EyeWorld Asia-Pacific September 2020 Issue

EWAP SEPTEMBER 2020 15 FEATURE two vital dyes that every practice can easily obtain, lissamine green and fluorescein, can tell a lot about the surface. She added that looking at the glands, eyelid margins, meibomian gland orifices, and staining the conjunctiva and cornea will tell a lot of the story. Dr. Trattler said he uses a slit lamp exam to diagnose dry eye. He examines the tear volume and degree of corneal staining. He will perform a subjective tear breakup time to evaluate the quality of the tear film. He also reviews the topography of patients scheduled for surgery, noting that irregular topography can potentially be a sign of dry eye. Dr. Trattler also evaluates the eyelids for MGD and blepharitis. Dr. Starr recommends the quick and directed yet thorough “look, lift, pull, push,” or LLPP, ocular surface exam for all patients undergoing surgery. Treatment If the focus is stabilizing the tear film as quickly as possible prior to cataract surgery, Dr. Matossian’s treatment is intentionally more aggressive to get the patient to that level quickly as opposed to treatment for the chronic, long-term period post-cataract surgery. To get the surface tuned up, first educate the patient or they won’t be compliant, she said. Next, start the patient on oral omega-3 supplements, a heated, microwaveable mask, and preservative-free artificial tears. They will continue with all of these post-surgery. She uses a short-term steroid BID for 2 weeks to get the surface optimized, but this is discontinued after cataract surgery. Dr. Matossian recommends a treatment like LipiFlow (Johnson & Johnson Vision) or a combination of LipiFlow and BlephEx to evacuate the meibomian glands and exfoliate the biofilm on the lid margin to achieve a more stable tear film as quickly as possible in preparation for surgical measurements. Dr. Trattler said it’s important to determine if you’re dealing with evaporative or aqueous deficient dry eye. For aqueous deficient dry eye, he typically treats with topical steroids short term and often starts long-term therapy with Restasis (cyclosporine, Allergan), Xiidra (lifitegrast, Novartis), or Cequa (cyclosporine, Sun Pharma). He also considers whether a punctal plug might be helpful to raise the tear film. Dr. Trattler said that if the patient has blepharitis, he would treat with topical steroids to help quiet inflammation, along with hypochlorous acid spray and warm compresses. If patients aren’t responding well, he discusses additional therapies with them including LipiFlow or TearCare (Sight Sciences). While there is no rigid standard of care for treatment, Surface qualifier images from the Cassini (Cassini Technologies) showing missing and irregular lines consistent with an unstable tear film. Placido disc images from OPD-Scan III (Nidek) showing irregular and warped mires consistent with an unstable tear film. Source (all): Cynthia Matossian, MD