5 ways to integrate ocular surface care into your patients’ regimen

Laura M. Periman, MD, starts treatment with patients for ocular surface care 6 weeks prior to surgery for best results. Provide patients with detailed preoperative kits to ensure compliance.

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Managing cataract surgery and ocular surface disease can be tricky and can vary from patient to patient. However, by properly screening patients first and following the steps below, optimal ocular surface results can be achieved preoperatively and postoperatively.

1. Give all cataract patients a SPEED questionnaire

We have good evidence of the high prevalence of dry eye and meibomian gland dysfunction (MGD) in older adults. Any cataract surgeon focused on optimizing the accuracy of his or her surgical results has to take this seriously, because dry eye has been correlated with IOL calculation errors and poor refractive outcomes.¹

The answer is better, more consistent screening. In my practice, every cataract patient is supposed to complete a SPEED questionnaire at check-in. A SPEED score ≥8 automatically triggers my technicians to add a layer of dry eye testing before I see the patient.

In our case, that includes osmolarity, MMP-9, and meibography. A higher SPEED score also prompts me to look carefully for comorbidities and exacerbating medications. I also pay close attention to lid anatomy, lid closure, and lid mechanics in my exam.  None of this adds much to my total time with the patient, but it does help ensure that I catch more dry eye before surgery.

Our surgeries and topical medications can indeed exacerbate ocular surface disease and if dry eye and MGD are not recognized and treated prior to surgery, then patients often blame the surgery, the surgeon, and sometimes the entire eyecare team.

Ocular surface problems represent a brewing storm on the horizon. As tempting as it is to focus only on the refractive or cataract surgery, ocular surgery may steer your patient straight into that storm.

2. Have a postoperative plan for the patient with MGD

For patients with significant MGD, a short, 6-week course of topical and nutritional therapy will likely not be sufficient to truly address all of the six interrelated pathophysiologic processes that are affecting their meibomian gland function and tear film quality.

The topical medications and surgical impact on the corneal nerves may make the MGD worse postoperatively. In many cases, I tell them that rehabilitation of their ocular surface will be a two-step process. Phase 1 is getting them ready for surgery with the kit described earlier. Phase 2, after they have recovered from surgery, involves treating their MGD to get the most out of their new vision.

I like to treat these patients with a foundational therapy of omega-3 fatty acids and an immunomodulator. Then I’ll layer on as appropriate a combination of hypochlorous acid (Avenova) to control the bacterial component of MGD, intense pulsed light (IPL) for inflammation, and thermal pulsation therapy (Lipi- Flow) for the gland obstruction.

In my clinical experience, waiting until after cataract surgery and making sure I have cleared up the inflammation first helps to ensure that patients get a longer duration of effect from the thermal pulsation therapy. Practically, identifying the problems before surgery and separating out dry eye and MGD management from cataract or refractive surgery also separates out the surgical event from the longer-term maintenance of the tear film and ocular surface health.

Education, images, and objective testing help patients to understand that surgery did not cause their lid problems. MGD has to be treated as a separate problem from cataract and refractive surgery-but one that very much affects their quality of vision and satisfaction with the surgery.

3. Improvise when time constrained

Younger patients may not routinely get a dry eye screening, but we need to make sure we have easy ways to evaluate the ocular surface quickly when something during the exam suggests it may be a contributing factor. I recently worked in a family friend for an eye exam while she was home from college on break. This young computer science major was complaining of blurry, fluctuating vision.

It turns out she was wearing orthokeratology lenses at night. Both eyes had significant corneal warping and, in the left eye, subepithelial fibrosis, mild haze, and an off-center optical axis that contributed to her visual complaints and reduced BCVA.

Since we had not done a full dry eye workup on her, I performed a quick retroillumination exam of the lower lids which identified significant gland dropout.

Then, I took a quick infrared image of the meibomian glands using a topographer (ReSee-Vit Antares, Veatch Instruments). While this is not as detailed as meibography (Antares, Lumenis Corporation) that is typically performed, it was a rapid test that then demonstrated the significant gland atrophy problem to the young patient.

Once thought to be an age-related condition, MGD is showing up increasingly in children and young adults.²

A recent study also demonstrates that contact lens wear causes significant morphological and functional changes in the meibomian glands.³ We do not yet know whether changing wear habits or reducing digital device use can reverse damage and lead to improvements.

