Ocular Surface News is a free bi-weekly newsletter which focuses on the complex subject of diagnosing and treating ocular surface disease including dry eye.
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August 17, 2023

The Things We Don’t Think of When We Aren’t Asked

As humans, we are pretty good at compartmentalizing our lives, especially when the dots don’t connect between each part. Is this what happens in the exam room when a patient pipes up with important medical history information near the completion of their eye examination? Astute clinicians excel in these situations. They can put all the puzzle pieces together with seemingly disparate facts, even when patients don’t think the information is relevant.

Over the next several issues, we will feature many of the recently published “A Lifestyle Epidemic: Ocular Surface Disease” reports from the Tear Film and Ocular Surface Society International Workshop, all of which dispel dogma, reveal knowledge gaps and remind clinicians of significant aspects of ocular surface health. In this issue’s columns, we discuss the “Impact of Elective Medications and Procedures on the Ocular Surface” report. Elective medications and procedures are among the more common and essential bits of information patients often neglect to report in the exam setting.

Take, for example, the 27-year-old morning television news anchor who had such extreme dry eye that she would wear only one contact lens a day, alternating eyes each day. She wore glasses once on the air and viewers had so many comments about them that her producer suggested she not wear them again. Her medical and ocular history were negative, but she had significant meibomian gland dropout. After re-questioning her history and medications, she ultimately remembered two courses of isotretinoin (Accutane) treatment for acne. The dryness began with the second round two years prior. She didn’t think the isotretinoin could be connected, so she didn’t bring it up initially. How about a more obvious case of a 57-year-old female who had newly occurring dry eye following an elective eyelid procedure that she didn’t note to her doctor, or the 65-year-old male in for a dry eye examination who recently had glaucoma surgery after taking multiple glaucoma drops for years but didn’t record any of that on his medication/ surgery list? While glaucoma drops are not quite elective, patients may not make the connection between dry eye and the medications they take or procedures they’ve had.

The point is, there are many details that patients neglect or forget to bring up in the exam for several reasons. They may be focused solely on the reason for the visit, and the doctor may be as well; perhaps the patient is there for a cataract evaluation and eye dryness may be furthest from mind. Whether past or recent, medication use and/or surgical procedures could have simply been forgotten. Elective procedures, especially cosmetic, may be embarrassing for a patient to discuss. Patients’ daily lives may be chaotic at the time of their appointment, and they might forget to bring up information that they meant to discuss. The list goes on.

As clinicians, it is essential to keep pressing for information when the clinical puzzle pieces don’t add up. Patients don’t usually aim to be deceptive; they just might need the right prompt to jog their memory. Your conversation with them, usually while at the slit lamp, can result in the “ah-ha” moment that cracks the case. When you stumble on relevant information and the patient marvels, “I didn’t think of that,” they will be happy you were there to make the connection.


Kelly K. Nichols, OD, MPH, PhD
Editor


An Important Dialogue—Discussing Preventive Ocular Surface Steps Prior to Surgical Intervention

One of the most important steps in achieving surgical outcome goals is “priming and prepping” the ocular surface. In a perfect world, every patient would have taken all of the necessary measures to prepare the ocular surface and eyelids for the operating room, but we know that can be a challenge. Here’s how I lead each surgical patient through preparation to reach the best outcomes.

Educating Patients Pre-Operatively
I like to use analogies that are easy for patients to understand when I explain the importance of preparing the cornea (which I refer to as the windshield of the eye) and the eyelids (which I compare to windshield wipers) for any cataract, refractive or eyelid procedure. Once we establish better ocular hygiene habits before surgery, I take it a step further and educate patients on the need for continued long-term maintenance after surgery.

Treating the Ocular Surface
Unfortunately, patients often present for surgery and claim that they don’t remember any guidance from previous providers that stressed the importance of maintaining good ocular health and hygiene. If a potential surgical patient arrives with a dry ocular surface from blepharitis and Demodex, getting that patient ready for surgery may take longer than expected. I typically explain to patients that “this delay isn’t because the surgeon wants to postpone surgery. It means we want to get accurate measurements and we do that by operating on hydrated eyes in their prime.”

