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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