Catalytic Health

4 B.J.: What about the patient that has mild lid disease, rapid tear breakup and significant corneal staining. Would you delay surgery to improve the surface D.M.: I would treat the patient with artificial tears, ideally without a preservative. I really like gel at night. I also ask patients about how they heat their homes – wood-burning heat is especially drying – and I recommend a humidifier accordingly. If the ocular surface has improved three to four months later, I repeat the biometry. I make sure that patients continue their efforts until the surgery, explaining that the surgery will be better tolerated by them and easier for me. H.C.: Patients don't like to delay surgery, so communication is very important. It's important to set the expectation that dry eye disease may be more symptomatic as they heal after cataract surgery, and as they taper off steroids. This helps to reinforce the importance of taking the time for good eye hygiene. B.J.: The literature suggests that treating patients with a steroid, cyclosporine, or both, can improve the post- operative outcome, if the patient has keratitis associated with dry eye. This is something I do in my practice. Do you do this as well, with more severe dry eye patients? S.Z.: As we get into more advanced dry eye, I bring cyclosporine, oral tetracycline, and punctal occlusion into my therapeutic armamentarium, depending on the severity of the case and the underlying cause. I also use a short course of a steroid drops for about one month before measurements and surgery. This is not ideal for long-term treatment, but it reduces some of the inflammation in order to improve our measurements and maximize our surgical outcomes. H.C.: It's important to use steroids, when necessary, but also to explain the importance of tapering off the steroids, because chronic use can lead to glaucoma. G.R.: If we see a significant amount of keratitis, I will use cyclosporine ahead of surgery. B.J.: Is there anything you do differently in the operating room for patients with dry eye disease? G.R.: We use a wick for dilating patients, so we're not always adding drops, which makes patients more comfortable. D.M.: After the surgery, I like to put a pressure patch on those patients with severe dry eye disease and have them sleep with it the first night. This seems to lower patients' pain, because they don't open their eyes, and they don't have their eyelid rubbing on the surface that has ultimately dried during the surgery. H.C.: I also patch the eye for patients after surgery. I usually see patients a few hours later, as my patients often tend to be discharged on the same day. When I check their eyes, I don't usually put another drop of topical anesthetic in, because that can further dry the eye. In addition, when preparing for surgery, I only put the anesthetic in the surgical eye. If you anesthetize both eyes, the blink rate will be reduced in both eyes. B.J. Let's discuss a case. A 73-year-old male was referred for possible cataract surgery. His only complaint was decreasing vision over the past year. The initial examination revealed ocular rosacea with meibomian gland disease, 20/30 and 20/40 best corrected vision, a rapid tear breakup and central epithelial basement membrane dystrophy (EMBD) lines as well as inferior superficial punctate keratitis in both eyes. How do you manage this patient? S.Z. I would treat the ocular surface with the TLC method I mentioned earlier and oral doxycycline or minocycline. I would also treat the EBMD with phototherapeutic keratectomy. I would expect the vision to improve significantly after these treatments, and the patient may not end up needing cataract surgery at this point. We really can't tell until we clean things up because the surface is so poor and affecting the vision in ways we cannot measure. D.M.: Again, I would start by asking the patient to describe his symptoms. He likely thinks his red eye and burning are from his cataract, and that the surgery will fix the problem. I would explain that the ocular surface problems are separate from the cataract issue, and that he has to put effort into treating the ocular surface. I would encourage eyelid hygiene and artificial tears, and then I would start doxycycline on the second visit. If the tear film and surface hasn't improved by the third visit, I would address the EBMD with a superficial keratectomy or a PTK. H.C. After optimizing the ocular surface, the patient may be happy with their vision and comfort level. It makes the risk-benefit decision regarding surgery more straightforward for the patient. G.R.: This is one of the most common complex cases I see. I divide my treatment approach for these patients into two steps. First, I focus on fully treating the meibomian gland dysfunction with lid hygiene, doxycycline, fusidic acid, and lubricating drops. I bring them back three months later, and do a superficial keratectomy. I use anesthetic,

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