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Treat blepharitis preoperatively for optimal cataract surgery results
Patients may confuse ocular surface conditions with their cataract symptoms.
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Untreated blepharitis can cause an abnormal tear film, resulting in evaporative dry eye and possibly an increased risk of infection after cataract surgery. Aggressive treatment to improve the signs and symptoms of blepharitis before surgery can prevent postoperative complications and result in a better outcome, according to sources.
“Patients with blepharitis have a higher concentration of bacteria in and around their eyes, which may be a source of infection following surgery,” William B. Trattler, MD, told Primary Care Optometry News. “Also, we want to ensure accurate measurements so that we can we can provide our patients with the optimal intraocular lens selections. Patients with blepharitis have evaporative dry eye, which can result in inaccurate topography and keratometry readings. This can potentially throw off our IOL power selection. Additionally, for patients with significant astigmatism, inaccurate keratometry/topography can result in reduced accuracy with toric IOL axis alignment or limbal relaxing incisions.”
A poster presented at the annual American Society for Cataract and Refractive Surgery Symposium on Cataract, IOL and Refractive Surgery earlier this year showed that 60% of patients scheduled for cataract surgery have blepharitis. Considering the prevalence in this patient population, Katherine Mastrota, OD, suggests a careful preoperative evaluation.
“In any surgery, most ocular infection is from the skin’s surface,” Dr. Mastrota said in an interview. “When you have high bacterial counts on the lids and lashes, the bacteria can invade the small wound. You want to prepare the patient for a successful surgery by having an optimum ocular surface and being sure the area around the eye is clean.”
Preoperative evaluation
Tracy S. Swartz, OD, MS, recommends expressing the meibomian glands during the clinical evaluation.
“In a normal patient, without too much pressure, an oily substance will come out of the gland,” she said in an interview. “But if you press on someone’s eyelid and nothing comes out, that patient has posterior blepharitis.”
Blepharitis treatment
For patients with mild blepharitis, David R. Hardten, MD, typically starts with lid hygiene and instructs patients to use warm compresses, lid scrubs and over-the-counter shampoo to cleanse the eyelids. For more severe cases, topical Azasite (azithromycin, Inspire) and oral antibiotics such as Oracea (doxycycline, Galderma) might also be helpful.
“In some cases, Restasis (cyclosporine ophthalmic emulsion, Allergan) seems to work relatively well,” Dr. Hardten told PCON. “Antibiotics and steroids are also helpful, but we worry about glaucoma from chronic steroids in the older population and glaucoma or cataract in the younger population. Oral medications such as doxycycline are oftentimes quite effective.
“A combination of some of these therapies works well,” he continued. “Because there are a variety of treatments, we basically try to tailor the treatment so it doesn’t have many side effects or high toxicity but is aggressive enough to have a good outcome.”
According to Dr. Swartz, Azasite should be used preoperatively to treat blepharitis and continued after surgery to get the best result.
“I like Azasite because it changes the meibum and improves the quality of the tear film so patients’ vision will get better and the ocular surface will improve,” Dr. Swartz said.
She begins concurrent treatment with Azasite and Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb) for patients with significant blepharitis to reduce inflammation and make the eye more comfortable approximately 3 to 4 weeks before surgery. This preoperative treatment prevents the patient from having postoperative complications, she said.
“Patients with blepharitis who undergo cataract surgery are more likely to have complications after surgery that will make them miserable,” Dr. Swartz said. “That’s particularly true with a premium IOL patient; you don’t want them to have any problems after surgery. By prepping the eye prior to surgery, you’re preventing them from having an exacerbation after surgery.”
Differentiating ocular surface issues
Dr. Hardten said that some patients might confuse their ocular surface conditions with their cataract symptoms. To temper patient expectations, it is crucial to educate patients about which symptoms are a result of their cataract and which are a result of dry eye or blepharitis.
“If you take a patient who thinks they only have a problem with cataracts and after surgery they’re still left with uncomfortable and irritated eyes or fluctuating vision, they’re going to be unhappy because they might have been blaming those symptoms on their cataract,” he said. “It’s important to figure out what’s going on with the blepharitis and then address that beforehand so they can separate those issues in their mind.”
Patients who have “new” blepharitis or dry eye after cataract surgery may be blepharitis or dry eye patients in whom their doctor did not identify these issues before the surgery, Dr. Hardten said.
“The biggest problem is a tear film that is not as stable as it could be before surgery,” he said. “Postoperative dry eye does not start because of surgery; the patient has an underlying problem that was not diagnosed or managed preoperatively that tends to get worse after surgery. Doctors know if they’re being aggressive enough in their treatment if IOL patients are happy with the quality of their vision.” – by Stephanie Vasta
References:
- Groden LR, Murphy B, Rodnite J, Genvert GI. Lid flora in blepharitis. Cornea. 1991;10(1):50-53.
- Luchs J, Buznego C, Trattler W. Prevalence of blepharitis in patients scheduled for routine cataract surgery. Poster presented at: ASCRS Symposium on Cataract, IOL and Refractive Surgery; April 11, 2010; Boston, MA.
- David R. Hardten, MD, can be reached at Minnesota Eye Consultants, 710 E. 24th St., Suite 100, Minneapolis, MN 55404; (612) 813-3600; fax: (612) 813-3658; drhardten@mneye.com. Dr. Hardten is a consultant to Inspire and Allergan.
- Katherine Mastrota, OD, MS, is center director at Omni Eye Surgery, 36 East 36th Street, New York, NY 10016. She can be reached at (212) 353-0030; fax: (212) 353-0083; KatherineMastrota@msn.com. Dr. Mastrota is a consultant to Allergan, Bausch + Lomb and Inspire.
- Tracy S. Swartz, OD, MS, can be reached at Vision America, 1150 Eagletree Lane, Huntsville, AL 35801; (256) 533-8801; tracysswartz@hotmail.com.
- William B. Trattler, MD, can be reached at 8940 N. Kendall Drive, #400, Miami, FL 33176; (305) 598-2020; fax: (305) 274-0426; wtrattler@gmail.com. Dr. Trattler is a consultant to Allergan and Inspire.
