Supplement to EyeWorld October 2013

The status of dry eye care in surgical practices

Dry eye is very common amongpatients presenting for cataractor laser vision correction surgery. If the dry eye is nottreated preoperatively, it can re-

duce the quality of preoperative data and canhave a negative impact on surgical outcomes.

Just prior to ASCRS, we surveyedcataract and refractive surgeons about the incidence of dry eye in their surgical patients,their awareness of current guidelines for thediagnosis and treatment of dry eye, and howthey typically screen patients for dry eye, inorder to understand the current state of dryeye care in surgical practices. The resultswere quite illuminating. For example, althoughresearch shows that rates of dry eye are veryhigh in cataract-age populations, most respondents (65.7%) said that fewer than 20% of their cataract patients have dry eyethat requires treatment other than artificialtears.

Most respondents (76.7%) also estimatedthat fewer than 20% of their laser vision correction patients required treatment otherthan tears for dry eye. These results suggestto me that dry eye is significantly underdiag-nosed in surgical patients and may not be treated as aggressively as the literaturerecommends.

Continuing Medical Education (CME)Accreditation StatementThis activity has been planned and implemented in ac-cordance with the Essential Areas and policies of theAccreditation Council for Continuing Medical Education(ACCME) through the joint sponsorship of the AmericanSociety of Cataract and Refractive Surgery (ASCRS)and EyeWorld. ASCRS is accredited by the ACCME toprovide continuing medical education for physicians.

Educational ObjectivesOphthalmologists who participate in this course will:• Understand the key study data on the prevalence

rates of dry eye signs and symptoms in patientsundergoing cataract and refractive surgery;

• Identify the impact of DED on the various preoper-ative and postoperative elements of cataract andrefractive surgery, and understand how this impacts outcomes; and

• Develop palliative and therapeutic treatmentstrategies to manage DED patients in an anteriorsegment surgical setting, both preoperative andpostoperatively.

Designation StatementThe American Society of Cataract & Refractive Surgerydesignates this live educational activity for a maximumof 1.0 AMA PRA Category 1 Credits.™ Physiciansshould claim only credit commensurate with the extentof their participation in the activity.

Claiming CreditTo claim credit, participants may either fax in the post-activity test or visit www.CMESupplements.eye-world.org to download the post-activity test and creditclaim. All participants must pass the post-activity testwith a score of 75% or higher to earn credit. Whendownloading the material, standard internet access isrequired. Adobe Acrobat Reader is needed to view thematerials. CME credit is valid through February 28,2014. CME credit will not be awarded after that date.

Notice of Off-Label Use PresentationsThis activity may include presentations on drugs ordevices or uses of drugs or devices that may not have

been approved by the Food and Drug Administration(FDA) or have been approved by the FDA for specificuses only.

ADA/Special AccommodationsASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act(ADA) and the rules and regulations thereof. Any participant in this educational program who requiresspecial accommodations or services should contact Laura Johnson at ljohnson@ascrs.org or 703-591-2220.

gery with complaints of poor night vision andfluctuating vision, but no complaints of ocularirritation or foreign body sensation. A relativelylow percentage (17%) said they were likely totreat that patient for dry eye, while 34% weresomewhat unlikely and 26% very unlikely tooffer dry eye treatment prior to surgery.

This can be a mistake because dry eye inelderly patients is more likely to manifest asfluctuating vision than as foreign body sensa-tion, as Dr. Trattler explains elsewhere in thissupplement.

In fact, we have very good evidence-based guidelines for diagnosis and treatmentof dry eye. Divided into Levels 1 through 4,these guidelines have been published in theDEWS reports and elsewhere, yet most of ourrespondents were uncertain whether they werefollowing the guidelines. It can be difficult tostay current with recommendations in thisevolving field, but it behooves us all as surgeons to ensure that we are adequatelyscreening for and addressing ocular surfaceproblems in our surgical patients. Even mild tomoderate dry eye can be treated effectively toimprove postoperative outcomes.

Dr. Shamie is from the Doheny Eye Institute, Keck School ofMedicine, University of Southern California. She can be contacted at nshamie@yahoo.com.

