Dealing With Dry Eye Prior to Cataract Surgery

This episode tackles dry eye disease (DED) in two parts: (1) how to discuss treatment regimens with patients and (2) how to manage DED prior to cataract surgery or microinvasive glaucoma surgery (MIGS). Listen as Neda Shamie, MD, provides advice on approaching patients with DED and how to help them adhere to treatments. Later, Robert Noecker, MD; Nathan Radcliffe, MD; and Eric Donnenfeld, MD, share their insights into how to convince DED patients to improve their ocular surface before cataract surgery or MIGS.

Speaker 1:

Informed Consent: Getting to Yes is editorially independent content supported with advertising by Abbott.

Marguerite:

Welcome to Informed Consent: Getting to Yes. I'm Marguerite McDonald of the Ophthalmic Consultants of Long Island, in Lynbrook, New York.

Ranna:

And I'm your co-host, Ranna Jaraha.

Marguerite:

The idea behind this podcast is to share with you advice from the experts on how to quickly, efficiently, and truthfully explain a procedure or a treatment to your patients and get them to agree to it. Today's topic is the treatment of dry eye, which is very important as a prelude to cataract surgery, but also as a stand-alone condition.

Ranna:

I notice that your OCLI website includes the statistic from the American Academy of Ophthalmology, that up to 12 million Americans suffer from a disease called dry eye syndrome.

Marguerite:

That's right.

Ranna:

We hear different names used to refer to it. Dry eye, dry eye syndrome, dry eye disease.

Marguerite:

They're basically the same, except that dry eye syndrome or disease tends to indicate that it's a little more chronic and serious. But even minor dry eye issues can be major issues before surgery. That's why today's podcast is in two parts. In Part One we'll delve deeply into the treatment of dry eye and its many possible causes as the patient's main issue. In Part Two we'll talk about how eye surgeons deal with dry eye prior to cataract surgery, or MIGS, microinvasive glaucoma surgery.

Ranna:

Let's introduce the guest that we spoke with for this topic. First, for Part One.

Neda:

My name is Neda Shamie. I am in California. I'm a cornea specialist. My academic interests are in corneal transplantation, advanced cataract surgery, but also ocular surface disease and dry eyes. I'm in private practice in a practice that does a lot of clinical trials, and studies, and academic work but in a private setting in Los Angeles.

Marguerite:

Later we'll also hear from three esteemed eye surgeons, including my colleague, Dr. Rob Noecker. He's the Director of the Glaucoma Service at Ophthalmic Consultants of Long Island and Connecticut, and also an Assistant Clinical Professor of Ophthalmology at Yale.

Rob:

Thank you very much for having me, Marguerite.

Marguerite:

Next is Dr. Nate Radcliffe, Assistant Clinical Professor of Ophthalmology at NYU, and Director of the Glaucoma Service, who did his fellowship at New York Eye and Ear with Dr. Bob Rich.

Nate:

It's great to be here, Marguerite.

Marguerite:

And we also have another colleague of mine, Dr. Eric Donnenfeld, a founding partner of the Ophthalmic Consultants of Long Island, and a Clinical Professor of Ophthalmology at NYU.

Eric:

Thank you, Marguerite. It's good to be here with you.

Ranna:

And now, Part One.

Marguerite:

Neda, I'm sure you find people coming in for cataract surgery or corneal surgery and you diagnose the dry eye, but I'm sure you also have people coming in because they know you are a dry eye expert, probably mostly female, but we all know the face of dry eye is changing. Wouldn't you agree?

Neda:

Yeah. Absolutely. I most definitely diagnose it on my surgical patients, but yes, we are definitely a center where patients who have gone to multiple practices and may have not had success with the treatment regimens recommended do seek us out. Sometimes I don't know exactly how they find us, but I've been told that there are several dry eye blogs that in California and my name comes up a lot on those blogs.

Marguerite:

Great. So when you get one of these patients who's been doctor-shopping with no relief, take us through how you approach it, what you say to them to get them to stick with the regimen you recommend and be compliant.

Neda:

One of the challenges, as you know, with the category of patients who've been to multiple doctors and then finally reach us is really going through their history, what they've tried, have they given the treatment options, the full course that they need to before giving up on it. So there's a lot of chart biopsy-ing that happens.

Ranna:

Chart biopsy. Nice term. What about establishing rapport?

