EyeWorld India March 2021 Issue

EWAP MAR C H 2021 39 CORNEA impregnated hydrogel insert (Dextenza, Ocular Therapeutix) placed in the inferior punctum preop, periop, or postop. Both are viable alternatives to the tapering steroid drop burden, Dr. Matossian said. Generally, there is minimal short-term exacerbation of dry eye from modern phaco surgery, Dr. Pflugfelder said, except in patients with severe aqueous tear deficiency. Cataract surgery will exacerbate dry eye, Dr. Sheppard said. “You’re putting a lot of drops in and adding preservatives after holding the eye wide open with a speculum, thereby prohibiting blinking and desiccating the corneal epithelium with high intensity focal illumination.” Dr. Sheppard said he likes to use a non-steroidal and a steroid for all cataract patients. There’s a lot of clinical research and several FDA-approved products that can reduce that dosage, he added. Dexycu and Dextenza reduce the need for topical steroids. Physicians can use continuous intraoperative irrigation of Omidria (phenylephrine and ketorolac, Omeros), which circulates ketorolac in the eye throughout the surgical case and reduces pain and inflammation after cataract surgery, he said, adding that he thinks this significantly reduces the need for subsequent non-steroidal drops. LayerBio is developing a biodegradable NSAID ring attached to the IOL haptic that can provide weeks of intracameral anti-inflammatory therapy without drops. Minimizing dry eye issues There are other ways physicians can try to minimize ocular surface issues, Dr. Sheppard said. For example, during surgery, physicians can minimize the amount of light blast as well as the amount of exposure created by the speculum by opening it just enough to access the eye safely. Physicians can also train staff to irrigate the eye frequently, protecting the ocular surface. Many will put a small layer of viscoelastic on the cornea, Dr. Sheppard said. He concluded with the following caveats: Don’t forget the patient’s environment, occupation, and avocations; don’t forget the systemic medications your patients are taking; and don’t forget nutrition, both diet and supplementation, for surface control before, during, and after cataract surgery. EWAP Editors’ note: Dr. Matossian is in practice with Matossian Eye Associates, Doylestown, Pennsylvania, and has relevant interests with Quidel, TearLab, BlephEx, NuSight, Olympic Ophthalmics, Physician Recommended Nutriceuticals, Allergan, Novartis, Sun, Bruder, Alcon, Johnson & Johnson Vision, Sight Sciences, Kala, Lumenis, Bausch + Lomb, EyePoint, and Ocular Therapeutix. Dr. Pflugfelder is Professor of James and Margaret Elkins Chair in Ophthalmology, Baylor College of Medicine, Houston, Texas, and has relevant interests with Kala, Novartis, Senju, Kowa, and Dompe. Dr. Sheppard is in practice with Virginia Eye Consultants, CVP Physicians partner, Norfolk, Virginia, and has relevant interests with Allergan, AbbVie, Alcon, Novartis, Bausch + Lomb, LayerBio, Omeros, EyePoint, Ocular Therapeutix, Sun, Novaliq, Quidel, Johnson & Johnson Vision, TearLab, and LacriScience. John So-Min Chang, MD Hong Kong Sanatorium & Hospital, 2 Village Road, Happy Valley, Hong Kong john.sm.chang@hksh.com ASIA-PACIFIC PERSPECTIVES D r. Matossian’s comment about telling the patient that they have two diseases is very important. Patients must understand dry eye disease (DED) is a chronic disease and must be fully addressed especially if they want a premium lens; even a monofocal/ monofocal toric is not a good idea if the tear film is unstable because the calculations can be inaccurate. She reported a patient with DED whose initial cylinder was 1.5 D and decreased to 0.7 D after 2 weeks of treatment. 1 Dry eye tests are very useful. I particularly like the meibography in which the images are easy to explain and understand when you show the patients. The tear film breakup time (TBUT) is also an excellent assessment of the quality of the tear film. Videotaping of the TBUT at the slit lamp after fluorescence staining is an easy way to show and explain to the patients. This is also an easy way to show the patients how they are getting on with their therapy. Patients are much more compliant when they see evidence of their problems. Seeing an improvement is a great drive for patients to continue their efforts. The proper measurement of the corneal curvature is extremely important for IOL power calculation. However, it is more difficult to get proper and accurate measurements in patients with DED; often tear supplements are added before measurement. A study conducted by Röggla 2 showed that a period of more than 5 minutes should be allowed to pass before measurements. If measured before 5 minutes, astigmatism changes of more than 0.5 D are possible in 13.2% and 34.4% in normal and dry eyes, respectively. Recent studies have shown that there is correlation between DED and hypovitaminosis D. 3 In Asia, although there is an abundance of sunlight in most countries, Asian women tend to spend less time outdoors, and therefore are more prone to hypovitaminosis D. I frequently recommend that patients take flax seed (omega 3) supplements that contain vitamin D as well. I also like to use a short course of loteprednol etabonate pre measurement (for IOL calculation) along with the treatments recommended by Dr. Matossian to shorten the time needed to optimize the ocular surface. Patients are also warned that their DED may be worse for some time after surgery and the dry eye treatment may have to continue for quite a long time since it is a chronic disease. References 1. Matossian C. The neglected refractive interface: Impact of the tear film on refractive cataract surgery outcomes — Preop planning and postop outcomes in patients with dry eye. EyeWorld CME Supplement . 2014 Sep. 2. Röggla V, et al. Influence of artificial tears on keratometric measurements in cataract patients. American Journal of Ophthalmology . 2021 Jan;221: 1-8. 3. Askari G, et al. Association between vitamin D and dry eye disease: A systematic review and meta-analysis of observational studies. Cont Lens Anterior Eye. 2020 Oct;43(5):418-425. doi: 10.1016/j.clae.2020.03.001. Editors’ note: Dr. Chang declared no relevant financial interests.