EyeWorld Asia-Pacific December 2016 Issue

December 2016 EWAP NEWS & OPINION 63 loss of 6.9%. Three percent of patients lost two lines or more of best corrected visual acuity, and there were eight posterior capsule ruptures, five of which were within his first 2 months. In the end, Dr. Vryghem said it’s not a device we really need, but if we want cataract surgery with less energy distribution, then nanolaser could be an affordable option over phacoemulsification. Anja Liekfeld, MD , Berlin, Germany, presented results from a similar study of 100 consecutive patients, also having a few instances of posterior capsule rupture (two within her first 20 patients), but no lines of vision loss were observed. Based on it being an easily transferrable procedure with no significant endothelial cell damage and lower energy delivered to the eye, it is “at least as good and safe as the gold standard,” she said. Finally, Gangolf Sauder, MD, Mannheim, Germany, presented the results of a randomized prospective study comparing nanolaser cataract surgery vs. phacoemulsification in 76 patients. Though no statistically significant endothelial cell loss was observed between the two groups at 3 months postop, the nanolaser group had 2.7% endothelial cell loss 1 year postop compared to 7% in the phaco group. Dr. Sauder also reported significantly less energy delivered to the eye in the nanolaser group. Dry eye in refractive and cataract surgery Beatrice Cochener, MD , Brest, France, chairperson of an ESCRS/EuCornea symposium, called ocular surface disease a “hot topic” in ophthalmology. The effect of preexisting dry eye on outcomes was discussed, as well as postop dry eye, diagnosis, treatment, and new technologies. It is well known that dry eye is one of the most common postLASIK complaints, Renato Ambrósio Jr., MD , Rio de Janeiro, Brazil, said. “LASIK, because of the flap cut and because of the ablation, it creates a problem of the nerves [and] we don’t have any evidence that LASIK was the real cause of the problem … or if the cases merely represent individuals who suffered progression of an underlying subclinical dry eye condition,” Dr. Ambrósio said. With that in mind, the issue of LASIK-related dry eye starts preoperatively. Just talking to patients and understanding why they want refractive surgery could reveal some underlying issues that indicate dry eye that should be better understood or addressed prior to surgery. When a patient presents post- LASIK with dry eye complaints, listening to symptoms, asking about any systemic diseases or medications, and conducting ocular surface imaging, advanced testing for osmolarity, Schirmer’s testing, and a thorough ocular surface exam can help determine the next mode of action for management. As with dry eye treatment, optimizing the ocular surface includes nutritional supplementation, artificial tears and ointments, lid hygiene, topical steroids, short-term antibiotics, growth factors, and more. Surgical strategies to reduce LASIK-related dry eye specifically could include making a thinner flap with a larger hinge, Dr. Ambrósio said. Performing femtosecond laser LASIK over using a microkeratome also results in less dry eye. Choosing another refractive procedure with less incidence of postop dry eye, such as small incision lenticule extraction (SMILE) or phakic IOLs, is an option as well, especially for patients with more risk for dry eye. Addressing dry eye preoperatively is also important for positive outcomes in refractive cataract surgery because the effect of dry eye on the ocular surface can throw off measurements and lead to inaccurate IOL calculations. The mechanism for dry eye after cataract surgery includes corneal sensitivity impairment, inflammation and goblet cell loss, and meibomian gland dysfunction. “All of these mechanisms are tightly interlaced,” Rita Mencucci, MD , Florence, Italy, said. There is also an uncertain effect of incision location on dry eye markers relative to location of corneal nerves, and incision shape seems to also have an effect on dry eye, Dr. Mencucci said. In addition to these factors, Dr. Mencucci said diabetic patients are at higher risk for postop dry eye after cataract surgery, even if they didn’t present symptoms preoperatively. However, complete resolution is usually seen within 3 months. The presence of dry eye, untreated preoperatively, could lead to an off-target refractive outcome. Dry eye postoperatively could make patients unhappy with their procedure despite an otherwise perfect surgery. “Hopefully, the innovations in diagnostic and surgical techniques will help in reducing the recovery time and severity of dry eye after IOL procedures,” Dr. Mencucci said. Penny Asbell, MD , New York, discussed the various factors that could lead to dry eye but went into specific detail about neuropathic pain and how it could relate to dry eye. “What about the patient with chronic pain even years after LASIK? … This unhappy patient could have and maybe it even started before surgery—ocular surface disease or dry eye disease. But the other kind of patient … is a patient who we are not certain of the etiology, and this falls into that category of neuropathic pain,” Dr. Asbell said. Patients with this type of pain, which is not induced by a stimulus, don’t have symptoms to match what is seen at the slit lamp. When provoked with pain, they might have a lower threshold to an otherwise normal stimulus or an enhanced response to a noxious stimulus, Dr. Asbell said. If the pain is due to lesion of nerves, a physician might be able to see the damage if it is in continued on page 63