BLOG: Help your surgeon, patients by optimizing the corneal surface

ByJosh Johnston, OD, FAAO

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Visual outcomes after cataract surgery depend on accurate planning.

Ophthalmologists depend on accurate presurgical measurements to plan the surgery and select the appropriate IOL power for patients. Untreated dry eye disease (DED) throws uncertainty into this process, as it affects biometry and keratometry readings for cataract surgery, as well as refraction in refractive surgery This, in turn, has an impact on surgical outcomes and can lead to a refractive surprise.

Additionally, any refractive or cataract surgery can worsen existing DED, and the procedure itself can induce dry eye.

It is important to screen all patients for ocular surface disease (OSD) prior to surgery. The condition is highly prevalent, as was elucidated by Trattler's Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) multicenter observational study of 136 patients (aged 55 years) undergoing cataract surgery (Trattler et al). Although almost 60% had never complained of foreign body sensation, more than 60% had a tear breakup time of 5 seconds or less, almost 80% of eyes had positive corneal staining, and 50% of the eyes had positive central corneal staining.

Josh Johnston

Patients may or may not be having symptoms, but if I identify DED before surgery, I explain the importance of treatment. I let patients know that we want to get their corneas as pristine as possible, that way when they have surgery, the surgeon can get good measurements, which are important for the high technology implants we use today. Ultimately, we do not want them to be drier after the procedure, and we want the best outcome possible.

Depend on an algorithm

Optometrists should have a systematic process for screening for and diagnosing OSD. Several algorithms have been devised to simplify the process, with one created by American Society of Cataract and Refractive Surgery (ASCRS) specifically for presurgical patients (Starr et al).

Most algorithms start with a questionnaire. ASCRS created the ASCRS-Modified Preoperative OSD Standardized Patient Evaluation of Eye Dryness II questionnaire (SPEED II; with permission from Johnson & Johnson Vision), designed specifically for preoperative refractive surgery patients. The group recommends point-of-care tear testing to assess osmolarity and matrix metalloproteinase-9 to identify inflammation on the ocular surface. For the clinical exam, the group uses the terms “look, lift, pull, push” to describe a quick, focused assessment of the ocular surface.

In presurgical patients, the goal is to quickly restore ocular surface health, so an aggressive approach is indicated. The ASCRS algorithm instructs to start treatment beginning at step 2 or later of the TFOS DEWS II treatment guidelines (Craig et al). Interventions are based on disease subtype and severity.

Treatment options

Eysuvis (Kala Pharmaceuticals) is a recently approved steroid indicated for the short-term treatment of the signs and symptoms of DED, dosed four times a day for 2 weeks. I can couple that with other topical anti-inflammatory therapies, whether that be Cequa (cyclosporine ophthalmic solution 0.09%; Sun Ophthalmics); Restasis (cyclosporine 0.05% ophthalmic emulsion; Allergan); or Xiidra (lifitegrast 5% ophthalmic solution; Novartis). Typically, a combination of those will start to treat inflammation and rehabilitate the ocular surface. If the disease is more advanced, I may consider an amniotic membrane.

When a patient has meibomian gland dysfunction, an in-office heat-based procedure like LipiFlow (Johnson & Johnson Vision), Systane iLux (Alcon), TearCare (Sight Sciences) or intense pulsed light can rapidly improve meibomian gland health. Our practice has treated more than 400 patients with LipiFlow and has had excellent results increasing the quantity and quality of meibum decreasing the severity of MGD.

It is imperative that optometrists take an active role in preparing patients for surgery, and that requires screening for OSD and treating it before the procedure. Patients will thank you for ensuring they have a successful surgical experience.

References:

• Ale Magar JB. Nepal J Ophthalmol. 2013;doi:10.3126/nepjoph.v5i1.7815.
• Craig JP, et al. Ocul Surf. 2017;doi:10.1016/j.jtos.2017.08.003.
• Epitropoulos AT, et al. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2015.01.016.
• Goldberg DF. Int Ophthalmol Clin. 2011;doi:10.1097/IIO.0b013e31820f1f76.
• Kim P, et al. Int Ophthalmol Clin. 2012;doi:10.1097/IIO.0b013e31824b4504.
• Li XM, et al. Cornea. 2007;doi:10.1097/ICO.0b013e31812f67ca.
• Manning CA, Kloess PM. J Cataract Refract Surg. 1997;doi:10.1016/s0886-3350(97)80318-5.
• Oh T, et al. Jpn J Ophthalmol. 2012;doi:10.1007/s10384-012-0117-8.
• 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.
• Yu Y. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2015.06.036.

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