Dry eye disease (DED) is one of the most common disorders I see in my practice, and it can significantly affect cataract surgery outcomes. DED not only leaves patients feeling uncomfortable but also hinders surgeons’ ability to get accurate preoperative measurements and negatively affects postoperative quality of vision. Aggressively optimizing the ocular surface, both pre- and postoperatively, makes a huge difference in terms of clinical outcomes.
My practice has instituted a specific protocol for identifying DED. Every cataract surgery patient completes an Ocular Surface Disease Index questionnaire and gets a tear osmolarity score when he or she walks in the door. If the TearLab (TearLab) detects an osmolarity score of 315 mOsm or higher, no preoperative workup is done until I examine the patient; I have found that this approach prevents a lot of cataract surgery workups from having to be thrown out once DED is treated. If a patient’s condition is not optimal for obtaining refractive measurements and undergoing surgery, we aggressively treat the DED first.
We strive to educate patients about why they have DED, focusing on the meibomian glands and their contribution to this condition. We are big believers in strategies that aim to make the meibomian glands work better, along with treating any aqueous tear deficiency. Younger patients with mild dry eye, no significantly elevated tear osmolarity, and no detection of MMP-9 (RPS) are typically started on a conservative therapy with artificial tears and warm compresses. We will continue this therapy as long as patients are showing improvement. Nutritional supplements are also helpful; however, we have found that compliance wanes over time, as the capsules are generally taken four times daily and many patients find this inconvenient.
If the patient has meibomian gland disease (MGD) or a poor response to artificial tears, our next step is Restasis (cyclosporine ophthalmic emulsion; Allergan). Although effective on its own, we have found that when used in conjunction with a lid hygiene routine (Avenova; Nova Bay), Restasis works better, faster, and more effectively. The mechanical wiping of the lids and the Neutrox in Avenova helps remove bacteria that clog the meibomian glands, while Restasis combats the inflammatory component of DED. This pairing has been one of our secrets to success with patients who have more moderate to severe stages of dry eye. Our current regimen pairs using twice-daily Restasis with once-daily Avenova usage.
For patients with severe DED, the next step in our regimen is intense pulsed light therapy (IPL) utilizing the Toyos Technique.1 IPL is an intense flash of light with heat that coagulates the telangiectatic vessels at the eyelid margins that are common with MGD. This has a direct thermal effect on the meibomian glands that, in effect, melts the gummed up secretions to help unclog the glands. IPL tends to work best in patients who have ocular rosacea, and they report tremendous symptomatic relief. However, we will administer this therapy to any patient who does not respond to other treatments. Treatments are generally performed once a month for 4 months, and then maintenance treatments are done as needed, typically once a year. Patients will also continue their Avenova usage to maintain lid hygiene.
As a premium lens surgeon, I have found that the number-one factor contributing to my success and to my patients’ satisfaction is my attention to DED. Rather than being irritated by a delay in their cataract surgery, most patients are impressed by our attention to detail and strive for perfection. When it comes to DED, patient education, aggressive preoperative treatment, and appropriate postoperative management are key for premium lens patients.
By Dr. Ivan Mac
Article originally published on Millennial Eye, September 2016