EyeWorld Asia-Pacific June 2017 Issue

EWAP CORNEA 45 June 2017 Views from Asia-Pacific Kyung Chul YOON, MD, PhD Professor, Department of Ophthalmology, Chonnam National University Hospital, Gwangju, South Korea 42 Jebong-ro, Dong-gu, Gwangju 61469, South Korea Tel. no. +82-10-9220-0234 Fax no. +82-62-227-1642 kcyoon@jnu.ac.kr I believe that preoperative evaluation and management of dry eye should be performed in all patients undergoing cataract surgery. Preparation and optimization of the ocular surface is important to achieve better postoperative visual and refractive results. This is especially important in patients who are scheduled for multifocal intraocular lens surgery. Identifying dry eye patients Before cataract surgery, I ask all patients dry eye-related symptoms and use symptoms questionnaires such as the Ocular Surface Disease Index, 5-Item Dry Eye Questionnaire and questionnaires associated with computer vision syndrome. However, one should keep mind that many older patients do not complain of typical symptoms before surgery. Conventional diagnostic tests for dry eye including tear film break-up time (BUT), Schirmer’s test, and ocular surface staining may be necessary in those cases. In particular, evaluation of tear film break-up pattern along with evaluation of Meibomian gland dysfunction should be emphasized. Recently, for screening preoperative dry eye, I preferentially use Keratograph 5M (Oculus, Germany) which can give much information on the ocular surface (Placido-disc topography), tear film (non-invasive tear film break-up time and tear meniscus height) and Meibomian gland (meibography). Managing the condition When dry eye is identified preoperatively, I treat patients with vigorous lubrication with preservative-free artificial tears, anti-inflammatory agents (topical cyclosporine), mucin secretagogue (topical diquafosol), and, when necessary, oral antioxidant agents (omega-3 fatty acids). After several weeks of treatment, stability in topographic images as well as improvement of ocular surface signs need to be confirmed before cataract surgery is scheduled. Counseling patients on expectations Proper counseling of patients is necessary regarding postoperative dry eye and avoidance of unrealistic expectations of surgical outcome. Despite treatment, an increase in higher-order aberration and deterioration of functional vision can limit postoperative patient satisfaction. Editors’ note: Dr. Yoon is a consultant for Novartis (Basel, Switzerland) and Santen (Osaka, Japan). LIM Li, MD Senior Consultant, Corneal Service Singapore National Eye Centre 11 Third Hospital Avenue, Singapore 168751 lim.li@snec.com.sg D ry eye and lid margin disease are common conditions in patients presenting for cata-ract surgery. Significant dry eye and lid margin disease can adversely affect cataract surgery outcomes. Studies show that preoperative biometry measurements, in particu-lar keratometry measurements, are affected by dry eyes and this could translate into inaccurate refractive outcomes after cataract surgery. Cataract surgery could also worsen the preexisting dry eye and lid margin disease. Besides dry eyes, other condi-tions such as pterygium and corneal abnormalities may also affect cataract surgery outcomes. Hence, it is important to optimize the ocular surface before cataract surgery in order to improve postoperative outcomes especially when using premium intraocu-lar lenses. When planning for cataract surgery, it is important to perform a careful evaluation of the ocular surface and adnexa to determine if the patient has significant dry eye and lid margin disease. These conditions should be treated prior to biometry measure- ments and cataract surgery. Artificial tears, nutritional supplements, punctal occlusion and topical cyclosporine A could be used for patients with dry eye disease. For mei-bomian gland disease and blepharitis, topical antibiotic ointments, warm compresses, and lid scrubs could be utilized and short courses of topical steroids could be pre-scribed to reduce ocular inflammation. For more severe meibomian gland disease, oral doxycycline treatment may be warranted. Abnormalities such as pterygium encroaching on to the limbus and cornea should be surgically excised with conjunctival grafting prior to biometry measurements in order to achieve accurate keratometry measurements. Corneal abnormalities such as anterior basement membrane dystrophy could induce irregular astigmatism and, as such, mul-tifocal lens implantation should be avoided. Patients with other corneal conditions such as Fuchs’ endothelial dystrophy with central guttata often have symptoms of glare and hence multifocal lens implantation should also be avoided. Lid malpositions should be evaluated and if significant should be surgically corrected before cataract surgery. These malpositions include entropion/ ectropion, floppy lids and lagophthalmos. Just prior to cataract surgery, in order to optimize the ocular surface, it is good practice for patients to be given a prophylactic 3-day course of topical antibiotics and non-steroidal anti-inflammatory medications even if they do not have ocular surface or lid margin issues. Editors’ note: Dr. Lim declared no relevant financial interests. continued on page 46 Significant pterygium should be excised with conjunctival grafting prior to biometry measurements in the preparation of cataract surgery. Source: Lim Li, MD