The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: the effect of dry eye

Efficacy of a new water-free topical cyclosporine 0.1% solution for optimizing the ocular surface in patients with dry eye and cataract

This is a pooled analysis from 2 phase III clinical trials investigating a water-free topical cyclosporine 0.1% for the treatment of moderate to severe dry eye. The analyses included 1162 patients: 35% with cataract, 20% with pseudophakia, and 45% without cataract. Demographics or baseline characteristics were comparable across groups except for age and vision. The cyclosporine-treated patients achieved large mean improvements from baseline by day 15: -3.7 in patients without cataract, -3.2 in patients with cataract, and -3.1 in pseudophakic patients. These improvements were statistically significantly higher compared with the respective vehicle groups. In the cataract subgroup, 59% of patients treated with cyclosporine achieved ≥3 grade improvements in corneal staining score, as early as day 15. The magnitude of the effect and early onset of action make this new cyclosporine solution a promising candidate for preoperative management of ocular surface in patients undergoing cataract surgery.

Impact of thermo-mechanical skin treatment on refraction and keratometry in patients with dry eye disease and the implications for cataract surgery

PURPOSE

To determine the changes in keratometry measurements and refraction in patients having the thermo-mechanical periorbital skin treatment, Tixel®, to treat dry eye disease (DED).

METHODS

A multi-centre, prospective, non-masked study was conducted. DED patients were recruited in 3 international centres and were evaluated in 5 visits separated by an interval of 2 weeks except for the last visit which took place after 18 weeks from visit 1. The same clinical examination was performed at all visits: OSDI questionnaire, tear stability, keratometry, best corrected visual acuity and refraction. Tixel® treatment was applied at the first 3 visits.

RESULTS

89 participants (24 males/65 females; mean age: 55.0 ± 14.2 years) were included: 20 presented moderate DED symptoms and 69 severe DED symptoms. Significant differences were found for the spherocylindrical refraction (vector analysis) between visit 1 and visits 2 and 3. Following cumulative analysis, 11.86 % and 16.94 % of participants had more than 0.5 dioptre (D) change in mean keratometry and keratometric astigmatism, respectively, at 3 months post-treatment. A total of 5.40 % had a sphere and cylinder change greater than 0.50D and 16.21 % had the axis changed more than 10 degrees (vector analysis). These changes were particularly significant in patients with severe DED symptoms.

CONCLUSIONS

Keratometry readings and refraction can change following thermo-mechanical skin treatment for DED, especially in those patients with severe DED symptoms. This should be considered as potential errors in intraocular lens calculations may be induced.

Effect of Long-Acting Diquafosol Sodium on Astigmatism Measurement Repeatability in Preoperative Cataract Cases with Dry Eyes: A Multicenter Prospective Study

INTRODUCTION

Dry eye can compromise corneal astigmatism measurement repeatability during preoperative cataract surgery examination. No previous studies have analyzed the effectiveness of long-acting 3% diquafosol sodium (LA-DQS) on astigmatism measurement repeatability. This research assessed the effect of LA-DQS on astigmatism measurement repeatability in preoperative patients with cataract and short tear break-up time (TBUT) type dry eyes in both eyes of the same patient. Correlations between repeatability and TBUT, corneal high-order aberrations (HOAs), and corneal astigmatism magnitude were also analyzed.

METHODS

In total, 122 eyes (61 patients) with short TBUT-type dry eye were enrolled. Preoperatively, only one eye of all patients was treated with LA-DQS for 4 weeks. TBUT and corneal HOAs were checked using CASIA 2 before and 4 weeks post-treatment. The cylindrical power and meridian of astigmatism were measured at 3- and 4-week post-treatment using IOLMaster 700. Power vectors J0 and J45 were used for astigmatism calculations. Repeatability of astigmatism measurements was assessed as the within-subject standard deviation (Sw). The relative effects of TBUT and HOAs on J0 Sw and J45 Sw were also analyzed. Comparative changes in these variables were evaluated between treated and non-treated eyes, with additional analysis of their correlations.

RESULTS

Treated eyes exhibited significant improvements in TBUT, HOAs, and post-treatment measurements of J0 Sw and J45 Sw at 3 and 4 weeks. In non-treated eyes, J0 Sw and J45 Sw showed significant correlation with TBUT and corneal HOAs. HOAs showed stronger relative associations with J0 Sw and J45 Sw than TBUT. In non-treated eyes, no significant correlation was found between cylindrical power and astigmatism measurement repeatability.

CONCLUSIONS

In short TBUT-type dry eye, preoperative treatment with LA-DQS significantly improved astigmatism measurement repeatability. This may improve the precision of intraocular lens (IOL) power calculations regardless of the magnitude of corneal astigmatism, especially when toric IOLs are used.

Prophylactic Therapy for Long-Term Ocular Discomfort After Cataract Surgery

PURPOSE

The cataract surgery dissatisfaction rate is 20% to 35% due to ocular surface discomfort. We investigate the ocular surface discomfort after surgical failure as a consequence of age-related parainflammation. We also aim to prevent it by immune-modulating prophylactic management.

METHODS

Monocentric clinical trial realized in a teaching hospital. Prospective, randomized, open-label, unmasked clinical trial. One hundred patients diagnosed with cataracts underwent phacoemulsification surgery. Groups A (<65 years; n = 25) and B (>75 years; n = 25) received surgery only. Groups C and D (both >75 years and both n = 25) used cyclosporine A 0.1% cationic emulsion (CE) eye drops or CE lubricating eye drops (both twice daily), respectively, for 30 days before surgery. Patients were followed up 90 days after surgery. The primary outcome was postoperative ocular surface failure; secondary outcomes examined the influence of prophylactic cyclosporine A 0.1% CE therapy on ocular surface outcomes.

RESULTS

Group B demonstrated greater severity regarding ocular surface signs and symptoms throughout the study period, versus all other groups. Signs/symptoms were typically lower in Group A. Group C achieved significant reductions in conjunctival Symptom Assessment in Dry Eye values ( P < 0.05), conjunctival hyperemia severity ( P < 0.01), and meibomian gland dysfunction ( P < 0.001) at Day 45, versus Group B, and tear break-up time was increased ( P < 0.001). Ocular surface inflammatory marker transcription (HLADR, intercellular adhesion molecule 1 [ICAM-1], and interleukin 6 [IL-6]) was significantly downregulated in Group C, versus Group B, at 90 days ( P < 0.05).

CONCLUSIONS

Cataract surgery induced ocular surface system failure with a clinically significant persistent inflammatory status (InflammAging) in patients older than 75 years. Prophylactic cyclosporine A 0.1% CE eye drops were associated with improved ocular surface homeostasis and reductions in inflammatory markers.

Validity and reliability of the Thai version of the ASCRS SPEED II preoperative OSD questionnaire in Thai cataract surgery candidates

OBJECTIVES

To develop a Thai version of the American Society of Cataract and Refractive Surgery (ASCRS)-modified Standard Patient Evaluation of Eye Dryness (SPEED) II© preoperative ocular surface disease (OSD) questionnaire (ASCRS SPEED II-Thai) and evaluate its validity and reliability in Thai cataract surgery candidates.

METHODS

The original English version of the questionnaire was translated and adapted cross-culturally to Thai language. The ASCRS SPEED II-Thai was evaluated for content validity, internal consistency, and test-retest reliability. Five experts in the ocular surface field critically reviewed the ASCRS SPEED II-Thai to measure the content validity indexes (CVI). A total of 105 cataract surgery candidates were recruited from an ophthalmology clinic to complete the questionnaire. Cronbach's alpha and intraclass correlation coefficient (ICC) were calculated to assess internal consistency and test-retest reliability, respectively.

