BLOG: Consider the ocular surface in all surgical patients
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Key takeaways:
- The health of the ocular surface is important in patients with glaucoma or cataract.
- Optimization of the ocular surface will lead to improved outcomes after surgery.
I think of my clinic as a triad, encompassing three conditions: dry eye disease, glaucoma and cataract.
Within this triad, dry eye disease (DED) has a direct effect on both the subjective and objective outcomes of glaucoma and cataract surgery. We know DED is exceedingly common, with global epidemiological studies putting the prevalence anywhere from 5% to 50%. Based on U.S. data from the National Health and Wellness Survey, approximately 16.4 million people have been diagnosed with the condition with millions more going undiagnosed. These numbers increase with age, and therefore a large number of our glaucoma and cataract patients present with the condition — whether or not they have overt symptoms.
Garbage in, garbage out
We must pay close attention to the ocular surface in patients presenting for cataract surgery for multiple reasons. Subjectively, the incisional nature of cataract surgery means that DED will almost always worsen postoperatively. I tell patients, “You may think you do not have dry eye, but it is important we optimize the health of the ocular surface before your procedure to minimize any discomfort after surgery.” The second reason that the health of the ocular surface is crucial in these patients is that it allows us to obtain the highest-quality, most accurate measurements possible for planning surgery. This in turn ensures the best possible outcomes. In short: The healthier the ocular surface, the better the uncorrected visual acuity.
In the setting of glaucoma surgery, the ocular surface discussion takes on even greater importance as, on many occasions, I will be combining a glaucoma procedure with cataract surgery. Although recently gaining more attention, the importance of the ocular surface to glaucoma surgical outcomes has been somewhat overlooked. Just like an unhealthy cornea can affect the accuracy of biometry and keratometry necessary for cataract surgery, it can also have an impact on visual field testing and retinal nerve fiber layer measurements on OCT. A poor ocular surface can throw off these readings and make patients’ glaucomatous damage be inaccurate.
A healthy canvas on which to work
In thinking about glaucoma surgery, we first establish the patient’s stage. That staging process is based on the clinical exam and on a variety of tests. If the testing is unreliable, we run the risk of making a suboptimal surgical plan for the patient. Therefore, it is critical to treat the ocular surface in this patient population.
Glaucoma medications along with their preservatives are known to have adverse cumulative effects on the ocular surface, such as decreasing goblet cells and increasing inflammatory markers in the tear film. Beyond that, there can be changes to the meibomian glands, exacerbating dysfunction. Starting with an inflamed ocular surface — particularly if a conjunctival glaucoma procedure is being considered — will not give patients the best chances for success.
I attribute our improved outcomes in part to aggressively treating dry eye. I believe a healthier conjunctiva helps create a prettier bleb with less episcleral fibrosis and Tenon’s thickening. The status of the ocular surface may not seem paramount in the presence of a blinding condition such as glaucoma, but I would argue the optimization of the ocular surface should be done in parallel as the improvement in pressure.
References:
• Farrand KF, et al. Am J Ophthalmol. 2017;doi:10.1016/j.ajo.2017.06.033.
• Nijm LM, et al. Asia Pac J Ophthalmol (Phila). 2020;doi:10.1097/APO.0000000000000327.
• Stapleton F, et al. Ocul Surf. 2017;doi:10.1016/j.jtos.2017.05.003.
• Trattler WB, et al. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S120159.
• Zhou X, et al. Ophthalmol Ther. 2022;doi:10.1007/s40123-022-00557-0.
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