EyeWorld Asia-Pacific March 2021 Issue

36 EWAP MAR C H 2021 CORNEA by Ellen Stodola Editorial Co-Director Handling dry eye prior to cataract surgery Contact information Matossian: cmatossian@cmassociatesllc.net Pflugfelder: stevenp@bcm.edu Sheppard: docshep@hotmail.com This article originally appeared in the December 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. I t’s important to address underlying conditions prior to cataract surgery, and dry eye is one such condition. Physicians must identify and treat it to ensure the tear film is optimized and measurements are correct. Diagnostics and testing available There are a variety of highly clinically useful dry eye diagnostics available. John Sheppard, MD, said that some of the most common options include the osmolarity test (TearLab), MMP-9 testing (Quidel), and meibography from a number of companies. Dr. Sheppard said that in order to be optimally reimbursed, the tests need to be chronologically spread out. Many insurers will only reimburse for one dry eye test or procedure per visit, which requires close monitoring by the billing staff. He decides in each patient what needs to be addressed first: inflammation, tear concentration, or the lids. He added that artificial tears, punctal plugs, and other medications have a role as well. If the patient has a tear supply problem, Dr. Sheppard said punctal plugs are a great option because they retain natural tears and reduce need for artificial tears, which may irrigate away essential tear proteins and surfactants. “I prefer to use plugs whenever practical, especially if the inflammation is under control,” Dr. Sheppard said. He also mentioned that there is an “entire menu” of anti-inflammatory medications, including Cequa (cyclosporine, Sun Ophthalmics), Restasis (cyclosporine, Allergan), and Xiidra (lifitegrast, Novartis). While you wouldn’t use all of these at the same time, Dr. Sheppard said he may use one of them in combination with a smart steroid. Stephen Pflugfelder, MD, said that there are a variety of conventional tests that should be performed ahead of cataract surgery, such as slit lamp exam of the cornea/conjunctiva and lids, symptom questionnaire, dye staining, TBUT, and Schirmer’s testing. Additionally, he said that corneal topography can be used to evaluate corneal smoothness (using a Placido- based instrument) and anterior segment OCT to measure the tear meniscus height (tear volume). Dr. Pflugfelder said that he will typically perform TBUT, corneal fluorescein staining, and topography on every patient and will obtain other tests as indicated. “From my perspective, a symptom questionnaire, slit lamp exam to evaluate for conjunctivochalasis, TBUT, cornea fluorescein staining, and topography should be performed,” he said. He also commented on use of medications like Restasis, Xiidra, and Cequa, noting that the patient profile should guide choices. “Restasis and Cequa work well for aqueous deficiency, and I prefer Xiidra for more symptomatic patients with less dye staining,” he said. “We are fortunate to have several options to evaluate the tear film and ocular surface prior to cataract surgery,” said Cynthia Matossian, MD. “It’s a great idea to engage the patient with a simple questionnaire, such as the SPEED questionnaire or another similar option.” These are available online at no charge, she added. Dr. Matossian added that tear osmolarity and MMP-9 point-of-care tests are objective parameters to demonstrate tear osmolarity and the presence of inflammation, respectively. Additionally, she said that meibography is a great imaging system of the meibomian glands. “The black and white images are easy for patients to understand. Even an untrained eye will be able to tell an abnormal image from a normal one,” she said. Vital dyes, such as fluorescein and lissamine green, are important to describe the level of ocular surface staining. Dr. Matossian said she employs all of these tests in her practice but noted that they have shortened the questionnaire to three questions for efficiency. Her process includes the three- question questionnaire, tear osmolarity, MMP-9 testing,