RESULTS

During the translation and cross-cultural adaptation processes, only two minor modifications were made to the original version for clarification without changing their meaning. All items in the ASCRS SPEED II-Thai had an item-level CVI of 1.00, representing complete agreement among content experts. The scale-level CVI was 1.00, indicating excellent content validity of the questionnaire. The participants found no difficulty in understanding each question in the pilot test. Cronbach's alpha for the ASCRS SPEED II-Thai was 0.82, indicating good internal consistency. The test-retest reliability was good to excellent, with ICC values ranging from 0.83 to 1.00 (P < 0.001).

CONCLUSIONS

The ASCRS SPEED II-Thai is a valid clinical tool with adequate reliability for preoperative OSD screening among Thai cataract surgery candidates.

Clinical features and comprehensive treatment of persistent corneal epithelial dysfunction after cataract surgery

OBJECTIVE

Evaluation of clinical efficacy and safety of tobramycin/dexamethasone eye ointment in treating persistent corneal epithelial dysfunction (PED) after cataract surgery.

METHODS

26 cases diagnosed as PED after cataract surgery accept the tobramycin/dexamethasone ophthalmic ointment and intense pulse light treatment in the Xiamen University of Xiamen eye center between September 2016 and April 2022 were retrospectively analyzed, mainly including clinical manifestations, characteristics of morphological changes imaged by in vivo confocal microscopy, meibomian glands infrared photography, lipid layer thickness (LLT), management and therapeutic effects.

RESULTS

There were 26 eyes, include 8(35%) males and 15(65%) females with an average age of 69.6 ± 5.2 years(50 to 78 years). The mean hospitalization time was (18.4 ± 7.5) days after cataract surgery. Twenty patients had meibomian gland dysfunction. Infrared photography revealed varying loss in the meibomian glands, with a mean score of 3.8 ± 1.2 for gland loss. The mean LLT was 61.6 ± 8.4 nm. After treatment, 20 patients were cured, and 3 received amniotic membrane transplantation. After treatment, the uncorrected visual acuity (UCVA) and best-corrected vision activity (BCVA) improved (P < 0.001), and there was no significant difference in intraocular pressure (IOP) before and after treatment (P > 0.05).

CONCLUSIONS

The early manifestation of PED after surgery is punctate staining of the corneal epithelium. Tobramycin and dexamethasone eye ointment bandages have a good repair effect. The meibomian gland massage combined with intense pulse light treatment can effectively shorten the course of the disease.

Comparison of corneal topography maps obtained using the IOLMaster 700® and the Anterion® in candidates for toric IOL implantation

OBJECTIVES

To compare central corneal topography (CT) obtained using the IOLMaster 700® biometer to corneal topography obtained using a Swept-Source OCT-based predicated topographer (PT), in candidates for toric intraocular lens (IOL) implantation.

METHODS

A retrospective comparative study was conducted in consecutive patients undergoing a routine cataract surgery assessment with significant astigmatism on keratometry. Each patient was examined using both the IOLMaster 700® (Carl Zeiss Meditec, Jena, Germany) and the Anterion® (Heidelberg Engineering, Heidelberg, Germany) for routine preoperative measurements. The corneal axial anterior power map obtained with each device was then anonymized and analysed independently by two ophthalmologists using a reading grid. The reading grid assessed the usual parameters describing astigmatism and evaluated if a toric IOL was indicated or a second topography examination was needed to confirm the indication.

RESULTS

In total, 169 eyes of 120 patients were included. The inter-examination agreement for the astigmatism description ranged from 56 to 85% depending on the reader and parameter. The decision to implant a toric IOL based on the axial map was the same in 59-60% of cases depending on the examiner. A second examination was needed in 18-25% and 8-14% of cases after CT and PT, respectively. The IOLMaster 700® central anterior axial map allowed toric IOL implantation in 58-70% of cases with no need for second corneal examination.

CONCLUSION

The agreement between the anterior axial maps obtained using both devices was good. However, in about a quarter of the cases, dedicated topography had to be performed to confirm the surgical indication.

Dry Eye Disease in the Middle East and Northern Africa: A Position Paper on the Current State and Unmet Needs

In the Middle East and Northern Africa (MENA), dry eye disease (DED) is often misdiagnosed or overlooked. This review summarizes a series of conversations with ophthalmologists in the region around a variety of climatic, lifestyle, and iatrogenic factors that contribute to specific features of DED in the MENA region. These considerations are further classified by patient lifestyle and surgical choices. All statements are based on discussions and formal voting to achieve consensus over three meetings. Overall, a deeper understanding of the disease characteristics of DED specific to MENA can better guide local eyecare practitioners on appropriate management and follow-up care. Additionally, population-based studies and patient and physician education on ocular surface diseases, together with the use of culturally appropriate and language-specific questionnaires can help ease the public health burden of DED in this region.

Cataract surgery in setting of ocular surface disease

PURPOSE OF REVIEW

The purpose of this article is to review the available strategies to successfully identify and manage ocular surface disease (OSD) pre, intra and post-cataract surgery.

RECENT FINDINGS

Cataract surgery and OSD have an intricate relationship: the surgical procedure can induce or exaggerate OSD symptoms, while OSD can negatively impact surgical refractive outcomes and increase the rate of postoperative complications.

SUMMARY

Improving the health and stability ocular surface is the key to enhance post cataract surgery refractive outcomes and avoid complications. This is pivotal for patients affected by severe OSD, but is also important for patients with minimal signs or symptoms. A correct diagnosis and a stepwise approach are the keys to improve the quality of life of such patients.

Noninvasive screening of ocular surface disease in otherwise healthy patients scheduled for cataract surgery

PURPOSE

To evaluate prevalence and characteristics of pathological ocular surface findings in healthy patients undergoing cataract surgery using a noninvasive ocular surface workup and a validated questionnaire.

DESIGN

Prospective single-centre study (sub-analysis clinical trial no. NCT05754437).

METHODS

Healthy patients undergoing senile cataract surgery were screened preoperatively by Oculus Keratograph (K5 M; Oculus GmbH, Wetzlar, Germany) for the evaluation of tear meniscus height (TMH), non-invasive keratograph break-up time (NIKBUT), and meibomian gland dropout. Ocular discomfort symptoms were scored by ocular surface disease index (OSDI) questionnaire.

RESULTS

120 eyes of 120 patients (62 females, 58 males; mean age 73.85 years, range 47-91 years) were included. All patients had at least 1 abnormal finding, while 19 (15.8%; 95% CI [0.09-0.22]) had alterations of all parameters. In detail, 39 patients (32.5%; 95% CI [0.24-0.41]) had pathological TMH (mean 0,15 mm [0.03 SD]), 102 (85%; 95% CI [0.79-0.91]) had pathological NIKBUT (mean 3.64 s [2.63 SD]), 117 (97.5%; 95% CI [0.95-1]) had some degree of gland dropout (mean 1.62 [0.70 SD]), 78 patients (65%; 95% CI [0.56-0.74]) had pathological OSDI scores (mean 28.63 [15.08 SD]). Using TFOS DEWS II criteria, 66 patients (55%; 95% CI [0.42-0.60]) resulted affected by dry eye.

CONCLUSIONS

This quick noninvasive screening documented the high prevalence of pathological ocular surface parameters in patients without risk factors or previous diagnosis of dry eye who are scheduled for cataract surgery.

Preventing and Managing Iatrogenic Dry Eye Disease during the Entire Surgical Pathway: A Study Focusing on Patients Undergoing Cataract Surgery

Patient expectations for cataract surgery are continuously increasing, and dry eye disease (DED) represents a major cause of patient dissatisfaction in eye surgery. The present opinion paper aims to provide useful insights to improve the entire pathway of a patient undergoing cataract surgery, from the preoperative setting to the postoperative one. The available evidence from main clinical trials published on this topic is presented in association with experience-based points of view by the authors. Ocular surface disease (OSD) is common in patients presenting for cataract surgery, and more than half of these patients have DED and meibomian gland dysfunction (MGD), even in the absence of symptoms. Therefore, there is a need to encourage preoperative assessments for the risk of DED development or worsening in all patients as a routine approach to cataract surgery. New all-in-one diagnostic machines allow for fast and noninvasive screening of the ocular surface status. Once a preoperative diagnosis of DED/OSD is reached, ocular surface optimization should be obtained before surgery. In the case of unresolved OSD, the decision to delay surgery should be considered. The surgical procedure can be optimized by avoiding large incisions, limiting microscope light intensity and exposure, and avoiding an aspirating speculum or preserved eye drops. Postoperatively, the continued avoidance of preserved agents is advisable, as well as a limited exposure to epitheliotoxic antibiotics and nonsteroidal anti-inflammatory drugs. Short-term, preservative-free, soft corticosteroids may be useful for patients with extensive or persistent inflammation.