Appropriate assessment is an ongoingchallenge in busy surgical practices. Althoughsurgeons know the importance of identifyingand treating dry eye preoperatively, they oftendon’t spend enough time assessing and opti-mizing the ocular surface, which can contributeto less-than-optimal results. When we askedsurvey participants how they routinely evaluatedry eye in surgical patients, the results werequite varied:• Corneal staining: 82.9%• Tear break-up time: 80%• Conjunctival staining: 51.4%• Schirmer’s: 42.9%• Meibomian gland expression: 34.3%• Questionnaire: 28.6%• Topography: 22.9%• OCT: 8.6%

Corneal and conjunctival staining andTBUT, not surprisingly, are leading diagnosticapproaches. It is encouraging to see that topography is increasingly being used to assess the ocular surface, as it can be a powerful diagnostic tool. However, while manydry eye experts have abandoned the use ofSchirmer’s as a diagnostic tool, this is not reflected in general practice.

TreatmentWe also asked how respondents would treat a65-year-old patient presenting for cataract sur-

This CME supplement is supported by an unrestrictededucational grant from Allergan.

Financial Interest Disclosures: The faculty have disclosed the following financial interest relationships within the last 12 months:

ASCRS

by Neda Shamie, MD

Staff member Laura Johnson has no financial interests to disclose. Staff consultant Jan Beiting has received a retainer, ad hoc fees, or otherconsulting income from AcuFocus, Abbott Medical Optics, Iridex, Johnson& Johnson Vision Care Inc., TearScience, and WaveTec Vision Systems.

Francis S. Mah, MD, has received a retainer, adhoc fees, or other consulting income from: Alcon,ForSight Labs, and ISTA. He is a member of thespeakers bureaus of Allergan and Bausch +Lomb.

Craig McCabe, MD, PhD, FACS, is a member of the speakers bureaus of: Alcon Laboratories,Allergan, Bausch + Lomb, and Merck.

Neda Shamie, MD, has received a retainer, ad hoc fees, or other consulting income from: Allergan, Bausch + Lomb, and Nicox. She is amember of the speakers bureaus of Allergan,Bausch + Lomb, and Merck.

William B. Trattler, MD, has received a retainer,ad hoc fees, or other consulting income from: Abbott Medical Optics, Allergan, Bausch + Lomb,CXLUSA, Ferrara Ophthalmics, LensAR, andLenstec. He is a member of the speakers bureauof Oculus. He has received partial or full researchfunding from Bausch + Lomb and Hoya VisionCare and has received travel expense reimburse-ment from Abbott Medical Optics.

George O. Waring IV, MD, FACS, has received a retainer, ad hoc fees, or other consulting income from: Abbott Medical Optics, Alcon, Allergan, Allcerated Vision, ACE Vision Group,AcuFocus, Bausch + Lomb, FocalPoint Asia, Revital Vision, and SRD Vision. He has receivedtravel expense reimbursement from Reichert.

Can improved ocular surfacecare really impact cataract andrefractive surgery outcomes?

Prevalence of dry eye in surgical populationsby William B. Trattler, MD

Dry eye is very common. In fact,approximately 40% to 50% ofmy patients who present forother complaints have dry eye.While it is more common in

older patients, it’s not uncommon to see patients in their teens and 20s with dry eye.

Risk factors for dry eye include older age,omega-3 deficiency, hormonal issues, low-humidity environments, computer work, andlifestyle factors, such as lack of sleep, smok-ing, or drinking alcohol.

Dry eye is prevalent among patients presenting for cataract and refractive surgery.Failure to treat dry eye preoperatively reducesquality of preoperative data, reduces visualacuity, and limits satisfaction.

Dry eye in cataract surgery patientsTo determine the prevalence of dry eye in patients undergoing cataract surgery, we conducted a prospective study at nine sitesacross the country. The Prospective Health Assessment of Cataract patients’ Ocular surface (P.H.A.C.O.) study included 272 eyes in 136 patients who were scheduled forcataract surgery. Patients’ average age was 70years.

Schirmer’s test results showed that 53%were normal (>10 mm) and 47% were abnormal(10 mm or less). Of those with abnormal results, 21% had scores of 5 mm or less, which is strongly correlated with dry eye.

Patients’ average tear break-up timeacross the nine sites was 4.95 seconds, with63% of patients having tear break-up times of5 seconds or less, which is a very rapid, abnormal tear break-up time.

We also found that 77% of eyes hadsome staining of the cornea, but, more importantly, 50% of eyes had staining in thecentral part of the cornea. This is important be-cause it can significantly affect imaging resultsand impact IOL calculations.

