Managing Ocular Surface Disease to Optimise Surgical Outcomes

Supplement February 2018

Supported by an unrestricted educational grant from Shire, Novartis & TearLab

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Managing Ocular Surface Disease to Optimise Surgical Outcomes

Cataract surgery itself also may induce or worsen dry eye disease, particularly in patients with preexisting dry eye, decreasing tear meniscus, tear film breakup time, and Schirmer’s test results and increasing corneal fluorescein staining (Figures 1 and 2).8,9 Virtually all patients who have corneal refractive surgery have dry eye symptoms after the procedure, and 10% to 30% will have persistent dry eye after LASIK.10

Ophthalmologists need to optimise the ocular surface before performing preoperative measurements and before surgery, especially in patients receiving premium IOLs. In cases of severe ocular surface disease, it may be necessary to postpone surgery until the surface is optimised.

PINPOINTING DRY EYEIt is essential to recognise a disparity between signs and symptoms. Patients may not mention dry eye symptoms because their symptoms are minor or they consider them unimportant. In addition, older patients with neurotrophic dry eye may be asymptomatic.

Ophthalmologists have a number of tools at their disposal to diagnose dry eye and identify its origin, which will guide them in developing the correct treatment strategies. Treatment options for aqueous deficiency dry eye include artificial tears, punctal plugs, autologous serum, anti-inflammatory topical treatment, oral omega-3 supplements, and cholinergics such as oral pilocarpine. However, meibomian gland disease may be treated with artificial tears (with or without lipid component), lid hygiene, topical azithromycin, systemic doxycycline derivatives, oral omega-3 supplements, in-office lid cleansing with a hand-held device, thermal pulsation, or meibomian gland probing.

CONCLUSIONUndiagnosed dry eye compromises visual quality and may lead to suboptimal refractive outcomes after cataract or corneal refractive surgery.

Surgeons need to diagnose and manage dry eye before and after surgery to provide the excellent visual outcomes patients expect from their procedures.

REFERENCES1. Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop. Ocul Surf. 2007; 5:75-92.2. Trattler WB, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017; 11:1423-1430.

Dry eye may be an unrecognised obstacle as surgeons strive to achieve optimal visual outcomes from cataract or refractive surgery and provide the postoperative results patients expect.

Left untreated, dry eye causes tear film instability, impacting preoperative measurements and, consequently, postoperative vision.1 It also may increase the risk of postoperative complications or infection and reduce patient satisfaction after successful cataract surgery.

COMMON CONDITIONDry eye may be more common than recognised. Trattler et al. reported that among 136 patients having cataract surgery, dry eye was diagnosed previously in only 22%.2 On examination, corneal staining was present in 77% of patients, and approximately 63% had a significantly reduced tear film breakup time of 5 seconds or less.

Ophthalmologists may miss dry eye because they are more focused on surgery than ocular surface disease or because patients have visual impairment and underrate their dry eye symptoms. Therefore, dry eye testing may not be performed.

Dry eye significantly affects optical quality and patients’ quality of life.3,4 Ridder et al. found that dry eye significantly decreased reading speed, and as symptoms increased, speed decreased.5

Using a driving simulator for patients with dry eye, Deschamps et al. reported that the condition was associated with a significantly increased reaction time and increase in percentage of missed targets.6

IMPACT ON SURGICAL OUTCOMESWhen preoperative measurements are performed in patients with dry eye, they can lead to incorrect intraocular lens (IOL) calculations and suboptimal visual outcomes. Epitropoulos et al. reported that average K and anterior corneal astigmatism measurements were more likely to vary in eyes with a hyperosmolar tear film, increasing differences in IOL calculations.7

Dry eye significantly affects optical quality and patients’ quality of life

Elisabeth M. Messmer, MD

Figure 1. Right eye of patient with cataract and mild corneal staining Figure 2. Left eye of the same patient with severe corneal staining after cataract surgery 2 years earlier

A Healthy vs. Dysfunctional Ocular Surface and the Impact on Surgical Outcomes Undiagnosed dry eye may significantly diminish patient satisfaction after surgeryBy Elisabeth M. Messmer, MD

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Managing Ocular Surface Disease to Optimise Surgical Outcomes

Ideal Diagnostic Tools: Using Diagnostic Information to Guide Treatment Decisions Choosing the correct diagnostics helps clinicians establish the origin of dry eye and customise treatmentBy José Güell, MD

Tear film quality is the most important factor enabling refractive and cataract surgeons to achieve high-quality visual outcomes from surgery.

Current technologies offer the potential to provide superior vision, but we cannot deliver the excellent visual results our patients now expect without assessing and managing the tear film.