Utilizing visual symptoms to distinguish dry eye from glaucoma, cataract, and suspect glaucoma patients: a cross-sectional study

BACKGROUND

The diagnosis of dry eye and other common ophthalmological conditions can be supported using patient reported symptoms, which is increasingly useful in contexts such as telemedicine. We aim to ascertain visual symptoms that differentiate dry eye from cataract, glaucoma, or glaucoma suspects.

METHODS

Adults with dry eye, glaucoma, cataract, and suspected glaucoma (controls) completed a questionnaire to rate the frequency and severity of 28 visual symptoms. Univariate, followed by multivariable logistic regression with backward stepwise selection (p < 0.05), determined the individual symptoms and set of symptoms best distinguishing dry eye from each of the other conditions.

RESULTS

Mean age of 353 patients (94 glaucoma suspect controls, 79 glaucoma, 84 cataract, and 96 dry eye) was 64.1 years (SD = 14.1); 67% were female and 68% White. Dry eye patients reported more frequent light sensitivity (OR = 15.0, 95% CI = 6.3-35.7) and spots in vision (OR = 2.8, 95% CI = 1.2-6.3) compared to glaucoma suspect controls. Compared to glaucoma patients, dry eye patients experienced more frequent light sensitivity (OR = 9.2, 95% CI = 2.0-41.7), but less frequent poor peripheral vision (OR = 0.2, 95% CI = 0.06-0.7), difference in vision between eyes (OR = 0.09, 95% CI = 0.01-0.7), and missing patches of vision (OR = 0.06, 95% CI = 0.009-0.3). Compared to cataract patients, dry eye patients reported more frequent spots in vision (OR = 4.5, 95% CI = 1.5-13.4) and vision variability across the week (OR = 4.7, 95% CI = 1.2-17.7) and were less likely to report worsening vision (OR = 0.1, 95% CI = 0.03-0.4) and blindness (OR = 0.1, 95% CI = 0.02-0.8).

CONCLUSION

Visual symptoms may serve as a complementary tool to distinguish dry eye from various ocular conditions, though the symptoms that best distinguish dry eye differ across comparisons. Differentiating how patients visually perceive common eye diseases may be used in a variety of clinical settings to rule out specific conditions.

Risk Factors for Meibomian Gland Disease Assessed by Meibography

Purpose

To elucidate risk factors for meibomian gland disease (MGD) and understand associated changes in meibography and in relation to ocular surface disease.

Patients and Methods

As part of the standard workup for ocular surface disease at a tertiary academic center, 203 patients received an ocular history and lifestyle questionnaire. The questionnaire included detailed inquiries about ocular health and lifestyle, including makeup use, cosmetic eyelid procedures, screen time, and contact lens habits. Subjects also took the standardized patient evaluation of eye dryness (SPEED) II questionnaire. Meibomian gland (MG) dropout and structural changes were evaluated on meibography and scored by three independent graders using meiboscores. Statistical analysis was conducted to identify significant risk factors associated with MG loss.

Results

This retrospective, cross-sectional study included 189 patients (378 eyes) with high-quality images for grading, and the average age was 67 years (77% female). Patients older than 45 years had significantly more dropout than younger patients (p < 0.01). Self-reported eye makeup use did not significantly impact MG loss. Patients with a history of blepharoplasty trended toward higher meiboscores, but the difference was not statistically significant. Self-reported screen time did not affect meiboscores. Contact lens use over 20 years was associated with significant MG loss (p < 0.05). SPEED II scores had no relationship to meiboscores (p = 0.75).

Conclusion

Older age is a significant risk factor for MG loss. Any contact lens use over 20 years also impacted MG dropout. Highlighting the incongruence of symptoms to signs, SPEED II scores showed no relationship to the structural integrity of MGs.

0.2% Betamethasone Sodium Phosphate: A Multicenter, Randomized, Double-Masked Study to Compare Its Ocular Safety, Tolerability, and Efficacy to Vehicle in Cataract Surgery Subjects

Purpose

To compare the preservative-free corticosteroid 0.2% betamethasone sodium phosphate BID (SURF-201) to vehicle BID in patients undergoing routine cataract surgery.

Methods

Phase 2, multicenter, randomized (1:1 ratio), double-masked, vehicle-controlled, parallel-group study in patients scheduled for uncomplicated cataract surgery without the aid of a femtosecond laser. Subjects instilled topical medications for 16 days beginning the day before cataract surgery (Day -1), 1 dose administered at least 1 hour prior to cataract surgery (on Day 0) and 1 dose on the evening after cataract surgery, and then 2 doses administered each day through Day 15; patients were re-evaluated on Days 22 and 32 to ensure no rebound inflammation. Primary outcome was the difference in the proportion of subjects with anterior chamber cell (ACC) grade 0 between the two groups at Day 15. Secondary outcomes included pain scores and overall safety.

Results

There was a statistically significant difference (P=0.004) in the proportion of subjects in the SURF-201 treatment group with an ACC grade of 0 at Day 15 (n=22/39 [56.4%]) compared to subjects in the vehicle treatment group (n=9/43 [20.9%]). There was no statistically significant difference (P=0.528) in the proportion of subjects in the SURF-201 treatment group who had a visual analog scale pain score of 0 at Day 15 (n=35/38 [89.7%]) compared to subjects in the vehicle group (n=33/40 [82.5%]). A slightly higher incidence of adverse events occurred in subjects in the SURF-201 treatment group (n=27/40 [67.5%]) compared to the vehicle treatment group (n=23/43 [53.5%]).

Conclusion

SURF-201 is an effective topical, preservative-free corticosteroid when dosed BID for the treatment of postoperative inflammation and prevention of pain in a post-cataract population.

Meibomian gland dysfunction and blepharitis: A common and still unsolved ophthalmic problem

Blepharitis and meibomian gland dysfunction (MGD) are very common, usually underdiagnosed and underappreciated diseases. More than 50% of patients seeking ophthalmologic consultations have symptoms and signs indicating one or both entities. We summarize the key points of diagnosis and management of both diseases, comparing the work of Dry Eye Workshop II (2017) with the dry eye blepharitis syndrome unification theory. The impact of MGD/blepharitis on ocular surgery also is described. Although MGD and blepharitis seem to be uncurable, most of the time they can be successfully controlled. Different management options are available, but the key to success remains simple-routine eyelid hygiene and moisturizing with the use of preservative-free lubricants.

Dry Eye Disease as a Cause of Refractive Errors After Cataract Surgery - A Systematic Review

Dry eye disease (DED) is a multifactorial ocular surface disorder characterized by loss of tear film homeostasis with associated ocular symptoms, like dryness, foreign body sensation, and inflammation. Numerous reports confirm an increase in dry eye symptoms after cataract surgery. DED also significantly disturbs preoperative biometric measurements, mainly by changes in keratometry measurements. The purpose of this study is to evaluate the effect of DED on biometric measurements before cataract surgery and postoperative refractive errors. PubMed database was searched for keywords: cataract surgery, dry eye disease, refractive error, refractive outcomes, keratometry, and biometry. Four clinical studies evaluating the effect of DED on refractive errors were included. In all studies, biometry was performed before and after dry eye treatment, and the mean absolute error was compared. Various substances have been used to treat dry eye, such as cyclosporin A, liftitegrast, and loteprednol. The refractive error was significantly lower after treatment in all studies. The results unanimously indicate that refractive errors can be reduced by proper treatment of DED before cataract surgery.

