November 2018

COVER FEATURE

Improving the ocular surface for cataract and refractive surgeons
Challenging dry eye cases


by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor


An example of graft-versus-host disease. These cases may be challenging to treat, and surgeons may want to avoid using premium lenses in these patients.
Source: Melissa Daluvoy, MD


Experts discuss how to handle a variety of scenarios

Optimizing the ocular surface is an important step for treatment of patients with dry eye. Depending on the patient and co-existing conditions, full optimization may prove particularly challenging for ophthalmologists. Melissa Daluvoy, MD, assistant professor of ophthalmology, Duke University Eye Center, Durham, North Carolina, Deborah Jacobs, MD, associate professor of ophthalmology, Harvard Medical School, Boston, and Bennie Jeng, MD, professor and chair of the Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, weighed in on a variety of scenarios and how they would approach these patients.

Scenario 1:
Progressive keratoconus

The first scenario involves a patient with progressive keratoconus and severe atopic keratoconjunctivitis with diffuse corneal and conjunctival staining and active lid eczema. EyeWorld asked Drs. Daluvoy, Jacobs, and Jeng about their protocol to settle the ocular surface prior to crosslinking in such cases.
Dr. Daluvoy said she would aggressively treat the surface disease. “To start, I would try petroleum jelly or a mild hydrocortisone ointment to the lids and treat the surface with a course of mild topical steroid and preservative-free tears,” she said. “I would also reiterate the importance of not rubbing the eyes.” Other treatments might include oral doxycycline or prescription-strength dry eye medications.
In terms of residual corneal staining, Dr. Daluvoy said she would tolerate only a mild amount because of concern about poor healing after epithelial debridement.
Dr. Jacobs said she is not currently doing crosslinking. “I think that the goal, as far as the ocular surface [is concerned], is to optimize healing—especially if the procedure is to be epi-off—to reduce the likelihood of persistent epi defect or residual haze. You would want to have the surface at a plateau, and if there is some staining, so be it.”
Dr. Jacobs is a “huge fan” of soft steroid ointment (loteprednol or fluorometholone) at bedtime for treatment and suppression of atopic blepharoconjunctivitis. Some patients benefit from tacrolimus ointment as a steroid suppressing strategy, she added. “I would continue this through the post-crosslinking period in addition to protocol topical steroid drops.”
Dr. Jeng said that before any ocular surgery or procedure, eyelid disease needs to be addressed. Atopic keratoconjunctivitis is especially difficult for a lot of ophthalmologists, he said. Treating it systemically is the only way to address it, he added.
Dr. Jeng noted that he tries not to use steroids on the eyelid because the eyelid skin is so thin, and it can cause depigmentation. Since this is a systemic disease, Dr. Jeng said it’s important to “buddy up with an allergist.”
When considering residual corneal staining, Dr. Jeng stressed again that the systemic disease has to be under good control, and you need to make sure the body and eyelids are “as optimized as possible.” Invariably, these patients will still get staining, he said.
If a patient has atopic disease and keratoconus and you want to crosslink them, you need to realize they could end up with slow-healing epithelium. For these patients, Dr. Jeng suggested considering an epi-on protocol so you don’t destroy the epithelium. Or, if you do epi-off (the current FDA-approved protocol), he said a contact lens or amniotic membrane could help them epithelialize again after.
“In terms of giving them better vision, these patients do well with a scleral lens,” Dr. Jeng said. “It not only gives them better vision by giving a new surface to see out of but also keeps them more comfortable.”

