Ocular Surface Rehab

Rapid techniques can improve refractive surgery outcomes. Howard Larkin reports from ASCRS in Las Vegas, USA

Whether corneal- or lens-based, treating patients for existing ocular surface disease (OSD) a month to two before refractive surgery can improve vision outcomes and patient satisfaction, said Elizabeth Yeu MD at a Refractive Surgery Day session. Acute ocular surface rehabilitation before surgery could well spell the difference between patients perceiving OSD treatment after surgery as a normal part of care versus an unexpected complication they may blame on surgery.

“We know if [patients] start out with bad OSD or even marginally compensated disease, they will decompensate with progression and chronicity to elevated disease even three to six months after surgery,” Dr Yeu said. Often OSD can be identified during dilated eye exams by staining to reveal any corneal damage. She recommended taking more chair time to counsel such patients on the difference between blur due to refractive error and vision fluctuation due to OSD before starting treatment.

TREAT AND OBSERVE While the goal is to rapidly turn OSD around before surgery, the specific treatment depends on the aetiology of the disease, Dr Yeu said. She reviewed several rapid techniques for acute treatment of OSD to both head off visual fluctuation and manage patient expectations.

Perioperative therapies may be more aggressive to address acute disease, she noted. Topical steroids can be a quick way to rehabilitate damaged corneas—with loteprednol 0.5% ointment currently the only commercially available preservative-free option. Compounded preservative-free Dexamethasone (0.01%, 0.025%, or 0.1%) solution can be used, and so can the recently approved loteprednol 0.25% for treating acute dry eye flares. Both are excellent go-to drops for preoperative ocular surface normalisation. Preservative-free artificial lubricants are another go-to treatment, and self-retaining amniotic membranes may be suitable for some cases. For glaucoma patients, a temporary switch to oral agents rather than topical medications may help if clinically appropriate, she added.

Observing how OSD responds to acute treatment is a critical step, Dr Yeu said. A poor response three to four weeks after treatment indicates a more recalcitrant disease that may require additional treatment and an altered surgical plan, possibly delaying surgery.

CHRONIC MANAGEMENT Chronic dry eye disease (DED) management is critical to improving long-term outcomes, Dr Yeu said. Patients with meibomian gland dysfunction may be treated with routinely scheduled microblepharoexfoliation and/or thermal pulsation and expression. This may include oral omega fatty acid supplementation and chronic, immunomodulation therapy.

Anti-inflammatory strategies are important. Therapies that may not have worked when the eye was inflamed, such as punctal plugs, may be reinstituted with more success once it is under control, Dr Yeu said. Nanosuspensions of loteprednol can help reduce signs and symptoms of dry eye within two weeks. In addition to corticosteroids, cyclosporine A 0.05% and 0.09% may increase tear production while lifitegrast has been shown to reduce higher order aberrations and improve the accuracy of refractive accuracy with cataract surgery.

“That is a steroid-sparing opportunity to help turn their surface over.”

Other anti-inflammatory agents include azithromycin, which can improve MGD and may be superior to tetracyclines for this purpose. Similarly, minocycline can eradicate bacteria and improve MGD, while doxycycline decreased inflammation and improves corneal wound healing, Dr Yeu observed.

She said to observe the upper and lower lid margins for anterior blepharitis, particularly Demodex blepharitis and MGD. The BlephEx® (Alcon) device removes biofilm that can improve lid margin hygiene, greatly reducing collarette presence at the lash margin base, thus helping to treat the Demodex infestation. Heating devices followed by manual expression also help unblock meibomian glands, leading to increased tear film breakup time and improvement in symptoms lasting six months or more. These problems can occur even in younger patients, so look for meibomian gland dropout and other evidence of MGD, she advised.

REFRACTIVE DIAGNOSTIC CLUES Inconsistencies in readings among different diagnostic devices can be a sign of evaporative dry eye disease (EDDE) with early tear break-up time, Dr Yeu said.

“You can have great imaging per device, but it doesn’t correlate with one another because of that evaporation. This is where we want to treat the patient for the MGD, for the Demodex because we know with Demodex it can populate anteriorly as well as in the meibomian glands, it can induce higher MMP-9, it does decrease tear break-up time.” Treating Demodex blepharitis can improve evaporative disease as well, she noted.

For patients with severe disease not responsive to steroids, such as with central staining, a self-retaining amniotic membrane can be the solution, Dr Yeu said. She presented a case in which a 71-year-old who had been treated for a year with steroids for DED but still wasn’t ready for surgery responded well to this treatment.

“We want to identify and rapidly rehabilitate the surface. There are going to be different silos of treatment. What we do for acute rehabilitation may be different, but we also have to take them back and lead them into what we will do chronically for them,” Dr Yeu concluded.

Dr Elizabeth Yeu is a Cornea, Cataract, External Disease, and Refractive Surgery specialist. She is an Assistant Professor of Ophthalmology, Eastern Virginia Medical School, Norfolk, Virginia, USA, and the medical director of the Virginia Surgery Center. She is also the co-host of the popular Ophthalmology Quicksand Chronicles podcast. eyeulin@gmail.com