CASE STUDY

Managing Dry Eye

Treating this patient's ocular surface preoperatively hastened recovery time

BY DAVID R. HARDTEN, M.D.

Dry eye syndrome is the result of insufficient tear production, excessive tear evaporation, or abnormal tear composition. Published literature tells us up to 25% of patients in our offices complain of these symptoms.¹

As clinicians, we know dry eye is much more prevalent in practice than the literature seems to indicate. There are various estimates of the prevalence of the disease. One noted report estimates 10 to 14 million Americans suffer dry eye symptoms,² another estimated that the syndrome affects 20 million Americans,³ and others note up to 20% of adults older than 45 experience dry eye symptoms.¹ The prevalence of treated dry eye has been cited to be 0.4% to 0.5% and is highest among women and the elderly, with patients 65-years-old and above about four times more likely to be diagnosed with either dry eye syndrome or tear film insufficiency.⁴ Lastly, one population-based study found a prevalence of 8% in those younger than 60-years-old, but 19% in those older than 80.⁵ The Beaver Dam Eye Study showed that age was the biggest contributory factor to dry eye syndrome. Some medications (such as diuretics, antidepressants and antihistamines) are associated with a higher risk of developing dry eye, while others (such as angiotensin-converting enzyme inhibitors) are associated with lower risk.⁶

In the past 10 years, ophthalmologists have begun to better understand the pathophysiology behind dry eye syndrome, and we now have more effective treatments to use in combating this disease. Topical cyclosporine 0.05% (Restasis, Allergan, Inc., Irvine, Calif.) has helped increase tear production in people with chronic dry eye. Newer artificial tear formulations have been shown to work on both the ocular surface and at the cellular level to provide relief from symptoms. In fact, we have learned so much about this syndrome that a new term for it was recently proposed — dysfunctional tear syndrome — and treatment recommendations for different types and severity have been suggested.⁷

Case Study

In this case, a 70-year-old male presented with cataract in his left eye. A year earlier, he had problems with a long recovery from cataract surgery in his right eye performed by another surgeon and complained of occasional irritation of his eyes.

The most common reasons for slow recovery after cataract surgery are dry eye or cystoid macular edema (CME). Because the patient had some symptoms that could possibly be due to dry eye, we needed to carefully evaluate the impact of his ocular surface on the potential recovery after surgery, with an emphasis on creating a healthy ocular surface before upsetting his corneal balance with surgery and non-steroidal use to reduce the chances of CME. The patient clearly had a positive ocular stress test. (Figures 1 and 2 illustrate epitheliopathy with and without fluorescein staining.) The ocular surface stress test is the evaluation of the cornea after the stress of anesthetic, tonometry, pachymetry, dilating drops and the typical wait before a complete eye examination.⁸

Figures 1 (left) and 2 (right) illustrate epitheliopathy with and without fluorescein staining.

There were numerous issues with this patient, but a major question we needed to address was how to manage the ocular surface, as increased dry eye is often more pronounced after cataract surgery.⁹

Our practice uses the International Task Force (ITF) panel consensus recommendations for assessing patients. The ITF panel noted that the severity of the disease indicates the appropriate therapeutic options, with a step-wise approach recommended.⁷

The ITF panel identified four severity levels. The mildest is level 1, where treatment begins with patient education. This sounds intuitive, but many patients may not be aware of how their environment may aggravate their condition. The ITF panel also suggests preserved tears at this early stage. By level 2, the group suggests moving to unpreserved tears, gels, ointments and topical cyclosporine 0.05%, along with topical steroids if warranted. By level 3, the panel recommends oral tetracyclines and punctal plugs, presuming the inflammation is well controlled. Level 4 is typically when surgical intervention, such as tarsorrhaphy, becomes helpful.

As the figures illustrate, the irregular epithelium after the ocular surface stress test in an asymptomatic patient should alert a clinician to the potential for problems with the ocular surface postoperatively. Alerting patients to the signs and symptoms of dry eye can help manage their expectations. Additionally, helping patients identify the preoperative symptoms can help in monitoring differentiating symptoms postoperatively.

To manage the patient preoperatively, we started with lid hygiene, Optive artificial tears (Allergan), and topical cyclosporine 0.05%. Once we were convinced the surface could tolerate surgery without exacerbating the dry eye symptoms, we performed phacoemulsification and IOL implantation. In this patient, we chose to use ketorolac 0.4% (Acular-LS, Allergan) because it appears to have minimal toxicity to the ocular surface while having excellent efficacy.

This patient did not develop unforeseen complications after the cataract surgery and has remarked that his symptoms were not nearly as noticeable after this surgery. His long recovery from his first eye surgery was likely related to a poor ocular surface. I believe that properly preparing the ocular surface before undergoing phacoemulsification reduced the potential for further corneal insult and increased dry eye severity in this patient.

Consensus Treatment Guidelines

I have found the ITF consensus guidelines to be valuable, although my personal belief is that they are a bit on the conservative side when it comes to implementing treatment, especially in patients undergoing ocular surgery, such as cataract or refractive surgery. Identification of patients who may be at risk post-op allows us to discuss dry eye with them, aiding in post-op management. If I see patients after cataract or refractive surgery complaining of dry eye symptoms where I didn't identify them in the preoperative workup and begin treatment, then I know that I am not being aggressive enough in my preoperative diagnosis of this problem. My general recommendations for patients who are at risk of dry eye postoperatively are a high-quality artificial tear and topical cyclosporine.

With this patient, we were able to control his dysfunctional tear syndrome and improve the ocular surface before he underwent cataract surgery. Pretreating the surface with cyclosporine 0.05% and Optive aided in a quick recovery postoperatively. A 4-week postoperative course of non-steroidal anti-inflammatory drugs, continuing the cyclosporine and tears for 6 months post-op, allowed for an uneventful recovery. OM

References

1. Brewitt H, Sistani F. Dry eye disease: the scale of the problem. Surv Ophthalmol. 2001;45 (suppl 2):S199-S202.
2. Anzaar F, Foster CS. Dry eye syndrome. eMedicine Web site. Available at: www.emedicine.com/oph/TOPIC597.htm. Accessed May 8, 2008.
3. Market Scope. Report on the Global Dry Eye Market. St. Louis, MO: Market Scope; 2004.
4. Yazdani C, McLaughlin T, Smeeding JE, Walt J. Prevalence of treated dry eye disease in a managed-care population. Clin Ther. 2001;23:1672-1682.
5. Moss SE, Klein R, Klein BE. Prevalence and risk factors for dry eye syndrome. Arch Ophthalmol. 2000;118:1264-1268.
6. Moss SE, Klein R, Klein BE. Incidence of dry eye in an older population. Arch Ophthalmol. 2004;122:369-373.
7. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional Tear Syndrome Study Group. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006;25:900-907.
8. Hardten, DR. Dry eye disease in patients after cataract surgery. Cornea 2008;27 (in press).
9. Li XM, Hu L, Hu J, Wang W. Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. Cornea. 2007;26(9 suppl 1):S16-S20.

David R. Hardten, M.D., directs the research department and is the fellowship director at Minnesota Eye Consultants. He is an adjunct associate professor of ophthalmology at the University of Minnesota. Dr. Hardten is a consultant to Allergan and AMO.