WHEN A PATIENT EXPRESSES interest in refractive cataract surgery and visits my office, it is highly likely that our conversation will revolve around enhancing the condition of their ocular surface and lid margins before proceeding with cataract surgery. In fact, in my clinical practice, I would venture to say that approximately 90% of our patients require some form of optimization for their ocular surface or lid margins before we consider moving forward with cataract surgery.
Moreover, the need for ocular surface or lid margin optimization is not restricted to my older patients. This need applies to younger patients as well, who might be coming in for a cornea-based refractive procedure or implantable collamer lenses.
Within the pages of this article, I will elaborate on the proven techniques I have used to meticulously prepare my patients for the most favorable condition before their refractive cataract surgery.
Explaining the Need
A significant proportion of our patients in need of cataract surgery often contend with the dual challenge of ocular surface and lid margin conditions. This combination encompasses a spectrum of issues, including Demodex blepharitis, meibomian gland dysfunction (MGD), compromised tear film quality, ocular rosacea, epithelial basement membrane disease, and sometimes Salzmann’s nodules.
In these situations, I emphasize to our patients that there is no need to rush into surgery. Instead, I stress the importance of addressing and resolving their ocular surface and lid issues before proceeding. Our foremost goal is to ensure the optimal health of their eyes, a critical step in guaranteeing the finest surgical outcomes and preserving the quality of their vision. I also underscore that prioritizing the resolution of these concerns expands their opportunities for selecting advanced-technology intraocular lenses, enhancing their potential for a superior visual outcome.
While some patients are aware that they may have ocular surface disease, others, having lived with it chronically, are not as aware. I start asking them whether their eyes itch or tear much, whether they feel dry, or whether their vision fluctuates, and these questions help them realize that we need to address what is causing their symptoms before we proceed with surgery.
For instance, in cases in which a patient presents with severe Demodex blepharitis, I employ a visual aid by capturing a photograph of their eyelashes—a practice that often elicits a strong reaction. This visual evidence tends to be quite impactful and motivates patients to address and promptly resolve the issue, driven by the desire to eliminate it.
Similarly, when faced with patients dealing with ocular rosacea, I initiate the conversation by inquiring about their experience with rosacea on their nose or cheeks. This discussion segues into an exploration of how this condition can extend to the eyelids and negatively impact the functionality of their meibomian glands, ultimately affecting their visual clarity.
I go on to elucidate that ocular rosacea is a condition marked by its cyclic nature, characterized by good and bad days. Our shared objective is to increase the frequency of good days and minimize the bad ones. To illustrate, we aspire for them to reach a point where they can go through a substantial portion of a day without the need for artificial tears or experiencing any eye discomfort. This improvement in their ocular comfort should persist for several consecutive days, marking a substantial enhancement in their overall quality of life.
For patients with Demodex blepharitis, I am beginning to see amazing results from Xdemvy (lotilaner ophthalmic solution) 0.25% (Tarsus Pharmaceuticals). Xdemvy was approved for treatment of Demodex blepharitis by the FDA in July 2023. The twice-daily eye drop is designed to eradicate the Demodex mite infestation that is the root cause of the disease.
I have prescribed XDEMVY to close to 40 to 50 patients and have observed vast improvement in Demodex blepharitis, if not complete eradication of the disease. This improvement, in turn, decreases any meibomian gland disorder that patients may have and of course helps to restore tear film stability.
In a particular case, I made a diagnosis of severe Demodex blepharitis with the presence of grade 4 collarettes. Following a 6-week treatment regimen with Xdemvy, the results were striking. Notably, all signs of inflammation and redness had completely subsided, and the collarettes were no longer present. Upon close examination with the slit lamp, the patient’s eyelids and lashes appeared flawless, demonstrating a remarkable transformation in the patient’s ocular health and aesthetics.
