Take care of ocular surface before — and after — cataract surgery
Click Here to Manage Email Alerts
Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
This month, Alice T. Epitropoulos, MD, FACS, discusses optimization of the ocular surface before cataract surgery. We hope you enjoy the discussion.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
In recent years, we have come to realize how important it is to address the ocular surface in patients who are scheduled for cataract surgery.
Recent studies have documented a high prevalence of dry eye disease (DED) in surgical patients, even when subjective symptoms are not present. The PHACO study showed that 63% of patients had an abnormal tear breakup time, 77% of eyes had some corneal staining, and yet only 13% had symptoms. A study by Gupta and colleagues showed that 63% of patients had an abnormal MMP-9 and almost 40% had positive corneal staining. Looking at point-of-care tests, 85% of patients had at least one abnormal test, and 48% had abnormal values in both the tear osmolarity and MMP-9 tests. The message is that we, as clinicians, need to presume that anyone coming to us for cataract or refractive surgery has dry eye until proven otherwise, especially considering the high number of asymptomatic patients.
Untreated DED can affect our biometry measurements. In a paper we published in the Journal of Cataract & Refractive Surgery, we observed high variability in average keratometry and anterior corneal astigmatism in hyperosmolar patients, with a significant impact on IOL power calculation.
Preoperative evaluation
When patients come to my practice for a refractive or cataract evaluation, they are asked to fill out a dry eye questionnaire. It takes less than a minute in the waiting room, and it helps us to determine if patients have symptoms, grading the frequency and severity of symptoms based on the SPEED score. For patients with a score of 8 or higher, my technicians will proceed with point-of-care testing, including tear osmolarity and MMP-9 and meibography. I also train my technicians to evaluate tear breakup time and corneal fluorescein staining using a fluorescein strip.
If patients are asymptomatic, I have a similar protocol but do not necessarily include the point-of-care testing upfront. I might do it later in a follow-up visit if it it indicated. Screening and evaluation are performed to identify if there is visually significant ocular surface disease that may potentially affect our surgical outcomes.
Treatment
The ASCRS preoperative ocular surface disease algorithm is a useful consensus-based tool for the management of ocular surface disease in surgical patients. It provides a screening method, and in case of significant DED, it recommends taking action with treatment before proceeding with cataract surgery. The TFOS DEWS II guidelines recommend a tiered approach for treating DED. First-line interventions include over-the-counter artificial tears, nutritional supplements, and environmental and lifestyle modifications. Second-line interventions include prescription topical and systemic medications including nasal stimulation, immunomodulators such as lifitegrast or cyclosporine, or even topical steroids. In-office procedures such as punctal occlusion, thermal pulsation treatment with LipiFlow (Johnson & Johnson Vision), iLux (Alcon) or TearCare (Sight Sciences), and microblepharoexfoliation (BlephEx) are all effective treatments to address an unstable or unhealthy tear film. If patients have rosacea, blepharitis or meibomian gland dysfunction, I often recommend topical azithromycin or oral doxycycline in more advanced cases. Third-line treatment may include cryopreserved (Prokera, BioTissue) or dry amniotic membrane therapy and/or autologous serum eye drops in more advanced patients.
Above all, the golden rule is: Never hesitate to delay surgery until the ocular surface is optimized and allows for reliable and predictable measurements.
Supplements and new products
A prospective comparative study published by Park and colleagues showed the efficacy of the re-esterified triglyceride form of omega-3 supplementation in reducing the signs and symptoms of DED after cataract surgery. Statistically significant improvement in staining and OSDI symptom scores and MMP-9 were reported. I am a big advocate of omega-3 as a primary therapy for treating dry eye disease, and the benefits are now backed up by science. Some years ago, we published in Cornea a multicenter prospective study in which 105 subjects were randomly assigned to receive either a re-esterified omega-3 supplement or placebo. The study met both sign and symptom endpoints to a great degree of statistical significance. That included tear osmolarity, tear breakup time, MMP-9 positivity, the reduction in omega-3 index levels and symptom scores. But in order to achieve this statistical significance and maximize the effects, we had to utilize a product that is in the most bioavailable form, the re-esterified triglyceride form, and a little over 2 g in a ratio that has more anti-inflammatory EPA than DHA, which is a 3-to-1 ratio. Not all omega-3 products are the same, and several studies utilizing different dosages and forms have not yielded the same results. If I see signs of DED, I start out by using a good quality omega-3.
There are new products in the pipeline, some just recently approved. One of them is Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb), which helps stabilize the tear film in patients with evaporative DED. Another one is Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus), approved for the treatment of Demodex blepharitis. Addressing blepharitis is important in these presurgical patients to help reduce the risk for endophthalmitis and to optimize the health of the tear film. Furthermore, Aldeyra has a RASP inhibitor that shows promise for treatment of signs and symptoms of DED, and the FDA has accepted its new drug application.
There is now more awareness and a better understanding of DED. We have realized that it is the No. 1 reason why patients are unhappy or dissatisfied with their result after cataract or refractive surgery, and in recent years, studies have highlighted the importance of preoperative identification and management of coexisting ocular surface disease and tear film abnormalities.
As cataract surgeons, we have DED on our radar screen.
- References:
- Epitropoulos AT, et al. Cornea. 2016;doi:10.1097/ICO.0000000000000940.
- Epitropoulos AT, et al. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2015.01.016.
- Gupta PK, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.06.026.
- Hovanesian J, et al. Clin Ophthalmol. 2020;doi:10.2147/OPTH.S264520.
- Matossian C. Clin Ophthalmol. 2020;doi:10.2147/OPTH.S263046.
- Park J, et al. Br J Ophthalmol. 2021;doi:10.1136/bjophthalmol-2020-317164.
- Starr CE, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2019.03.023.
- Trattler WB, et al. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S120159.
- For more information:
- Alice T. Epitropoulos, MD, FACS, of the Cataract and Refractive Center of Ohio, can be reached at eyesmd33@gmail.com.
Collapse
Read more about
Click Here to Manage Email Alerts