Neda:

Most definitely establishing a rapport with them is challenging, more challenging than a patient whose initial visit is with us, who've lost their hope in the doctors they've worked with. So the first step I take is really going through all the treatment options they've gone through, and making sure that I know how long they've tried something. If they tell me, "Oh, I've tried RESTASIS," or "I tried Lotemax," or, "I tried such and such medication and it didn't work for me," I don't take that without really asking how compliant they were and how long they tried it. As we know, dry eye treatment requires a commitment and consistency. That's one of the important things. So we literally sit down and go through step-by-step.

That's one category of patients. Then, there's been many times where I say, "Well, I know you've tried it, but can we start on my algorithm because I want to know that in my hands it hasn't worked?" And so there is some frustration on their part because they think, "Okay, well, I have to start all over again." But then there are those patients who are committed to the treatment and they have documented their treatment and the full course, and they are still not responding, and then I move on from there.

Marguerite:

Often the doctor shoppers have transferred their anger onto us. You have to deal with that first, and sometimes even to the point of saying, "You know, I'm trying to help you. I am so sad that previous efforts haven't worked, but I'm on your team." Do you ever use verbiage like that?

Neda:

Absolutely. I also use verbiage saying that, "I won't give up on you. That I will ... This is going to be a journey that we're going to be on together, and that you can count on the fact that I will never give up on you." But I do say that, "I can't promise that I will make you 100% better, but I promise that I will take every step possible and we'll work together. We'll be partnered on this journey and communicate." I also am very open to their own personal need to research, and, "Doc, you know, can ... How about I try this or try that?"

As long as there is no concern for toxicity, I've been open to patients' desire to take control of their own treatment in some degree. As long as they stick with the regimen that I recommend, they can supplement to some degree if they like.

Marguerite:

Now, a big issue with dry eye is compliance and having people stay on whatever you recommended for them. So we all have to learn how to give our little pitch, our little speech in the shortest amount of time possible so we can get out of the exam lane, and yet inspire the patient to stay on it for weeks, months, years, as needed. For instance, I find that it's critical to say the right thing about RESTASIS. If you don't explain it in the beginning they will quit after three days. Do you have a concise little pitch?

Neda:

My pitch usually with RESTASIS is that I demonstrate to them the evidence of inflammation in their eye. That's the easiest approach, because obviously RESTASIS having antiinflammatory properties is ... And also it being indicated to increase tear production in those patients thought to have dry eyes due to inflammation and such, to say, "Well, what you're using is just covering up the problem. It's not getting to the crux of the problem, and here is an opportunity you have to treat the disease at its core, and more importantly, over time studies have shown that it could potentially not only reverse your issue but also slow it down where progression won't occur," and this is based on studies on RESTASIS.

But what I do tell them is that the same way that their dry eyes didn't happen overnight, that they need time for ... RESTASIS needs time to reverse the problem and really help their body make more of its own tears, and to make a commitment to it. I do, if they have punctate staining, I start steroids at the same time as RESTASIS and I start a short course of steroids, just a couple of weeks, and that tends to kickstart their symptoms. But I don't say, "Start steroids first and then RESTASIS," because what happens is if they start the steroids they'll feel better and they'll never start the RESTASIS.

Marguerite:

I absolutely agree. And one phrase I find that I have to repeat a lot is, I say, "Dry eye and blepharitis can be controlled but not cured," because a lot of them think it's like conjunctivitis, like it's going to be gone in a week or so. When you say that it's like most of the conditions we face in medicine, diabetes, I say ... This is my most favorite analogy, I guess. I say, "One shot of insulin doesn't cure you of diabetes but it will control it for that day." That's the kind of analogy that I use. Do you use that kind of thing?

Neda:

The analogy here in West Los Angeles and Beverly Hills that works is wrinkle cream. I say, "You start using eye cream or BOTOX, you're not going to stop doing BOTOX." And they seem to relate to that, and it's the whole commitment and it's really preventing progression and possibly reversing some damage that's already been done. And it helps that I, myself, have been on RESTASIS for five years, so it's helped ... When I share that with the patients, that when I started having dry eyes five years ago and started RESTASIS, I tried to wean myself off and every time I did I felt like I went back to where I started.

And it also helps that after 12 years of experience with RESTASIS we have data that has shown patients who stuck through the treatment over two yeas they've had improvement in their tear production, even after the first six months.

Marguerite:

I have one last question before we begin Part Two. What's your experience with cryo-preserved amniotic membrane? I've found it to be very useful.