Most patients in the P.H.A.C.O. study didnot complain of ocular irritation or a sandy sen-sation. Interestingly, 59% of patients had noforeign body sensation whatsoever. Twenty-eight percent reported a foreign body sensa-tion some of the time, while 13% had a foreignbody sensation most or all of the time. Oph-thalmologists will miss many cases of dry eyeif they rely on reports of foreign body sensa-tion. We need to examine and evaluate the ocular surface to detect cases.

In our study, we used the grading score of the DEWS system, and 81% of our patients had moderate to severe dry eye (Figure 1).1 The DEWS report shows that onceeyes have corneal staining, there is damage tothe cornea. Even mild staining (not necessarilycentral but any staining) pushes patients up toa Level 2, which is the level at which initiationof prescription therapy is recommended.

Our study found that dry eye signs arevery common in patients who are scheduledfor cataract surgery, and patients are oftenasymptomatic. Both a rapid tear break-up timeand corneal staining will significantly impactkeratometry and topography (Figure 2).

Figure 1. Eighty-one percent of patients had moderate to severe dry eye.

Figure 2. Dry spots on topography. The dry spots are causing some elevation right next to the white spot, which is loss of information. When using topography to look for dry eye, look for these dry spots or irregularities.

Dry eye in the laser vision correction populationDry eye often causes contact lens intolerance,which motivates many people to seek LASIK.It has been found that one in six contact lenswearers will drop out of contact lens wear, anddryness and discomfort are the primary rea-sons for contact lens drop out. Patients aretypically in their mid-20s when they drop out.

A study conducted by Dan Durrie, MD,evaluated patients before and after LASIK withregard to dry eye. He found that patients com-ing in for LASIK were often contact lens intol-erant and had pre-existing dry eye. Shortlyafter surgery, patients’ dry eye level increaseda small amount; however, three to six monthsafter surgery, their dry eye level was slightlyless than it was preoperatively.

Dry eye has real consequences for laservision correction candidacy, visual outcomes,and patient satisfaction. It can cause inaccu-rate preoperative wavefront measurements, inaccurate topography, blur or fluctuating vision, and discomfort.

We have very good stepwise protocols forclassifying and treating dry eye. Unfortunately,most people don’t use them. In 2012, only27% of ophthalmologists reported knowingand/or regularly using treatment Delphi/DEWSguidelines.1

It’s important for ophthalmologists to determine preoperatively whether patientshave dry eye and then treat them appropri-ately. Patients with a healthy ocular surfacewill achieve much better imaging results andsurgical outcomes.

Reference1. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tearsyndrome. A Delphi approach to treatment recommen-dations. Cornea. 2006;25:90-97.

Dr. Trattler is director of cornea, Center for Excellence in Eye Care, Miami. He can be contacted at wtrattler@gmail.com.

Can improved ocular surface care really impact cataract and refractive surgery outcomes?

Clinical cases

Case 1: LASIK candidacy with mild dry eyeby George O. Waring IV, MD, FACS

Mild to moderate chronic keratoconjunctivitissicca is often underdiagnosed and under-treated. However, these patients can be suc-cessfully converted to laser vision correctionby optimizing the ocular surface.

Ocular surface optimization (OSO) is aphrase I use to describe utilizing whatevertherapeutic regimen necessary to improve theocular surface health in an attempt to convertpatients to a safe and successful surgical pro-cedure—whether this is laser vision correctionon the cornea or an advanced technology IOL.

Take the recent case of a 55-year-old female non-contact lens wearing plano-

presbyope who wants laser vision correction to reduce her dependence on her readingglasses. Her slit lamp examination was signifi-cant for decreased tear film volume, mild inspissation, conjunctivochalasis, inferior staining, and early nuclear sclerosis bilaterally.Treatment options in the U.S. include LASIK,PRK, CK, dysfunctional lens replacement, orno surgery at all.

We counseled her carefully about herdysfunctional lens changes and her mild butchronic dry eye to make sure that her expecta-tions were set appropriately. We instated sixweeks of ocular surface optimization. For thispatient, we recommended hourly preservative-free tears, topical cyclosporine twice a day,and reverse bioengineered oral omega-3 fattyacids. Ocular surface optimization was fol-lowed with serial refractions, topographic andtomographic evaluation.