I recommended immediate discontinuance of orthokeratology and instructed she return to glasses and soft contacts along with anticipatory guidance that the vision will fluctuate as the corneal warpage improves.  I started her on omega-3 supplements (to help compensate for her self-reported nutrient-poor college diet) and the topical immunomodulator that her insurance would cover-in this case, lifitegrast (Xiidra, Takeda Pharmaceuticals).

She also had acne rosacea and was using harsh skin washes that can affect the meibomian glands. I like to treat inflammatory skin conditions with intense pulsed light (IPL) therapy and educate the patient on ingredients and skin care practices anywhere near the eyelids that negatively impact dry eye and MGD.    

4. Encourage collaboration to benefit your glaucoma patients

Glaucoma patients have very high rates of ocular surface problems due to the preservatives and active ingredients in IOP-lowering medications.  In fact, 58% of patients using topical glaucoma drops and 92% of those on prostaglandin monotherapy have MGD.⁴  Working together with our networks of referring optometrists and with glaucoma colleagues, we have a huge opportunity to help these patients. 

Optometrists should be encouraged to refer these patients earlier for laser trabeculoplasty, with or without a minimally-invasive glaucoma surgery (MIGS) procedure and cataract surgery if indicated.  These options can reduce the number of topical medications needed to control IOP.

It is highly satisfying to see the patient’s symptoms, appearance and ocular surface improve as drops are minimized.  We also need to aggressively rehabilitate the ocular surface with oral omega-3 supplements, a topical immunomodulator (cyclosporine or lifitegrast), and other treatments as needed, including BlephEx (Scope Ophthalmics) to remove scales and debris, LipiFlow, IPL, and/or TrueTear (Allergan).

Six months later, these patients often look entirely different, with a sparkle in their eye again.  “Saving” their ocular surface benefits everyone, including the referring optometrist, who may otherwise be dealing with variable refractions, glasses remakes, contact lens intolerance, contact lens dropout, patient dissatisfaction, and noncompliance with topical glaucoma therapy.

5. Make your life easier with a kit

I tell patients that most people would not attempt to run a marathon without training.  Similarly, they shouldn’t have eye surgery without getting their ocular surface in better shape. The concept of getting “measure twice and cut once” is one that resonates very easily with patients, especially if we can show them objective measures such as osmolarity, MMP9, topography or a clinical photograph to illustrate how much corneal staining they have or how bad their glands look.  

I am very confident that I can get most eyes in better shape during the 6-week interval between the initial cataract or refractive surgery consultation and surgery, as long as treatment is started right away and the patient complies throughout that preop period. 

I know I’m asking them to do a lot, so I make it easier on them with written instructions, a treatment schedule and a starter kit.  My kit contains a hypochlorous acid lid cleanser (Avenova), heat mask (Bruder), preservative free artificial tears, an immune modulator (Restasis (Allergan), or Xiidra) and an Omega-3 supplement (HydroEye, ScienceBased Health).

I tell them if they follow this regimen, we can measure biometry at the next visit and typically proceed with the surgery we’ve scheduled in 6 weeks.  If a steroid is necessary, and the insurance covers it, I reach for low BAK formulations to minimize the counterproductive impacts of the preservative.

Disclosures:

Laura M. Periman, MDDr. Periman is an ocular surface disease specialist in Seattle, Wash. She is a consultant for Advanced Tear Diagnostics, Allergan, Eyedetec, Eyevance, Lumenis, Science Based Health, Shire, Sun, TearLab, Visant and Umay. Contact her at dryeyemaster@gmail.com. Follow her on Twitter at @DryEyeMaster.

References:

1. Epitropoulos A, Matossian C, Berdy GJ, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg 2015;41(8):1672-7.

2. Gupta PK, Stevens MN, Kashyap N, Priestley Y. Prevalence of meibomian gland atrophy in a pediatric population. Cornea 2018;37(4):426-30.

3. Uçakhan Ö, Arslanturk-Eren M. The role of soft contact lens wear on meibomian gland morphology and function. Eye Contact Lens 2018. [Epub ahead of print]

4. Mocan MC, Uzonosmanoglu E, Kocabeyoglu S, et al. The association of chronic topical prostaglandin analog use with meibomian gland dysfunction. J Glaucoma 2016;25(9):770-4.