Perioperative Dry Eye Treatment Necessary for Better Postoperative Outcomes

One of the many important benefits of my membership in the CEDARS/ASPENS Society is our ability to reach out for “curbside consultations”.

This morning, as I prepared for clinic hours, I read through the latest, a request from Tim Page of Michigan for advice on a case referred to him involving a dissatisfied patient with the multifocal IOL. I’m pretty sure all of the cataract surgeons in our group implant some or all of the options in this class; preoperative decision-making (e.g. what type of IOL to use) and postoperative challenges are fertile fields for our discussions.

Darrell E. White

Tim’s colleague noted that the central ring of the multifocal IOL was bisected by the edge of the pupil on the nasal side, implying that the IOL was slightly off center temporally. However, when the pupil was dilated, the IOL appeared perfectly centered on both the pupil and the line of sight. Did the patient require laser pupilloplasty? Should the surgeon put on a capsular tension ring? Perhaps an IOL swap was the answer, removing the multifocal IOL in favor of a monofocal IOL. All sorts of measurements followed – we all like to ask about things like kappa angle, mu tuning and higher order aberrations – but at least part of the answer was obvious when an image of the topography appeared: the patient had a dry eye.

All the dry eye experts (DED) in our group were waiting for this shoe to drop. The patient had not been treated for DED before the operation and was not taking any medication that would treat it at this stage. By the time all shared data was obtained, the patient was far enough away from surgery that he was no longer receiving typical perioperative drops, so he was not even taking topical steroids. While the jury will be out on the more exotic options mentioned above, the majority of respondents on this thread agreed that the first thing to do is to aggressively treat dryness before making decisions about whether a additional surgery was warranted or not.

Whether or not you plan to use a presbyopia-correcting IOL, whether it’s a multifocal or extended depth-of-field (EDOF) IOL, dryness can derail the refractive cataract train even after surgery. technically perfect. Refractive laser surgery of any kind runs a similar risk. It is important to remember that any anterior segment surgery that involves cutting the cornea, conjunctiva, or both is a pro-inflammatory experience that will lead to increased dryness on all ocular surfaces. Eric Donnenfeld and Bill Trattler were among the first surgeons to explore this, and both showed that cataract and laser refraction procedures caused all measurable parameters of dry eye to worsen. In a typically concise summary, Dr. Donnenfeld describes the surgeon’s conundrum: If you diagnose preop DED, that’s the patient’s problem; if you diagnose it after the operation, that’s up to you.

This is not a problem unique to advanced IOL implantation, although the higher expectations shared by surgeons and patients make it more difficult. Dryness not only affects postoperative vision and visual quality, but it can also lead to significant postoperative refractive surprises when it affects our baseline preoperative measurements. Dr Trattler shared a now famous case in which the original measurements showed 2 D of cylinder. A new measurement after a few weeks of treatment with artificial tears showed a perfectly spherical cornea and refraction. Alice Epitropoulos wins the best video award showing real-time improvement in preoperative measurements after stimulating a patient’s tear production with TrueTear (Allergan), eliminating the pseudocylinder.

Our approach to this problem at SkyVision is to aggressively seek out even the smallest sign or symptom of DED during every preoperative examination for cataract and refractive surgeries. The ASCRS algorithm is especially useful if you don’t typically focus on diagnosing and treating DED. Led by Chris Starr, the American Society of Cataract and Refractive Surgery research group encourages surgeons to use a “look, lift, push, pull” slit lamp examination. If DED is present, then consideration is given to whether it is or will be visually significant and will have an effect on preoperative measurements or postoperative outcomes. We are much more aggressive, especially if the plan is to insert a multifocal or EDOF IOL. A single point of staining, high tear osmolarity, or wobbly topography, and we’ll treat.

By the way, of all the DED algorithms that currently exist, the ASCRS offering is the most useful for the majority of ophthalmologists. Whether you are considering mitigating the effect of DED on preoperative measures, postoperative visual quality, or the all-too-common transient flare-ups of DED symptoms, finding the fastest, most direct solution is the solution in the majority of case. Almost all patients will benefit from aggressive lubrication with high quality artificial tears. Do yourself (and your patient) a favor and strongly encourage them to use preservative-free varieties. If you think chronic treatment is going to be necessary, start by all means preop. There is nothing to be gained by waiting after the procedure to write a prescription for Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) (or “Fauxstasis”), Cequa (cyclosporine ophthalmic solution 0.09% , Sun Pharmaceutical) or Xiidra (lifitegrast ophthalmic solution 5%, Novartis).

To get the fastest results, just remember two words: Ster. Rigid.

Remember White’s DED treatment rule: you can’t make an asymptomatic patient feel better. You and your patient would like to have the surgical experience as quickly as possible. Using this as justification for treating what the patient perceives as asymptomatic DED will usually convince them. The quickest route to correcting the deleterious effects of DED on the ocular surface is to prescribe topical steroids.

You can choose any steroid from the myriad of choices we all have, but my bias is to choose one that gives you the flexibility to leave your patient on medication during the perioperative period. Do you have a patient with a very dry eye, with a lot of spots and a tear break-up time measured in milliseconds? We love fluorometholone, especially fluorometholone acetate found in Flarex (Eyevance Pharmaceuticals). In its Phase 3 trial, it was subjected to a head-to-head comparison with Pred Forte (Prednisolone Acetate Ophthalmic Solution 1%, Allergan) (like we’ll never see that again!) and found to be just as potent with a fraction of the risk.

In the majority of cases where we need rapid rehabilitation of the ocular surface with the possibility of continuation of treatment, we go to the loteprednol section of the pharmacy. The best tested of these, and the only one with a label indication for DED, is Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals). Only two subjects in the extended FDA safety trial had IOP increases of 5 mm Hg or greater. That said, there are several other good branded options such as the Lotemax franchise (loteprednol etabonate, Bausch + Lomb), and in some markets there are reasonable generics as well. Four times daily for 2 weeks, then re-measure for your IOL calculations, followed by twice daily, if needed, during the perioperative period.

Find all preop DED patients. Come on everyone Tom Cruise/Superior gun “need for speed” and treat them in a way that follows your usual surgical routines as much as possible. And if you think the patients will need chronic treatment, start your immunomodulator preop. Keep postop DED from becoming your problem.

• For more information:
• Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.