Once we observed clinical improvement,we determined that LASIK was appropriate forher non-dominant eye and performed thin flaphyperopic femtoLASIK with a target of –1.25D. The flap diameter was programmed for 8.5mm with an intended flap thickness of 110 µm.Because we did not treat the patient’s domi-nant eye, we counseled her that she may feela difference transiently between the two eyes.Interestingly, postoperatively, she could tell nodifference between the two eyes with regard to dryness, which anecdotally supported ourefforts to optimize her ocular surface.

Dr. Waring is director of refractive surgery and assistant professor of ophthalmology, Medical University of South Carolina, Charleston, S.C. He can be contacted at georgewaring@me.com.

Case 2: Preop treatmentimproves surgical planning accuracyby Craig McCabe, MD

A75-year-old female was referredfor progressive vision loss andred eyes. She complained ofglare and difficulty driving at nightas well as painful, gritty eyes. Her

exam demonstrated a decreased tear menis-cus, 2+ inferior corneal punctate epithelial ero-sions, and a 3+ nuclear sclerotic cataract OU.The lid margin was normal. An OPD-Scan ofher left eye revealed a Placido image with the characteristic dull corneal light reflex andwavy, irregular mires, especially inferiorly, of adry ocular surface. I think these corneal reflexcharacteristics are the first detectable objectivesign of an underlying dry eye problem. Moreimportantly, I have found that postponing thelens calculation measurements of a premiumIOL patient until after his/her ocular surfacedisease has been treated, as measured by thePlacido image, results in significantly betterpostoperative uncorrected visual acuity,smaller target-manifest refraction mismatch,and a lower enhancement rate.

Six weeks after our dry eye treatment (artificial tears six times/day, loteprednol fourtimes/day, cyclosporine 0.5% two times/day,eye lid scrubs, and punctal occlusion), her dryeye symptoms were greatly improved. Com-pared to the first OPD-Scan, there was a noticeable improvement in the Placido imageof the axial map. Also, there were significantchanges in spherical aberration (decreasedfrom 0.241 µm to 0.136 µm.), K valueschanged in both magnitude (0.36 D) and direc-tion (12 degrees), and there was an increasein average pupil power (APP, 0.8 D). Thesechanges are important to the surgical planningbecause they can affect the IOL type and

power, as well as the magnitude and axis ofastigmatism correction.

In both eyes, dry eye treatment resultedin a 0.5 D change in the IOL power selected toachieve a plano result. It also revealed that hercorneal astigmatism was significant enough towarrant corneal relaxing incisions (CRIs).

One month after cataract surgery with amultifocal IOL and CRIs, her UCVA OS was20/20 and J1+ with a manifest refraction of –0.25 + 0.25 x 006 degrees. She was very sat-isfied with her new vision and enthusiasticallylooked forward to having surgery on her righteye. It is important to note that had we basedthe surgical plan on initial data without thebenefit of prior dry eye treatment, the patientwould likely have ended up with a manifest refraction of –0.75 +0.75 x 045 at best. Thus,preoperative treatment can mean the differ-ence between needing to perform an enhance-ment procedure on an unsatisfied patient andhaving a very satisfied premium lens patient.

Case 3: Postop treatmentimproves image qualityand satisfactionA 65-year-old female presented one week afteruncomplicated cataract surgery with a multifo-cal IOL in the left eye. She complained that theeye felt “sandy” and that her vision had wors-ened after postoperative day one. Her mani-fest refraction was –0.50 +1.50 x 175 degreesyielding a UCVA of 20/50 and J3. She was diagnosed with postoperative dry eye and irregular astigmatism (Figure 1). She beganthe dry eye therapy and was counseled on thepotential need for a CRI in the future.

On her return visit one month later, herexam showed improvements in: UCVA (20/25and J1), MR (–0.25 +0.75 x 178), total wave-front error (TWE, 1.089 µm to 0.580 µm), root

Figure 1: Case 3, postoperative day seven before dry eye treatment

continued on page 5

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Incorporating dry eye treatment into the surgical settingby Francis S. Mah, MD

There are three dry eye manage-ment models: integrated, delegated, and clinic. I personallyuse the integrated model. The delegated model is for very busy

surgical practices. These practices may havesome junior associates, specialists, or op-tometrists in the practice who enjoy managingdry eye patients and tuning them up prior tosurgery. Finally, there is a very comprehensiveclinic style, which is a new style of practice,where dry eye management is generating income.