Getting the ocular surface ready for surgery not only helps improve the consistency of the measurements we need to operate, but it also improves patient satisfaction after surgery.1 If patients are not already at the point of needing pharmaceutical intervention with cyclosporine (e.g., Restasis or Cequa) or lifitegrast (Xiidra), I at least recommend treating the ocular surface with a preservative-free artificial tear formulation. In our office, we provide coupons for several of our favorite brands to steer patients toward our preferred OTC eye drops.

Treating the Eyelids
Even in cataract and refractive surgeries, eyelids matter. Treating eyelids with eyelid scrubs or wipes helps decrease the risk of infections such as endophthalmitis.2 Unfortunately for some patients, using these products means they have to forgo their beloved lash extensions or false lashes for up to three months after surgery to decrease the risk of preventable infections.

For eyelid hygiene, several of my favorite options are also ones that are most convenient and comfortable. I currently recommend OCuSOFT’s wide range of scrubs and wipes, as well as iVIZIA (Thea) eyelid wipes for makeup removal, and TearRestore’s HylaWipes with hyaluronic acid and tea tree oil for blepharitis. In the future, I am excited to also offer additional options, such as the newly FDA-approved lotilaner ophthalmic solution 0.25% (XDEMVY) from Tarsus to help treat Demodex blepharitis prior to surgical intervention.

References:
1. Schechter B, Mah F. Optimization of the ocular surface through treatment of ocular surface disease before ophthalmic surgery: a narrative review. Ophthalmol Ther. 2022 Jun;11(3):1001-1015. doi:10.1007/s40123-022-00505-y
2. Niyadurupola N, Astbury N. Endophthalmitis: controlling infection before and after cataract surgery. Community Eye Health. 2008 Mar;21(65):9-10.
 

When patients present with signs or symptoms of ocular surface disease (OSD), many possible contributing factors need to be explored. One potentially overlooked contribution to patients’ OSD is any non-urgent elective procedures or medications (both topical and systemic) that patients have used to improve their quality of life or cosmetic appearance. These interventions are sometimes followed by OSD and paradoxically have the opposite effect of what patients were trying to accomplish.

Topical vasoconstrictors and drops that contain preservatives—such as benzalkonium chloride—may cause allergic, chemical, toxic and immune-inflammatory responses of the cornea, conjunctiva, tear film and corneal nerves which can worsen visual outcomes, especially when used chronically. These medications also reduce aqueous secretion and may destroy goblet cells, conjunctival and corneal epithelia and meibomian glands, which can result in long-term OSD. Topical corticosteroids, which are often used in the management of dry eye disease (DED), can cause elevated intraocular pressure, cataract allergies, decreased wound healing and increased susceptibility to infections. Elective systemic medications (e.g., cold medicines) have been linked to potentially sight-threatening drug-induced ocular surface immune reactions.

Periocular cosmetic and conjunctival surgery may be complicated by tear film abnormalities and OSD. Conversely, these procedures can result in corneal abrasions, lacrimal gland injury, granuloma formation, subconjunctival hemorrhage, edema, corneal dellen, conjunctival scarring and ischemia. Periocular procedures such as cosmetic lasers, plasma discharge and high-frequency radio waves are usually safe, but carry a risk for ocular surface damage, including burning and hyper- or hypopigmentation. The same is true for procedures that treat meibomian gland dysfunction and DED, such as thermal pulsation and intense pulsed light. To prevent complications, it is important to properly screen patients for whom these procedures may be contraindicated, and care should be taken during the procedures to protect the eyes and periocular skin. Better and less invasive procedures are being developed to decrease the adverse effects of these surgeries on the ocular surface.

LASIK, photorefractive keratectomy, corneal transplantation and other ophthalmic surgical procedures such as cataract surgery and phakic intraocular lens implantation often produce post-surgical DED and are primarily attributed to corneal nerve injury, reduced tear secretion, decreased blinking and medicamentosa. Compared with LASIK, small incision lenticule extraction (SMILE) does not require the creation of a flap and therefore induces less damage to corneal nerves, which might result in a lower risk of patients developing DED. Patients with diabetes and those with previous corneal-refractive procedures may experience more significant postoperative dry eye symptoms following cataract surgery.