How Can We Best Diagnose Severity Levels of Dry Eye Disease: Current Perspectives

Dry eye disease (DED) is a common ocular condition, but the diagnosis relative to other ocular conditions and the evaluation of severity of the condition has often been difficult. This challenge can be due to clinical signs and symptoms not always correlating with each other. An understanding of the various components which create the condition, as well as the diagnostic measures used to evaluate these components, is useful to the clinician working with DED patients. This review paper will discuss traditional diagnostic options, diagnostic imaging, and Advanced Point of Care testing capabilities to determine the severity level of dry eye disease more adequately.

Impact of Thermal Pulsation System Therapy on Pre-Operative Intraocular Lens Calculations before Cataract Surgery in Patients with Meibomian Gland Disfunction

In patients with eye surface disorders such as dry eye syndrome or Meibomian gland dysfunction (MGD) it is necessary to improve the tear film condition in order to obtain visual system measurements before cataract surgery. The aim of the project was to analyze the Thermal Pulsation System (TPS) impact on the visual system parameters used in cataract surgery qualification. The study included six patients (11 eyes) with MGD diagnosis. All patients were treated with TPS. The obtained results were compared and used to calculate the power and type of the intraocular lens (IOL). As a treatment result, the power of astigmatism has changed in 64% of the eyes. Planned surgical treatment type has changed in 27% of cases. TPS also affected the cylinder axis in three eyes, which was 27% of cases. Based on the calculations, power of the recommended IOL has changed in five eyes (46%). Stabilization of visual system parameters after TPS allowed to improve the accuracy of the results. It also ensured the proper astigmatism treating method during cataract surgery and allowed selection of the proper IOL power and type.

Solving STODS-Surgical Temporary Ocular Discomfort Syndrome

The term STODS (Surgical Temporary Ocular Discomfort Syndrome) has been coined to describe the ocular surface perturbations induced by surgery. As one of the most important refractive elements of the eye, Guided Ocular Surface and Lid Disease (GOLD) optimization is fundamental to success in achieving refractive outcomes and mitigating STODS. Effective GOLD optimization and the prevention/treatment of STODS requires an understanding of the molecular, cellular, and anatomic factors that influence ocular surface microenvironment and the associated perturbations induced by surgical intervention. By reviewing the current understanding of STODS etiologies, we will attempt to outline a rationale for a tailored GOLD optimization depending on the ocular surgical insult. With a bench-to-bedside approach, we will highlight clinical examples of effective GOLD perioperative optimization that can mitigate STODS' deleterious effect on preoperative imaging and postoperative healing.

ESCRS Clinical Trends Survey 2016-2021: 6-year assessment of practice patterns among society delegates

PURPOSE

To evaluate clinical opinions and practice patterns of delegates to the ESCRS.

SETTING

Clinical Trends Surveys were administered during annual ESCRS congresses held between 2016 and 2021, and data collected online and in-person.

DESIGN

Survey questions addressed several specialty areas, including cataract surgery, presbyopia-correcting and toric intraocular lenses (IOLs), ocular surface disease, and glaucoma.

METHODS

Survey results were compared and analyzed across 6 years. 4 main profile questions were used for cross-tabulation analyses of questions pertaining to refractive surgery-practice location, years in practice, primary surgery setting, and average annual volume of cataract surgery.

RESULTS

The highest number of responses (3019) was collected in 2019, with the lowest (569) received in 2020. The use of presbyopia-correcting and toric IOLs has increased significantly from 2016 to 2021, with certain respondent segments using them more frequently than others. Although optical biometry remains the preferred method for obtaining preoperative measurements, the use of tomography (Scheimpflug) has significantly increased. In 2021, 61.1% and 44.9% of respondents always performed preoperative checks of the ocular surface before refractive and cataract surgery, respectively. The number of respondents who perform glaucoma surgery has significantly decreased over the years, with an increasing number of delegates reporting having only a medical glaucoma practice. On average, 5.4% of patients with cataract and glaucoma underwent combined minimally invasive glaucoma surgery and cataract procedures in 2021.

CONCLUSIONS

Evaluation of the Clinical Trends Survey data provides valuable insights into the shifting practice patterns and clinical opinions of ESCRS delegates.

Prevalence of Dry Eye Disease Among Individuals Scheduled for Cataract Surgery in a Norwegian Cataract Clinic

Purpose

To determine the prevalence of dry eye disease (DED) in patients scheduled for cataract surgery in a Norwegian eye clinic.

Patients and Methods

218 patients scheduled for cataract surgery were examined for DED in one randomly selected eye and questioned regarding symptoms and risk factors. Patients were diagnosed with DED if they fulfilled the DEWS II criteria with symptom score >12/100 with Ocular Surface Disease Index (OSDI) questionnaire, and the presence of any of the three signs: tear osmolarity >307 mOsm/L in either eye or a difference in osmolarity between the two eyes of >8 mOsm/L, corneal fluorescein staining (CSF) ≥ grade 2 and non-invasive tear film breakup time (NIKBUT) of <10 seconds. Additional tests were the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, tear meniscus height (TMH), Schirmer 1, tear film thickness (TFT), corneal sensitivity and meibography (meiboscore). Dry eye test outcomes were correlated with risk factors for DED.

Results

The prevalence of DED was 55.5% according to the DEWS II criteria. The abnormal osmolarity percentage was 66.5, while 29.8% had shortened NIKBUT and 19.7% exhibited CFS ≥2. 57% had Schirmer 1 ≤ 10 mm/5 min, and 81.1% had a meiboscore of ≥1. 71.2% of subjects scored positive for DED symptoms using the OSDI questionnaire and 69.3% using SPEED. Logistic regression analysis showed that higher age correlated with a lower OSDI symptom score, reduced corneal sensitivity and increased meibomian gland atrophy. Female sex was associated with higher odds of having DED, abnormal NIKBUT and abnormal CFS. Ocular tests for DED did not correlate with OSDI symptom scores when assessed with Spearman`s rank analysis.

Conclusion

The prevalence of DED in an elderly Norwegian population scheduled for cataract surgery is high and associated with female sex. There was a lack of correlation between signs and symptoms of DED.

Understanding and Optimizing Ocular Biometry for Cataract Surgery in Dry Eye Disease: A Review

PURPOSE

To understand the impact of dry eye disease (DED) on the components of ocular biometry and ways to optimize the visual outcomes of cataract surgery in eyes with DED.

METHODOLOGY

A thorough literature review of the components pertaining to this review was undertaken using the databases, PubMed (from the year 2000), MEDLINE, CENTRAL (including Cochrane Eyes and Vision Trials Register; Cochrane Library: Issue 12 of 12 December 2019), metaRegister of Controlled Trials (mRCT) (www.controlled-trials. com), ClinicalTrials.gov (www.clinicaltrial.gov) and WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). The keywords used for the search included "cataract surgery" or "phacoemulsification" combined with "dry eye", "dry eye disease","biometry", "keratometry".

RESULTS

Publications considered for this review included meta-analysis, systematic reviews, case-control and cohort studies, case series, and laboratory-based studies. Published articles reporting tear film alteration in DED, its impact on the quality of vision and optical aberrations, the effect of topical medications on keratometry variations, and reports on optimizing the ocular surface before cataract surgery were included.

CONCLUSIONS

DED is a common entity seen in patients presenting to routine cataract clinics and is known to impact the accuracy, reliability, and repeatability of ocular biometry and IOL power calculations in them. This review intends to emphasize the preoperative screening for the presence of DED, initiation of appropriate medical management for optimization of the ocular surface before cataract surgery, and recommendations for performing biometry. The algorithmic approach proposed will help the general ophthalmologists in routine practice to provide quality care and acceptable visual outcomes in patients with pre-existing DED.

