EyeWorld Asia-Pacific March 2019 Issue

EWAP SECONDARY FEATURE 23 March 2019 I n our current age of premium IOL technology that emphasizes precision, the cataract and refractive surgeon can no longer ignore the ocular surface and its impact on visual outcome. The APACRS Principles of Preferred Practice for the management of the ocular surface in cataract and refractive surgery was published in 2017 as a guide to the management of such cases. 7KH WHDU ÀOP KDV WKH JUHDWHVW RSWLFDO SRZHU RI DQ\ RFXODU VXUIDFH ZLWK WKH FRUQHD DQG WHDU ÀOP PDNLQJ XS WZR WKLUGV RI WKH UHIUDFWLQJ SRZHU RI the eye. 1 ,UUHJXODU WHDU ÀOP DVVRFLDWHG ZLWK VLJQLÀFDQW GU\ H\H DQG RFXODU surface disease can affect cataract and refractive surgery in two ways: inaccurate preoperative measurements resulting in IOL miscalculation, and postoperative poor visual quality due to the higher order aberrations that it induces. 2 The following four scenarios focus on the management of challenging dry eye cases. Scenario 1 – Progressive keratoconus with severe atopic keratoconjunctivitis ,W LV LPSRUWDQW WR UHGXFH LQÁDPPDWLRQ DQG RSWLPL]H WKH RFXODU VXUIDFH SULRU WR FURVVOLQNLQJ LQ SDWLHQWV ZLWK NHUDWRFRQXV DQG DWRSLF H\H GLVHDVH otherwise there could be an increased incidence of postoperative corneal haze and subsequent corneal scarring. For severe atopic eye disease, topical preservative free steroids, mast cell stabilizers and cyclosporine A H\HGURSV PD\ EH XVHG WR UHGXFH WKH DOOHUJ\ DQG LQÁDPPDWLRQ ,I WRSLFDO medications fail, a short course of oral steroids may be added. A note of caution in atopic eczema cases: herpetic eye disease should be excluded SULRU WR FURVV OLQNLQJ Scenarios 2 and 4 – Severe graft-versus-host-disease related dry eye/Severe dry eye (Figure 1) Severe graft-versus-host-disease-related dry eye usually does not UHVSRQG ZHOO WR DUWLÀFLDO WHDUV DORQH 2WKHU IRUPV RI WUHDWPHQW FRQVLVW RI cyclosporine eyedrops, contact lenses (soft and scleral lenses), topical steroids, topical tacrolimus and autologous serum tears. Punctal occlusion treatment is controversial as the increased retention time of tears HQULFKHG ZLWK LQÁDPPDWRU\ F\WRNLQHV PD\ DJJUDYDWH H\H LQÁDPPDWLRQ It is important to optimize the ocular surface prior to cataract surgery. 3 Concurrent meibomian gland disease should also be addressed prior to cataract surgery. 4 (SLWURSRXORV HW DO UHSRUWHG WKDW K\SHURVPRODULW\ RI WKH WHDU ÀOP LV DVVRFLDWHG ZLWK VLJQLÀFDQWO\ PRUH YDULDELOLW\ LQ DYHUDJH . UHDGLQJV DQG DQWHULRU FRUQHDO DVWLJPDWLVP UHVXOWLQJ LQ VLJQLÀFDQW GLIIHUHQFHV LQ ,2/ power calculations. 5 Hence these patients should be excluded from multifocal IOL implantation due to inaccurate IOL calculations and reduced DFXLW\ IURP SRRU UHWLQDO LPDJH TXDOLW\ /LNHZLVH WRULF ,2/V VKRXOG EH DYRLGHG GXH WR LQDFFXUDFLHV LQ NHUDWRPHWU\ PHDVXUHPHQWV Scenario 3 – Moderate to high myope with limbal stem cell GHÀFLHQF\ &RQWDFW OHQV ZHDU LQGXFHG OLPEDO VWHP GHÀFLHQF\ LV D VLJQLÀFDQW complication and patients should stop wearing contact lenses permanently as continued contact lens wear can damage the limbal stem cells further. 7UHDWPHQW FRQVLVWV RI DUWLÀFLDO WHDUV WRSLFDO VWHURLGV ZLWK WKH PRUH VHYHUH FDVHV UHTXLULQJ DPQLRWLF PHPEUDQH JUDIWLQJ RU NHUDWRSODVW\ /DVHU YLVLRQ correction should be reserved for mild cases with stable ocular surface and FOHDU FHQWUDO FRUQHD 7KH /$6,. SURFHGXUH LV SUHIHUUHG RYHU VXUIDFH DEODWLRQ as the corneal epithelium is not debrided. References 7XWW 5 HW DO 2SWLFDO DQG YLVXDO LPSDFW RI WHDU EUHDN XS LQ KXPDQ H\HV Invest Ophthalmol Vis Sci. 2000 Dec;41(13):4117-23. 2. Montes Mico R. 5ROH RI WKH WHDU ÀOP LQ WKH RSWLFDO TXDOLW\ RI WKH KXPDQ eye. J Cataract Refract Surg . 2007 Sep;33(9):1631-5. %DODUDP 0 'DQD 05 3KDFRHPXOVLÀFDWLRQ LQ SDWLHQWV DIWHU DOORJHQLF ERQH marrow transplantation. Ophthalmol. 2001;108(9): 1682-1687. 4. Peral A, et al. Importance of lid hygiene before ocular surgery: qualitative and quantitative analysis of eyelid and conjunctiva microbiota. Eye and Contact Lens. 2016;42(6):366-370. 5. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of NHUDWRPHWU\ LQ FDWDUDFW VXUJHU\ SODQQLQJ J Cat Refract Surg. 2015; 41:1672-77 (GLWRUV· QRWH 'U /LP GHFODUHG QR UHOHYDQW ÀQDQFLDO LQWHUHVWV 9LHZV IURP $VLD 3DFLÀF Adj. Assoc. Prof. LIM Li, MBBS, 00HG 2SKWK )5&6 (G )$06 6·SRUH Senior Consultant, Corneal and External Eye Disease Service Singapore National Eye Centre 11 Third Hospital Avenue, Singapre 168751 lim.li@singhealth.com.sg Figure 1. Severe dry eye with interpalpebral punctate epithelial erosions secondary to chronic graft-versus-host-disease after allogenic bone marrow transplantation Source: Lim Li, MBBS, MMed(Ophth), FRCS(Ed), FAMS(S’pore) Continued on page 24