EyeWorld Asia-Pacific September 2020 Issue

FEATURE 14 EWAP SEPTEMBER 2020 W hen performing cataract surgery, it’s important to ensure the patient’s ocular surface is optimized prior to surgery, and this often means addressing the problem of dry eye. “Dry eye disease is extremely commonplace, and most of the patients who are in the age group for cataract surgery have a component of dry eye disease,” said Cynthia Matossian, MD. As such, she continued, it’s incumbent on the cataract surgeon to look for and diagnose dry eye disease when evaluating a patient for cataract surgery. Dr. Matossian stressed that it’s important to educate these patients that they’re dealing with more than one disease: One is the cataract, which can be cured by taking the lens out and replacing it with an implant, and the other is dry eye, which is ongoing and progressive. Prevalence of dry eye Dry eye disease is underdiagnosed and undertreated, said Alice Epitropoulos, MD. It is estimated that 30 million adults in the U.S. report symptoms without a formal diagnosis, and an estimated 16 million adults in the U.S. have been diagnosed, she said. Many patients who come in for a cataract surgery consult have poor vision and think it’s 100% caused by the cataract, said William Trattler, MD, but in reality, many have dry eyes that’s contributing to their complaints of blurred vision. The scope of this problem is huge, said Christopher Starr, MD. “One could argue that when you combine dry eye and ocular surface disease, it’s ubiquitous,” he said. “If you look for it, you’ll find it in almost everyone, especially in the cataract age group.” However, he noted that it doesn’t necessarily mean that it’s visually significant in everyone. Based on a paper Dr. Starr co-wrote in 2018, he said the overall prevalence of dry eye and ocular surface disease in cataract patients is about 80%. 1 Another factor is that many patients are asymptomatic, so symptoms may not be the best tool to diagnose dry eye. Dr. Starr noted that his study also found a tremendously high prevalence in patients who are completely asymptomatic on questionnaires; in the asymptomatic group, 85% had at least one abnormality in either tear osmolarity or MMP-9, and almost 50% of those patients had abnormalities on both osmolarity and MMP-9. The signs can be there despite symptoms, and it’s the signs, like corneal staining, that can be visually significant, he said. Dr. Epitropoulos mentioned the PHACO study by Trattler et al., which found that 77% of patients being evaluated for cataract surgery had corneal staining, and 63% of patients had an unstable tear film (rapid tear breakup time). 2 Diagnostics There are a number of diagnostics available when it comes to identifying dry eye. Dr. Starr citied a paper published in the Journal of Cataract & Refractive Surgery by the ASCRS Cornea Clinical Committee, which presented consensus guidelines on how to approach ocular surface disease in pre-cataract patients. 3 It included a recommended ocular surface disease screening battery utilizing both a novel symptom questionnaire and objective point-of-care testing for signs (tear osmolarity and MMP-9). The questionnaire incorporates elements from the SPEED and Dell IOL questionnaires and adds other scoreable elements for identifying non-dry eye disease ocular surface disease subtypes and their visual significance. Dr. Starr said the combination of using tear osmolarity and MMP-9 and the questionnaire can tell the physician a lot about whether ocular surface disease is present, how severe it is, and how visually significant it is. He thinks osmolarity is a good dry eye test, and the magnitude of the abnormal osmolarity test is linearly related to severity of dry eye. He thinks MMP-9 is a great adjunct as well, not just for dry eye disease but also for other subtypes of ocular surface disease that lead to inflammation. Dr. Matossian said that even if the doctor does not have diagnostic tests readily available, a basic slit lamp and AT A GLANCE • Millions of people in the U.S. have some form of dry eye. Not all dry eye is visually significant or symptomatic. • It’s important to diagnose dry eye and determine its potential impact prior to surgery. Patient questionnaires can be used, as can osmolarity and MMP-9 testing and slit lamp examination and staining. • Treatment options vary for dry eye but could include oral omega-3 steroids, a heated mask, preservative-free artificial tears, steroids, mechanical treatments, and punctal plugs. Some of these treatments may need to be continued postop as well. by Ellen Stodola Editorial Co-Director Addressing dry eye prior to cataract surgery This article originally appeared in the June/July 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Epitropoulos: eyesmd33@gmail.com Matossian: cmatossian@matossianeye.com Starr: cestarr@med.cornell.edu Trattler: wtrattler@gmail.com