NOV 06, 2017
Refractive Subspecialty Day 2016
Vision starts with the tear film, and any compromise in tear film integrity can result in IOL calculation errors, topographic abnormalities, and higher-order aberrations. It is estimated that 80% of the refractive integrity of the eye occurs at the air-tear interface. We have incredible tools to create quality vision from the inside, but a perfect 20% is still not enough when a higher yield can come from optimizing the ocular surface.
Pretesting: Patient questionnaires (either Ocular Surface Disease Index [OSDI] or Standard Patient Evaluation for Eye Dryness [SPEED]) and tear osmolarity testing. Abnormal tear osmolarity correlates with variable IOL power calculations. Efficient screening for the busy cataract and refractive surgeon: OSDI or SPEED and tear osmolarity.
Detailed external examination: Rule out concomitant allergies, incomplete blink, lid seal insufficiency, blepharitis, meibomian gland dysfunction (MGD) and non-obvious MGD. Rule out dry eye disease (staining and Schirmer) and goblet cell deficiency (tear breakup time, tear wet/spread). Quantify tear instability preoperatively and show objective improvements when possible (video keratography, point spread function, topography, wavefront aberrations, etc.).
Cyclosporine A: Prevents progression, prevents apoptosis of goblet cells and epithelial cells, prevents propagation of activated T cells. Enhances goblet cell density and tear film stability as soon as 6 weeks.
Loteprednol gel (Lotemax gel): Very low benzalkonium chloride (BAK) load and moisturizing glycerine helpful in anti-inflammatory effect, rapid disease state control, and minimal impact on BAK-sensitive cells (goblet and epithelial cells)
Preservative-free artificial tears, triglyceride fish oil supplements, warm compresses: Helpful for early/mild disease and as adjunctive treatment alongside pharmacologics 4. Treat MGD: warm compresses, lid massage, triglyceride fish oil, thermal pulsation (LipiFlow), etc.
- Ning L, Lin F, Huang Z, He Q, Han W. Changes of corneal wavefront aberrations in dry eye patients after treatment with artificial lubricant drops. J Ophthalmology. 2016; (10):1-11.
- Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015; 41(8):1672- 1677.