December 2020


Handling dry eye prior to cataract surgery

by Ellen Stodola Editorial Co-Director

LipiFlow during COVID-19
Source: Cynthia Matossian, MD

“The patient has to understand that s/he has two diseases: a cataract that can be ‘cured’ and dry eye disease, which is chronic and progressive, requiring treatment for life.”
—Cynthia Matossian, MD

It’s important to address underlying conditions prior to cataract surgery, and dry eye is one such condition. Physicians must identify and treat it to ensure the tear film is optimized and measurements are correct.

Diagnostics and testing available

There are a variety of highly clinically useful dry eye diagnostics available. John Sheppard, MD, said that some of the most common options include the osmolarity test (TearLab), MMP-9 testing (Quidel), and meibography from a number of companies.
Dr. Sheppard said that in order to be optimally reimbursed, the tests need to be chronologically spread out. Many insurers will only reimburse for one dry eye test or procedure per visit, which requires close monitoring by the billing staff. He decides in each patient what needs to be addressed first: inflammation, tear concentration, or the lids.
He added that artificial tears, punctal plugs, and other medications have a role as well. If the patient has a tear supply problem, Dr. Sheppard said punctal plugs are a great option because they retain natural tears and reduce need for artificial tears, which may irrigate away essential tear proteins and surfactants. “I prefer to use plugs whenever practical, especially if the inflammation is under control,” Dr. Sheppard said.
He also mentioned that there is an “entire menu” of anti-inflammatory medications, including Cequa (cyclosporine, Sun Ophthalmics), Restasis (cyclosporine, Allergan), and Xiidra (lifitegrast, Novartis). While you wouldn’t use all of these at the same time, Dr. Sheppard said he may use one of them in combination with a smart steroid.
Stephen Pflugfelder, MD, said that there are a variety of conventional tests that should be performed ahead of cataract surgery, such as slit lamp exam of the cornea/conjunctiva and lids, symptom questionnaire, dye staining, TBUT, and Schirmer’s testing. Additionally, he said that corneal topography can be used to evaluate corneal smoothness (using a Placido-based instrument) and anterior segment OCT to measure the tear meniscus height (tear volume).
Dr. Pflugfelder said that he will typically perform TBUT, corneal fluorescein staining, and topography on every patient and will obtain other tests as indicated. “From my perspective, a symptom questionnaire, slit lamp exam to evaluate for conjunctivochalasis, TBUT, cornea fluorescein staining, and topography should be performed,” he said.
He also commented on use of medications like Restasis, Xiidra, and Cequa, noting that the patient profile should guide choices. “Restasis and Cequa work well for aqueous deficiency, and I prefer Xiidra for more symptomatic patients with less dye staining,” he said.
“We are fortunate to have several options to evaluate the tear film and ocular surface prior to cataract surgery,” said Cynthia Matossian, MD. “It’s a great idea to engage the patient with a simple questionnaire, such as the SPEED questionnaire or another similar option.” These are available online at no charge, she added.
Dr. Matossian added that tear osmolarity and MMP-9 point-of-care tests are objective parameters to demonstrate tear osmolarity and the presence of inflammation, respectively. Additionally, she said that meibography is a great imaging system of the meibomian glands. “The black and white images are easy for patients to understand. Even an untrained eye will be able to tell an abnormal image from a normal one,” she said. Vital dyes, such as fluorescein and lissamine green, are important to describe the level of ocular surface staining.
Dr. Matossian said she employs all of these tests in her practice but noted that they have shortened the questionnaire to three questions for efficiency. Her process includes the three-question questionnaire, tear osmolarity, MMP-9 testing, and meibography, followed by lissamine green and fluorescein staining at the slit lamp with grading and evaluation of the ocular surface and lid margins.
Dr. Matossian said all patients get started on preservative-free artificial tears QID as a teaching tool on how to instill drops. Drop administration is not intuitive and is rather difficult to master by most patients, she explained.
Additionally, Dr. Matossian said if the MMP-9 test is positive, indicating the presence of inflammation on the ocular surface, she will prescribe an immunomodulator such as Restasis, Xiidra, or Cequa and let the patient know that this treatment is ongoing and will continue indefinitely after the standard postop cataract surgery drops are completed.
“I do not use punctal plugs as a first-line treatment,” Dr. Matossian said. “I wait for the surface inflammation to subside before considering plug placement.” Often, with a combination of a re-esterified triglyceride omega-3 (Physician Recommended Nutriceuticals), a heated moisture mask (Bruder), and a prescription immunomodulator, the tear film stabilizes in most patients, she said.

