Eyeworld CME Supplements

EW_FEB 2017_Supported by unrestricted educational grants from Alcon Laboratories Inc., Allergan Inc., Shire Pharmaceuticals, TearLab, and TearScience

This is a supplement to EyeWorld Magazine that doctors can take a test after reading and receive CME credits for.

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2 OSD: Honing diagnostic protocols to pinpoint disease, enhance surgical outcomes 3. Kim JS, et al. Assessment of the tear film lipid layer thickness after cataract surgery. Semin Ophthalmol. 2016 Sep 14:1–6. [Epub ahead of print] 4. Montés-Micó R. Role of the tear film in the optical quality of the human eye. J Cataract Refract Surg. 2007;33:1631–1635. 5. Goto E, et al. Impaired functional visual acuity of dry eye patients. Am J Ophthalmol. 2002;133:181–186. 6. Sall K, et al. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthal- mic emulsion in moderate to severe dry eye disease. Ophthalmology. 2000;107:631–639. 7. Kunert KS, et al. Goblet cell num- bers and epithelial proliferation in the conjunctiva of patients with dry eye syndrome treated with cyclosporine. Arch Ophthalmol. 2002;120:330–337. Dr. Trattler is in practice at the Center for Excellence in Eye Care, Miami. He can be contact- ed at wtrattler@gmail.com. result in improved preopera- tive testing results. Conclusion Patients have very high expectations of their cataract surgery outcomes, especially when investing in toric or multifocal IOLs. With ad- vanced technologies, sur- geons can deliver superior outcomes but only if they obtain accurate preoperative measurements. This often requires evaluation of the ocular surface, as well as treating dry eye and repeating topography and keratometry measurements at a later date, if necessary. References 1. Trattler W, et al. Cataract and dry eye: Prospective Health Assessment of Cataract Patients' Ocular Surface study. ASCRS•ASOA Symposium & Congress, March 2011. 2. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672–1677. have the patient return in 2 to 4 weeks for repeat topography and keratometry readings. Because dry eye is very prevalent in this population, surgeons need to be aware of how it will impact the accu- racy of our initial biometry measurements. If we do not optimize the ocular surface in patients with dry eye before repeating preoperative testing, patients may be under- or overcorrected. Furthermore, surgeons need to continue monitoring the ocular surface after surgery, which may induce or worsen dry eye. 3 In addition, untreated dry eye affects visual quality, causing optical aberrations. 4,5 Optimal refractive out- comes and patient satisfaction are especially important for those who are paying out of pocket for multifocal or toric IOLs or laser vision correc- tion. Mixed-mechanism OSD When isolating the cause of dry eye, surgeons may find ab- normalities in more than one of the three tear film compo- nents—aqueous, mucin, or lipid. The origin of dry eye di- rects our treatment strategies. For example, cyclosporine ophthalmic emulsion 0.05% increases aqueous production and goblet cell density. 6,7 Oth- er therapies for aqueous defi- ciency dry eye, such as topical steroids, punctal plugs, and lifitegrast, may play a role. In addition, patients with meibomian gland dysfunction may require treatments such as warm compresses, hypo- chlorous acid, topical azith- romycin, or oral doxycycline. Therapy for each patient's OSD can be individualized to improve the health of the ocular surface, which can In the PHACO (Prospec- tive Health Assessment of Cat- aract Patients' Ocular Surface) study, my colleagues and I studied 136 patients who were 55 years of age or older and scheduled for cataract surgery. Dry eye was reported in 22.1% of the patients enrolled; most patients denied significant OSD symptoms. 1 However, 76.8% had positive results on fluorescein corneal staining, with positive central stain- ing in half. These findings point out that many patients presenting for cataract surgery may not report dry eye symp- toms yet have significant dry eye that can impact cataract surgery testing. Besides the standard tests for dry eyes like fluorescein staining and tear break-up time, other diagnostic tests for dry eye have been correlat- ed with inaccurate cataract surgery keratometry readings. For example, Epitropoulos et al. reported that patients with osmolarity greater than 316 mOsm/L in at least one eye had significantly greater variability in their average K readings and corneal astig- matism compared with those with normal osmolarity (less than 308 in both eyes). 2 Pos- itive results for other diag- nostic tests for OSD, such as MMP-9 testing and dynamic meibomian imaging, would also likely be associated with inaccurate preoperative ker- atometry readings. In our practice, we have found that OSD needs to be identified on the preoperative examination of patients who are scheduled for cataract surgery. If OSD is present to a significant degree, it is like- ly that the topography and keratometry readings will be off (Figure 1). Therefore, we initiate treatment for OSD and continued from page 1 Figure 1. Corneal topography of a patient with ocular surface disease, which reveals corneal asymmetry. Ocular surface disease therapy followed 2 to 3 weeks later by repeat corneal topography would be helpful.

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