As cosmetic and refractive surgery options for patients continue to increase, so does the importance of screening patients for perioperative risk factors that could significantly reduce the risk of developing persistent adverse reactions. When we incorporate evidence-based knowledge into management decisions and anticipate possible negative outcomes that are associated with treatment options, we can approach treatment for each patient’s OSD more accurately and effectively.
 

ABSTRACT

TFOS Lifestyle: Impact of Elective Medications and Procedures on the Ocular Surface
José Alvaro P Gomes, Dimitri T Azar, Christophe Baudouin, Etty Bitton, Wei Chen, Farhad Hafezi, Pedram Hamrah, Ruth E Hogg, Jutta Horwath-Winter, Georgios A Kontadakis, Jodhbir S Mehta, Elisabeth M Messmer, Victor L Perez, David Zadok, and Mark D P Willcox

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.
 

Interventional Glaucoma and Why It Matters to the Ocular Surface

I rarely have the opportunity to write in this newsletter about glaucoma—another one of my greatest passions in optometry. Colleagues are often surprised to learn that I, as a “front-of-the-eye person” (a label I always rebut), have just as much experience with “back-of-the-eye” conditions. In fact, I teach our glaucoma course at UAB, and my previous PhD work was on the overlap in glaucoma and ocular surface disease (OSD). So, forgive me as I geek out over the next few paragraphs.

Those of us in the glaucoma space find ourselves amid a paradigm shift analogous to what retinal specialists experienced in the early 2000s following approval of ranibizumab (Lucentis) for the treatment of wet AMD. Technology is advancing rapidly, and we have more options than ever to attempt to slow our patients’ glaucomatous disease. This is the landscape of glaucoma management in the 2020s:
  1. The definition of controlled glaucoma is shifting. Previously, stable visual fields and stable retinal nerve fiber layer thicknesses were enough to consider glaucoma to be “controlled.” The standard of good control, however, is being elevated to include stable structure, stable function and a healthy ocular surface that is free of side effects commonly associated with glaucoma drops. Polypharmacy and the menace that is bezalkonium chloride (BSK) often lead to meibomian gland dysfunction, tear film instability, generalized ocular surface inflammation; the list goes on. Not only are these effects greatly associated with decreased quality of life, but—with equal importance—they have also been shown to limit IOP reduction! In other words, OSD can interfere with glaucoma therapy and permit glaucoma to plow onward with little restraint. Nowadays, we only consider patients to be controlled when their ocular surface is also controlled.
  2. We’ve reached the era of interventional glaucoma. Technically, anything we do to intervene, whether it’s drops, lasers or surgeries, is considered interventional glaucoma. The term is used more frequently, however, to describe procedural interventions, such as intracameral implants of bimatoprost (Durysta), selective laser trabeculoplasty, minimally invasive glaucoma surgery (MIGS) and more traditional (and invasive) glaucoma surgeries. With the shift toward prioritizing ocular surface health in glaucoma patients, we—at minimum—need to educate our patients on these options. With a combination of implants, lasers and MIGS, we could potentially forego drop therapy or at least reduce the drop burden for several years, if not more. There will continue to be a large portion of patients, perhaps even the majority, who opt for therapeutic intervention, but it’s our responsibility to present the options, provide the pros and cons and guide them in their decision making.
  3. Mild to moderate glaucoma patients can undergo minimally invasive procedures, separately from cataract surgery. MIGS became popular as an adjunct to cataract surgery, but now, we have amassed a critical amount of efficacy and safety data to justify standalone MIGS procedures. Microincisional technology is now available for goniotomies and canaloplasties, making these “old” procedures new again. We also have a standalone microstent option available with the Glaukos iStent infinite.
Regardless of our roles or experience in managing glaucoma, it is our responsibility as ocular surface enthusiasts to protect and advocate for the ocular surface and educate our patients on less-toxic alternatives to BSK-preserved drops. If you care about the surface, you have to care about glaucoma too.
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