Neda:

We use it quite often, actually. I agree with you. I think, especially with freeze-dried amniotic membrane, it's easier to use, it's more tolerable for the dry eye patients. We also obviously like the fresh-frozen. The PROKERA is very useful for the very severe cases, for the neurotrophic keratopathy patients, but the AmbioDisk I really like, and then other freeze-drieds with a contact lens, because it's a lot more easily tolerable by the patient. Unfortunately, though, to use it in both eyes it blurs the vision, so it really is not a bilateral treatment option, but it's a great one just to kickstart the patient.

We also use a lot of autologous serum for the patient with severe punctate keratopathy, or the patient with neurotrophic keratopathy, the diabetic patients, history of HS, fear of LASIK, the serum, autologous serum, is just a miracle option for many of these patients.

Speaker 1:

Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Abbott.

Marguerite:

Now we're going to focus on treating dry eye or ocular surface issues as a way of optimizing the outcomes of cataract and glaucoma surgery.

Ranna:

This leads to our discussion on MIGS.

Marguerite:

Yes. Here we go. Nate, I know you also treat a lot of dry eye. Old people get glaucoma and old people get dry eye. Do you have any words of advice? Do you tune people up before your cataract or glaucoma surgery, treat them for their dry eye in advance?

Nate:

Absolutely. And I will say that I spend ... 40% of glaucoma patients at least have dry eye, and I put that much time, 40% of my efforts for my glaucoma patients are directed towards their ocular surface. And that's because it's what they're telling me about them, listening to their complaints. I pay attention to dry eye. I tend not to use artificial tears. I have compliance issues already with patients on drops. If I'm going to use a drop, I want it to be one that's been shown to have a positive impact on a disease, so for me topical cyclosporine has been a big part of my practice. I also try to limit the offending agent, so I use laser trabeculoplasty to treat dry eye in glaucoma patients, and the purpose there is to get them off their glaucoma drops and protect their surface.

Rob:

Dry eye and glaucoma are two conditions that track each other and parallel very closely. You also have to realize that our therapy that we use to control intraocular pressure has adverse effects on the ocular surface, as any eye drop that we probably use chronically. I think we start certainly with preservative-free tears or low-frequency tears. I think we also can use ... I use Omega-3s. I like to use antiinflammatory agents such as cyclosporine. We also have a new agent available to us, Xiidra, which is-

Marguerite:

Lifitegrast.

Rob:

Yes. Thank you very much. That's a long word for me. I'm a glaucoma guy.

Ranna:

That's Dr. Rob Noecker.

Rob:

Improving the ocular surface in those preoperative settings I think is really, really crucial to maximizing their outcome, because once again, it's not uncommon at all, especially here. We're speaking now in the fall months where it tends to get dryer. I find patients are much more symptomatic, and once again, if they're continuing on glaucoma therapy that they're going to continue to be a high-risk patient. I have a lot of patients with rosacea, so I think doing IPL for those appropriate patients can be really good, and sometimes we do LipiFlow too. It's just getting them the last final tuneup before they go into the operating room and have to use a lot more postoperative medications and have alterations to their ocular surface done.

I do selective laser trabeculoplasty to try to maybe get them off a prostaglandin analog. These are the patients we are exactly considering MIGS. It's nice that we have procedures or this opportunity to get them off of their medical therapy, which may be exacerbating their ocular surface disease. The striking one are these patients you've done one eye, and they're still doing the old stuff in their other eye and you can see marked differences. One eye looks nice and white, the other one looks bloodshot and kind of irritated.

Rob:

I think also with MIGS and striving for better outcome with cataract surgery, as I've become a higher and higher volume cataract surgeon, I've been so impressed at the level of dry eye that appears in the perioperative cataract period. And so, if I have somebody who's thinking about cataract surgery but isn't ready to commit yet, that's the time to knock out their dry eye. And if I have a patient who's now going for cataract surgery, I might initiate therapy then in order to blunt the dry eye that I'm seeing at about four weeks that tends to thwart some of those great outcomes we can see with combined cataract and glaucoma surgery.

Marguerite:

I think an under-recognized cause of postop dry eye is the temporary lack of thalamus with exposure keratitis that these older people get after we crank their lids open with the speculum, and you have to crank them open even wider if we're doing a combined glaucoma and cataract procedure. Do you find that you have sometimes to add nighttime ointment for a few weeks or months afterward?

Rob:

I'm a big fan of nighttime ointment. Absolutely. I really try to use everything at my disposal to help these patients have the quickest recovery from these dry eye problems, and that's a great thought about the eyelid exposure. I hadn't thought about it.

Eric:

Garbage in means garbage out, and if you don't have a good ocular surface before surgery you can't give the patient the attention to detail that they deserve to get the best refractive outcome.