Models of managementIn the integrated model, dry eye managementis integral to the preoperative consult. The di-agnosis is made during the preoperative exam,and treatment is prescribed to prepare for sur-gery. Some practices may treat all or nearly allpatients. Surgical planning is not done until theocular surface is stable. This model typicallyincludes standard postoperative treatment pro-tocols. The literature supports this because thenumber one complaint following laser refrac-tive surgery and cataract surgery is dry eyes,and the majority of patients have dry eyes preoperatively, so it is important to identify and treat them preoperatively.

The delegation model is useful for a busyanterior segment surgeon or laser cataractsurgeon who wants to treat eyes with a healthyocular surface but minimize chair time. In thismodel, the preoperative and postoperativemanagement of dry eye is delegated to an op-tometrist or to a junior associate. Treatment, ifneeded, occurs before referral to the surgeon.

In a comprehensive dry eye clinic, patients undergo a full battery of tests and acomprehensive evaluation. Patients with dryeye signs or symptoms are often reappointedto a specialized dry eye clinic within the prac-tice. This clinic may offer out-of-pocket diag-

nostics and treatments, and it may sell nutriceuticals, etc. It can become a profit center and practice builder. In this model, dry eye care may proceed in tandem with thesurgical workup scheduling.

Every practice has its own approach, butthese three models demonstrate ways to suc-cessfully make dry eye evaluation and treat-ment a routine and effective part of surgicalcare.

Diagnosis and treatmentPreoperatively, to determine the degree of associated dry eye, slit lamp exam, Schirmer’stesting, fluorescein or lissamine green stain,and tear break-up time can be used. Other di-agnostic tools include blink rate, fluorophotom-etry, and tear osmolarity.

There are different types of patterns oftear film break-up time that might further iden-tify the deficiency in the tear film (Figure 1). Iput fluorescein in and after two minutes, I liketo examine for staining. Following this exam, Imeasure the seconds before the tear filmbreaks up on the surface of the cornea. I typi-cally use a conservative measure of 10 sec-onds as normal, but some people are using aneven more conservative 7 seconds as the ab-normal tear break-up time. Different types ofcorneal and conjunctival staining techniquesgive practitioners a picture of the patient’scorneal integrity. Fluorescein staining with a Wratten filter can show even minimal insult tothe cornea, and lissamine green and rose ben-gal can give similar clues to the health of thesurface of the conjunctiva.

For experimental studies, we primarilyuse the NEI grid for corneal staining (Figure 2).There are five zones on the eye, and eachzone is scored 0 to 3, for 15 possible points.

My primary approach is to base my diagnosis and management on actual symptoms. Dry eye disease symptoms include

discomfort, dryness, burning or stinging, for-eign body sensation, a gritty feeling, sticki-ness, blurry vision, photophobia, itching, andredness. Typically, patients will mention burn-ing or fluctuation in vision. For me, fluctuationin vision is enough to establish that the patientprobably has dry eye or ocular surface dis-ease. However, it is important to note thatsymptoms seldom correlate with clinical signs.

I like to personally look at the tear lake,and I stain with fluorescein and lissaminegreen to look for corneal and conjunctivalstaining as described above. I evaluate thetear film break-up time, which is easy to doand gives me an assessment of the meibo-mian glands and how they’re functioning. Finally, I push on the lower eyelid to look at thequality of the meibomian gland material andthe meibum itself. This rapid but effective series of exams can be done without disrup-tion of the clinical flow and can identify thosepatients who have ocular surface disease orwho may be at risk.

Preoperatively, practitioners can also incorporate the TearLab Osmolarity Test. It aids in management, and osmolarity is probably the future of tear diagnostics. At thisstage, for me it is more of a management toolrather than a diagnostic tool. We can also useLipiView, which measures the lipid in the tearsand is an excellent tool for assessing the func-tion of the meibomian glands. I typically do notuse this as a diagnostic tool. Instead, I use it tohelp educate patients.

Categorizing dry eyeIn 2006, a group of thought leaders includingindustry, PhDs, ophthalmologists, and op-tometrists met to consider a group finding onthe state of dry eye disease. One of the con-clusions of this “Delphi panel” was a chart thatbreaks the disease down into four categoriesof severity (Figure 3).