Montés-Micó emphasised the influence of the tear film on visual quality and reported that dry eyes are more likely to have large optical aberrations than those with a normal tear film.1

ARRAY OF DIAGNOSTIC OPTIONSOphthalmologists have a range of available tools to help them detect ocular surface disease and identify its origin. Traditional diagnostics include external examination, meibography, Schirmer’s test, conjunctival and corneal staining, and tear breakup time (Figure 1).

I have found tear breakup time to be one of the most useful tests because it demonstrates tear film function, while the

others show anatomy and biological and structural changes (Figure 2). I believe it is also one of the easiest ways to evaluate

tear film function. Ultimately, the functional status of the tear film influences whether the patient has good, intermediate, or poor vision.2

Tear breakup time is somewhat subjective, and to obtain the most accurate results, it should be performed before any other test.

I recommend using strips rather than drops of fluorescein, which may interfere with the tear volume. In addition, to standardise the procedure, ophthalmologists should always use the same light intensity.

In my experience, analysis with a double-pass instrument is the most important tool in identifying dry eye. Performing a series of objective scatter measurements, Yu et al. reported that this method may be even more likely to detect dry eye than tear breakup time, so it may be useful in identifying very early asymptomatic cases.3

After I have detected the existence of tear film abnormalities with it, we can perform additional tests to determine the origin of dry eye and develop a customized treatment strategy.

Figure 2. The deterioration of visual quality between blinks can be clearly observed (in this case, a mild evaporative dry eye) despite a normal tear breakup time and Schirmer test

Figure 1. Lissamine green corneo-conjunctival staining on a mild evaporative dry eye after cataract surgery. Without adequate management, postoperative functional visual results will be suboptimal

3. Tan CH, et al. Dynamic change of optical quality in patients with dry eye disease. Invest Ophthalmol Vis Sci. 2015; 56:2848-2854.

4. Benitez-Del-Castillo J, et al. Visual acuity and quality of life in dry eye disease: proceedings of the OCEAN group meeting. Ocul Surf. 2017; 15:169-178.

5. Ridder WH, et al. Evaluation of reading speed and contrast sensitivity in dry eye disease. Optom Vis Sci. 2013; 90:37-44.

6. Deschamps N, et al. The impact of dry eye disease on visual performance while driving. Am J Ophthalmol. 2013; 156:184-189.

7. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015; 41:1672-1677.

8. Li XM, et al. Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. Cornea. 2007; 26(9 Suppl 1):S16-S20.

9. Yu Y, et al. Evaluation of dry eye after femtosecond laser-assisted cataract surgery. J Cataract Refract Surg. 2015; 41:2614-2623.

10. Solomon R, et al. The effects of LASIK on the ocular surface. Ocul Surf. 2004; 2:34-44.

Dr. Messmer is professor of ophthalmology, Ludwig Maximilian University, Munich, Germany. She may be reached at Elisabeth.Messmer@med.uni-muenchen.de.

Dr. Messmer is a speaker or advisor for the following companies: Alcon Pharma GmbH, Dompé, Pharm-Allergan GmbH, Santen GmbH, Shire, Théa Pharma GmbH, TRB-Chemedica, Ursapharm Arzneimittel GmbH, and Visufarma.

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Managing Ocular Surface Disease to Optimise Surgical Outcomes

Point-of-care diagnostics, such as tear osmolarity, tear volume, MMP-9, and tear production, provide anatomical information and each of these aspects may have a significant influence on the final tear film function.

In my experience, after an abnormal evaluation with a double-pass instrument indicates that the patient has an unstable tear film, MMP-9 provides important information because it indicates the presence or absence of inflammation along with dry eye.

In a retrospective chart review of 100 cases, Sambursky reported that MMP-9 testing may help clinicians tailor their treatment strategies.4

Tear osmolarity provides important information in guiding treatment once I have determined the tear film function. Lemp et al. stated that tear osmolarity is the most useful test to detect and classify dry eye.5 The Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop defined tear hyperosmolarity and tear film instability as the causes of dry eye.6

After treatment, Benelli et al. reported that tear film osmolarity is the most measurable and objective test in assessing patients’ response.7

Of the meibomian gland diagnostics — meibomian gland imaging and lipid layer interferometry — I believe the images from interferometry are most valuable. Both provide high-quality meibomian gland images, but I am more experienced with interferometry, which also measures tear film thickness, blink rate, and partial blink rate. A relatively thin tear film lipid layer has been correlated with severe symptoms of dry eye.8

GUIDING TREATMENT STRATEGIESOphthalmologists are becoming increasingly aware of the potential of these tests to help them evaluate the function, anatomy, and biology of the tear film and are using more of these diagnostics to guide treatment.

