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Ocular surface disease needs to be managed before and after surgery
12/2/09 6:22 PM
Ocular surface disease needs to be managed before and after surgery
By Richard L. Lindstrom, MD
Ocular surface disease, including dry eye disease, blepharitis and ocular allergy, is a
common comorbidity in the surgical patient. As many as 50% of seniors presenting for
cataract surgery and 30% of younger patients presenting for LASIK, when evaluated
carefully, demonstrate some degree of ocular surface disease.
Select chart reviews of patients presenting for cataract surgery suggest that
we are significantly underdiagnosing dry eye, blepharitis and ocular allergy.
In the era of premium “lifestyle-enhancing” IOLs, it is time for all of us to
pay more attention to ocular surface disease in our surgical patients.
A new, easy-to-perform test for tear film osmolarity (TearLab), which can
be done by a technician, should enhance our ability to screen for aqueous
deficient or evaporative dry eye.
Richard
L.
Lindstrom
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Once recognized, I believe we have four stages of treatment that can enhance our patients’
surgical outcomes: ocular surface preparation before surgery; ocular surface protection
during surgery; ocular surface rehabilitation after surgery; ocular surface maintenance long
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Ocular surface disease needs to be managed before and after surgery
12/2/09 6:22 PM
term after surgery.
A few thoughts on each from my perspective. Once I make the diagnosis of ocular surface
disease, I treat it before surgery. Because I want a rapid response, I find myself using a
topical steroid routinely, often four times a day for 1 to 2 weeks preoperatively. This is an
effective regimen for all forms of ocular surface disease and can be combined with other
appropriate therapies, including artificial tears, punctal occlusion, lid hygiene, topical
antibiotics, oral doxycycline, nutritional supplements and topical cyclosporine as indicated.
Second, in the patient with significant ocular surface disease, I take special care to protect
the cornea and conjunctiva from surgical trauma. I have found the most effective tool here
is to coat the ocular surface with a dispersive viscoelastic such as Viscoat (chondroitin
sulfate, sodium hyaluronate, Alcon) or OcuCoat (hydroxypropyl methylcellulose, Bausch
& Lomb). This enhances the surgeon’s view during surgery, eliminates the need for the
assistant to constantly squirt balanced salt solution on the eye, and results in a much
healthier ocular surface postoperative, with better day 1 visual acuities. We almost all
routinely use an ophthalmic viscosurgical device to protect the endothelium. I suggest we
consider doing the same to protect the corneal and conjunctival epithelium. In addition,
surgery is a good time to consider placing a punctal plug when appropriate.
Third, we need to rehabilitate the ocular surface postoperatively. In the LASIK patient, this
can take months, and data is accumulating that a combination of long-term topical
lubricants and low-dose cyclosporine is quite effective, positively affecting patient comfort
and quality of vision.
Finally, the patient with ocular surface disease before surgery will still have ocular surface
disease after surgery. We need to educate the patient regarding their disease and the need
for long-term treatment.
I find it interesting that a surgical procedure often gets my patients started on a lifetime
regimen for their ocular surface disease that positively affects their quality of life and
captures them and their family for a lifetime of care in our practice. So, look for ocular
surface disease in your surgical patients, then prepare, protect, rehabilitate and maintain a
healthy surface, and your outcomes will improve and your practice will grow.
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