Clinical Outcomes of Cataract Surgery in Patients with Sjögren's Syndrome

This study compared the biometric accuracy and refractive outcomes, and ocular surface changes after cataract surgery in patients with Sjögren’s syndrome (SS, S group), non-SS dry eye patients (D group), and healthy controls (C group). The medical records of patients who underwent cataract surgery and met certain inclusion criteria were reviewed. In total, 167 eyes of 87 patients were enrolled. Refractive parameters were analyzed via optical biometry and combined ultrasound biometry and automated refractokeratometry. The mean absolute errors (MAEs), the uncorrected distance visual acuities (UDVAs), changes in the ocular staining score (OSS), and anterior chamber cell grades were compared for 12 months postoperatively. The S group evidenced more severe and persistent OSS exacerbation after cataract surgery; the OSS returned to baseline by 3 months postoperatively. The mean keratometric values showed a significant linear correlation. There was no significant intergroup difference in either the MAEs (p > 0.530) or anterior chamber inflammation (p > 0.436). The postoperative UDVA of the S group was poorer than that of the C group from 3 months postoperatively (p < 0.047) but not different from that of the D group (p > 0.311). With preoperative ocular surface optimization and optimal postoperative treatment of superficial keratitis, the refractive outcomes of SS patients were comparable to those of other groups and the postoperative UDVA was not inferior to that of non-SS dry eye patients.

The efficacy of ocular surface assessment approaches in evaluating dry eye treatment with artificial tears

This study evaluates the effectiveness of objective techniques in assessing dry eye disease (DED) treatment compared with the subjective assessment commonly used in clinical practice. Thirty subjects were recruited for two visits separated by 28(± 3) days of treatment with artificial tears. A buttery of common subjective assessment methods were accompanied by a set of objective techniques including measurement of noninvasive tear film break-up time (NIBUT), lipid layer thickness (LLT), and quantitative evaluation of tear film surface quality and dynamics (TFD). Additionally, meibography was performed. Two commercially available videokeratoscopes and a prototype of a lateral shearing interferometer were used for the measurements. Both subjective and objective techniques showed a positive effect of artificial tears in DED treatment. Statistically significant improvements were observed in subjective symptoms (from P < 0.001 for Ocular Surface Disease Index, OSDI to p = 0.019 for tearing), conjunctival redness (P = 0.022), ocular staining (P = 0.012), fluorescein tear film break-up time (P = 0.015), NIBUT (P = 0.037), LLT (P < 0.001), and TFD (P = 0.048). In general, weak or statistically insignificant correlations were observed between subjective and objective assessment methods. The apparent lack of correlation between these methods might indicate the complementary character of objective techniques that likely assess other characteristics of ocular surface health than those assessed subjectively.

Ocular surface optimization before cataract surgery

The evolution of refractive cataract surgery has increased patient expectations for visual outcomes following cataract surgery. Precise biometry and keratometry are critical for accurate intraocular lens (IOL) selection and favorable surgical outcomes. In patients with the ocular surface disease and corneal pathologies, preoperative measurements can often be erroneous, leading to postoperative refractive surprises and dissatisfied patients. Conditions such as dry eye disease, epithelial basement membrane dystrophy, Salzmann's nodular dystrophy, and pterygia need to be addressed thoroughly before performing cataract surgery to optimize the ocular surface, obtain high-quality preoperative measurements, and ultimately determine the appropriate IOLs. In this review, the various ocular surface pathologies affecting cataract surgery outcomes and options for treatment are discussed and the importance of optimization of the ocular surface before cataract surgery is reviewed.

Evaluation of Ocular Surface after Cataract Surgery—A Prospective Study

This study evaluated tear film and ocular surface parameters in patients after cataract surgery. Methods: a prospective clinical study included 48 eyes of 48 patients who underwent uncomplicated phacoemulsification performed by one surgeon. Tear break-up time (TBUT), Schirmer’s I test, Cochet–Bonnet esthesiometry and in vivo laser scanning confocal microscopy was carried out and the OSDI questionnaire was filled out. All tests were assessed before and 1 month after the surgery. Results: there were 32 (66.7%) women; 16 (33.3%) men, mean age was 74.08 ± 5.37. Mean TBUT at baseline was 8.6 ± 1.9 s, after the surgery, it was 7.7 ± 2.7 s, p = 0.004. Schirmer’s I test was 8.7 ± 3.9 mm versus 8.1 ± 3.7 mm, p = 0.002. Mean corneal nerve density at baseline was 15.70 ± 2.34 and at the first postoperative month 14.94 ± 1.48 mm/mm², p = 0.02. The OSDI questionnaire score increased from 12.15 ± 10.34 before the surgery to 13.79 ± 10.88 in the first postoperative month, p = 0.001. Conclusions: the ocular surface was affected 1 month after the cataract surgery: TBUT was shorter, Schirmer’s I test and corneal nerve density were decreased while the OSDI score increased.

Impact of Perioperative Dry Eye Treatment with Rebamipide Versus Artificial Tears on Visual Outcomes After Cataract Surgery in Japanese Population

Introduction

The present study aimed to compare the effects of rebamipide and artificial tears during the perioperative period of cataract surgery on the postoperative visual outcomes.

Methods

Seventy-two eyes from 36 patients with a cataract were enrolled. Rebamipide (group R) was administered in one eye and Mytear® artificial tear ophthalmic solution (group A) in the other eye from 4 weeks preoperatively to 3 months postoperatively. Tear breakup time (TBUT), high-order aberrations (HOAs), superficial punctate keratopathy in the central part of the cornea (C-SPK), and corrected distance visual acuity (CDVA) were assessed at baseline, 1 week, 1 month, and 3 months after cataract surgery with trifocal intraocular lens (IOL) implantation. Contrast sensitivity and disability glare with visual angle values compatible with spatial frequencies of 1.1, 1.8, 2.9, 4.5, 7.1, and 10.2 cycles/degree (CPD) were evaluated postoperatively. Between-group differences of all variables were analyzed.

Results

At baseline, no significant differences in the variables were noted between the two groups. Mean TBUT was significantly higher, while mean C-SPK and HOAs were significantly lower in group R than in group A at each assessment. Mean CDVA was significantly higher at 1 week and 1 month postoperatively in group R compared with group A; this value was not significant at 3 months. Between-group differences in contrast sensitivity and disability glare were statistically significant at all spatial frequencies, 1 week and 1 month postoperatively. At 3 months postoperatively, there were significant differences in contrast sensitivity and disability glare at most spatial frequencies.

Conclusion

Dry eye management with rebamipide in the perioperative period of cataract surgery with trifocal IOL implantation was significantly more effective than artificial tears in improving ocular surface condition, contrast sensitivity, and disability glare postoperatively.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00523-w.

Call to action: treating dry eye disease and setting the foundation for successful surgery

Dry eye disease (DED) is a common disease that can reduce the quality of life. Prevalence estimates vary but have been reported to be as high as 60% in some populations. Diagnosis is complicated by a multifactorial etiology and a disconnection between clinical signs and patient-reported symptomatology. Critically, preexisting DED can exacerbate postoperative dry eye symptoms and reduce patient satisfaction after ocular surgery, highlighting the value of thorough evaluation and screening for signs and symptoms of DED in preparation for ocular surgery. This article reviewed predisposing and exacerbating factors for DED and presented an argument for the importance of adequately treating DED prior to surgery, from the perspective of both the patient and the provider. It briefly reviewed currently available methodologies and emphasized the utility of multimodal diagnosis and treatment algorithms to optimize outcomes and patient satisfaction.

The Prevalence of Demodex Blepharitis in US Eye Care Clinic Patients as Determined by Collarettes: A Pathognomonic Sign

Purpose

Patients and Methods

Results

Conclusion

The Effect of Rebamipide on Refractive Accuracy of Cataract Surgery in Patients with Dry Eye

Introduction

Refractive accuracy is crucial for increasing patient satisfaction after cataract surgery. Tear film instability caused by dry eye can lead to inaccurate measurement of corneal power, which is one of the most important factors for postoperative refractive calculation. This study investigated the effect of 2% rebamipide ophthalmic suspension on the predicted refractive accuracy for cataract surgery in patients with dry eye.

