EyeWorld Asia-Pacific March 2021 Issue

CORNEA EWAP MAR C H 2021 37 and meibography, followed by lissamine green and fluorescein staining at the slit lamp with grading and evaluation of the ocular surface and lid margins. Dr. Matossian said all patients get started on preservative-free artificial tears QID as a teaching tool on how to instill drops. Drop administration is not intuitive and is rather difficult to master by most patients, she explained. Additionally, Dr. Matossian said if the MMP-9 test is positive, indicating the presence of inflammation on the ocular surface, she will prescribe an immunomodulator such as Restasis, Xiidra, or Cequa and let the patient know that this treatment is ongoing and will continue indefinitely after the standard postop cataract surgery drops are completed. “I do not use punctal plugs as a first-line treatment,” Dr. Matossian said. “I wait for the surface inflammation to subside before considering plug placement.” Often, with a combination of a re-esterified triglyceride omega-3 (Physician Recommended Nutriceuticals), a heated moisture mask (Bruder), and a prescription immunomodulator, the tear film stabilizes in most patients, she said. Optimizing before cataract surgery Dr. Pflugfelder said timing to optimize before cataract surgery is variable, but it usually takes 4–6 weeks. In explaining this process to patients, Dr. Pflugfelder tells patients that a smooth corneal surface is necessary for accurate IOL power calculations and the best outcome. Four to 6 weeks after beginning dry eye therapy is generally the best time to consider topography and biometry for IOL calculations. “We perform IOL calculations at that time if the corneal surface is healthy,” he said. “Sometimes we’ll repeat the calculations at the preop exam.” Dr. Matossian said that in order to optimize the ocular surface prior to cataract surgery, a more aggressive approach is required. She added that a short course of steroids such as loteprednol etabonate (Lotemax, Bausch + Lomb, or Inveltys, Kala) BID–QID is often necessary to control the surface inflammation. “The steroid is not refilled; it is used for acute inflammation control,” she said. “Thereafter, therapy for chronic disease continues with various at-home remedies, including oral omega supplements, lid hygiene with scrubs (NuLids, NuSight) or lid cleansers, heated moisture masks, and prescription pharmaceuticals.” She added that it’s also important to make sure patients are using a good quality artificial tear or given the option to stimulate their own tear production with an FDA- cleared device such as iTEAR 100 (Olympic Ophthalmics). Dr. Matossian said that additional in-office treatments may be required to maintain tear film homeostasis. Microblepharoexfoliation (BlephEx) to remove the built-up biofilm on the lid margins may not only help with blepharitis control but also potentiate the effects of other office-based therapeutics. “Treatments focused on heating and evacuating impacted meibum from the meibomian glands, such as LipiFlow [Johnson & Johnson Vision], TearCare [Sight Sciences], iLUX [Alcon], or intense pulsed light treatments [Optima IPL, Lumenis], to reduce inflammation by closing off abnormal blood vessels around the meibomian glands may be required,” she said. “To quell the flare-ups triggered by prolonged screen time, allergies, or contact lens overwear, short- term steroids are recommended [loteprednol, Eysuvis, Kala].” Another key aspect is explaining the optimization process to the patient. Dr. Matossian emphasized that communication prior to cataract surgery is crucial. “The patient has to understand that s/he has two diseases: a cataract that can be ‘cured’ and dry eye disease, which is chronic and progressive, requiring treatment for life.” Dr. Matossian said it’s important that this discussion with the patient happens before cataract surgery, or it may add chair time post-cataract surgery and further confuse or frustrate the patient. “Patient education is key not only to set proper expectations but also to get buy-in from the patient to adhere to the recommended at-home remedies and continue with the prescribed medications,” Dr. Matossian said. If properly explained, patients have no problem with a short wait time in order for their LipiFlow during the COVID-19 pandemic. Source: Cynthia Matossian, MD.