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Pre- Peri- and Post-operative

Practices For Managing the

Ocular Surface

Christopher E. Starr, MDAssociate Professor

Director, Refractive Surgery Service

Director, Cornea Fellowship

Director, Ophthalmic Education

Weill Cornell Medical Center

New York-Presbyterian Hospital

DEWS Dry Eye Definition

“Dry eye is a multifactorial disease of the tears and

ocular surface that results in symptoms of

discomfort, visual disturbance, and tear film

instability, with potential damage to the ocular

surface.

It is accompanied by increased osmolarity

of the tear film and inflammation of the

ocular surface.”

Definition and Classification of Dry Eye. Report of the Diagnosis and Classification Subcommittee of

the Dry Eye WorkShop (DEWS). Ocul Surf 2007;5:75-92

St Clair R, et al. Cataract Surgery in the Dry Eye Patient. IN: Cataract Surgery in Diseased Eyes;

Chakrabarti A, ed. 1st edition. 2014:1-7.

Pathogenesis of Dry Eye

• Inflammation

– Conjunctiva

– Cornea

– Tear film

• Decreased aqueous tear production (ADDE)

• Increased tear evaporation (EDE)

• Corneal sensitivity alterations / denervation

• Blink frequency changes

• Eyelid position abnormalities

Table 4

CORE

mechanisms

High

Evaporation Rate

Refractive Surgery

CL wear

Topical anesthesia

Systemic drugs

inhibit flow

Inflammatory

lacrimal damageSSDE; NSDE;

Lacrimal

Obstruction

– –

–

Xerophthalmia

Ocular allergy

Preservatives

CL wear?

Lacrimal

Gland

initial lacrimal stimulation

Low

Lacrimal

Flow

neurogenic

inflammation

increased

reflex drive

nerve

stimulation

Activate

Epithelial

MAPK +

NFB +

Hyperosmolarity

nerve

injury

Reflex

block

Tear

Film

Instability

Goblet cell,

glycocalyx mucin loss

Epithelial damage

- Apoptosis

– –

–

– –

–

++

+

Deficient or

unstable TF

lipid Layer

EnvironmentHigh Air Speed

Low Humidity

MGD

Blepharitis

Lid flora

lipases esterases

detergents

Tear

Low androgens

Aging

IL-1+

TNF +

MMPs

neurosecretory

block

The Mechanisms of Dry Eye

SOURCE: Lemp MA, et al. Ocul Surf. 2007; 5:75-92.

ASCRS Clinical Survey 2013. http://supplements.eyeworld.org

Dry Eye Disease

Clinical Practice Estimates

ASCRS Clinical Survey 2013

• Prevalence of DED

– Before refractive / cataract surgery

21.1% - 24.2%

• Incidence

– After surgery

35.7%

Dry Eye Disease: Preoperative

PHACO Study: Prospective, multicenter, observational

• 136 cataract surgery patients

• 9 U.S. sites

• Age: 71 ± 8 year

– Range: 55 - 88

• Only 30 (22.1%) reported a prior DED Dx

• 7 (4.9%) currently using cyclosporine drops

Trattler W, et al. Presented at annual meeting of ASCRS. March 2011.

Dry Eye Disease: Preoperative

PHACO Study Findings

• Symptomatic

– FBS 41%

13% ≥ half of the time

• Clinical exam

– Abnormal corneal

fluorescein staining 77% (50% central, level 3)

– TBUT ≤5 sec 63%

– Schirmer score <10 mm 49% (21% <5mm)

0

10

20

30

40

50

60

70

80

90

100

DED Dx FBS CornealStaining

TBUT Schirmer

Trattler W, et al. Presented at annual meeting of ASCRS. March 2011.

*LASIK and PRK

Levitt AE, et al. Molecular Pain. 2015;11:21.

DED After LASIK: 20-55% IncidenceStudy N Design Definition Incidence

Denoyer

(2014)60 Prospective series

Use eye drops:

6 mo43%

De Paiva

(2006)35

RCT (nasal vs

superior hinge)

Fluorescein

staining ≥3:

6 mo

36%

Shoja

(2007)95 Retrospective series

Subjective

symptoms:

6 mo

20%

Donnenfeld

(2003)52

RCT (nasal vs

superior hinge)

“Eyes drier than

before”:

6 mo

31%

Tuisku

(2007)20 cases Case-control

Subjective

symptoms:

2-5 yr

55%

Hovanesian

(2001)781* Mailed questionnaire

Subjective

symptoms:

≥6 mo

44%

Ocul Surf. 2007;5(2):93-107.

Why Post-LASIK/PRK Dry Eye?

Theories:

1. Decreased corneal sensation

– Reduced

Blinking

Lacrimal secretion

2. Disruption of trophic sensory support to the

denervated region

Preoperative Evaluation

• Patient history (Questionnaires, etc.)

