight Sciences and Sun.
Dry eye is common
When patients undergo a cataract surgery consultation and report reduced vision, they often attribute 100% of their vision problems to their cataract. Those patients are surprisingly often wrong.
Dry eye is common, so when we evaluate a patient for cataract surgery, we have to identify and treat. In many cases, we have to bring the patient back for repeat testing following treatment of their dry eye. Clinicians should be aware that if they perform cataract surgery without fine-tuning dry eye, their patients may be disappointed with their visual outcome. This is because dry eye can impact their vision postop. With this in mind, I evaluate all cataract patients for dry eye. I typically evaluate the volume of tears in the tear lake, perform corneal staining with fluorescein, measure tear breakup time and obtain topography.
For treatment, I first decide whether the patient has evaporative dry eye with blepharitis, aqueous deficient dry eye or a combination.
For evaporative dry eye, I start the patient on Avenova (0.1% hypochlorous acid, NovaBay) and topical steroids twice a day. In about 3% to 5% of patients, I will recommend a procedure first line, such as BlephEx microexfoliation, TearCare (Sight Sciences) or LipiFlow (Johnson & Johnson Vision) to further help the blepharitis.
For aqueous deficient dry eye, I typically start with a topical steroid twice daily for 2 to 3 weeks. I may place punctal plugs and also decide whether to use one of the FDA-approved dry eye therapies, such as Xiidra (lifitegrast ophthalmic solution 5%, Novartis), Cequa (cyclosporine ophthalmic solution 0.09%, Sun Ophthalmics) or Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). I start these medications before surgery and continue after surgery as part of a long-term strategy for dry eye therapy.
William B. Trattler, MD, is OSN Technology Section Editor. Disclosure: Trattler reports he is a consultant and/or speaker for Alcon, Allergan, Bausch + Lomb, BlephEx, Eyevance, Johnson & Johnson, Kala, Novartis, Oculus, Sight Sciences and Sun.
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