Optimizing before cataract surgery

Dr. Pflugfelder said timing to optimize before cataract surgery is variable, but it usually takes 4–6 weeks. In explaining this process to patients, Dr. Pflugfelder tells patients that a smooth corneal surface is necessary for accurate IOL power calculations and the best outcome.
Four to 6 weeks after beginning dry eye therapy is generally the best time to consider topography and biometry for IOL calculations. “We perform IOL calculations at that time if the corneal surface is healthy,” he said. “Sometimes we’ll repeat the calculations at the preop exam.”
Dr. Matossian said that in order to optimize the ocular surface prior to cataract surgery, a more aggressive approach is required. She added that a short course of steroids such as loteprednol etabonate (Lotemax, Bausch + Lomb, or Inveltys, Kala) BID–QID is often necessary to control the surface inflammation. “The steroid is not refilled; it is used for acute inflammation control,” she said. “Thereafter, therapy for chronic disease continues with various at-home remedies, including oral omega supplements, lid hygiene with scrubs (NuLids, NuSight) or lid cleansers, heated moisture masks, and prescription pharmaceuticals.” She added that it’s also important to make sure patients are using a good quality artificial tear or given the option to stimulate their own tear production with an FDA-cleared device such as iTEAR 100 (Olympic Ophthalmics).  
Dr. Matossian said that additional in-office treatments may be required to maintain tear film homeostasis. Microblepharoexfoliation (BlephEx) to remove the built-up biofilm on the lid margins may not only help with blepharitis control but also potentiate the effects of other office-based therapeutics. “Treatments focused on heating and evacuating impacted meibum from the meibomian glands, such as LipiFlow [Johnson & Johnson Vision], TearCare [Sight Sciences], iLUX [Alcon], or intense pulsed light treatments [Optima IPL, Lumenis], to reduce inflammation by closing off abnormal blood vessels around the meibomian glands may be required,” she said. “To quell the flare-ups triggered by prolonged screen time, allergies, or contact lens overwear, short-term steroids are recommended [loteprednol, Eysuvis, Kala].”
Another key aspect is explaining the optimization process to the patient. Dr. Matossian emphasized that communication prior to cataract surgery is crucial. “The patient has to understand that s/he has two diseases: a cataract that can be ‘cured’ and dry eye disease, which is chronic and progressive, requiring treatment for life.”
Dr. Matossian said it’s important that this discussion with the patient happens before cataract surgery, or it may add chair time post-cataract surgery and further confuse or frustrate the patient. “Patient education is key not only to set proper expectations but also to get buy-in from the patient to adhere to the recommended at-home remedies and continue with the prescribed medications,” Dr. Matossian said. If properly explained, patients have no problem with a short wait time in order for their eye surgeon to obtain more reliable measurements to use for IOL calculation and astigmatism planning.” In patients with more severe disease, it may take weeks or months to adequately tune up the ocular surface.  
To obtain pre-surgical topography, keratometry, and biometry, Dr. Matossian said, adequate tear film stabilization can typically be achieved within 2–3 weeks, assuming the patient adheres to the recommended at-home therapies and/or agrees to undergo an out-of-pocket, in-office treatment.

Lens choices

There are a variety of lens options that can be used for dry eye patients. Sometimes the patient makes it easy, Dr. Sheppard said, if they know what they do or don’t want or if they just want the option that will be covered by insurance.
“If you have someone with no dry eye, they can benefit from just about any IOL as long as the retinal architecture is intact,” Dr. Sheppard said. “If you have patients with recalcitrant dry eye, I’ll talk them out of a multifocal.” A toric lens makes a lot more sense for these patients, he added.
Dr. Pflugfelder agreed that toric lenses are well tolerated and also advised caution when recommending multifocal and EDOF IOLs in patients with tear instability, corneal epitheliopathy, or moderate to severe conjunctivochalasis.
“I am a firm believer in providing patients with the best possible vision through lens-based surgery, viewing cataract surgery as a refractive procedure,” Dr. Matossian said. “If possible, why not decrease dependence on spectacles?”  
She said that 0.5–1 D of astigmatism can be treated with LRIs or femto AIs, while astigmatism greater than 1 D can be treated with toric IOLs. “Astigmatism correction will ensure clearer images at all distances,” she said.
Presbyopia correction is ideal for patients who want to have greater independence from their glasses, Dr. Matossian said, adding that trifocal, multifocal, and EDOF IOLs provide nice options for patients to see far, intermediate, and near with little reliance on reading spectacles. However, she did note that macular and retinal health are key to ensure success with these IOLs. For patients with moderate to severe dry eye or for those with significant corneal pathology, Dr. Matossian discourages multifocal or EDOF IOLs.
Surface stabilization and accurate pre-surgical measurements are mandatory to nail the refractive target for best outcomes, Dr. Matossian said. “Thereafter, a commitment by the patient to maintain their ocular surface health by adhering to their prescribed daily routines and undergoing their annual or semi-annual in-office procedures is paramount.”