Before starting any treatment plan and taking into account that symptoms such as foreign body sensation, tearing, and redness are also present in other common pathologies such as hypersensitivity or infectious conjunctivitis, we should rely on a single and objective test to first evaluate tear film functional health, and I have found the double-pass instrument the best to start our evaluation

CONCLUSIONI encourage all ophthalmologists to test the range of available ocular surface diagnostic tools and ultimately choose the devices they find most useful.

REFERENCES1. Montés-Micó R. Role of the tear film in the optical quality of the human

eye. J Cataract Refract Surg. 2007; 33:1631-1635. 2. Goto E, et al. Impaired functional visual acuity of dry eye patients. Am

J Ophthalmol. 2002; 133:181-186. 3. Yu A-Y, et al. Assessment of tear film optical quality dynamics. Invest

Ophthalmol Vis Sci. 2016; 57:3821-3827.4. Sambursky R. Presence or absence of ocular surface inflammation

directs clinical and therapeutic management of dry eye. Clin Ophthalmol. 2016; 10:2337-2343.

5. Lemp MA, et al. Tear osmolarity in the diagnosis and management of dry eye disease. Am J Ophthalmol. 2011; 111:792-798.

6. Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop. Ocul Surf. 2007; 5:75-92.

7. Benelli U, et al. Tear osmolarity measurement using the TearLab osmolarity system in the assessment of dry eye treatment effectiveness. Cont Lens Anterior Eye. 2010; 33:61-67.

8. Blackie CA, et al. The relationship between dry eye symptoms and lipid layer thickness. Cornea. 2009; 28:789-794.

Dr. Güell is associate professor of ophthalmology, Autonomous University of Barcelona, Spain. He may be reached at guell@imo.es.

Dr. Güell is a founder and past president of Visiometrics and is a consultant for Théa.

Ultimately, the functional status of the tear film influences whether the patient has good, intermediate, or poor vision José Güell, MD

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Ophthalmologists are increasingly recognising the negative impact of dry eye on visual outcomes after cataract surgery; however, they may be surprised to learn how common it is among patients with cataracts.

It has been reported in the literature that 3% to 33% of patients with cataracts have ocular surface disease (OSD).1 In the PHACO study, Trattler et al. reported that 77% of patients scheduled for cataract surgery had positive corneal staining, although dry eye had been previously diagnosed in only 22%.2

OSD significantly affects visual outcomes of cataract surgery, and cataract surgery may exacerbate existing dry eye.3,4 Therefore, to achieve patient satisfaction it is important to take the necessary steps to identify dry eye and use effective treatment strategies before performing preoperative measurements or surgery.

DIAGNOSTIC GUIDANCESurgeons are more likely to diagnose severe dry eye but may overlook more subtle cases which can get significantly worse after surgery.

The first step is to note patients’ blink frequency while taking their history. Some older patients do not blink, particularly if they have Parkinson’s disease or are receiving psychopharmacological treatment for psychosis or depression. Such patients may develop problems after surgery and require more frequent follow-up visits.

Meibomian gland disease impacts patients’ tear film stability. Signs include an uneven lid margin, meibomitis with obstruction of glands, blepharitis, and a low tear breakup time (TBUT) (Figure 1). Functional visual acuity may be satisfactory immediately after the patient blinks but rapidly declines as the eye remains open and dry spots occur on the ocular surface. As a result, patients have difficulties performing visual tasks, especially reading. If meibomian gland disease is overlooked by the surgeon and thus remains untreated, these patients are most likely to be unhappy with their surgical results.

In addition, surgeons should examine the eye for lid parallel conjunctival folds (LIPCOFs), a sign of severe dry eye.

CONSIDERING TREATMENT OPTIONSThe most common treatment for dry eye is preservative-free artificial tears with a relatively low osmolarity to counteract tear film hyperosmolarity (Figure 2). There are numerous preparations to choose from. In general, hyaluronic acid has an advantage over other drugs because it is a natural constitute of the tear film that binds water and supports epithelial regeneration.

It is important to counsel patients with moderate disease that their OSD may worsen after cataract surgery. If patients are cautioned beforehand, they are not surprised if symptoms occur.

If patients have very severe dry eye and complain of foreign body sensation, we begin anti-inflammatory treatment with

Managing Ocular Surface Disease in Cataract Patients If overlooked, condition may diminish surgical outcomes

By Friedrich Kruse, MD

Figure 1. Signs of Meibomian Gland Dysfunction

Figure 2. Examples of common treatments for ocular surface diseases

topical cyclosporine as a second-line treatment.5 Alternately, lifitegrast may be used for severe dry eye, although we do not have experience with this medication.6 (Lifitegrast has not yet been approved for use in Europe.)