• Slit lamp exam

– Corneal / conjunctival staining

– Lid expression / lid position

– Schirmer’s test

– TBUT

– Look for non-DED masqueraders: chalasis, EBMD,

allergy, Salzmann’s nodules etc, etc

• Tear osmolarity & MMP-9

• Other new tests: lipid interferrometry, lactoferrin, non-

invasive TBUT devices, OCT, confocal etc.

Preoperative Assessment

• Ocular history questionnaires1

– Dry Eye Questionnaire (DEQ)

– SPEED, SANDE

– Ocular Surface Disease Index2,3

1American Academy of Ophthalmology. Dry Eye Syndrome. Preferred Practice Pattern. 20132Walt J. OSDI Administration and Scoring Manual. 20043Schiffman RM, et al. Arch Ophthalmol. 2000;118:615.

OSDI and Ocular Surface Disease

0-12 13-22 23-32 33-100

Normal Mild Moderate Severe

OSDI Questionnaire

• 12 questions

• 3 domains

1. Ocular symptoms

2. Vision-related function

3. Environmental triggers

• Assesses previous week

• Likert scale

• Mobile apps now available

Preoperative Evaluation

Office Management / Work-Up Protocol

• Train technicians to identify DED

– Careful history, quick no-touch exam

• If warranted, perform diagnostic tests before tear

film is disrupted by

– Dilating drops, bright lights, anesthetics, dyes...

• Osmolarity & MMP-9

• Non-invasive TBUT, OCT tear meniscus, topo, etc.

Chair Time Saved…

If DED diagnostic tests were done before the

ophthalmologist sees the patient

15

Vital Dye Staining

Slit Lamp Exam:

Fluorescein/

Lissamine/Rose Bengal

Features:

• Low tear lake

• Punctate epithelial

erosions

• Conj staining

• Lid margin stainingModerate-to-severe dry eye in a

cataract patient

Meibomian Gland Assessment

17

• Eyelid margin exam

– Inspissation

– Pitting

– Obstruction

– Telangiectasias

– Bacterial overgrowth

Collarettes, scurf

Demodex infestation

• Manual expression

– Assess quality of

meibum, gland

obstruction

Meibomian gland

dysfunction should be

treated before surgery

Meibomian Gland Dysfunction

86% of 224 DED patients had MGD1

To manage MGD preop

• Aggressive warm compresses

• Antibiotics

• Antimicrobial lid scrubs

• Omega-3 supplements

• As needed

– Oral tetracyclines or macrolides

– Azithromycin eye drops (off-label)

– Tea tree oil scrubs for demodex1Lemp MA, et al. Cornea. 2012;31:472.

New MGD Procedural Adjuncts

• Meibomian gland probes

• Intense pulse light lasers

• Thermal pulsation devices

Dry Eye Workshop: Dry Eye Severity Grading Scheme

Severity 1 2 3 4

Schirmer score

(mm/5 min)

Variable ≤10 ≤5 ≤2

SOURCE: DEWS. Lemp MA, et al. Ocul Surf. 2007;5:75-92.

Schirmer Testing

Schirmer I & II

• With/without anesthetic

– Without: basal &

reflex tears

– With: basal tears

– Nasal mucosa stimulated (II)

Time

Patient discomfort

Relatively high test variability

TBUT

Dry Eye Workshop: Dry Eye Severity Grading Scheme

Severity 1 2 3 4

TBUT (sec) Variable ≤10 ≤5 Immediate

• Interval between

– Last complete blink

– First dry spot appearance

• <10 seconds: DED

• <5 seconds

– Greater sensitivity

TBUT

Vislisel J. http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/TBUT/index.htm

NOTE: This patient also has punctate epithelial erosions

Dry Eye Severity Grading

Lemp MA, et al. Ocul Surf. 2007;5:75-92.

Preoperative Testing

Tear film is 1st and most

important refracting

surface of the eye

Change in anterior

curvature radius of tear film

from 7.8 to 7.6 mm = 1.30D

change in diopter power*

Delay preoperative measurements until

the tear film and ocular surface are optimized,

and measurements are consistent, reproducible, and high quality

*Montes-Mico R, et al. J Cataract Refract Surg. 2015;33:1631.

Tear Osmolarity and Keratometry

• Baseline K in subjects with

1. ≥1 hyperosmolar eye = DED (>316 mOsm/L) (n=50)

2. Both eyes normal osmolarity (<308 mOsm/L) (n=25)

• Second measurement within 3 weeks

• Group 1 vs. normal subjects (Group 2)

– Variability in K reading: P=.05

– % eyes with ≥1.0 diopter difference in measured

astigmatism: P=.02

– % Eyes with IOL power difference >0.5 P=.02

Analyses on groups made by self-reported dry eye: N/S

Epitropoulos AT, et al. J Cataract Refract Surg. 2015;41:1672.