Scenario 2:
Severe graft-versus-host disease related dry eye

The physicians discussed how they settle the ocular surface prior to cataract surgery and IOL calculations in patients with severe graft-versus-host disease related dry eye with diffuse corneal and conjunctival staining, and oral steroid induced dense posterior capsular opacity.
Dr. Jeng said that this can be an extremely challenging problem for patients. The ocular surface in these patients with bad dry eyes may or may not ever become normal, he said.
Dr. Jeng said that often these patients might do best with a scleral lens. He added that the surgeon may have to do the best he or she can with the Ks and biometry. These patients are generally going to be in a scleral lens, and after surgery they’ll be back in the scleral lens. “For that reason, if they’re already in a scleral lens to treat the ocular surface, don’t put in a toric because I don’t think they would get the benefit of it,” he said.
These cases are often recalcitrant to common dry eye treatments, Dr. Daluvoy said. They typically are already using preservative-free tears, punctal plugs, cyclosporine, etc., she said. “I am a big proponent of serum tears in these patients,” Dr. Daluvoy said. “I also use amniotic membrane graft in the clinic and in some cases recommend scleral lens fitting to let the surface improve.”
The goal, Dr. Jacobs said, is plateau. Plugs, lubricant, and low dose soft steroid (ointment form at bedtime) can be helpful, she said. “For these patients, comfort and quality of vision are more important than refractive outcome,” she said. “The goal is a well-healed wound and a comfortable eye.” If there is doubt about the IOL calculations, Dr. Jacobs said choosing more power in the IOL as a myopic result is always preferable to hyperopic.
Dr. Daluvoy and Dr. Jacobs said they don’t generally use postoperative topical NSAIDs in these cases. Dr. Daluvoy noted she would allow it if CME develops, but she watches the surface closely. Meanwhile, Dr. Jacobs recommends avoiding topical NSAIDs, unless there is a specific indication, such as a broken capsule or history of diabetic macula edema or postop CME in the fellow eye.
Dr. Jacobs added that corneal melt is a concern after topical NSAIDs. “These patients can melt quickly and don’t report symptoms as their background symptoms obscure the symptoms of the melt,” she said.
Surgeons may also want to use caution when choosing premium lenses in these cases. Dr. Daluvoy said she will not use extended depth of focus lenses in patients with graft-versus-host disease with a poor surface, and she noted that she would only choose a toric in a mild case if the measurements were consistent and stable.
Dr. Jacobs thinks that multifocal IOLs are not a good idea, and she would only use a toric IOL if the patient’s graft-versus-host disease and ocular surface have been stable for years and there is no likelihood of needing a scleral lens.
She added that she thinks a scleral lens can improve the surface, but “this would be an indefinite intervention and not simply a preop maneuver.” Soft lenses have also been shown to improve comfort, vision, and the ocular surface in ocular chronic graft-versus-host disease, Dr. Jacobs said.
She said “a patient who wears a scleral lens for ocular surface disease should not have a toric IOL.” There will be need for spectacle correction of astigmatism when a toric IOL is used in combination with a scleral lens, she said. The scleral lens can be refitted to incorporate a toric front surface, but this is tricky for both the patient and contact lens fitter.

Scenario 3:
Moderate to high myope with limbal stem cell deficiency

The third scenario involves a young patient with soft contact lens wear related limbal stem cell deficiency who is a moderate to high myope and wants to get rid of their contact lenses. The physicians were asked what regimen they use to optimize the ocular surface.
Dr. Jacobs said that most limbal stem cell deficiency (LSCD) will improve with low-dose soft steroid, elimination of problematic lens/solutions combos, and time. “Some can return to contact lens wear with altered lens wear and care regimens,” she said, adding that punctal occlusion can be helpful.
Dr. Daluvoy said that if the area is affecting the central visual acuity, she debrides and places an amniotic membrane graft. If there are only mild findings, she treats aggressively to start with oral doxycycline, topical steroids, and preservative-free artificial tears. Dr. Daluvoy is also quick to recommend serum tears.
She added that she will wait for the LSCD late staining changes to completely resolve prior to LASIK because she wants the patient to be clear for 1 year prior to refractive surgery. She added that she would tolerate only very mild residual peripheral late staining.
Dr. Jeng stressed that if a patient has stem cell deficiency from contact lens wear, they should be out of their contacts, and he noted that choosing refractive surgery should be a good option. He explained that before doing refractive surgery, you should wait until the patient is stable, though their issues may never resolve. He added that LASIK could be a better option because you don’t need to debride the epithelium.

Scenario 4:
Severe dry eye disease

So what do ophthalmologists tell patients with severe dry eye disease who need surgery but risk having a sub-optimal outcome due to their dry eye? EyeWorld asked for any pearls in counseling such patients.
Dr. Jeng said that each scenario depends on how bad a patient’s dry eyes are. “If they have dry eyes and decreased vision because of ocular surface changes from it, then they aren’t optimized for surgery,” he said.
Dr. Jeng added that he would work hard to optimize the patient, and if they’re still not optimizable, they would need to go into a scleral lens.
If Dr. Jeng thinks the patient’s surface is good enough for surgery without a scleral lens, he tells them their vision might not be quite as good right after surgery, but he stresses that they have to keep up with their treatment regimen.
Dr. Jacobs said she thinks the goal is good healing, with fully correctable vision postop. “The goal of spectacle independence may not be a reasonable expectation for someone with severe ocular surface disease about to undergo cataract surgery,” she said. “They may have read about premium IOL options or heard about them from friends or from your staff, but it is best to explain why these cutting-edge optical solutions might not be appropriate or might yield disappointing results.”
Dr. Daluvoy added that she explains it to patients like a math equation, stressing that “if we put the wrong numbers in to start, we will get the wrong answer.” It can be frustrating for the patient to wait when they think that if you could just take out the cataract or do LASIK, their vision would be fine. “I assure them it is what I would want for me or my family, and if I could fix it quickly with surgery, I certainly would,” she said. “Most of these patients are aware they have a surface issue, so they understand. It is much harder when they are comfortable and don’t know the contribution of the surface to their poor visual acuity.”

Editors’ note: Drs. Daluvoy and Jeng have no financial interests related to their comments. Dr. Jacobs was an employee of BostonSight in 2018.

Contact information

Daluvoy
: melissa.daluvoy@duke.edu
Jacobs: Deborah_Jacobs@MEEI.HARVARD.EDU
Jeng: BJeng@som.umaryland.edu

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