Methods

This single-center, prospective, open-label study included 35 dry eyes (with tear breakup time < 5 s) who underwent cataract surgery. The patients were treated with rebamipide for 4 weeks before the preoperative examination. In addition to the usual evaluation of biometric variables essential for cataract surgery, tear breakup time (TBUT), superficial punctate keratopathy in the central part of the cornea (C-SPK), corneal higher-order aberrations (HOAs), and predicted postoperative spherical equivalent (P-SE) were evaluated at baseline and 4 weeks after dry eye treatment. The patients’ subjective spherical equivalent (S-SE) was evaluated 1 month postoperatively. The difference between S-SE and P-SE was used to assess the accuracy of the P-SE. Improvement in TBUT, C-SPK, HOA, and the accuracy of P-SE after dry eye treatment were analyzed.

Results

The accuracy of the biometry readings for the achieved P-SE was within 0.25 D in 42.9% and 54.3%; within 0.5 D in 71.4% and 88.6%; and within 0.75 D in 88.6% and 97.1% of eyes before and after rebamipide treatment, respectively (p < 0.01). TBUT, C-SPK, and HOAs significantly improved after rebamipide treatment (p < 0.01).

Conclusion

Rebamipide significantly improved the corneal surface condition and accuracy of the predicted postoperative refraction in dry eyes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00457-3.

Optimizing the ocular surface prior to cataract surgery

PURPOSE OF REVIEW

Ocular surface disease can significantly impact the outcomes of cataract surgery. Recent studies have examined the efficacy of several new dry eye disease (DED) therapies, the extent to which epithelial debridement affects keratometric measurements in epithelial basement membrane dystrophy (EBMD) and Salzmann nodular degeneration (SND), and the predictability of refractive error following combined pterygium and cataract removal. This review aims to incorporate these newer studies in updating and further emphasizing the need for careful management and optimization of common ocular surface conditions prior to cataract surgery.

RECENT FINDINGS

Common ocular surface conditions such as DED, EBMD, SND, and pterygium can cause significant irregular astigmatism and higher-order aberrations. Their resolution can substantially alter biometry measurements in preparation for cataract surgery, affecting the final visual outcome. Newer therapies for DED, such as topical lifitegrast and thermal pulsation treatment, can aid in this optimization process. If superficial keratectomy or excisions of lesions on the ocular surface are performed, sufficient healing time is needed to allow the ocular surface to reach stability prior to biometry measurements.

SUMMARY

Ocular surface optimization is key to successful cataract surgery planning and reaching desired outcomes.

Accuracy and safety of partial thickness femtosecond laser radial and arcuate keratotomy incisions in porcine eyes

Background

To evaluate the accuracy and safety of micro radial and arcuate keratotomy incisions constructed by a femtosecond laser system with a curved contact patient interface in porcine eyes.

Methods

Partial thickness micro radial and arcuate keratotomy incisions were constructed in porcine eyes with a femtosecond laser system and evaluated for precision of depth, quality, and consistency. Optical coherence tomography was used to determine the accuracy and precision of incision depth. Corneal endothelial safety was assessed by a fluorescent live/dead cell viability assay to demonstrate laser-induced endothelial cell loss. Quality was evaluated by ease of opening and examination of interfaces.

Results

In two micro radial incision groups, intended incision depths of 50% and 80% resulted in mean achieved depths of 50.01% and 77.69%, respectively. In three arcuate incision groups, intended incision depths of 80%, 600 μm or 100 μm residual uncut bed thickness resulted in mean achieved depths of 80.16%, 603.03 μm and residual bed of 115 μm, respectively. No loss of endothelial cell density occurred when the residual corneal bed was maintained at a minimum of 85–116 µm. The incisions were easy to open, and interfaces were smooth.

Conclusions

A femtosecond laser system with curved contact interface created precise and reproducible micro radial and arcuate keratotomy incisions. Accuracy and precision of the incision depth and preservation of endothelial cell density demonstrated the effectiveness and safety of the system.

Should Artificial Tears Be Used During the Preoperative Assessment of Toric IOLs Before Age-Related Cataract Surgery? The TORIDE Study

PURPOSE

To assess the impact of the use of artificial tears during the preoperative work-up performed before age-related cataract surgery, when a toric intraocular lens (IOL) was indicated.

METHODS

This was a monocentric prospective study assessing 73 eyes of 51 patients, included consecutively after a preoperative work-up performed without artificial tears (no artificial tears group), when a toric IOL was indicated. Each included patient underwent a second series of examinations: biometry using the IOLMaster 700 (Carl Zeiss Meditec AG) and topography using the OPD-Scan II (Nidek), 1 minute after artificial tears instillation (artificial tears group; hyaluronate de sodium 0.15%, threalose 3% [Théalose; Théa]). Changes in anterior corneal astigmatism and subsequent changes in toric IOL calculation were analyzed. The error in predicted residual astigmatism was calculated.

RESULTS

Anterior corneal astigmatism and total corneal astigmatism measured with the IOLMaster 700 were significantly modified when artificial tears were instilled before the examinations (1.51 ± 0.57 diopters [D], range: 0.75 to -3.55 vs 1.42 ± 0.63 D, range: 0.42 to 3.35 D; P = .043 and 1.59 ± 0.54 D, range: 0.87 to 3.48 vs 1.51 ± 0.59 D, range: 0.56 to 3.27 D, P = .038, respectively). This modification led to a change in IOL cylinder calculation in 43.8% of cases and to a change in implantation axis greater than 10° in 17.7% of cases. These changes were significantly greater in patients with a breakup time (BUT) less than 5 seconds (57.5% and 27.8%, with P = .009 and .029, respectively). In the subgroup of patients with a BUT of less than 5 seconds, the mean absolute error in predicted astigmatism was significantly lower after artificial tears instillation (0.48 ± 0.50 D, range: 0.00 to 2.79 vs 0.37 ± 0.25 D, range: 0.00 to 1.10 D, P = .048).

CONCLUSIONS

Dry eye significantly impacted toric IOL calculations and should be taken into account during the preoperative assessments. Using artificial tears reduced the number of refractive errors. [J Refract Surg. 2021;37(11):759-766.].

Hyaluronic Acid/Trehalose Ophthalmic Solution in Reducing Post-Cataract Surgery Dry Eye Signs and Symptoms: A Prospective, Interventional, Randomized, Open-Label Study

The purpose of this prospective study was to evaluate the efficacy of the perioperative use of a hyaluronic acid (HA) and trehalose ophthalmic solution (Thealoz^® Duo) in reducing post-cataract surgery dry eye signs and symptoms in patients with mild/moderate dry eye disease (DED). One hundred and twenty patients, scheduled for unilateral cataract surgery, were randomized into three groups: (1) group A: HA/trehalose three times/day in the preoperative week and for 5 postoperative weeks; (2) group B: HA/trehalose for only 5 postoperative weeks; (3) group C: no artificial tears. In groups A and B, OSDI (Ocular Surface Disease Index) questionnaire scores were significantly lower than group C at all the postoperative visits; in group A they were significantly lower than group B on the day of surgery, with similar results in the first and fifth weeks after surgery. In groups A and B, break-up time (BUT) was significantly higher than group C during the postoperative period (p ≤ 0.001). In comparison to the preoperative values, BUT in group A remained stable 7 days after surgery; however, in groups B and C, it significantly decreased. In conclusion, the HA/trehalose ophthalmic solution effectively reduced post-cataract surgery DED signs and symptoms in patients with mild/moderate DED, particularly if also administered in the preoperative period.

Improved accuracy of intraocular lens power calculation by preoperative management of dry eye disease

Background

To evaluate the effects of pretreatment for dry eye disease (DED) on the accuracy of intraocular lens (IOL) power calculation.