If a patient needs treatment for ocular rosacea, I’ll begin intense pulsed light (IPL) therapy with the Lumenis OptiLight. This product is the only IPL that is FDA approved for the management of dry eye disease due to ocular rosacea. I usually elect to do 3-4 sessions of IPL about 3-4 weeks apart. This treatment helps to reduce dry eye symptoms, as well as promoting the function of the meibomian glands. It can also help address Demodex blepharitis. In my experience, most of my patients find symptom relief after a single treatment.
When performing IPL therapy, I pair it with a TearCare System (Sight Sciences) treatment. I clean the patient’s lids and lashes and then place the TearCare device for 15 minutes. This device loosens the impacted oil glands and allows for expression of the glands. I then perform the IPL treatment.
Epithelial Basement Membrane Disease
In cases in which patients are dealing with epithelial basement membrane disease, my approach often involves a procedure known as a superficial keratectomy, complemented by the placement of a Prokera (BioTissue) device. This combined approach typically yields favorable results by rejuvenating the functionality of the cornea’s surface layer epithelium and effectively “resetting” the affected area. This intervention is often integrated with other treatment modalities for comprehensive care.
Prokera, a cryopreserved amniotic membrane, plays a pivotal role in sustaining vital growth factors and essential nutrients. I have leveraged the remarkable properties of Prokera, not only in cases of epithelial basement membrane disease but also in the treatment of persistent epithelial defects and chemical burns, for which its therapeutic benefits have proven invaluable.
Occasionally, I encounter patients who have developed neurotrophic keratitis, often after a prolonged history of unsuccessful conservative treatments spanning months to years. The root causes can be multifaceted, stemming from factors such as uncontrolled diabetes, a history of Bell’s palsy, prior radiation therapy to the head or neck, herpetic keratitis, contact lens misuse, or previous refractive surgery. Remarkably, these patients typically present with pronounced ocular surface disease yet minimal discomfort.
In such scenarios I promptly instigate a treatment regimen that incorporates Oxervate (cenegermin-bkbj) ophthalmic solution 0.002% (Dompé) to effectively address the condition. To facilitate a seamless transition into the treatment protocol, I employ a Prokera device for 1 week, bridging the patient to the commencement of the treatment. This process is particularly valuable, as obtaining the medication can be a process that spans several weeks. The comprehensive Oxervate protocol extends over a 10-week period and, based on my extensive experience, consistently demonstrates an exceptional success rate. In fact, I can attest to remarkable 100% efficacy in managing these challenging cases.
In situations in which IPL treatment or Xdemvy may not be accessible, our commitment to optimizing the patient’s ocular surface and lids before proceeding with refractive cataract surgery remains resolute. Our goal is to elevate their baseline ocular health.
In these instances, we initiate a customized, twice-daily regimen aimed at improving the patient’s ocular condition. This regimen includes Eye Revive (Daily Practice), a comprehensive solution featuring a hydrating eyelid cleanser, an eyelid skin hydrator, and a brightening agent. Additionally, we incorporate the use of a Bruder mask and administer twice-daily heat treatments to promote ocular wellness. To address lubrication and comfort, we prescribe Refresh Optive Mega-3 (Allergan), a preservative-free artificial tear solution, ensuring a comprehensive approach to prepare the patient for upcoming surgery.
One of the distinctive attributes of my practice is the substantial presence of engineers among my patients. Nestled in Huntsville, AL, a city housing NASA’s renowned Marshall Space Flight Center, the expansive Redstone Arsenal, esteemed companies such as Teledyne Brown Engineering, Boeing, and Lockheed Martin, and an array of engineering-focused enterprises, I frequently engage with patients who are, in the truest sense, rocket scientists.
The demanding and detail-oriented nature of these individuals permeates their approach to every facet of their lives, including their eye care. Their expectations are exacting, underscoring the importance of delivering nothing short of exceptional care to meet their unique needs.
I have discovered that, by employing the aforementioned tools and strategies, I can consistently deliver the optimal outcomes for their refractive cataract surgery, meeting the rigorous standards that align with their professional expertise. ■