Ocular surface optimization key in refractive surgery management

Dry eye disease (DED) is extremely common in the adult population and important to diagnose and treat in patients undergoing corneal and cataract refractive surgery because it can affect vision, quality of life, and surgical outcomes, said Edward J. Holland, MD.

“For a long time, interest in DED among ophthalmologists was limited to cornea specialists who had to care for patients with advanced disease,” said Dr. Holland, professor of ophthalmology, University of Cincinnati, Cincinnati, OH. “Then, in the 1990s, refractive surgeons realized that DED was affecting the outcomes of their procedures, and their efforts drove the field to address DED.

“Now we have new technologies that are enhancing our ability to properly and efficiently diagnose DED, and we have new effective treatments that we can offer to our patients,” he added.

Further emphasizing the importance of diagnosing and treating DED prior to corneal or cataract refractive surgery, Dr. Holland cited studies showing that DED is a common cause for dissatisfaction in patients who had LASIK or multifocal IOLs. The explanation lies in the fact that irregularity of the tear film and ocular surface affect vision and the accuracy of preoperative measurements, including keratometry, topography, and wavefront aberrometry.

“If the DED was not identified and managed preoperatively, the patient blames the surgeon,” Dr. Holland said. “Patients told their surgery has to be delayed in order to optimize their ocular surface may be disappointed, but they will not be upset with you.”

DED diagnosis

Data indicating that the majority of people affected with DED have not been diagnosed underscores the importance of being proactive in identifying DED in refractive surgery patients. And, it is also important to determine DED subtype-does the patient have pure aqueous deficiency DED, evaporative DED related to meibomian gland dysfunction (MGD), or a mixed presentation, which is very common.

“DED that is primarily aqueous deficiency and DED related to MGD are two different disease processes, and they need to be approached with different management strategies,” Dr. Holland said.

Whereas in the past, diagnosis of DED was based mainly on evaluation of tear breakup time, ocular surface staining, and the Schirmers test, now there are objective point-of-care tests that include measurement of tear film osmolarity, inflammatory markers, lipid layer interferometry, and meibomian gland imaging

“When you see a patient with DED, think about MGD before you think about aqueous deficiency because you will be right more often than you will be wrong,” Dr. Holland said. “And, meibomian gland imaging is a huge diagnostic breakthrough for MGD because it not only helps to identify MGD, but it helps patients understand their disease.”

Treatment innovations

Treatment for DED has advanced from reliance on artificial tears and occasional use of an antibiotic/corticosteroid combination to incorporate use of omega-3 nutritional supplements and topical anti-inflammatory treatment.

In addition, there are new specific treatments for MGD, including in-office thermal pulsation and intense pulsed light therapy with meibomian gland expression. Topical azithromycin and oral tetracycline are also used as treatment for MGD, and Dr. Holland emphasized that low dose treatment with tetracyclines (e.g., doxycycline 50 mg/day) is effective and well-tolerated.

To rapidly improve the condition of the ocular surface in a patient who is anxious to have surgery, Dr. Holland suggested the use of pulsed therapy with a topical corticosteroid to reduce inflammation combined with thermal pulsation if the patient has MGD.

Patients should also be started on maintenance therapy for their DED, which might include oral omega-3 supplementation and a topical agent for inflammation control, either cyclosporine emulsion 0.05% or lifitegrast 5.0%.

“It is important to make sure the ocular surface stays healthy in the postoperative period,” Dr. Holland said.