EyeWorld India March 2017 Issue

60 EWAP PHARMACEUTICALS March 2017 Facing dryness by Maxine Lipner EyeWorld Senior Contributing Writer Improving the ocular surface before cataract surgery W hen a patient has dry eye, cataract surgery may need to wait a bit so physicians can address this. EyeWorld took a close look at how various pharmacologic treatments can make a difference for those with dry eye. Spotting surface issues It begins by identifying cataract patients who may have dry eye. Because of its potential to affect patients’ quality of life, daily functioning, and cataract and refractive surgery outcomes, Alice Epitropoulos, MD , clinical assistant professor, Ohio State University Wexner Medical Center, Columbus, Ohio, recently led a study considering the effect of tear osmolarity on keratometry. 1 This study showed that tear film hyperosmolarity was associated with an increased variability of keratometry measurements used for determining IOL power and toric IOL planning, Dr. Epitropoulos said. “These findings confirm the importance of evaluating the surface in our cataract patients,” she said. “Fortunately, newer technologies have emerged that are improving our ability to properly diagnose and screen our preoperative cataract patients for dry eye disease.” Dr. Epitropoulos starts out by asking patients to fill out a dry eye questionnaire, which she finds is an efficient method of documenting patient complaints prior to testing and receiving drops. After the questionnaire, if a patient is symptomatic, she empowers her technicians to proceed with point-of-care tests including the TearLab Osmolarity System (TearLab, San Diego), InflammaDry (Rapid Pathogen Screening, Sarasota, Florida), and LipiView II (TearScience, Morrisville, North Carolina). “These are useful tools in evaluating dry eye but should not take the place of our actual exam,” Dr. Epitropoulos said, adding that it’s still important to look at the tear film, lid margins, and quality of the meibum. Likewise, Edward Holland, MD , professor of ophthalmology, University of Cincinnati, routinely questions patients about symptoms related to the ocular surface. “The typical symptoms of dry eye such as burning, irritation, and redness are important, but fluctuation in vision is also common, especially in older patients,” Dr. Holland said, adding that if patients are symptomatic, he performs tear osmolarity testing, which he views as the best screening method. After screening, he assesses the severity of the disease and whether it is a result of aqueous tear deficiency, meibomian gland dysfunction, or a combination. “I think it’s important to diagnose the exact etiology of dry eye because the treatments are going to be different,” Dr. Holland said. Treatment considerations Since the typical cataract patient must wait several weeks to get on the schedule, Dr. Holland puts the milder cases—patients who are symptomatic with conjunctival injection, rapid tear break-up time, and fluctuating vision, but with minimal or no corneal staining—on the surgical schedule and begins to tackle the ocular surface disease. “We typically manage those types of patients with an omega-3,” he said, adding that he likes the re-esterified form of this since it is better absorbed and has better efficacy. In addition to 2 grams of omega-3 twice a day, Dr. Holland recommends that the patient use an artificial tear. “If we think the patient has aqueous tear deficiency, we will initiate Xiidra [lifitegrast, Shire, Lexington, Massachusetts] because of the rapid onset of action and excellent efficacy. Many patients in the clinical trial had efficacy as early as 2 to 4 weeks,” he said. 2 For patients with moderate to severe disease, in whom he sees corneal staining but who are getting fluctuations on various tests, he advises caution. “Those patients are at risk of getting the wrong IOL power,” Dr. Holland said. “We wouldn’t want to risk picking a toric lens because we MGD with meibomian gland dropout and abnormal meibum Source: Edward Holland, MD