MMP-9

• Nonspecific inflammatory marker

• Elevated in tears of patients with

– Dry eye

– Other ocular surface diseases1

• 10-minute self-contained test2

– Sensitivity: 85%

– Specificity: 94%

1Kaufman HE. Cornea. 2013;32:211. 2Sambursky R, et al. JAMA Ophthalmol. 2013;131:24.

Treating Dry Eye

1 Mild, episodic, No

to mild clinical signs

2 Moderate or chronic

Visual symptoms Some clinical signs

3 Severe or chronic with

marked central staining, reduced TBUT, other

signs

4 Severe, disabling with marked clinical signs

and symptoms

If Level 1 treatments are inadequate, add:

If Level 2 treatments are inadequate, add:

If Level 3 treatments are inadequate, add:

Education

Environmental/ dietary modification

Eliminate drying systemic meds

Artificial tears (preserved)

Gels/ointments

Eyelid therapy

Anti-inflammatories (cyclosporine, steroids), omega-3 FA

Tetracycline

Punctal plugs

Switch to unpreserved tears

Serum tears

Contact lenses

Permanent punctal occlusion

Secretagogues

Moisture chamber goggles

Systemic anti-inflammatory agents

Surgery (lid surgery, amniotic membrane transplant, etc.)

Pflugfelder SC, et al. Ocul Surf. 2007;5:163-178

Preoperative Treatment

Since surgery needs to be delayed the goal is to

treat DED aggressively to rapidly optimize the

surface

– Cyclosporine 0.05% BID and topical steroids

– lubrication (pfats, ointments, inserts)

– +/- topical/oral antibiotics

– +/- punctal occlusion

– +/- Adjunctive MGD procedures when

appropriate

• Clinical improvement within 2-4 weeks

Preoperative Treatment

Environmental recommendations for DED patients

• Humidify

• Avoid blowing air

• Maintain hydration

• Prevent Computer Vision Syndrome

– Frequent breaks

– Conscious blinking

– 20/20/20 rule

Intraoperative Management

Intraoperative Management

DED

• Topical eye drops have potential for corneal

epithelial toxicity

– Anesthetics

– Drops with preservatives, e.g., BAK

• For severe DED or those with BAK sensitivity

– Tetracaine with chlorbutanol preservative

Chlorbutanol less toxic to corneal epithelium than

BAK1,2

1Lazarus HM, et al. Lens Eye Toxicity Res. 1989;6:59-852Salonen EM, et al. Cutan Ocular Toxicol. 1991 10:157-166.

Intraoperative Management

MGD and Blepharitis

• Excess meibum on cornea

– Risks

Obscure view

Possible risk of

postop infection

♦ Endophthalmitis

♦ TASS

Corneal Macrowash

• Remove the cannula from the BSS container

• Irrigate the cornea and surrounding tissue with a

high-volume BSS flow

OR

• Phacoemulsification handpiece

– Irrigation-only or phaco-mode

• Irrigate using foot control

Amjadi S, et al. J Cataract Refractive Surg. 2010;36:1453-1454.

Limbal Incisions & Corneal Sensitivity

Paired LRI

• >50% reduction in corneal sensation

– 39% of patients

– Persisted >3 months

Donnenfeld E,, Starr CE et al. Presented at AAO: Orlando, FL; May 2011.

Hinge Position and Dry Eye: LASIK

N = 52 104 eyes

– Superior-hinge vs. Nasal-hinge

- Corneal sensation was reduced in eyes with either

superior- or nasal-hinge corneal flaps at 1 week, 1

month, and 3 months after surgery (P < 0.001).

- A significant reduction in corneal sensation

remained at 6 months in corneas with superior-

hinge flaps (P < 0.001) but not in corneas with

nasal-hinge flaps (P = 0.263).

- Dry eye signs and symptoms were milder in nasal-

hinge eyesDonnenfeld E, et al. Ophthalmology. 2003;110:1023.

New Refractive Method

SMILE (n=30) vs. LASIK (n=30)

• SMall Incision Lenticule Extraction

1 mo 6 mo

SMILE LASIK SMILE LASIK

OSDI 20 25 8 21*

TBUT 6 5 7 5

Schirmer I 13 20 17 17

Osmolarity 305 316* 300 315*

Dry Eye

Severity

1 1.5 0.2 1.2*

*P<.01

Denoyer A, et al. Ophthalmology. 2015.122;669-676.

Postoperative Care

Postoperative Care

Typical Regimen

• Antimicrobials

• Anti-inflammatories

– Corticosteroids

– NSAIDs

– Cyclosporine if DED

• Lubricants

Postoperative Care - Antimicrobials

• Antimicrobial fluoroquinolones

– Moxifloxacin (0.5%), gatifloxacin (0.3%),

ofloxacin (0.005%), ciprofloxacin (0.0006%),

levofloxacin (0.005%), besifloxacin (0.6%)

• Rabbit study: 6 d effect on epithelial thickness1

– Moxifloxacin (no BAK): N/S

– All others: Sig’t Decrease P<.05

• In DED patients non-BAK drops may be

preferable

1Kovoor TA, et al. Eye Contact Lens. 2004;30:90.

