Knowing the approach to each step of ocular management can optimize patient vision.
Reviewed by Selina McGee, OD, FAAO
Achieving the best vision possible by managing existing dry eye disease is necessary for all patients prior to undergoing cataract consultation and for managing postoperative cases.
In this article, Selina McGee, OD, FAAO, founder and chief optometrist of Bespoke Vision in Edmond, Oklahoma, walks clinicians through how she handles these cases with a discussion of 2 patients.
This was a 78-year-old man who presented with complaints of difficulty adjusting to different light levels in both eyes over a 6-month period. The patient, who is retired and is an avid photographer, was using a monovision contact lens in the left eye.
The ocular history included mild macular drusen in both eyes, for which he used the AREDS 2 (Bausch+Lomb) vitamin formulation. The examination showed full ocular range of motion with no restrictions, no afferent pupillary defect, unremarkable visual fields, intraocular pressures (IOPs) in the mid-teens, and right eye positivity for matrix metalloproteinase-9based on the results of the InflammaDry test (Quidel). The binocular visual acuities (VAs) were 20/25 and 20/20-1 at near vision. Collarettes were present in the lids and lashes. The bulbar/palpebral conjunctiva were white and quiet. The anterior chamber was deep and quiet, and the iris was normal.
The examination showed meibomian glands that were nonfunctional; the osmolarity values were 314 and 310 mOsm/kg. He had nuclear sclerotic cataracts in both eyes of grades 2 to 3.
Based on the assessment, the patient needed optimization of the ocular surface before the cataract consultation and subsequent surgery could be scheduled. The patient desired the least dependence possible on spectacles and contact lenses.
McGee’s plan for the patient started by addressing his ocular surface disease using an immunomodulator, a steroid pulse, and varenicline (Chantix; Pfizer) twice daily with a lid cleanser. In 4 weeks following this management, the patient returned for a follow-up assessment of the ocular surface. The next steps were scheduling the cataract consultation and discussing the intraocular lens (IOL) options. The recommendation for the patient was implantation of the Light Adjustable Lens (RxSight) because he had intensive demands and macular drusen were already reducing contrast sensitivity.
The examination showed that the ocular surface had improved. The VAs in the right and left eyes, respectively, were 20/30 and 20/200 PH 20/25. The collarettes also improved, and the bulbar/palpebral conjunctiva were white and quiet. The osmolarity values were 308 and 302. When the InflammaDry test was repeated, both eyes attained a negative result.
The superficial punctate keratitis resolved in both eyes. The tear break up times (TBUTs) were 9 and 7 seconds, and the tear meniscus heights were 0.25 and 0.28 mm. The cataract consultation was scheduled.
This was a 76-year-old man who was referred by an external glaucoma surgeon for a dry eye consultation. The patient’s complaints were burning, itching, dryness, and painful, red, gritty, and watery eyes that had worsenedover the previous 2 months. He had glaucoma in both eyes, was on multiple medications, and had already had a minimally invasive glaucoma surgical procedure.
At the time of the examination, the patient was taking cyclosporine twice daily, instilling Oasis TEARS (OASIS Medical), using brimonidine tartrate/timolol maleate ophthalmic solution 0.2%/0.5%twice daily, and instilling bimatoprost 0.01% (Lumigan; Allergan) every night at bedtime in both eyes.
The bilateral VA was 20/20-1 and the same for near vision in both eyes. He had collarettes with severe telangiectasia in both eyes. The bulbar/palpebral conjunctiva showed +3 injection bilaterally. He had superficial punctate keratitis inferiorly in both eyes. The TBUTs were 2 and 3 seconds and the tear meniscus heights were 0.34 and 0.25 mm.
There was no afferent pupillary defect; the osmolarity values were 337 and 339. The InflammaDry test showed a positive result in both eyes. The IOPs were 6 and 15 mm Hg.
The patient received a diagnosis of keratoconjunctivitis sicca, ocular rosacea, meibomian gland disease, and Demodex blepharitis. The plan for this patient was to provide solutions that were ocular sparing. He was to continue the immunomodulator, add varenicline twice daily with a lid cleanser, and begin intense pulsed light (IPL) treatment with a deep lid office treatment. The patient was scheduled to return in 2 weeks for a second IPL treatment.
The osmolarity values decreased to 302 and 292. The InflammaDry test showed negative results in both eyes. The collarettes improved and the bulbar/palpebral conjunctiva showed trace injection. The superficial punctate keratitis resolved in both eyes, the TBUTs were 10.2 and 10 seconds, and the tear meniscus heights were 0.20 and 0.24 mm.
McGee said, “Dry eye disease affects every facet of our practices, [eg], refraction, contact lenses, refractive surgery, cataract surgery, and aesthetic procedures. Our patients come to us because they want to see their very best.” Managing the ocular surface helps achieve that common goal.
McGee continued by saying, “Clinicians must screen, diagnose [disease], and manage the ocular surface for all patients. Clinicians should ask themselves the following questions and implement accordingly: ‘What’s my lid and lash strategy, my ocular surface optimization strategy, and my dry eye disease [management] algorithm?’”