Methods

Patients who underwent uneventful cataract surgery were included in the study. IOL power was determined using the SRK/T and Barrett Universal II (Barrett) formulas. The patients were divided into non-pretreatment and pretreatment groups, and those in the pretreatment group were treated with topical 0.5% loteprednol etabonate and 0.05% cyclosporin A for 2 weeks prior to cataract surgery. Ocular biometry was performed in all groups within 2 days before surgery. The mean prediction error, mean absolute error (MAE), and proportions of refractive surprise were compared between the non-pretreatment and pretreatment groups at 1 month postoperatively. Refractive surprise was defined as MAE ≥ 0.75D.

Results

In a total of 105 patients, 52 (52 eyes) were in the non-pretreatment group and 53 (53 eyes) in the pretreatment group. The MAE was 0.42 ± 0.33, 0.38 ± 0.34 (SRK/T, Barrett) and 0.23 ± 0.19, 0.24 ± 0.19 in the non-pretreatment and pretreatment groups, respectively (p < 0.001/=0.008). The number of refractive surprises was also significantly lower in the pretreatment group. [non-pretreatment/pretreatment: 9/2 (SRK/T); 8/1 (Barrett); p = 0.024/0.016]. Pretreatment of DED was related to a reduction in postoperative refractive surprise. [SRK/T/Barrett: OR = 0.18/0.17 (95% CI: 0.05–0.71/0.05–0.60), p = 0.014/0.006].

Conclusions

The accuracy of IOL power prediction can be increased by actively treating DED prior to cataract surgery.

Effect of Cyclosporine 0.09% Treatment on Accuracy of Preoperative Biometry and Higher Order Aberrations in Dry Eye Patients Undergoing Cataract Surgery

Purpose

To determine the effect of topical cyclosporine 0.09% on ocular surface regularity and the predictive accuracy of preoperative corneal power measurements in patients undergoing cataract surgery.

Setting

Private practice.

Design

Open-label, multicenter, prospective study.

Methods

Seventy-five patients (75 eyes) who presented for cataract surgery evaluation with signs of dry eye disease were prescribed topical cyclosporine 0.09% for 28 days BID. Corneal curvature measurements, slit lamp exam, and Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire were evaluated at the initial and follow-up visits. Cataract surgery occurred 1 to 3 weeks after the second biometry visit. Refraction and corrected distance visual acuity measurements were performed 1-month post-surgery. The primary outcome was the difference in absolute prediction error of 1-month spherical equivalent refractive outcome before and after cyclosporine treatment. Secondary outcomes included the effect of topical cyclosporine 0.09% on ocular surface irregularity.

Results

Sixty-four patients completed the study. The absolute prediction error of 1-month spherical equivalent refractive outcome was 0.39 ± 0.30 D vs 0.33 ± 0.25 D (P < 0.03) before and after treatment, respectively. The proportion of eyes that achieved the target refraction was greater based on measurements after topical cyclosporine 0.09% than would have occurred using pre-treatment measurements.

Conclusion

Cataract surgery patients with dry eye who are prescribed topical cyclosporine 0.09% BID for 28 days pre-surgery showed a statistically significant improvement in the prediction error of the spherical equivalent outcome of surgery. Other measures of dry eye severity showed significant improvements after treatment.

A Single-center Retrospective Trial of a Blink-assisted Eyelid Device in Treating the Signs and Symptoms of Dry Eye

SIGNIFICANCE

The clinical features of meibomian gland disease include altered tear film stability, damage to the ocular surface, symptoms of ocular surface irritation, and visual fluctuations. Finding an adequate treatment to alleviate a patient's signs and symptoms is vital to caring for those with dry eye disease resulting from meibomian gland disease.

PURPOSE

The purpose of this analysis was to determine whether the controlled heating of meibomian glands with the SmartLid devices (TearCare) combined with evacuation of the liquefied meibum using a handheld clearance assistant would improve a patient's dry eye symptoms (as measured by the Standardized Patient Evaluation of Eye Dryness [SPEED] questionnaire) and signs (as measured by meibomian gland expression [MGE] scores).

METHODS

This study involved a retrospective analysis of data gathered in a single-center ophthalmology/optometry practice. The symptom frequency and severity were assessed using the SPEED questionnaire, and the signs were assessed via MGE scores before and after (8 to 12 weeks) treatment. A further analysis evaluating efficacy in subgroups based on age, race, and sex was performed. A statistical analysis was performed with t tests for group comparisons.

RESULTS

A SPEED questionnaire was answered by 92 patients with dry eye disease. In addition, each patient's meibomian gland function was recorded as MGE scores for each eye (176 eyes). These procedures were completed before and approximately 8 weeks after a single bilateral TearCare treatment. The median total SPEED score was reduced from 16 to 9, and the total MGE scores improved from 5.0 to 9.0 in the right eye and 4.0 to 9.0 in the left eye after a single TearCare treatment.

CONCLUSIONS

A single TearCare treatment was effective in reducing both the signs and symptoms of dry eye in all subjects.

Comparison of Preoperative Measurements with Intraoperative Aberrometry in Predicting Need for Correction in Eyes with Low Astigmatism Undergoing Cataract Surgery

Purpose

To determine whether intraoperative aberrometry during cataract surgery measures higher levels of absolute astigmatism than preoperative biometry readings and which method yields a lower, final level of astigmatism if the two do not agree.

Patients and Methods

Retrospective record review of all patients who underwent uncomplicated cataract surgery from February 2015 to May 2019 with planned intraoperative aberrometry. Data analysis included preoperative keratometry, total astigmatism as measured by intraoperative aberrometry, intraocular lens model and power used, and postoperative manifest refraction ≥1 month after surgery. The primary outcome measure was the proportion of patients requiring astigmatism correction (≥0.5 D) when measured by preoperative keratometry vs intraoperative aberrometry. Secondary outcomes included postoperative residual astigmatism, where adjusted preoperative astigmatism fell below the 0.5 D threshold for treatment but the intraoperative measurement was ≥0.5 D or ≥1.0 D.

Results

A total of 451 patient records were evaluated. Intraoperative aberrometry measured statistically higher levels of mean astigmatism than keratometry (0.86 D vs 0.79 D, respectively; P < 0.0001) and significantly greater astigmatism among patients with 0.5–1.5 D of adjusted preoperative astigmatism (P < 0.0001). Significantly more patients qualified for with-the-rule astigmatism correction when measured by intraoperative aberrometry (n=339; 75%) than by preoperative keratometry alone (n=314; 70%); P < 0.03. This difference did not hold for against-the-rule or oblique astigmatism. For patients whose preoperative biometry astigmatism differed from intraoperative biometry, final postoperative astigmatism was lower when corrected if the adjusted preoperative and intraoperative measurements had a vector difference of <0.5 D, but there was no additional benefit in final astigmatism reduction when the vector difference was ≥0.5 D.

Conclusion

Using intraoperative biometry readings can produce lower postoperative astigmatism than using preoperative biometry readings, but caution should be used when interpreting intraoperative readings that disagree with preoperative measurements with a vector magnitude of >0.5 D.

Ocular Surface Changes Associated with Ophthalmic Surgery

Dry eye disease causes ocular discomfort and visual disturbances. Older adults are at a higher risk of developing dry eye disease as well as needing for ophthalmic surgery. Anterior segment surgery may induce or worsen existing dry eye symptoms usually for a short-term period. Despite good visual outcomes, ocular surface dysfunction can significantly affect quality of life and, therefore, lower a patient’s satisfaction with ophthalmic surgery. Preoperative dry eye disease, factors during surgery and postoperative treatment may all contribute to ocular surface dysfunction and its severity. We reviewed relevant articles from 2010 through to 2021 using keywords “cataract surgery”, ”phacoemulsification”, ”refractive surgery”, ”trabeculectomy”, ”vitrectomy” in combination with ”ocular surface dysfunction”, “dry eye disease”, and analyzed studies on dry eye disease pathophysiology and the impact of anterior segment surgery on the ocular surface.