Considerations for patients with previous refractive surgery

“Previous refractive surgery patients are the great nightmare of the cataract surgeon,” Dr. Sheppard said.
The worst of these, he said, are the patients who have had RK because they have “amazing amounts of distortion.” Sometimes, they’re so distorted that you’re not sure where the axis lies, he added. LASIK is the next worst particularly in light of a high incidence of ocular surface disease, Dr. Sheppard said, and PRK is also notorious for causing dry eyes. Even SMILE can cause dry eye but seems to be the least offensive.
His strategy gears the timing and intensity of therapy to the underlying conditions.
If someone had myopic refractive surgery, their corneal curvatures will change, Dr. Sheppard said. This not only makes it more difficult to come up with precise sphere and cylinder calculations, but it also affects the type of lens you select. Patients lose positive asphericity of the cornea and may become flat or negatively aspheric, and you must choose the type of IOL appropriate for that corneal curvature.
Dr. Pflugfelder added that some of these patients have a mild component of keratoneuralgia that can be worsened with cataract surgery. “They can be identified as pain out of proportion to signs,” he said. “Some post-LASIK patients may also have dry eye that should be treated as noted above.” Dr. Sheppard added that toric IOLs can limit the use of LRIs, which further disturb corneal nociceptor architecture despite advances in femtosecond laser cataract surgery.

Can cataract surgery aggravate dry eye?

Ocular surgery causes an inflammatory insult to the eye leading to exacerbation of pre-existing dry eye disease, Dr. Matossian said. The preservatives in the eye medications prescribed pre- and post-surgery may have a toxic effect on the corneal epithelium. “Typically, three medication categories are used: an antibiotic, an NSAID, and a steroid,” she said. “Each is used with a different frequency over a varying number of days or weeks.”
Dr. Matossian added that these medication schedules not only lead to a perceived burden by patients and their caregivers but also are wrought with non-compliance. “Patients either forget to use their drops or inadvertently miss their eye altogether, leading to a less than ideal postoperative course.”
Two recently FDA-approved steroids can be used either intracamerally at the conclusion of cataract surgery by placing a tiny spherule of dexamethasone under the iris or inside the capsular bag (Dexycu, EyePoint Pharmaceuticals) or via an intracanalicular dexamethasone-impregnated hydrogel insert (Dextenza, Ocular Therapeutix) placed in the inferior punctum preop, periop, or postop. Both are viable alternatives to the tapering steroid drop burden, Dr. Matossian said.
Generally, there is minimal short-term exacerbation of dry eye from modern phaco surgery, Dr. Pflugfelder said, except in patients with severe aqueous tear deficiency.
Cataract surgery will exacerbate dry eye, Dr. Sheppard said. “You’re putting a lot of drops in and adding preservatives after holding the eye wide open with a speculum, thereby prohibiting blinking and desiccating the corneal epithelium with high intensity focal illumination.”
Dr. Sheppard said he likes to use a non-steroidal and a steroid for all cataract patients. There’s a lot of clinical research and several FDA-approved products that can reduce that dosage, he added. Dexycu and Dextenza reduce the need for topical steroids.
Physicians can use continuous intraoperative irrigation of Omidria (phenylephrine and ketorolac, Omeros), which circulates ketorolac in the eye throughout the surgical case and reduces pain and inflammation after cataract surgery, he said, adding that he thinks this significantly reduces the need for subsequent non-steroidal drops. LayerBio is developing a biodegradable NSAID ring attached to the IOL haptic that can provide weeks of intracameral anti-inflammatory therapy without drops.

Minimizing dry eye issues

There are other ways physicians can try to minimize ocular surface issues, Dr. Sheppard said. For example, during surgery, physicians can minimize the amount of light blast as well as the amount of exposure created by the speculum by opening it just enough to access the eye safely. Physicians can also train staff to irrigate the eye frequently, protecting the ocular surface. Many will put a small layer of viscoelastic on the cornea, Dr. Sheppard said.
He concluded with the following caveats: Don’t forget the patient’s environment, occupation, and avocations; don’t forget the systemic medications your patients are taking; and don’t forget nutrition, both diet and supplementation, for surface control before, during, and after cataract surgery.

About the physicians

Cynthia Matossian, MD

Matossian Eye Associates
Doylestown, Pennsylvania

Stephen Pflugfelder, MD
Professor and James and Margaret Elkins Chair in Ophthalmology
Baylor College of Medicine
Houston, Texas

John Sheppard, MD
Virginia Eye Consultants,
CVP Physicians partner
Norfolk, Virginia

Relevant disclosures

: Quidel, TearLab, BlephEx, NuSight, Olympic Ophthalmics, Physician Recommended Nutriceuticals, Allergan, Novartis, Sun, Bruder, Alcon, Johnson & Johnson Vision, Sight Sciences, Kala, Lumenis, Bausch + Lomb, EyePoint, Ocular Therapeutix
Pflugfelder: Kala, Novartis, Senju, Kowa, Dompe
Sheppard: Allergan, AbbVie, Alcon, Novartis, Bausch + Lomb, LayerBio, Omeros, EyePoint, Ocular Therapeutix, Sun, Novaliq, Quidel, Johnson & Johnson Vision, TearLab, LacriScience



Handling dry eye prior to cataract surgery Handling dry eye prior to cataract surgery
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