Perioperative dry eye treatment necessary for best postop outcomes
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One of the many significant benefits of my membership in the CEDARS/ASPENS society is our ability to reach out for “curbside consults.”
This morning while I was getting ready for clinic hours, I scrolled through the latest, a request from Tim Page of Michigan for advice on a case referred to him involving an unhappy multifocal IOL patient. I am pretty sure that all of the cataract surgeons in our group implant some or all of the options in this class; preop decision-making (eg, what type of IOL to use) and postop challenges are fertile fields for our discussions.
Tim’s colleague noted that the central ring of the multifocal IOL was bisected by the pupil edge on the nasal side, implying that the IOL was slightly decentered temporally. However, when the pupil was dilated, the IOL appeared to be perfectly centered on both the pupil and the line of sight. Did the patient need a laser pupilloplasty? Should the surgeon put in a capsular tension ring? Perhaps an IOL exchange was the answer, removing the multifocal IOL in favor of a monofocal IOL. All kinds of measurements followed — we all love to geek out on stuff like angle kappa, chord mu and higher-order aberrations — but at least one part of the answer was obvious when a picture of the topography came up: The patient had a significant dry eye.
All of the dry eye disease (DED) experts in our group had been waiting for this shoe to drop. The patient had not been treated for DED preoperatively and was not on any medications that would treat it at this point. At the time all of the shared data had been obtained, the patient was far enough out from surgery that they were no longer on any typical perioperative drops, so they were not even taking topical steroids. While the jury will remain out on the more exotic options noted above, a majority of the respondents on this email thread agreed that the first order of business was to aggressively treat the dryness before making any decisions about whether or not additional surgery was warranted.
Whether or not you are planning on using a presbyopia-correcting IOL, be it a multifocal or an extended depth of focus (EDOF) IOL, dryness can derail the refractive cataract train even after a technically perfect surgery. Laser refractive surgery of all kinds runs a similar risk. It is important to remember that any anterior segment surgery that involves cutting the cornea, conjunctiva or both is a pro-inflammatory experience that will lead to increased dryness on all ocular surfaces. Eric Donnenfeld and Bill Trattler were among the first surgeons to explore this, and both showed that cataract and laser refractive procedures caused a worsening of all dry eye measurables. In a typically pithy summation, Dr. Donnenfeld describes the surgeon’s conundrum: If you diagnose DED preop, it is the patient’s problem; if you diagnose it postop, it is yours.
This is not a problem that is unique to advanced IOL implantation, although the higher expectations shared by both surgeons and patients does make it more challenging. Dryness not only affects postop vision and visual quality, but it also can lead to significant postop refractive surprises when it affects our basic preop measurements. Dr. Trattler has shared a now-famous case in which the original measurements showed 2 D of cylinder. Remeasuring after a couple of weeks of treatment with artificial tears showed a perfectly spherical cornea and refraction. Alice Epitropoulos takes the best video prize by showing real-time improvement in preop measurements after stimulating a patient’s tear production with TrueTear (Allergan), eliminating pseudo-cylinder in the process.
Our approach to this problem at SkyVision is to aggressively look for even the smallest sign or symptom of DED during every preop examination for both cataract and refractive surgeries. The ASCRS algorithm is particularly helpful if you do not typically concentrate on diagnosing and treating DED. Led by Chris Starr, the American Society of Cataract and Refractive Surgery research group encourages surgeons to use a “look, lift, push, pull” exam at the slit lamp. If DED is present, one then seeks to determine if it is or will be visually significant and will have an effect on preop measurements or postop outcomes. We are much more aggressive, especially if the plan is insertion of a multifocal or EDOF IOL. A single staining spot, elevated tear osmolarity or a wonky topography, and we are going to treat.
As a quick aside, among all of the DED algorithms that are out there at the moment, the ASCRS offering is the most useful for the majority of ophthalmologists. Whether you are contemplating mitigating the effect of DED on preop measurements, postop visual quality or the all-too-common transient flare-ups of DED symptoms, seeking the fastest, most direct solution is the ticket in the majority of cases. Almost every patient will benefit from aggressive lubrication with high-quality artificial tears. Do yourself (and your patient) a favor and strongly encourage them to use preservative-free varieties. If you think chronic treatment is going to be necessary, by all means start preop. There is nothing to be gained by waiting until after the surgery to write a prescription for Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) (or “Fauxstasis”), Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical) or Xiidra (lifitegrast ophthalmic solution 5%, Novartis).
To get the fastest results you only need to remember two words: Ster. Roids.
Remember White’s rule of DED treatment: You cannot make an asymptomatic patient feel better. Both you and your patient would like to get on with the surgical experience as quickly as possible. Using this as the justification for treating what the patient perceives as asymptomatic DED will usually win them over. The fastest route to fixing the deleterious effects of DED on the ocular surface is to prescribe topical steroids.
You can choose any steroid among the myriad of choices we all have, but my bias is to choose one that gives you the option of leaving your patient on the medication through the perioperative period. Do you have a patient with a very dry eye, one with lots of staining and a tear breakup time measured in milliseconds? We like fluorometholone, specifically fluorometholone acetate as found in Flarex (Eyevance Pharmaceuticals). In its phase 3 trial, it was subjected to a head-to-head comparison with Pred Forte (prednisolone acetate ophthalmic solution 1%, Allergan) (as if we will ever see that again!) and was found to be equally potent with a fraction of the risk.
In the majority of cases in which we need rapid rehabilitation of the ocular surface with the possibility of ongoing treatment, we are heading to the loteprednol shelf at the pharmacy. The best tested of these, and the only one with an on-label indication for DED, is Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals). Only two subjects in the FDA extended safety trial had an IOP rise of 5 mm Hg or greater. Having said that, there are several other good branded options such as the Lotemax franchise (loteprednol etabonate, Bausch + Lomb), and in some markets, there are reasonable generics as well. Four times daily for 2 weeks and then remeasure for your IOL calculations, followed by twice daily, if necessary, through the perioperative period.
Find every patient with DED preop. Go all Tom Cruise/Top Gun “need for speed” and treat so that you stay as close to your regular surgical routines as possible. And if you think patients will need chronic treatment, start your immunomodulator preop. Keep postop DED from becoming your problem.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
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