ocular surface & dry eye
Surface diseases going underdiagnosed

Even though the vast majority of cataract patients have an underlying ocular surface disease, physicians say many are not being diagnosed

A patient with significant aqueous deficient dry-eye condition
Source: Esen K. Akpek, M.D.

According to some estimates, about 30% of patients needing cataract surgery have not been diagnosed for an ocular surface disease. Paul N. Arnold, M.D., Mountain Home, Ark., estimates that at least one third of his cataract patients have some degree of ocular surface disease such as blepharitis, dry eye, corneal epithelial base membrane dystrophy or degeneration.
“Dry eye is just so common in the elderly population,” said Vance Michael Thompson, M.D., Sioux City, S.D., “it is rare to see somebody without it.”
But both Drs. Arnold and Thompson said it is a disease that is going undiagnosed. In fact, Dr. Thompsons said about 30% of his anterior segment patients are not diagnosed. One problem causing this under diagnosis include the fact that someone can have a normal looking ocular surface and still have reduced tear film production making it difficult to diagnosis in a busy clinic.
Another problem Dr. Thompson points to is that ocular surface disease “is not very exotic like surgery. It is something that we need to have increased awareness.”

Treating cataract patients

Because dry-eye disease is common in elderly patients, Dr. Arnold said most of his patients are already on some sort of regiment for those existing conditions such as warm water compresses or artificial tears.
Regardless if the patient is on a treatment regimen or not, Dr. Arnold said the first step is to make sure the surface disease is under control. Accomplishing this can mean increasing the use of artificial tears, switching to nonpreserved tears or some type of night-time gel or ointment and possibly warm water compresses.
“It is basically trying to come up with a combination of those two things that will fit into the patient’s lifestyle or geared to however frequently they require those things.” Which Dr. Arnold said is usually twice per day.
He said he usually uses a steroid drop such as prednisolone acetate drops, a nonsteroidal anti-inflammatory drug (NSAID) and a fourth-generation fluoroquinolone. “In my view, the data are pretty clear that the fourth-generation fluoroquinolones do penetrate so they are probably beneficial in preventing endophthalmitis whereas earlier generations really didn’t penetrate sufficiently,” Dr. Arnold said.
“Secondly, steroids have kind of been the mainstay at reducing post-op inflammation, and then thirdly, I think the nonsteroidals have been shown to decrease the incidents of CME after cataract surgery.” If he thinks they are necessary Dr. Arnold said he also will use punctal plugs.
Dr. Thompson said his practice is aggressive to clear surface disease with punctal plugs, Restasis (ophthalmic cyclosporine 0.05%, Allergan, Irvine, Calif.) or night-time ointments for patients with evaporative dry-eye or aqueous deficiency.
Also in evaporative cases, Dr. Thompson said he checks the lids for meibomian gland disease.
If it is an aqueous deficient dry-eye, he said he uses lubricants and cyclosporine to simulate tear production and block outflow with plugs.
If the patient is both aqueous deficient and evaporative, then he said he treats the meibomian secretions with warm packs and massage. He also might use a lid scrub if there is a blepharitis component. If it still is persistent, Dr. Thompson said he will use the tetracycline family to improve the flow of the meibomian secretions. “I try to separate it into a therapeutic regime versus optical situation,” Dr. Thompson said.
Post-operatively, Dr. Thompson said increasing tear volume with plugs is important; cyclosporine takes a little longer, so he uses them in conjunction for an immediate and long-term effect. Tear supplements also help. If night-time drying is a problem for the patient, he will use ointments and tell patients not to use a ceiling fan.
Dr. Arnold said he has patients on drops four times per day for at least three to four weeks post-operatively. While they are on these drops, he does not push them to get back onto their tears or night-time lubricant if they already were using them pre-operatively until after that three- to four-week period. In about 10% of patients, he has seen the development of superficial punctate keratopathy (SPK) due to the preservatives in the medications or from the post-op NSAIDs.

Refractive surgery and surface disease

During the ASCRS•ASOA Symposium & Congress in San Francisco this past April, Simon R. Bababeygy, M.D., recent graduate, Stanford University School of Medicine, Palo Alto, Calif., and Edward E. Manche, M.D., director, Cornea and Refractive Surgery, and associate professor, Stanford University School of Medicine, provided data for a presentation about LASIK’s and PRK’s effect on patients with pre-existing dry-eye symptoms.
For the presentation, Dr. Bababeygy and his colleagues performed a study that included 68 eyes of 34 patients. Each patient had one eye treated with wavefront-guided LASIK and the other eye with wavefront-guided PRK, and each patient also self-evaluated the frequency and severity of their dry-eye symptoms pre-operatively and post-operatively.
According to his findings, there was a significant increase in symptom frequency for both procedures at one-month post-op; however, both numbers decreased significantly from the first month to the third month as the symptoms returned close to baseline. In fact, the difference between the baseline and the third month post-op was not statistically significant. And at 12 months post-op, the symptoms actually decreased slightly from baseline, but this also was not statistically significant.
The results were similar for the severity of the symptoms as well with a significant increase for both procedures at one month post-operatively but returning near to baseline three months post-operatively.
The study also reported that there was a mild elevation of foreign body sensation at the first month, and it varied for the next few months before returning near to baseline at 12 months. And the PRK group had more visual fluctuations initially, and by three months, the two are similar and they both return to baseline by 12 months.
The study concluded, there is an increase in the frequency and severity of dry-eye symptoms and vision fluctuations in the early post-operative period, but the study suggests all of these symptoms return to post-op in both LASIK and PRK groups after about one year.
Kerry D. Solomon, M.D., Arturo and Holly Melosi Professor of Ophthalmology, Medical University of South Carolina, Charleston, S.C., also presented data on refractive patients with pre-existing dry-eye symptoms.
In a review assessing patient satisfaction with LASIK within his own practice, Dr. Solomon said there 103 patients included of which 84 answered a questionnaire; six were excluded as undecided.
There were four dissatisfied patients—two were under corrected; one had dry-eye; and one complained of night-time symptoms. There were five other patients that were dissatisfied, but after an enhancement procedure, they became satisfied.
The dry-eye patient was a 23-year-old woman with a history of dry-eye symptoms. Pre-existing dry-eye symptoms are not necessarily a counter indication for LASIK, Dr. Solomon said noting that 11% of the patients in this study had such conditions.
“Patients are four times more likely after LASIK to have their dry-eye symptoms made better than worse,” Dr. Solomon said.
Dr. Thompson said that if a patient with pre-existing dry-eye symptoms does not respond to pre-op treatment, then he would not consider the patient to be a good candidate for refractive surgery. “But we do this surgery on a tremendous amount of dry-eye people, but they have responded to previous therapy,” Dr. Thompson said.

Editors’ note: Drs. Arnold, Thompson, Manche, and Solomon have no financial interests related to their comments.

Contact information

Arnold: paulnarnold@gmail.com
Manche: 650-725-5765, eemanche@yahoo.com
Solomon: 843-792-8854, solomonk@musc.edu
Thompson: 877-522-3937, thompsov@sanfordhealth.org