EyeWorld India March 2019 Issue

22 EWAP SECONDARY FEATURE March 2019 Challenging dry eye cases by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor AT A GLANCE • In patients with limbal stem cell deficiency, it’s possible to choose a refractive procedure, but you should wait until the limbal stem cell deficiency is resolved, or as optimized as possible, before proceeding with a refractive procedure. • In graft-versus-host disease, a multifocal or toric IOL should generally be avoided. A scleral lens, however, may work well for these patients. • In atopic keratoconjunctivitis, eyelid disease should be addressed prior to surgery. Experts discuss how to handle a variety of scenarios O ptimizing the ocular surface is an important step for treatment of patients with dry eye. Depending on the patient and coexisting conditions, full optimization may prove particularly challenging for ophthalmologists. Melissa Daluvoy, MD, assistant professor of ophthalmology, Duke University Eye Center, Durham, North Carolina, Deborah Jacobs, MD, associate professor of ophthalmology, Harvard Medical School, Boston, and Bennie Jeng, MD, professor and chair of the Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, weighed in on a variety of scenarios and how they would approach these patients. Scenario 1: Progressive keratoconus The first scenario involves a patient with progressive keratoconus and severe atopic keratoconjunctivitis with diffuse corneal and conjunctival staining and active lid eczema. EyeWorld asked Drs. Daluvoy, Jacobs, and Jeng about their protocol to settle the ocular surface prior to crosslinking in such cases. Dr. Daluvoy said she would aggressively treat the surface disease. “To start, I would try petroleum jelly or a mild hydrocortisone ointment to the lids and treat the surface with a course of mild topical steroid and preservative-free tears,” she said. “I would also reiterate the importance of not rubbing the eyes.” Other treatments might include oral doxycycline or prescription- strength dry eye medications. In terms of residual corneal staining, Dr. Daluvoy said she would tolerate only a mild amount because of concern about poor healing after epithelial debridement. Dr. Jacobs said she is not currently doing crosslinking. “I think that the goal, as far as the ocular surface [is concerned], is to optimize healing—especially if the procedure is to be epi-off—to reduce the likelihood of persistent epi defect or residual haze. You would want to have the surface at a plateau, and if there is some staining, so be it.” Dr. Jacobs is a “huge fan” of soft steroid ointment (loteprednol or fluorometholone) at bedtime for treatment and suppression of atopic blepharoconjunctivitis. Some patients benefit from tacrolimus ointment as a steroid suppressing strategy, she added. “I would continue this through the post- crosslinking period in addition to protocol topical steroid drops.” Dr. Jeng said that before any ocular surgery or procedure, eyelid disease needs to be addressed. Atopic keratoconjunctivitis is especially difficult for a lot of ophthalmologists, he said. Treating it systemically is the only way to address it, he added. Dr. Jeng noted that he tries not to use steroids on the eyelid because the eyelid skin is so thin, and it can cause depigmentation. Since this is a systemic disease, Dr. Jeng said it’s important to “buddy up with an allergist.” When considering residual corneal staining, Dr. Jeng stressed again that the systemic disease has to be under good control, and you need to make sure the body and eyelids are “as optimized as possible.” Invariably, these patients will still get staining, he said. If a patient has atopic disease and keratoconus and you want to crosslink them, you need to realize they could end up with slow-healing epithelium. For these patients, Dr. Jeng suggested considering an epi-on protocol so you don’t destroy the epithelium. Or, if you do epi-off (the current FDA-approved protocol), he said a contact lens or amniotic membrane could help them epithelialize again after. “In terms of giving them better vision, these patients do well with a scleral lens,” Dr. Jeng said. “It not only gives them better vision by giving a new surface to see out of but also keeps them more comfortable.” Scenario 2: Severe graft-versus- host disease related dry eye The physicians discussed how they settle the ocular surface prior to cataract surgery and IOL calculations in patients with severe graft-versus-host disease related dry eye with diffuse corneal and conjunctival staining, and oral steroid induced dense posterior capsular opacity. Dr. Jeng said that this can be an extremely challenging problem for patients. The ocular surface in these patients with bad dry eyes may or may not ever become normal, he said. Dr. Jeng said that often these patients might do best with a scleral lens. He added that the surgeon may have to do the best he or she can with the Ks and biometry. These patients are generally going to be in a scleral lens, and after surgery they’ll be back in the scleral lens. “For that reason, if they’re already in a scleral lens to treat the ocular An example of graft-versus-host disease. These cases may be challenging to treat, and surgeons may want to avoid using premium lenses in these patients. Source: Melissa Daluvoy, MD