On this episode of Interventional Mindset, Preeya K. Gupta, MD, is joined by Mina Farahani, MD, to discuss how ophthalmologists can identify dry eye and determine the etiology during cataract consults and prescribe optimal therapies to effectively manage symptoms before surgery.
Dr. Farahani is a cornea, cataract, and refractive specialist who practices at Spindel Eye Associates in Derry, New Hampshire.
Practical steps for diagnosing dry eye during cataract evaluations
Dr. Farahani noted that she assesses patients for dry eye in every cataract consult, because it can be easy to miss a dry eye diagnosis if it isn’t actively being looked for, and untreated dry eye may lead to dissatisfied post-op patients.1
Case in point, a study led by Dr. Gupta found that as many as 80% of patients who present for cataract surgery evaluation have ocular surface disease (OSD), and of these patients, almost 50% were asymptomatic.2
Key diagnostic tests Dr. Farahani relies on to screen patients for dry eye and determine the etiology include:
- Tear osmolarity
- MMP-9 testing
- Modified SPEED 2 questionnaire
However, diagnostics are only one small piece of the puzzle. Dr. Farahani also recommended performing a slit lamp exam with fluorescein to visualize any corneal staining, measuring the tear breakup time (TBUT), and evaluating the tear lake on the lower lid.
If she suspects a patient has evaporative dry eye, she carefully examines their lid margin to check for collarettes (a pathognomonic sign of Demodex blepharitis),3 and presses on their eyelid to check the quality of the meibum.
Pearl: The earliest sign of dry eye disease is lissamine green staining on the conjunctiva, which can occur before corneal staining.
To learn how to discern the etiology of dry eye based on staining patterns, watch the full interview!
Identifying the optimal treatment for dry eye patients
Using the results from this comprehensive and concise ocular surface evaluation, Dr. Farahani then determines which therapy to recommend to address the underlying reason for the patient’s symptoms.
Treating inflammatory dry eye
If a patient presents with significant inflammation, redness, and staining on the ocular surface, as well as elevated MMP-9 and tear osmolarity testing, she targets the inflammation with either a lifitegrast drop or one of the several cyclosporine-based drops on the market.
Managing evaporative and mixed-mechanism dry eye
Meanwhile, for patients with evaporative dry eye due to meibomian gland dysfunction (MGD), Dr. Farahani recommends that they start a lid hygiene regimen at home with warm compresses—even if they undergo an in-office procedure for MGD—so that they have a maintenance routine in between sessions.
She has also had success with prescribing MIEBO (perfluorohexyloctane ophthalmic solution, Bausch+Lomb) to MGD patients as it forms a protective coating on the ocular surface to directly address the symptoms of evaporative dry eye.
The key ingredient, perfluorohexyloctane, is a semifluorinated alkane that forms a monomolecular layer over the tear film, acting as a physical barrier that reduces tear evaporation and friction during blinking, which may protect corneal epithelial cells and support overall ocular surface healing.4-7
As such, MIEBO has become her go-to drop for patients who have reported using artificial tears three times or more per day with no success because studies have shown that it can stay on the ocular surface for up to 6 hours.8,9 This, in conjunction with an at-home lid hygiene regimen, tends to effectively manage the MGD.
For patients with mixed-mechanism dry eye, Dr. Gupta has found that anti-inflammatory drops and MIEBO can work synergistically to address both the inflammatory and evaporative components of dry eye for lasting symptom relief.
To read more about the findings from the clinical trials for MIEBO, check out the article Managing Evaporation for Better Patient Outcomes!
Patient education on dry eye therapies
It is crucial to educate dry eye patients on the chronic nature of the disease at the first visit so they have clear expectations of the treatment process.
Dr. Farahani likes to tell patients, “We’re going to start some treatments based on your exam. We may have to switch things around based on how you respond to them and what insurance covers. The reality is that insurance may fight us for some of these medications, but we will work together to get you relief.”
When explaining the purpose of warm compresses, she tells patients that there is water and oils in their eyelids, and the warm compress helps to “melt the butter” in their eyelids to unclog the oils—and she has found that patients resonate with this explanation.
She then hands them a personalized homework sheet that outlines what they should do to maintain their ocular surface health, a list of detailed instructions for a lid hygiene regimen, and the products that she recommends (ex., heating masks and lid scrubs).
Tips for improving patient adherence to dry eye treatments
As having to adjust to a multi-step treatment regimen can be overwhelming for some patients, she added that it is critical to select a few targeted interventions to start, and eventually build up to including more in order to minimize the risk of nonadherence.
Additional recommendations for improving compliance with dry eye medications include:
- Discussing ways to increase the tolerability of anti-inflammatory drops, such as refrigerating the vials, to minimize the risk of stinging and burning
- Offering samples in-clinic so patients can build confidence in the treatment
- Dosing drops in the exam chair so patients know what to expect when they instill the medication
- Dr. Gupta mentioned that this has been particularly helpful with MIEBO, because the drop is so small (11μL),4 that some patients accidentally put in multiple drops at once
- Fortunately, there are easy instructions for priming MIEBO to ensure that only one drop comes out by squeezing it, turning the bottle upside down, and then releasing a drop
- Video instructions on how to prime the bottle can be found here
- Some patients on MIEBO benefit from using a compatible size 14 nanodropper to slow the delivery and make the bottles last longer
Final thoughts
Assessing cataract patients for dry eye disease is necessary to ensure that patients are satisfied post-operatively by reducing the risk of residual refractive errors.
Fortunately, a quick ocular surface examination combined with a questionnaire, MMP-9 and tear osmolarity testing, and evaluation of the eyelids for Demodex blepharitis and MGD can catch most dry eye patients.
Based on the results of the exam, ophthalmologists can take advantage of the assortment of dry eye therapies for both inflammatory and evaporative dry eye and invest time and resources into educating patients on dry eye to ensure that they are consistent with treatments at home to effectively prepare their ocular surface for cataract surgery.