Ranna:

That's Dr. Eric Donnenfeld.

Eric:

So when I have a patient who has the topography that shows frank dropout, that means that I'm not getting the information that I need, and it can throw off the lens power calculation, as well as their keratometry, and give you the wrong axis for the astigmatism. So on these patients I very aggressively treat their ocular surface disease in an attempt to improve the ocular surface, and you can do this in as quickly as two weeks, you can have a dramatic improvement on the ocular surface that allows patients to come back and be remeasured. What I'll commonly do for these patients who have this type of disease, I will explain to them that they have cataracts, they need to have cataract surgery, but we want to improve our likelihood of giving them the refractive result that they're looking for.

When that happens I'll have the patient book the day of the surgery, usually a month or so in advance, and I'll bring him back two weeks later to reexamine them after I've instituted the right protocol to bring back their ocular surface to where I want it to be.

Marguerite:

If you have put them on cyclosporine or lifitegrast, do you find that two weeks is usually enough to make a big difference?

Eric:

Cyclosporine has been shown to be very effective, but it doesn't work in two weeks. Lifitegrast, on the other hand, does work more rapidly, so I think you get a more rapid response with lifitegrast, but I'll often combine it with a combination of amino modulation and a corticosteroid as well. My favorite treatment to rapidly improve the ocular surface is to combine a loteprednol, maybe four times a day, with lifitegrast twice a day, and bring them back a month later. And that's great for aqueous deficiency dry eye, but as you know, Margaret, you're one of the world's experts in this area, meibomian gland dysfunction plays a very significant role as well, and there's a very significant role here to improve the meibomian glands, and for that there's a lot of new therapies that are very helpful.

The one that I find that works the best and the fastest, is to use LipiFlow on these patients to improve the meibomian gland secretions, which helps resolve their dry eye. The cortical steroids help as well, and then some therapies like Avenova to help the lid margins is very helpful for improving them quickly. I usually put them on some Omega-3 supplementation as well, which is good long-term solutions for these patients, but it doesn't act quickly.

Marguerite:

I agree with you. I think you can see LipiFlow results very quickly, and BlephEx too. BlephEx has been very helpful tuning people up for cataract surgery. Let's wrap things up with Neda's thoughts on handling a cataract patient who has no idea that dry eye is an issue.

Neda:

To convince that patient, well, it's more than just your cataract. It's challenging. But as is with anything else in medicine, I think having that rapport with your patient and having a conversation, I take advantage of slit-lamp photography, engaging the patient with educational material images. I've gone to Google Images sometimes to just pick out pictures or photos of patients with meibomian gland disease, or punctate staining of their eye, and have used terms like, instead of punctate staining, terms like erosions on the surface of your eye, or scratches on the surface to really get them to relate to the problem.

I don't do the measurement until they have received at least two to four weeks of treatment, depending on the severity of their dry eye condition. I'm booked out for surgery at least that long, so it gives me time to optimize their ocular surface. In some cases, if it's really severe, I have considered not just starting drops but putting an AmbioDisk on the surface, really optimizing the ocular surface quickly as much as possible. I don't hesitate starting steroids on these patients when they're in the perioperative or preoperative phase, again to speed it up so that their ocular surface is optimized. I also engage them in the conversation, because obviously postoperatively these are patients who may need persistent treatment long-term.

I think meibography, LipiView, tear osmolarity, InflammaDry, all of those tools give us talking points, validate our clinical assessment, and sometimes actually help us in our clinical assessment, because we may also be thrown off. I also pluck lashes and I look for demodex if I have a high enough suspicion, and have taken an image of the critter under the microscope and have shown the patients. But most definitely, I think InflammaDry, tear osmolarity, and LipiView and meibography are fantastic tools as is, as I mentioned, topography. Again, talking points that we can discuss with our patients.

Marguerite:

I totally agree with you. Showing an abnormal meibography picture to a patient, it's like a brick in their face. You can say, "You have abnormal dropout," etc., but when they see that picture they believe it especially shown next to a normal picture. Meibography, as far as I'm aware, is available through two sources. One is the TRUEscience Technology, and the other is the OCULUS 5M.

Ranna:

Lots to consider. Lots of ways of Getting to Yes.

Marguerite:

Absolutely, and lots of other useful insights about dry eye as well. So for Ranna and myself, please join us for the next Informed Consent: Getting to Yes episode, when we explore an entirely different topic.

Speaker 1:

Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Abbott.