Iatrogenic Dry Eye Disease: Dealing with the Conundrum of Post-Cataract Discomfort. A P.I.C.A.S.S.O. Board Narrative Review

The incidence and prevalence of dry eye disease (DED) after cataract surgery is greatly underestimated. The severity of dry eye symptoms has been reported to peak 7 days after cataract surgery and may persist for months, significantly affecting patients' quality of life (QoL). The importance of considering surgical outcomes not only in terms of visual acuity, but also in terms of the patients' QoL, necessitates the assessment and evaluation of the ocular surface by the cataract surgeon prior to the procedure. This narrative review, drafted by the P.I.C.A.S.S.O. (Italian Partners for the Correction of Ocular Surface Alterations) board, analyses the physiopathology of post-cataract surgery DED and highlights the pre-, intra- and postoperative risk factors that may alter ocular surface homeostasis; it proposes a practical comprehensive algorithm for the prevention, treatment and management of DED associated with cataract surgery. Particular attention needs to be paid to the pre- and intraoperative risk factors to reduce the incidence of postoperative dry eye and to improve cataract surgery outcome.

The Effect of Lifitegrast on Refractive Accuracy and Symptoms in Dry Eye Patients Undergoing Cataract Surgery

Purpose

To determine the effect of lifitegrast ophthalmic solution 5% on improving the tear film, biometry/keratometry, and refractive accuracy for dry eye patients scheduled for cataract surgery.

Patients and Methods

Multicenter, prospective, open-label study of 100 eyes of 100 patients undergoing cataract surgery who had a confirmed diagnosis of dry eye. Patients underwent biometry at baseline and again after a 28-day course of lifitegrast 5% BID. Primary outcome was an improvement in the accuracy of preoperative anterior corneal power measurements at predicting postoperative spherical equivalent (SE) pre- and post-lifitegrast treatment. Secondary outcomes included changes in dry eye symptoms and corneal staining.

Results

The accuracy of the biometry readings for the achieved refractive SE: within 0.25 D in 47% and 50% of eyes before and after the initial lifitegrast treatment, respectively; within 0.5 D in 71% and 79% of eyes before and after the initial lifitegrast treatment; and within 0.75 D in 81% and 91% of eyes before and after the initial lifitegrast treatment (p < 0.04).

Conclusion

Lifitegrast 5% significantly improved preoperative corneal surface measurement accuracy in patients with confirmed dry eye who were scheduled for cataract surgery.

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/uSDGfO8JGAc

Impact of Thermal Pulsation Treatment on Astigmatism Management and Outcomes in Meibomian Gland Dysfunction Patients Undergoing Cataract Surgery

Purpose

This study aimed to assess the effects of thermal pulsation system (TPS) treatment on astigmatism management in meibomian gland dysfunction (MGD) patients undergoing cataract surgery.

Patients and Methods

This single-center pilot study included 25 eyes of 23 patients who had visually significant cataract and concomitant MGD-associated dry eye in at least 1 eye and were willing to undergo TPS treatment and wait for at least 6 weeks for tear film stabilization prior to cataract surgery. Post-TPS keratometric readings were used for presurgical planning, and the actual postoperative residual refractive astigmatism (RRA) was recorded. Pre-TPS keratometry was used to mathematically simulate the RRA that would have been obtained from the lens choice and astigmatism management without TPS treatment.

Results

Following TPS treatment, the magnitude of astigmatism increased in 52% of eyes, decreased in 24%, and remained unchanged in 24%. Correspondingly, astigmatism treatment modality changed in 68% of eyes after tear film stabilization with TPS treatment. The type of astigmatism management increased (ie, shifted from no treatment to LRI or LRI to toric IOL) in 25% of eyes and decreased in 8%. Actual RRA ≤0.5 D was achieved in 76% of eyes, compared to simulated RRA ≤0.5 D in 40% of eyes (p=0.004).

Conclusion

Stabilization of the tear film with TPS treatment resulted in less RRA than if pre-TPS keratometric readings had been used to determine the astigmatism management method and toric IOL power and axis.

An algorithm for the preoperative diagnosis and treatment of ocular surface disorders

Any ocular surface disease (OSD), but most commonly, dry-eye disease (DED), can reduce visual quality and quantity and adversely affect refractive measurements before keratorefractive and phacorefractive surgeries. In addition, ocular surgery can exacerbate or induce OSD, leading to worsened vision, increased symptoms, and overall dissatisfaction postoperatively. Although most respondents of the recent annual American Society of Cataract and Refractive Surgery (ASCRS) Clinical Survey recognized the importance of DED on surgical outcomes, many were unaware of the current guidelines and most were not using modern diagnostic tests and advanced treatments. To address these educational gaps, the ASCRS Cornea Clinical Committee developed a new consensus-based practical diagnostic OSD algorithm to aid surgeons in efficiently diagnosing and treating visually significant OSD before any form of refractive surgery is performed. By treating OSD preoperatively, postoperative visual outcomes and patient satisfaction can be significantly improved.

Cataract surgery and dry eye disease: A review

AIM

To review published literature concerning cataract surgery and dry eye disease (DED).

METHODS

A search was undertaken using the following: PubMed (all years), Web of Science (all years), Ovid MEDLINE(R) (1946 to 12 December 2019), Ovid MEDLINE(R) Daily Update 10 December 2019, MEDLINE and MEDLINE non-indexed items, Embase (1974-2019, week 49), Ovid MEDLINE (R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily (1946 to 12 December 2019), CENTRAL (including Cochrane Eyes and Vision Trials Register; Cochrane Library: Issue 12 of 12 December 2019), metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). Search terms included 'cataract surgery', 'phacoemulsification' and 'cataract extraction', combined with 'dry eyes' and 'ocular surface'. Relevant in-article references not returned in our searches were also considered.

RESULTS

Publications identified included systematic reviews, meta-analysis, randomized controlled trials, cohort studies, case series and laboratory-based studies. Published data highlighting the burden of DED both prior and following cataract surgery were reviewed as well as studies highlighting the effects of cataract surgery on the ocular surface, intra-operative measures to reduce deleterious effects on the ocular surface and current evidence on the management options of post-operative DED.

CONCLUSIONS

DED is common and can be exacerbated by cataract surgery. Ophthalmologists need to assess for pre-existing DED and instigate treatment before surgery; be aware of reduced accuracy of measurements for surgical planning in the presence of DED; limit intra-operative surgical factors damaging to the ocular surface; and consider management to reduce DED post-operatively.

Matching the Patient to the Intraocular Lens: Preoperative Considerations to Optimize Surgical Outcomes

The intraocular lens (IOL) selection process for patients requires a complex and objective assessment of patient-specific ocular characteristics, including the quality and quantity of corneal astigmatism, health of the ocular surface, and other ocular comorbidities. Potential issues that could be considered complications after surgery, including dry eye disease, anterior or epithelial basement membrane dystrophy, Salzmann nodular degeneration, and pterygium, should be addressed proactively. Aspheric IOLs are designed to eliminate the positive spherical aberration added by traditional IOLs to the pseudophakic visual axis. Spherical aberration may be a consideration with patient selection. Patient desire for increased spectacle independence after surgery is one of the main drivers for the development of multifocal IOLs and extended depth-of-focus (EDOF) IOLs. However, no one single multifocal or EDOF IOL suits all patients' needs. The wide variety of multifocal and EDOF IOLs, their optics, and their respective impact on patient quality of vision have to be understood fully to choose the appropriate IOL for each individual, and surgery has to be customized. Patients who have undergone previous LASIK or who have radial keratotomy and ocular pathologic features, including glaucoma, age-related macular degeneration, and epiretinal membrane, require specific considerations for IOL selection. Subjectively, patient-centered considerations, including visual goals, lifestyle, personality, profession, and hobbies, are key elements for the surgeon to assess and factor into an IOL recommendation. This holistic approach will help surgeons to achieve optimal surgical outcomes and to meet (and exceed) the high expectations of patients.