In addition, punctal plugs may be useful in long-standing severe dry eye. In the future, clinicians may be able to use nasal tear stimulation to treat dry eye; however, we await more information about this technology.7

Patients with severe meibomian gland disease with surface inflammation who complain of itching and burning as indicated by poor functional vision, lid abnormalities, and a low TBUT often benefit from preservative-free steroids, which dramatically improve surface quality. As in more mild forms of meibomian gland disease, patients need to use lid scrubs and warm compresses to soften the meibum; they also may also benefit from slow-release tetracycline or topical azithromycin.

In addition, clinicians may recommend thermal pulsation for patients with meibomian gland disease.8

CONCLUSIONSurgeons need to keep in mind that OSD may affect as many as one-third of patients with cataracts. In addition to discussing surgical and technology options with patients, such as femtosecond laser-assisted cataract surgery and multifocal intraocular lenses, I recommend that they also counsel patients about the potential impact of OSD and how long symptoms may last. If patients are unaware that they have OSD that may worsen after surgery, they may blame the surgery for their symptoms.

It is important to counsel patients with moderate disease that their OSD may worsen after cataract surgery Friedrich Kruse, MD

Managing Ocular Surface Disease to Optimise Surgical Outcomes

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Managing Ocular Surface Disease to Optimise Surgical Outcomes

Undiagnosed tear film instability can significantly affect visual quality and cylinder and refractive power measurements. This can lead to inaccurate intraocular lens (IOL) calculations and suboptimal visual outcomes,

diminishing patient satisfaction after surgery, particularly in those with premium IOLs. Furthermore, undiagnosed dry eye may worsen after surgery.1

In hyperosmolar eyes, Epitropoulos et al. noted that average K and anterior corneal astigmatism measurements varied and were associated with differences in IOL calculations.2

Reviewing a number of studies, Montés-Micó reported large optical aberrations in patients with dry eye that can result in blurred vision.3

A Deeper Look at OSD Diagnosis and Treatment Surgeons may underestimate the likelihood of dry eye, leading to suboptimal surgical results

By Béatrice Cochener, MD, PhD

Figure 1. Point of care testing options Figure 2. Examples of treatment options

Because many patients with an unstable tear film are asymptomatic or have less obvious dry eye, surgeons must perform preoperative measurements with more than one device and check for discrepancies and image stability; one should be able to correlate the refraction, biometry, and corneal topography. If there is a disparity, it is recommended to instill one drop of artificial tears in the eye to optimise the surface before corneal topography.

When measurements and images continue to vary related to an unstable tear film, one to three months of treatment with ocular lubricants help optimise the ocular surface and measurements are repeated. In severe cases that do not respond to lubricants, cyclosporine or other treatments may

REFERENCES 1. Report of the Definition and Classification Subcommittee of the

International Dry Eye Workshop. Ocul Surf. 2007; 5:75-92.2. Trattler WB, et al. The Prospective Health Assessment of Cataract

Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017; 11:1423-1430.

3. Li XM, et al. Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. Cornea. 2007; 26(9 Suppl 1):S16-S20.

4. Han KE, et al. Evaluation of dry eye and meibomian gland dysfunction after cataract surgery. Am J Ophthalmol. 2014; 157:1144-1150.

5. Stonecipher KG, et al. The IMPACT study: a prospective evaluation of the effects of cyclosporine ophthalmic emulsion 0.05% on ocular surface staining and visual performance in patients with dry eye. Clin Ophthalmol. 2016; 10:887-895.

6. Holland EJ, et al. Lifitegrast clinical efficacy for treatment of signs and symptoms of dry eye disease across three randomized controlled trials. Curr Med Res Opin. 2016; 22:1-7.

7. Friedman NJ, et al. A nonrandomized, open-label study to evaluate the effect of nasal stimulation on tear production in subjects with dry eye disease. Clin Ophthalmol. 2016; 10:795-804.

8. Schallhorn CS, et al. Effectiveness of an eyelid thermal pulsation procedure to treat recalcitrant dry eye symptoms after laser vision correction. J Refract Surg. 2017; 33:30-36.

Dr. Kruse is professor and chairman, Department of Ophthalmology, University Hospital Erlangen, Germany, and president of EuCornea. He may be reached at Friedrich.Kruse@uk-erlangen.de.

Dr. Kruse has been a speaker for Santen and TRB Chemedica.

