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Satisfaction after cataract surgery

Attention to the ocular surface key for planning and visual function

Cheryl Guttman Krader

Posted: Saturday, February 1, 2020

Optimisation of the ocular surface is a key factor for achieving success in cataract surgery because an abnormal tear film affects visual performance and the accuracy of biometric measurements used for IOL power calculation, said Béatrice Cochener-Lamard MD, PhD, at the 37th Congress of the ESCRS in Paris, France.

“The tear film not only provides protection. It has real optical power,” said Dr Cochener-Lamard, Professor and Chair of Ophthalmology, University Hospital of Brest, France.

“Preoperative treatment of ocular surface disease to restore tear film stability and ocular surface integrity will allow for more accurate measurements and better functional outcomes.”

Data showing that dry eye disease and meibomian gland dysfunction (MGD) are common in the cataract surgery patient population and often asymptomatic reinforce the need for surgeons to look for these conditions and not just rely on subjective reports from patients to identify individuals with dry eye.

“Take time to detect ocular surface disease. Look at ocular surface staining, tear stability, keratometry and topography,” Dr Cochener-Lamard advised.

“Blinking frequency and the capacity of the lid to cover the cornea are also very important and can now be measured, and new diagnostic tools can assess tear meniscus height, tear break-up time and meibomian gland morphology.”

THE TREATMENT LADDER
Ocular surface optimisation is approached using a graduated therapeutic strategy. All patients, however, are advised to use artificial lubricants, preferably preservative-free, and educated about their condition and lifestyle and environmental modifications to address exacerbating factors.

An anti-inflammatory medication may be needed as a second step. A topical corticosteroid can act quickly to improve the ocular surface, but should be given only as a short course. Topical cyclosporine is indicated for more severe disease, but its side-effects can cause patients to discontinue treatment before onset of efficacy.

“Concomitant short-term use of a topical corticosteroid will accelerate the improvement at the stage of the introduction of cyclosporin with a synergistic effect of the combination,” Dr Cochener-Lamard said.

Because evaporative disease due to MGD is the principal cause of dry eye in the cataract surgery population, intervention is also likely needed to restore the tear film lipid layer. Targeted therapies include lipid-containing ocular lubricants and multiple methods to reduce meibomian gland obstruction and improve the biofilm.

Topical and oral antibiotics that have anti-inflammatory activity can also be used. Clinicians also should not overlook the possibility of Demodex infestation, which can be identified as cylindrical lash deposits and treated with products containing tea tree oil. Other interventions to consider include essential fatty acids and punctal plugs. Rehabilitative exercises can help improve blink quality. Abnormalities of eyelid conformation should also not be overlooked.

Béatrice Cochener-Lamard: beatrice-cochener-lamard@chu-brest.fr