Ocular surface key to surgical success

With the rapid advances in the subspecialty of lens refractive surgery-such as femtosecond lasers, premium IOLs, and astigmatism management-the importance of ocular surface optimization cannot be overemphasized. In this edition of Focus on Refractive Surgery, Kenneth A. Beckman, MD, FACS, describes a stepwise approach to assessing and addressing the ocular surface to enhance outcomes with cataract surgery.

-George O. Waring IV, MD

In addition, an optimized surface may decrease the postoperative aberrations that may compromise postoperative visual acuity. This article discusses my strategies to optimize the ocular surface to allow for the best possible results with cataract surgery.

Preoperative evaluation

It is critical to pay close attention to the lid margins, cornea, and tear film. The lid margins and tear film often are the source of poor outcomes. Common lid margin findings include thickened meibomian gland secretions and lash debris, for which aggressive treatment is essential.

I instruct patients with lid margin disease to use warm compresses and lid hygiene. My first-line medical regimen is topical azithromycin (AzaSite, Merck) b.i.d. for 2 days, followed by q.h.s. for up to 4 weeks. Luchs demonstrated that topical azithromycin with warm compresses was superior to warm compresses alone for treatment of the signs and symptoms of posterior blepharitis.¹

Tear film dysfunction frequently co-exists with lid margin disease and may also contribute to poor outcomes. I frequently measure the tear breakup time and assess conjunctival staining with lissamine green. Although the Schirmer test can give useful information, I do not typically use this test. Tear osmolarity evaluation has become available and can also offer useful objective data as to the quality of the tear film.

To treat the tear film, I prefer preservative-free artificial tears and frequently add topical cyclosporine A (Restasis, Allergan) b.i.d. immediately. Patients need to be counseled to understand that these treatments do not work overnight and may take 6 weeks or more for improvement to be seen.