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Ocular Surface Disease: Supplement April 2018 Accurately Diagnose & Effectively Treat Your Surgical Patients

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Ocular Surface Disease: Supplement April 2018 Accurately Diagnose & Effectively Treat Your Surgical Patients Ocular Surface Disease: Supplement April 2018 Accurately Diagnose & Effectively Treat Your Surgical Patients Supported by an unrestricted educational grant from Ocular Surface Disease: Accurately Diagnose & Effectively Treat Your Surgical Patients Prevalence of Ocular Surface Disease and Its Impact on Surgical Outcomes Accurate diagnosis of dry eye disease is critical before cataract or refractive surgery By Elisabeth M. Messmer, MD ry eye is a common disease, but it may remain EPIDEMIOLOGY OF DRY EYE SYNDROME undetected. If it is not treated before cataract or 1-4 refractive surgery, patients may have suboptimal visual AFTER CATARACT SURGERY outcomes from their procedures. D l Very limited data available, mostly small descriptive/ IMPACT ON CATARACT SURGERY non-randomised studies There are a number of triggering factors for dry eye (Figure 1). l 10-20% of patients: DED induced or worsened after Cataract surgery worsens or causes dry eye in approximately uncomplicated cataract surgery 10% to 20% of patients (Figure 2).1-4 l In all studies: Signs and symptoms of dry eye In a study of 136 patients with a mean age of 71 years who increase after surgery were having cataract surgery, 22% had a prior diagnosis of dry eye that was not treated.5 Thirty-one percent complained l In most studies: gradual improvement of signs and of stinging, burning or other symptoms of dry eye when asked symptoms of dry eye within 3 months about their symptoms, and 41% reported a foreign body l In some studies: signs and symptoms persist > 3 months sensation. When the patients were examined, 77% had corneal staining and 50% had central staining. Figure 2 Denervation is probably the most important factor in the pathogenesis of dry eye after cataract surgery. A corneal incision Research comparing femtosecond laser-assisted cataract in the temporal area leads to decreased corneal sensation, but this surgery (FLACS) vs. conventional phacoemulsification surgery also occurs in other parts of the cornea, such as the incision site showed an increase in dry eye symptoms and ocular surface for the second port.6 The central cornea also showed decreased staining in both groups.4 However, in the FLACS group, ocular sensation on day 1, day 7 and day 15 after cataract surgery. surface staining increased significantly 1 day, 1 week and 1 month after surgery. However, approximately 50% of the study population had preexisting dry eye. The incidence of dry eye Cataract surgery worsens or causes increased to approximately 70% at 1 week and approximately 60% at 1 month. In the FLACS group, there was more severe dry dry eye in approximately 10% to eye in patients with pre-existing dry eye. 20% of patients – Elisabeth M. Messmer, MD This clearly shows that our cataract surgery patients will have pre-existing dry eye that will worsen after surgery. We also need to consider that dry eye can affect intraocular After cataract surgery, the meniscus may decrease, and we lens (IOL) calculations. Epitropoulos et al. reported that dry may find a decreased Schirmer’s test and tear film breakup eye and increased tear hyperosmolarity were associated with time, as well as ocular surface staining.2 more variability in average K readings and anterior corneal The incidence of meibomian gland dysfunction may increase astigmatism.7 As a result, there were significant differences in after cataract surgery. A prospective, observational case series of IOL power calculations. 58 eyes of 48 patients showed changes in lid margin abnormalities In a study by Szakáts et al., examining factors associated with after cataract surgery.3 This population already has a high incidence patient satisfaction, 50% were satisfied with their cataract of meibomian gland dysfunction at baseline, before surgery, and surgery and 50% were dissatisfied.8 The following factors were meibomian gland dysfunction increases after surgery. associated with dissatisfaction: decreased tear film stability, changes in the ocular surface disease index and the visual function index and worse results on the anxiety questionnaire. TRIGGERING FACTORS FOR DRY EYE When Woodward et al. examined patient dissatisfaction after multifocal IOL implantation, dry eye especially played a major role.9 INTRINSIC EXTRINSIC IMPACT ON CORNEAL REFRACTIVE SURGERY l Age l Local environment (low humidity, windy conditions, Jabbur et al. reported that dry eye was one of the major reasons l Gender 10 seasonal influences) patients were not satisfied after refractive surgery. l Hormones In a study of SMILE vs. LASIK, there was a high incidence of l Dietary imbalance in (esp. menopause and mild to moderate dry eye 1 month after both procedures, but it omega 3/6 intake reduced androgen levels) remained significantly higher in the LASIK group vs. the SMILE l 11 l Autoimmune disorders Use of video display group 6 months after surgery. One month after surgery, (rheumatoid arthritis, l Contact lens use corneal sensitivity was better in patients who had SMILE vs. systemic lupus erythematosus, LASIK, but it was normal at 6 months in both groups. l Exposure to medications/ thyroid disease) Pre-existing dry eye is a risk factor for postoperative dry preservatives l Inflammatory bowel disease eye; therefore, it is important to identify patients at risk l Ocular surgery before surgery. Ophthalmologists should identify risk factors, l Dermatological disorders ask patients about their symptoms and diagnose dry eye by (Rosacea, psoriasis, pemphigus, pemphigoid etc.) performing a comprehensive examination. It is important to inform patients about the possibility of postoperative dry eye Figure 1 before refractive surgery. 