EyeWorld India March 2020 Issue

CORNEA 48 EWAP MARCH 2020 their plans. If OSD is present, then treatment should take place preoperatively. Treatment before surgery If you see a patient with DED who is not having surgery, you may add treatments methodically. However, if it’s a preop patient who is eager to have a cataract removed, trying several treatments at once is often the way to go, according to the surgeons. The ASCRS algorithm divides patients with OSD as having non-visually significant or visually significant OSD. The ones with visually significant OSD require more pretreatment and may need to postpone their surgery. “Never hesitate to delay surgery until the ocular surface is healthy enough,” Dr. Epitropoulos advised. Although the algorithm recommends waiting 2–4 weeks before starting treatment and repeating measurements, she will typically wait 4–6 weeks. Dr. Mah usually schedules surgery 6 weeks out. The algorithm suggests reworking your way through the beginning of the algorithm when a patient returns after treatment. The goal prior to surgery is to either eradicate OSD completely or convert it from visually-significant to non- visually significant OSD via an aggressive treatment regimen targeting each OSD subtype. Some ocular surface problems such as EBMD, floppy eyelid syndrome, or Salzmann’s nodules may require surgical interventions preoperatively when deemed visually-signifcant. However, if the patient has DED or MGD, more treatments are needed. For aqueous-deficient dry eye, preservative-free artificial tears, over-the-counter gels and ointments, and an immunomodulator such as lifitegrast (Xiidra, Shire) or cyclosporine A (Restasis, Allergan) are often used, Dr. Mah said. Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharma), approved in the U.S. but not yet commercially available, may become a third possible option, he added. Some patients may require the immunomodulator chronically, even after surgery. A topical corticosteroid also may be used for a short time before surgery. For patients with MGD and blepharitis, treatments such as warm compresses, lid scrubs, thermal pulsation, blepharoexfoliation, oral doxycycline or minocycline, topical antibiotics, intense pulsed light therapy, and tea tree oil may be used, according to sources. In addition to those treatments, Dr. Epitropoulos will recommend omega-3 supplements, particularly higher- quality ones that have been re- esterified and provide users with the full omega-3 dose available in the supplement, she said. In severe dry eye, Dr. Farid will use serum eye drops or a PROKERA (Bio-Tissue), the latter of which provides a microenvironment for healing, she explained. Dr. Mah prefers to use serum or amniotic eye drops before using PROKERA. Ocular allergies sometimes are also a problem to be addressed before surgery, Dr. Mah said. Patient education Patient education is a crucial part of any preop surgery prep, but it’s especially important when explaining to asymptomatic patients with DED why the condition may become symptomatic after surgery. This could involve the continuous use of agents like cyclosporine or lifitegrast or working toward better lid management. “As a referral doctor, I see patients on a routine basis who complain about their quality of vision after surgery. They have good vision, but they are unhappy patients,” Dr. Ayres said. “They don’t understand how they went in feeling fine and then come out not feeling fine. Warning patients about the symptoms of dry eye will help them understand the problem.” EWAP References 1. Jones L, et al. TFOS DEWS II management and therapy report. The Ocular Surface. 2017;15;3;575–628. 2. Milner MS, et al. Dysfunctional tear syndrome: Dry eye disease and associated tear film disorders—new strategies for diagnosis and treatment. Curr Opin Ophthalmol. 2017;27:Suppl 1:3–47. 3. American Academy of Ophthalmology Cornea/External Disease Committee. Dry Eye Syndrome PPO . 2018. Available at: https:// www.aao.org/preferred-practice- pattern/dry-eye-syndrome-ppp-2018 4. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg . 2019;45:669–684. 5. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg . 2015;41:1672–1677. Editors’ note: Dr. Ayres is a cornea specialist at Wills Eye Hospital, Philadelphia, and declared no relevant financial interests. Dr. Epitropoulos is affiliated with the Ophthalmic Surgeons & Consultants of Ohio, The Eye Center of Columbus, clinical assistant professor, The Ohio State University, Columbus, Ohio, and has relevant financial interests with AbbVie, Alcon, Allergan, AMO, Biotissue, Johnson & Johnson Vision, PRN, Shire, SUN, Takeda, TearCare, TearLab, and TearScience. Dr. Farid is director, cornea, cataract, and refractive surgery, vice- chair of ophthalmic faculty, professor of ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, California, and has relevant financial interests with Allergan, Bio- Tissue, CorneaGen, Dompe, Eyepoint, Eyevance, Johnson & Johnson Vision, KALA, and Shire. Dr. Mah is affiliated with Scripps Health, La Jolla, California, and has relevant financial interests with Avedro. Dr. Starr is associate professor of ophthalmology, director, Cornea Fellowship, Refractive Surgery Service, and Ophthalmic Education, Weill Cornell Medicine, New York Presbyterian Hospital, New York, and has relevant financial interests with Alcon, Allergan, Blephex, Bruder, Dompe, Eyevance, Johnson & Johnson Vision, Kala, Shire, Sun, TearLab, and Quidel. Look-Lift-Pull-Push H ere are some highlights of what is recommended in the LLPP mnemonic described in the paper by the ASCRS Cornea Clinical Committee. Find more details in the algorithm paper. 4 • Look at the blink quality and quantity, examine the eyelids, and look for signs of anterior and posterior blepharitis. • Lift and pull up the eyelid to rule out superior EBMD and identify floppy eyelid syndrome and eyelid laxity, because these are often missed in exams. • Push on the lower lid margin to express the meibum.