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Managing Ocular Surface Disease to Optimise Surgical Outcomes

be useful, but such patients may not ever be candidates for refractive surgery. The accompanying sidebar describes two typical scenarios in testing for and treating dry eye.

If patients have visual concerns after surgery, we examine them for dry eye. For example, if a patient is adjusting to new multifocal IOLs and does not have significant refractive error but complains of difficulty reading at the computer, blink speed may have decreased, causing tear film irregularity. Frequent computer and tablet use probably increases meibomian gland dysfunction because users blink less frequently and completely.

When comparing subjects reading hard copy vs. computer text, Chu et al. noted that computer users had a greater percentage of incomplete blinks, although their blink rate was not reduced.4 The increased partial blink ratio contributes to tear film irregularity, leading to dry eye symptoms and patient frustration.

These cases can be very challenging for ophthalmologists because testing does not indicate obvious dry eye.5 Note that blinking re-education can be an additive treatment to warming care of lids, which will help break this vicious circle.

Frequent computer and tablet use probably increases meibomian gland dysfunction because users blink less frequently and completely Béatrice Cochener, MD, PhD

Common OSD scenarios

SCENARIO 1

A man with astigmatism and cataracts who would like to be spectacle free complains of fluctuating vision but does not complain of dry eye symptoms.

Diagnostic options for tear film assessment include external examination, meibography, Schirmer’s testing, conjunctival and corneal staining, double-pass analysis, and tear breakup time. Point of care diagnostics include tear osmolarity, MMP-9, tear volume, and tear production. Meibomian gland diagnostics include meibomian gland imaging and lipid layer interferometry.

The preoperative measurements are inconsistent. In addition, osmolarity and MMP-9 testing are positive, and the patient shows staining and meibomian gland dropout. Therefore, surgery is delayed until the ocular surface is optimised and measurements are stable and consistent.

In this case, potential treatments for aqueous deficiency include artificial tears, a topical steroid, and cyclosporine or lifitegrast (if available). To treat meibomian gland disease, the ophthalmologist also may prescribe warm compresses and lid hygiene, omega-3 supplements, blinking exercises, thermal pulsation, or other options.

SCENARIO 2

A middle-aged woman reports dry mouth, dry and irritated eyes, intermittent blurred vision, and painful joints.

Diagnostic options include those listed in Scenario 1, as well as screening for Sjögren’s syndrome because of mouth and eye dryness and joint pain.

Her tear film osmolarity and MMP-9 results are positive, and she has mild meibomian gland atrophy. She has a reduced tear breakup time and tear meniscus, as well as corneal staining and positive Sjögren’s screening.

Treatment choices for dry eye include the following: artificial tears, cyclosporine or lifitegrast (if available), and topical steroids. Meibomian gland disease may be treated with warm compresses, lid hygiene, thermal pulsation, blinking exercises, omega-3 supplements, as well as others. In addition, the patient is referred to a rheumatologist because of positive Sjögren’s screening results.

Figures 1 and 2 show point-of-care testing options and treatment options.

CONCLUSIONDry eye disease can reduce the accuracy of measurements for cataract surgery, which can lead to inaccurate IOL calculations. Therefore, it is important to check for inconsistencies between measurements, as well as image stability. In some cases, surgeons may need to treat dry eye before repeating preoperative tests, and in severe cases, surgery may need to be delayed—or even avoided.

REFERENCES1. Oh T, et al. Changes in the tear film and ocular surface after cataract

surgery. Jpn J Ophthalmol. 2012;56:113-118. 2. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of

keratometry for cataract surgery planning. J Cataract Refract Surg. 2015; 41:1672-1677.

3. Montés-Micó R. Role of the tear film in the optical quality of the human eye. J Cataract Refract Surg. 2007;33:1631-1635.

4. Chu CA, et al. Blink patterns: reading from a computer screen versus hard copy. Optom Vis Sci. 2014;91:297-302.

5. Szakáts I, et al. Dry eye symptoms, patient-reported visual functioning, and health anxiety influencing patient satisfaction after cataract surgery. Curr Eye Res 2017; 42:832-836.

Dr. Cochener is chair and professor of the Ophthalmology Department at Brest University Hospital, France, general secretary of EUCornea, and president-elect of ESCRS. She may be reached at beatrice.cochener-lamard@chu-brest.fr.

She is a consultant and/or clinical investigator for Cutting Edge, Staar, RVO, Zeiss, Santen, Alcon, Physiol, Théa, and Johnson & Johnson Vision.

Supported by an unrestricted educational grant from Shire, Novartis & TearLab

Supplement February 2018