Figure 1. Here we see the progression from a lubricated/protected ocularsurface with an intact tear film (post blink in a healthy eye) begin todegrade as time moves forward. Notice by 5 seconds, there is significantexposure to the cornea, and by 16 seconds we can say that the surface isfar less protected than it was after the blink.

Figure 2. NEI grid for corneal staining

Can improved ocular surface care really impact cataract and refractive surgery outcomes?

After categorization, the group attemptedto apply suggested treatment protocol to thelevels of severity. While there is still a greatdeal of debate here, the Delphi group doessuggest a first-line approach of lubricant eyedrops before the disease progresses to moresevere stages.

The most valuable treatments for chronic dry eye in the surgical setting are topical cyclosporine, topical steroids, andpunctal occlusion.

Using topical cyclosporine 0.05% im-proves ocular surface health and decreasesartificial tear use. It has also been associatedwith faster recovery and better outcomes fordry eye patients undergoing LASIK.

Corticosteroids have been shown to beeffective even for patients with severe dry eyewho had no improvement from other treatmentmodalities. However, the well-known side ef-fects of corticosteroids usually preclude theirlong-term use.

Punctal occlusion can be helpful for patients with aqueous tear deficiency whenmedical means of aqueous enhancement areineffective or impractical (Figure 4). Treatmentwith punctal occlusion results in decreasedsigns and symptoms. There are advantages tosemipermanent plugs. For example, they canbe removed if the patient develops epiphora or

foreign body sensation from the plugs them-selves. Punctal occlusion may also be madepermanent with a disposable thermocautery orradiofrequency needle. For most patients, asemipermanent procedure should be consid-ered first. The disadvantage of punctal occlu-sion is that it does not reverse the altered tearcomposition that underlies dry eye disease.Additionally, occlusion has the effect of retain-ing unhealthy tears on the ocular surface,which significantly decreases corneal sensa-tion and tear production.

For Level 1 dry eye, try to eliminate thefollowing exacerbating factors:• Wind, air conditioning, dry heat,

high altitudes• Smog, exhaust, smoke• Prolonged computer use• Contact lens wear• Medications that contribute to

keratoconjunctivitis siccaAlso, preserved tears can be used up

to four times a day. If these measures are ineffective or impractical, I use topical cy-closporine, which is the treatment of choice forLevel 2 dry eye. For Level 3 dry eye, punctalplugs are used. I prefer to treat the inflammationbefore inserting plugs so that healthy tears areretained on the ocular surface.

Intraoperatively, minimize commercialdrops and benzalkonium chloride. Additionally,try to minimize anesthetic drops. Balanced salt solution or viscoelastics can optimize theocular surface. Also, try to reduce incisionsizes, which will disrupt less corneal nerves.

Postoperatively, minimize the frequencyof dosing commercial eye drops, and aggres-sively treat ocular surface disease. I typicallyhear the majority of complaints of dry eyesymptoms when the anti-inflammatories arediscontinued following cataract surgery. At thatpoint, I reinstitute cyclosporine or artificial tearsaggressively.

To summarize, there are a variety of mod-els for effective and consistent dry eye man-agement in the surgical setting. Diagnosis andtreatment can be streamlined in the surgicalsetting but not ignored. Treating dry eye aggressively both pre- and postoperativelyachieves optimal surgical results.

Dr. Mah is the director of cornea and external disease, and co-director of refractive surgery, Scripps Clinic Torrey Pines, La Jolla, Calif. He can be contacted at mah.francis@scrippshealth.org.

Figure 3. Four categories of dry eye severity Figure 4. Punctal occlusion

mean square (RMS, 0.93 D to 0.31 D) for a3.0-mm pupil and a much sharper and moreregular Placido image.

Three months later, she agreed to a smallCRI that further improved her UCVA (20/20and J1+) and MR (+0.25 D sphere), TWE(0.349 µm), and RMS (0.22 D).

In this case, treatment of postoperativedry eye turned an unhappy multifocal IOL

patient into a happy one. The improvement inher refraction after treatment demonstrates the importance of optimizing the ocular surface before performing costly and/or invasive cor-rective procedures that may further stress analready compromised ocular surface. By cor-recting ocular surface disease through dry eyetreatment both before and after cataract surgery with premium lens implants, the two

most common causes of patient dissatisfac-tion, namely ametropia and dry eye disease,can be significantly reduced.

