EyeWorld Asia-Pacific June 2017 Issue

June 2017 EWAP CORNEA 55 by Vanessa Caceres EyeWorld Contributing Writer Primer for dry eye diagnosis and treatment before dry eye AT A GLANCE • Dry eye is common in patients who require cataract surgery, but it is often underdiagnosed. • Surgeons should use a battery of diagnostic tests to evaluate for dry eye preoperatively. • When dry eye is diagnosed, explain to patients why treatment is so important and how they have a crucial role in improving dry eye. • Treatments for dry eye vary depending on the type that is seen. • Schedule surgery a few weeks out so there is time to reevaluate the patient and look for ocular surface improvement. For better surgical outcomes, don’t miss this all-too-common ocular surface problem D ry eye before cataract surgery is more common than you might think. Although estimates vary, a PHACO study which focused on the prevalence of dry eye in cataract surgery found that almost two-thirds of patients had clinical signs of dry eye. Even so, Edward Holland, MD , director of cornea, Cincinnati Eye Institute, Cincinnati, said he thinks dry eye is “one of the most underrecognized and neglected conditions.” “There are an estimated 55 million people with dry eye, but only 16 million receive a diagnosis,” he continued. “In cataract surgery, the busy comprehensive surgeon is not always looking out for dry eye.” “With cataract surgery, it’s our obligation to consider every patient as possibly having dry eye,” said Vincent P. de Luise, MD , FACS , assistant clinical professor of ophthalmology, Yale University School of Medicine, New Haven, Connecticut, and adjunct clinical professor of ophthalmology, Weill Cornell Medical College, New York. Dry eye left untreated before surgery can worsen postoperatively, potentially leading patients to think the surgery—and the surgeon—did something wrong. By evaluating and treating dry eye before a cataract procedure, you can stop patients from blaming you for less than stellar results. Although the diagnosis of dry eye before cataract surgery is important in all patients, it’s especially crucial in premium IOL recipients. Patients expect excellent outcomes with premium IOLs, and a problematic ocular surface can affect results. “You want a wow factor for them,” Dr. de Luise said. “We have to do extra due diligence from a chair time standpoint and with appropriate diagnostics so we can achieve our refractive target and outcomes,” said Elizabeth Yeu, MD , Virginia Eye Consultants, Norfolk, Virginia. Here’s a primer on how to evaluate and treat dry eye in your cataract surgery population. Evaluation, diagnosis Before you even see patients, educate technicians and other staff members about the prevalence of dry eye, Dr. Holland recommended. This prompts them to keep dry eye forefront in their mind as they evaluate patients. Many dry eye-focused ophthalmologists will use questionnaires such as the SPEED II questionnaire—available online— to assess patient perception of ocular surface problems. However, because not all dry eye patients will have symptoms, your diagnostic testing needs to go beyond just the questionnaire, said John Hovanesian, MD , clinical instructor, Jules Stein Eye Institute, University of California, Los Angeles. Dr. Hovanesian, along with other dry eye experts, uses tests such as tear film osmolarity. “Tear film osmolarity is considered abnormal when it’s greater than about 308 in either eye or there’s a variability greater than 8 between eyes,” he said. “That would usually indicate there’s a component of aqueous deficiency.” Another test commonly used is the matrix metalloproteinase-9, which can help indicate if inflammatory dry eye is present, Dr. Hovanesian said. Tear film break-up (TBUT) time is another long-standing test Lissamine green staining of the conjunctiva and cornea Source: Vincent P. de Luise, MD, FACS continued on page 56