Often, I see patients who are referred to my cornea practice for surgery. The following case demonstrates the importance of evaluating the ocular surface before surgery.

CORNEAL CROSS-LINKING EVALUATION

A 22-year-old man was referred to me for a cross-linking evaluation for keratoconus. He reported blurred vision, ghost images, monocular diplopia, and photophobia. These symptoms had progressed noticeably over the past month. His best corrected visual acuity was 20/40 in the right eye and 20/50 in the left eye. His topographies looked somewhat unusual (Figure 1). Is this keratoconus?

We evaluated this patient for dry eye, which is our usual protocol for any presurgical patient. We found significant corneal staining in both eyes (grade 3 OD, grade 2 OS), high tear film osmolarity (307 OD, 336 OS), and rapid tear breakup time (3 seconds OU). This patient has severe dry eyes. He also has irregular astigmatism secondary to ocular surface disease.

Is this keratoconus? Three key indicators on this patient’s topography raised my suspicions. First, this is a superior cone. Both eyes show superior steepening, which is unusual. Second, one of the hallmarks of keratoconus is thinning of the cornea where it becomes steep, but this is not evident in this case. Third, the posterior elevation should be in the middle of the cone, but it is not. These atypical findings indicate there’s something unusual about this case.

I decided to treat the patient’s dry eyes first. I prescribed a topical steroid, preservative-free artificial tears, and lid hygiene. After 2 weeks, the patient’s visual acuity was 20/25 in both eyes, and the staining had resolved. His tear film osmolarity was still abnormal (304 OD, 320 OS), but was decreasing. Figure 2 shows his topographies.

It’s particularly important for patients to understand that dry eye is a chronic disease that requires ongoing treatment. While the initial therapy cools down the ocular surface, it’s not a long-term solution.

I tapered the steroid and prescribed a maintenance regimen of an immunomodulator and preservative-free artificial tears. Although the patient doesn’t appear to have meibomian gland dysfunction, I recommended omegas and lid hygiene as a precaution.

Does this patient need cross-linking? The answer is no.

This patient came in with suspicion of one condition—keratoconus—and was found to have another: dry eye disease. There is still some suspicion for keratoconus, and the patient will need to be monitored over time, but does not require intervention at this time.

CONCLUSION

Key takeaways from this case include:

• The tear film is the most important refractive surface.
• All patients require evaluation of the ocular surface prior to ocular surgery.
• Unusual findings, such as visual acuity that’s inconsistent with what’s seen on clinical examination, should trigger an ocular surface evaluation.
• An ocular surface in poor condition may lead to misdiagnosis and inappropriate treatment.

CASE DISCUSSION

Dr. Matossian: Dr. Beckman raised a good point. Just because we treat a patient’s dry eye disease prior to surgery doesn’t mean treatment should stop after surgery. The message has to be clear to our patients that they have two diseases. One is the reason we are taking them to the OR, let’s say cataracts, and the other is an ongoing, progressive, chronic disease—dry eye—for which they'll need lifelong treatment.

Ms. Barkey, what has your experience taught you about this type of case?

Ms. Barkey: Surgeons should be prepared for how patients may react to a diagnosis of dry eye that requires treatment, especially when their referral was for a surgical evaluation. Some may suspect a bait-and-switch scenario, because you’re adding procedures to a surgery. Some patients may opt for dry eye treatment and not follow up for the cataract surgery. It’s best to have a plan ready to offer these patients.

In our practice, 80% of our patients decide to proceed with dry eye treatment prior to surgery. The others wait until after surgery. Our counselors reassure patients, “The decision is completely up to you.” We document the patient’s decision on our consent form by having the patient initial that they have elected to proceed with dry eye treatments prior or elected to wait.

Dr. Beckman: I assume you’re not allowing patients to postpone certain therapies, such as lubricants and medications, which should be started immediately.

Ms. Barkey: Yes. I’m referring to the cash out-of-pocket treatments, such as IPL or thermal pulsation. Some patients want only the treatments that insurance will cover.

Dr. Beckman: I agree. That being said, if a therapy is needed to allow a patient to proceed, they need to understand that not proceeding with therapy may put them at risk for poor outcomes with surgery. Fortunately, these patients are usually able to do well with medical treatment alone, which is typically covered by surgery.

It is not common to require cash-pay treatments to prepare for surgery if they are able to start medical therapy. I explain that we have three main concerns for any patient considering surgery. The first is always to prevent infection. The second, for cataract surgery, is to ensure that our IOL calculations are accurate. As you can see from my case, IOL calculations based on the patient’s entering topographies would have been worthless. The third is that we want to avoid postoperative aberrations caused by a poor ocular surface. This also reinforces the need for lifetime maintenance after surgery.

Dr. Matossian: Dr. Beckman prescribed an immunomodulator for his patient. We now have three excellent options in this class. These include cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), cyclosporine ophthalmic solution 0.09% (Cequa, Sun Ophthalmics), and lifitegrast ophthalmic solution 5% (Xiidra, Shire). How do you choose which medication to use, Dr. Gupta?

Dr. Gupta: In the perioperative setting, I choose the medication that will give a fast response, because most patients don’t want to delay surgery. Tolerability is an issue with some of these medications, and it’s difficult to know who will tolerate one drop better than the other. Sometimes, we fear topical steroids, but in this setting where we’re trying to rehabilitate the surface rapidly, I think steroids absolutely have a role. I like to also add an immunomodulator like lifitegrast simultaneously in somebody who has a long-term risk of dryness. The steroids will work acutely to provide relief and the immunomodulator anti-inflammatory helps the patient through surgery but more importantly in the long-term. I think that is a safe approach.

Dr. Matossian: All of us instruct our patients to use artificial tears. Brand-specific recommendations help our patients select the proper items at the pharmacy. A product such as Systane (Alcon) may benefit the patient in this case.

Dr. Gupta: I like Systane Complete (Alcon), because it has an ingredient that supports the lipid layer.

Dr. Matossian: I’ve learned from experience to be specific whenever I recommend artificial tears or any over-the-counter products to my patients. One of my patients was using an anti-allergy eye drop thinking it was a substitute for artificial tears. The antihistamine in that ophthalmic preparation was exacerbating his dry eye disease. Another patient, a truck driver, used an ointment in his eyes because the label said, “For severe dry eye.” He got behind the wheel after applying the ointment and nearly had an accident because he couldn’t see. Since then, I’ve learned that we need to be very clear on what we recommend, even if it’s something as basic as a lubricant or an artificial tear.

Dr. Gupta: I agree. When we send patients to purchase an over-the-counter product—and they’re looking at an aisle of artificial tears—it can be overwhelming.

In my practice, we arm patients with a printed sheet, listing the brands that we recommend. I circle the name of the product that I believe would be best for the individual patient. Shopping becomes a little less complicated for patients when they can refer to this sheet in the store.

Dr. Beckman: We also give patients a list of recommended products to guide them to the ones I want them to use. I always tell them, “Stay away from anything that says, ‘Gets the red out.’ Stay away from the giant generic bottles of store brand products.” Often, patients come to our office with a big bottle of saline. We also tell patients if they’re going to be using the tears more than three or four times a day, they should look for a preservative-free product.

Dr. Periman: The science of artificial tears has become quite sophisticated. The mindfully designed artificial tears are formulated with complex ingredients that protect the ocular surface from continuing desiccating stress and apoptosis or cell death. I agree that specifically recommending a treatment is good practice.

Ms. Barkey: Another approach is to offer the products for sale in your office. Patients appreciate the convenience of one-stop shopping, and you can be assured they will leave your office with the product you recommend. ●