Dr. McCabe is a clinical instructor, Vanderbilt University, and inprivate practice, Murfreesboro, Tenn. He can be contacted atDrMcCabe@McCabeVisionCenter.com.

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Ocular surface optimization protocolby George O. Waring IV, MD, FACS

The first step in optimizing the ocu-lar surface is to characterize thedeficiency or disorder by determin-ing the etiology, whether meibo-mian gland dysfunction, aqueous

tear deficiency, allergic conjunctivitis, underly-ing systemic disorder, or a combination of anyof the aforementioned.

Often, Baby Boomers presenting for surgery display clinical signs of chronic dry eye(such as conjunctivochalasis) with a multifacto-rial etiology. As a result, my first line treatmentmay include preservative-free tears everyhour, twice-daily cyclosporine, and reverse bioengineered oral omega-3 supplements. Ifthat regimen is ineffective, we may instate alow dose steroid and lower plugs. If this is noteffective, we move on to preservative-freegels, upper plugs, and LipiFlow.

Patients who require ocular surface optimization include those with irregular astig-matism that may be related to keratoconjunc-tivitis sicca, those with moderate (Level 2) dryeye or worse, and those who are 50 years ofage or older who have even mild dry eye signsor symptoms. In this age group, I have a verylow threshold for treatment.

In young patients or in patients who havemild dry eye, the therapy should be continuedfor three to six months. For moderate to severe cases, we continue our recommendedocular surface optimization (OSO) regimenpostoperatively, often with modifications to tailor the treatment to the patient’s lifestyle.However, many patients require continuedtherapy indefinitely. It is important to tell pa-tients that it is often a lifetime commitment. Inaddition, we are careful to set patient expecta-tions appropriately regarding postoperative

dryness with the technique of underpromisingand overdelivering.

I recently treated a 65-year-old womanwith mild hyperopia who wanted out of herreading and distance glasses. Slit lamp examwas remarkable for decreased tear lake, 1+anterior staining, 1-2+ conjunctivochalasis,and 1-2+ nuclear sclerosis. Topography wasremarkable for mild irregular astigmatism con-sistent with keratitis sicca and normal kerato-metric values. Treatment options included dysfunctional lens replacement, CK, LASIK,PRK, and no surgery at all. Although we feltthat a dysfunctional lens replacement wasclearly indicated, the patient felt strongly aboutpursuing LASIK.

As mentioned above, the first step intreating this patient is to optimize the ocularsurface and then address the dysfunctionallens. This patient indicated that she was not in-terested in lens surgery, which is pretty rare inour practice. We counseled this patient care-fully about her dry eye to make sure that shehad realistic expectations. We instated sixweeks of ocular surface optimization with frequent preservative-free tears, cyclosporinetwice a day, and reverse bioengineeredomega-3 fatty acids, and we performed serialtopography/tomography and manifest refrac-tion to see that they stabilized. The figuresshow her preoperative tomography and her tomography after six weeks of ocular surfaceoptimization.

In this case, we performed thin flap hyperopic LASIK in both eyes. The target forher dominant eye was plano, and the target forher nondominant eye was –1.25 D. The flap diameter was programmed for 8.5 mm with anintended thickness of 110 µm. We decreased

the flap diameter somewhat even though it’s ahyperopic treatment, as she was older and hadmoderate dry eye to minimize impact on thenerve plexus. Postoperatively, she was 20/20J1+. She had a stable ocular surface and waswithout subjective dryness and without com-plaints after six weeks of treatment.

Because of this patient’s conjunctivocha-lasis and small cornea, these eyes can be diffi-cult to dock depending on your femtosecondlaser. I offset to the side, which engages theloose conjunctiva, then slide centrally so theflap is perfectly centered on the intended treat-ment.

It is not uncommon to encounter irregularepithelium when initiating flap lifts in elderlypatients. Additionally, these patients may dis-play an irregular hypertrophic epithelial healingpattern postoperatively that is often self-lim-ited, which this patient experienced. Other-wise, the case was uneventful, and the patientwas very happy with her postoperative uncor-rected acuities of 20/20 and J1+. She knowsthat she will be returning to my office within 10year to have her lenses replaced.

