Eyeworld Daily News

EW SHOW DAILY 30 Tuesday, April 29, 2014 Meeting Reporter E valuating patients for cataract surgery has always meant determining if astigmatism is present (and if so, how to treat it) and performing numerous diagnos- tic exams to ensure the correct IOL power is chosen. These days, extensive ocular surface screening is equally necessary—even if it means delaying cataract surgery to treat the patient's dry eye first. Neda Shamie, MD, Los Angeles, moderated an EyeWorld CME Education event on "The Neglected Refractive Interface: Impact of the Tear Film on Refrac- tive Cataract Surgery Outcomes." A recent ASCRS survey found osmo- larity and interferometry testing is not used very often (17% and 10%, respectively). "Over the next few years, expect these percentages to be on the rise," she said. Respondents said 21.1% of cataract patients pres- ent with at least level 2 ocular sur- face disorders (OSD), and about 24% of laser vision correction patients present with at least level 2 OSD. "If you were looking just for OSD, I have a feeling you'd see more than just 20%," she said. When thinking about refractive index, "the greatest change in index of refraction is between air and the tear film," said Marjan Farid, MD, Irvine, Calif. "This provides the tear film with the greatest optical power of any ocular surface." A "good" blink will completely restore the tear film, but in patients with dry eye, between blink effects are exaggerated compared to normal eyes, she said. "Cataract surgery causes micro- scopic ocular surface damage that contributes to dry eye," Dr. Farid said; this is a population already at a higher risk for dry eye based on age and hormonal factors. Postopera- tively, topical drops can cause addi- tional surface toxicity, patients can worsen dry eye disease from stop- ping or minimizing the regular topical dry eye treatment, and patients may end up with worsened meibomian gland dysfunction because they've stopped warm compresses and lid hygiene. About 10 years ago, "no one talked about dry eye and cataract surgery," said Eric D. Donnenfeld, MD, New York. Before surgery, many patients with marginal dry eye can compen- sate for tear film problems, he said. "But if you don't treat the surface, you'll turn a marginally compen- sated eye to an overtly dry eye. These patients will blame you for their dry eye," he said. Pay attention to the ocular surface, experts say " T his will be known as the year when MIGS comes of age," said Kerry D. Solomon, MD, Mt. Pleasant, S.C., at the EyeWorld Education event "Micro-Invasive Glaucoma Surgery (MIGS): Bridging Basic Sci- ence with Clinical Application." It was obvious from the well- attended session and the panelists' presentations that interest in MIGS will indeed continue to surge, espe- cially with the introduction of the iStent Trabecular Micro-Bypass Stent (Glaukos, Laguna Hills, Calif.). MIGS has enabled cataract surgeons to diversify their practice, Dr. Solomon added, pointing out that many of the session's panelists were cataract and not glaucoma specialists. Still, they all have found a place in their practice for MIGS. "With MIGS we are able to better control disease and reduce medication burden. This fits well with our premium offerings," Dr. Solomon said. Dr. Solomon went on to share that he uses the iStent in about 5% to 10% of his cataract surgery volume. It's specifically indicated in patients with a documented presence of primary open-angle glaucoma (POAG) as seen on optical coherence tomography or visual field testing. He would like to eventually expand this use to patients with ocular hypertension and pseudophakic POAG. Preliminary results in a study of Dr. Solomon's patients found that 88% who had used one drop preop Session addresses MIGS advances and surgical learning curve by Vanessa Caceres EyeWorld Contributing Writer were able to discontinue their drops after surgery. Patients who did not use any medications preop lowered their IOP by more than 20%. Eric D. Donnenfeld, MD, Rockville Centre, N.Y., focused on the safety profile of MIGS. "My new gold standard with cataract surgery is a safe procedure with no postop glasses or glaucoma medications," he said. By using the iStent instead of long-term glaucoma drops, ophthalmologists can help reduce medication expenses, eliminate by Michelle Dalton EyeWorld Contributing Writer Dr. Shamie moderated "The Neglected Refractive Interface: Impact of the Tear Film on Refractive Cataract Surgery Outcomes." He recommended making dry eye testing a part of every clinical exam. He will treat dry eye patients preoperatively for about 2 weeks, using both a steroid and anti- inflammatory topical therapies. When recommending nutritional supplements to patients, suggest omega-3s that are triglyceride formulations, as they're more absorbable than other types. Dry eye can affect keratometry, topography, and wavefront imaging, said Cynthia Matossian, MD, Doylestown, Pa. Using numerous case studies to illustrate her point, Dr. Matossian showed topography images that clearly showed abnor- mal surfaces and said that if she had not delayed surgery to treat the dry eye component, "I would have ended up with an incorrect IOL power." "Unresolved dry eye can affect your decisions about lens exchange or enhancement." Optimize the ocular surface preop, separate the biometry appointment from the cataract consult visit and talk to your patients about why they need to have a good quality tear film before surgery to help ensure a better visual outcome. EW Editors' note: This event was supported by an unrestricted educational grant from Allergan.

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