1 Ocular Surface Disease: Accurately Diagnose & Effectively Treat Your Surgical Patients CONCLUSION small-incision cataract surgery or phacoemulsification. Cornea. Although preoperative dry eye is common, surgeons may 2008; 27 (suppl 1):S13-18. overlook signs and symptoms when preparing a patient for 7. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of ocular surgery. Consequently, patients may be dissatisfied with keratometry for cataract surgery planning. J Cataract Refract Surg. their surgical outcomes. Therefore, it is important to treat dry 2015; 41:1672-1677. eye before surgery because it may affect IOL calculations and 8. Szakáts I, et al. Dry eye symptoms, patient-reported visual postoperative outcomes. Treatment of preoperative dry eye is functioning, and health anxiety influencing patient satisfaction after cataract surgery. Curr Eye Res 2017; 42:832-836. particularly important in patients receiving premium IOLs. 9. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after REFERENCES multifocal intraocular lens implantation. J Cataract Refract Surg. 2009; 35:992–997. 1. Kasetsuwan N, et al. Incidence and pattern of dry eye after cataract 10. Jabbur NS, et al. Survey of complications and recommendations for surgery. PLoS One. 2013; 8:e78657. management in dissatisfied patients seeking a consultation after 2. Li XM, et al. Investigation of dry eye disease and analysis of the refractive surgery. J Cataract Refract Surg. 2004; 30:1867-1874. pathogenic factors in patients after cataract surgery. Cornea. 11. Denoyer A, et al. Dry eye disease after refractive surgery: 2007; 26(9 Suppl 1):S16-20. comparative outcomes of small incision lenticule extraction versus 3. Han KE, et al. Evaluation of dry eye and meibomian gland dysfunction LASIK. Ophthalmology. 2015; 122:669-676. after cataract surgery. Am J Ophthalmol. 2014; 157:1144-1150. 4. Yu Y, et al. Evaluation of dry eye after femtosecond laser-assisted Dr. Messmer is professor of ophthalmology, Ludwig Maximilian cataract surgery. J Cataract Refract Surg. 2015; 41:2614-2623. University, Munich, Germany. She may be reached at Elisabeth. 5. Trattler WB, et al. The Prospective Health Assessment of Cataract [email protected]. Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Dr. Messmer is a speaker or adviser for the following companies: Clin Ophthalmol. 2017; 11:1423-1430. Alcon Pharma GmbH, Dompé, Pharm-Allergan GmbH, Santen GmbH, 6. Sitompul R, et al. Sensitivity change in cornea and tear layer due Shire, Théa Pharma GmbH, TRB-Chemedica, Ursapharm Arzneimittel to incision difference on cataract surgery with either manual GmbH, and Visufarma. Understanding of Physiopathology: Diagnosing and Treating OSD based on DEWS II International workshop offers new insights in defining and managing dry eye disease Christophe Baudouin, MD, PhD, FARVO he International Dry Eye Workshop (DEWS) II gathered 150 members from 23 countries, bringing new The new definition still includes concepts, definitions, and aetiological approaches to hyperosmolarity and inflammation, but it also T dry eye disease, as well as the concept of the vicious circle of dry eye disease that I introduced during the first Dry Eye introduced neural sensory abnormalities… Workshop (DEWS I).1,2 The workshop also covered neuropathic – Christophe Baudouin, MD, PhD, FARVO pain, iatrogenic dry eye, new diagnostic technologies, and new etiology-based therapies. That workshop also defined the role of hyperosmolarity and DEFINING THE DISEASE inflammation in dry eye. A decade ago, DEWS I introduced new concepts in dry eye, The second workshop changed the definition to a certain defining it as a disease of the tears and ocular surface (rather than extent. Dry eye is a disease of the ocular surface resulting from as a syndrome) that causes symptoms and visual disturbances. loss of homeostasis (Figures 1 to 3). It is a question of regulation of the ocular surface in contact with the environment, a concept that is more useful in understanding dry eye. The new definition still includes hyperosmolarity and inflammation, but it also introduced neurosensory abnormalities, which are important. However, I am disappointed that the new definition no longer describes the influence of dry eye on vision. Dry eye is not only a stinging or irritated eye. Its impact on quality of vision is also very important, especially when a patient is having refractive or cataract surgery.3 CLASSIFYING DRY EYE Although we classify dry eye as aqueous-deficient vs.
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