It is important to consider ocular surfaceoptimization in patients with mild to moderatedry eye to convert them to LASIK or advancedtechnology IOL candidates. The next genera-tion of procedures, such as corneal inlays,pockets, SMILE, and biomechanical modula-tion, will provide for further penetration into thismarket.

Dr. Waring is director of refractive surgery and assistant professor of ophthalmology, Medical University of South Carolina, Charleston, S.C. He can be contacted at georgewaring@me.com.

Can improved ocular surface care really impact cataract and refractive surgery outcomes?

Can improved ocular surface care really impact cataractand refractive surgery outcomes?

In a survey conducted at a CME symposium presented at ASCRS, 850 attendees were reached, representing175,000 refractive procedures, 450,000cataract procedures, and 43,000

premium IOL procedures annually. More than one-third of these attendees have a premium IOL conversion rate of more than10%. More than half (57%) practice outsidethe United States.

Figure 1

Figure 2 Figure 3

Impact: Change in OpinionMoore Outcome Level 3

Attendees were surveyed about theiropinions and practices before and after attend-ing the symposium. After attending the sympo-sium, there was a highly statistically significantshift in the belief that mild to moderate dry eyein surgical patients has a significant impact onvisual outcomes (Figure 1).

Additionally, there was a significant shiftin awareness. Participants were asked, “Whatpercentage of cataract surgery patients pres-ent with Level 2 dry eye requiring treatmentbeyond artificial tears?” Before the sympo-

sium, none of the respondents answered cor-rectly. After the symposium, 21% respondedcorrectly (Figure 2).

There was also a shift in knowledge. Before the symposium, most (54%) partici-pants did not know whether they diagnose andtreat dry eye in a manner consistent with theguidelines. After the cases and presentationsfocusing on defining Level 2 dry eye and identifying treatment per the guidelines, 77% correctly identified the major differentiator between Level 1 and 2 (Figure 3).

Highly statistically significant (p<0.01) shift in the belief that mild to moderatedry eye in surgical patients has a significant impact on visual outcomes

Impact: Knowledge ShiftMoore Outcome Level 3

What percentage of cataract surgery patients present withLevel 2 dry eye requiring treatment beyond artificial tears?

Impact: Knowledge ShiftMoore Outcome Level 3

% strongly agreeing nearly doubled

n = 145

Total agree/strongly agree

Strongly agree

69

37

85

72

Prior to symposium no respondents answered >60% and only 6% answered >40%

(Most thought it was <20%)

PHACO Study resultspresented by Dr. Trattler

Afterward, 21% responded correctlyand 56% said >40%

This shift in awareness ishighly statistically significant

(p<0.01)

(According to PHACO Study, it is >60%)

Pre-ASCRSMajority (54%) did not know whether they

diagnose and treat consistent with guidelines

Cases and presentations focused on defining Level 2 dry eye and identifying

treatment per guidelines

Post-Symposium77% correctly identified major

differentiator between Level 1 & 2

Understanding of guidelines(DTS/DEWS/DELPHI) for diagnosis

& treatment of dry eye

7

CME Questions (Circle the correct answer)

Copyright 2013 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS.

1. According to the DEWS report, at what level ofdry eye severity should therapy be initiated?a. 1b. 2c. 3d. 4

2. According to the NEI grid for corneal staining,the eye is divided into how many zones?a. 3b. 4c. 5d. 6

3. According to the NEI grid, what is the maximum possible score for each eye?a. 15b. 18c. 21d. 24

4. A patient presents to you with complaints ofdryness requiring frequent artificial tears with-out relief. Your exam reveals marked punctatestaining, some central corneal staining, and

filaments in the tear film. At what level of dry eye disease should this patient be characterized, according to the Delphi Panel Consensus for dry eye?a. 1b. 2c. 3d. 4

5. In treating the patient described in Question 4,which of the following treatments do the Delphipanel guidelines recommend adding for the firsttime at this level of dry eye?a. Nonpreserved tears b. Punctal plugsc. Punctal cautery d. Topical steroids

6. According to Dr. Waring’s ocular surface optimization protocol for patients undergoingsurgery, what is the second line of treatment?a. Cyclosporine and omega-3 supplementsb. Cyclosporine and preservative-free tearsc. Upper plugs and LipiFlowd. Lower plugs and a low dose steroid

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Can improved ocular surface care really impact cataract and refractive surgery outcomes?