Postoperative Care - Antimicrobials

Staph sp

• Kill effectiveness in vitro2

– Gatifloxacin > Moxifloxacin > BAK

2Hyon JY, et al. J Cataract Refract Surg. 2009;1609.

Topical moxifloxacin may be beneficial for patients

• With DED-induced epitheliopathy

BAK-preserved fluoroquinolones may be superior for patients

• At higher infection risk

• With active infection

Postoperative Care - NSAIDs

• Commonly used

– Ketorolac 0.5%, bromfenac 0.09%

– Napefenac 0.1%, flurbiprofen sodium 0.03%

– Used for reduction of pain and inflammation

Reduced rate of CME

• Possible common adverse effects

– Delayed healing of corneal epithelial defects

– Rare

Corneal melting

Postoperative Care - NSAIDs

• Use with caution in dry eye patients

• Special precautions in:

– Underlying autoimmune conditions, e.g.,

Sjögren’s syndrome

Stevens-Johnson syndrome

Graft-versus host disease

– Patients with a history of preservative

intolerance

Use preservative free formulation or

Use formulations dosed once daily or

Do not use NSAIDs

Postoperative Care - Lubrication

DED patients

– Aggressive use of artificial tears / gels

Symptomatic relief

Improved vision quality

Facilitates ocular surface healing

– Minimize exposure to toxic preservatives

Postop Visual Acuity

At postop visit

• If

– Poor visual acuity test results

– Patient reports glare, halos, or fluctuating vision

• Test visual acuity

• Instill artificial tear

– Wait 10-15 min

– Retest visual acuity

– If visual symptoms improve then treat surface

more aggressively

Case - Presentation

• 71 yo woman presents for 2nd opinion

• 5 weeks post cataract surgery OD

• Multifocal IOL

• Paired LRI – 3:00 & 9:00

• Meds: Topical

– Prednisolone BID

– NSAID QD

– Fluoroquinolone QID

Case - Presentation

Complaints

• Fluctuating, poor quality vision OD

• Glare, halos, starbursts, mild FBS

• Concerned if she’s “healing correctly”

• Concerned about having surgery in OS

Case Presentation - Exam

Visual Acuity:

• OD: UCVA 20/40 distance, J3 near

• Fluctuated with rapid blinking

• 10 min after artificial tears

– 20/20-

Manifest refraction

• OD: -0.25 sphere

Keratometry

• OD: 46.25 / 46.00

Case Presentation: Exam

LRI Incision

Well-centered

multifocal IOL

Why is she so unhappy?

Case Presentation: Exam

49

MGD & telangiectasias, thick

meibum with expression

Central Corneal PEE

Tear osmolarity: 320 / 345 (consistent with severe DED)

TBUT <5s

LRI Staining

Soapy/foamy tears

Low tear lake

Case Presentation: Topography

50

Symptoms related to DED. Treat aggressively…

• Stop fluoroquinolone (BAK)

• Stop NSAID (epithelial toxicity)

• Start topical azithromycin QHS (off-label use)

• Oral omega-3 supplementation (fish/flaxseed oil)

• Preservative-free lipid-based artificial tears

– 8 x/d or more PRN

• Topical cyclosporine A 0.05% BID

• Continue topical steroid BID

Case Presentation: Treatment

Case Presentation: Treatment

• Warm compresses

• Lid hygiene

• Lid massage

– Thermal pulsation treatment if available

• Lifestyle

– Humidifier in bedroom (40% humidity)

– Computer Vision Syndrome precautions

Blink more often

Lower / tilt computer screen

Periodic forced blinking / squeezing

• Start similar regimen OS preoperatively…

“…After Refractive Surgery Elsewhere”

• 101 patients (164 eyes) sought consultation

• Most common subjective complaints

– Blurred distance vision (59%)

– Glare and night-vision disturbances (44%)

– Dry eyes (21%)

• Most common complications

– Overcorrection (30%)

– Irregular astigmatism (29%)

– Dry eyes (30%)…

Jabbur NS, et al. J Cataract Refract Surg. 2004;30:1867.

Final Points

1. Dry eye disease is very common in the

ophthalmic surgery population, but it is often

not the main complaint

2. Signs and symptoms may be poorly

correlated

3. Defer refractive measurements and surgery

until the ocular surface is optimized

4. Refractive surgery can worsen DED,

especially with LRIs or superior-hinged flaps

5. Treat DED aggressively before and after

surgery for the best visual outcomes