Impressions and Takeaways From Patient Case #1


Selina McGee, OD, FAAO, shares her comprehensive examination and treatment approach, underscoring the importance of tailoring treatments based on the individual's dry eye evaluation.

Selina McGee, OD, FAAO: Because he has ocular surface issues, he's got corneal staining. So those keratometry measurements and looking at what his implant lens could be, those can fluctuate anywhere from a diopter all the way up to 3 diopters. So we have to focus on his ocular surface. And I do that before I sent him for a cataract consultation.

Our plan for this patient was to start him on an immunomodulator because he has high osmolarity. I also did a steroid pulse because we've got corneal staining, and he had MMP-9 that was positive.

I wanted to have a strategy where I was sparing the ocular surface because this patient will go into surgery. He's going to be on a lot of drops post surgery. I want to spare the ocular surface as much as I can to and have a long-term strategy already in place. For him, I also had varenicline [twice a day] with a lid cleanser. When I was seeing this patient, lotilaner had not been approved yet. And…for this patient at that moment, this is what I did because I had a lid cleanser that was the best that we could do for his Demodex. Looking at it now, lotilaner something else that I would prescribe because I can utilize that twice a day for 6 weeks and really clean up that lid margin so that he goes into surgery with clean lids as well.

We started those things, and I asked him to return to clinic in about 4 weeks for ocular surface reassessment to make sure the front surface was optimized and ready for surgery. I did…schedule his cataract consult because it typically takes about 4 to 6 weeks to get in with my surgeon. So I wanted him to not have a delay there.

I set that up in about 6 weeks that way. If everything was great at 4 weeks, he would already be on the books. If it wasn't, then we can always call and reschedule that. So he was scheduled with a cataract consult, discussed in-depth his IOL [intraocular lens[ options, and we have lots. But for this patient, because he has an epiretinal membrane, he's already got macular drusen, and he's used to wearing mono-vision contact lenses, I can do a light-adjustable lens with him. Because it's adjustable, I can really refine that after his surgery so we get his mono-vision exactly how the patient desires. And I chose light adjustable lenses also because I don't want any higher-order aberrations.

I don't want to split light with any of the multifocal lenses. And I didn't choose an extended depth of focus lens because of his needs and because he's already used to using mono-vision. When I send all that to the surgeon, they’re going to look at that and assess and look at numbers and make sure that's still a good plan. But if I've already talked about all those things, that conversation is easier. So that was our plan and moving forward, 4 weeks presurgical. He comes back right as 20/30, left is still 20/200, remember that says reading eye. His speed had come down a couple of points and his osmolarity had definitely improved. No inflammation, collarettes improved, bulbar and palpebral conjunctiva, white and quiet. And his SPK [superficial punctate keratitis] was completely resolved. His tear breakup time was even a little bit longer. Tear meniscus height was still consistent at 0.25 and 0.28.

We did choose at this point to move forward with his cataract consult. And he was scheduled with the surgeon with the intent of utilizing light adjustable lenses.

Some questions to think about and go through, is what is your ocular surface optimization strategy? You need one in your clinic, whether you're doing cataract consult or co-managing with your surgical partners. If you have a heavy contact lens clinic, if you're doing refractions, glaucoma patients, bottom line is that we need to have an optimization strategy for all of those things because we want our patients to see well. That's why they're coming in to see us. And if their ocular surface is not optimized, they're not going to have the best chance of that. How does the presence of dry eye impact refractive correction? Because that air interface where light is first bent, if that is not in good shape, and if the front surface is not stabilized, the patient's going to have fluctuating vision. And that's one of the common complaints with patients that have dry eye disease, they're going to have vision that fluctuates because their tear foam is not stable. That's one of the things that we really want to achieve alongside homeostasis is a stable tear film so that we give our patients high-quality vision that's consistent.

What potential complications or challenges can come about during or after surgery if dry eye is not adequately managed? Well, you can have a less-than-desirable postsurgical outcome.

The patient may not achieve the kind of vision that they want because we didn't have good measurements coming in. We want our patients and even if they're doing a monofocal lens, they haven't chosen a premium choice, they want to have the best vision possible. So for them to achieve that, we have to address the ocular surface. And we've all had those patients who come back after cataract surgery [and] the front surface wasn't optimized, and now the patient is suffering and they think that their cataract surgery caused their dry eye. And it's really hard to overcome those. It's important to have these conversations and address things before surgery because together, if we talk about it before surgery, that is an education and an explanation. If we talk about it after surgery and we're trying to regroup, that sounds like an excuse and that's hard for patients to overcome.

What is your first-line approach for managing dry eye? We have options, but it's really important for us to address each part of what's happening on the front surface. If a patient has Demodex blepharitis, then we can specifically address that. If they have ocular rosacea, we can specifically address that with intense pulse light. If we have meibomian gland dysfunction, we need to address that specifically. And if we have high osmolarity and dry eye present, we need an immunomodulator to work on that immune mediated part of dry eye that the body is losing homeostasis. Then, if we want to stabilize the tear film, we can use medications like varenicline because that makes the body make its own tears on demand. There's nothing you and I can do to replicate the body's natural tear. It has over 2000 different components. For us to be able to address a patient and have them make their own tears, that’s really important.

It’s prudent for us to make sure that we properly diagnose the patient with each diagnosis and then tailor and customize that treatment to the patient and meet them where they are.

When do I prefer using an ocular-sparing medication like a nasal spray? I like it in lots of places. So think about your patients that wear makeup, think about your patients that wear contact lenses. You know, this is a surgical case or a glaucoma patient that's already on drops. Maybe it's a [patient with dry eye] already on drops, and we need the body to make its own tears. We want that on demand so we can stabilize that tear film. In all of those places I'm going to reach for a nasal spray and spare the ocular surface. Patients wearing makeup don't want to put drops in and things run down their face.

There's lots of drops they can't use with contact lenses. For our [patients with] glaucoma specifically, we want to do everything we can to spare that ocular surface because typically they're on drops for the rest of their life unless we're doing some sort of interventional therapy. Those are all places that I like to use ocular-sparing therapies.

The key takeaways from this case are understanding the patient and their lifestyle, and marrying the technology to the patient. But the best technology is not going to help us if we don't do a good job on optimizing the ocular surface.

Transcript is AI-generated and edited for clarity and readability.

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