Optometric Management

FEB 2017

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22 F E B R U A R Y 2 0 1 7 • O P T O M E T R I C M A N A G E M E N T . C O M FEATURE ANNUAL MEDICAL SERVICES ISSUE HERE'S HOW TO PREVENT DRY EYE DISEASE IN PATIENTS UNDERGOING CATARACT OR REFRACTIVE SURGERY MANAGE DED IN SURGICAL PATIENTS Brit t any Mit chell, O.D., Birmingham, Ala. D RY EYE disease (DED) should be on our diagnostic radars for surgical patients, as cata- ract and refractive surgery— and the medications used in the post-operative period — influence the integrity of the ocular surface and, there- fore, can lead to or worsen existing DED. In many instances, patients link their ocular surface issues, and subsequent effects on vision, as a complication of surgery. Proper education and patient preparation is key to creating a successful patient experience. Here, I explain how, specifically, cataract and refractive surgery affect the integrity of the ocular surface and the steps to manage DED before and aer surgery. EFFECT ON OCULAR SURFACE Regarding cataract, DED aer cataract surgery is multifactorial. In many instances, the patient popula- tion undergoing cataract surgery is already much more likely to have pre-existing ocular surface issues that will be compounded peri-operatively and post-operatively, due to their advanced age. us, it is essential to treat any underlying issues prior to referral for cataract surgery, if possible. Factors that create or increase the incidence of DED in the immediate post-op period include re- duced corneal sensitivity from either topical drugs or from corneal nerve transection, topical anesthesia drops during surgery and during post op and some other potential causes, such as the use of povidone iodine employed before surgery and the aspirating speculum used during surgery. DED that develops days to weeks aer surgery can stem from the elevation of inflammatory cytokines, goblet cell loss, meibomian gland dysfunction and hypersensitivity effects from preservatives, such as benzalkonium chloride (BAK), found in post-op medications. Similarly, in corneal refractive surgery, studies show that DED post-operatively occurs from previously un- treated DED, and it has been theorized that the altera- tion of the corneal nerves during surgery from creat- ing the flap leads to a decrease in aqueous lacrimal deficiency, a drop in blink rate and more long-term challenges, including the activation of the inflamma- tory cascade, creating an increase in cytokines, which causes a disruption in both the corneal and conjunc- tival tissues. Further, many of the DED-related issues that cataract surgery patient's experience, corneal re- fractive surgery patients experience as well. PRE-OPERATIVE CARE Taking all these factors into account, it is impor- tant to treat patients appropriately both before and aer surgery, so they can achieve potentially better visual outcomes. As mentioned, cataract patients tend to have DED prior to surgery. For this reason,

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