Cynthia Matossian;  Special to Ophthalmology Times® 

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Patient expectations for cataract surgery are very high, especially when it comes to advanced-technology implants. To meet those expectations, we need accurate preoperative measurements as a basis for IOL calculations, and we cannot have accurate measurements without a stable tear film.

Objective tests such as tear osmolarity and matrix metalloproteinase 9 (MMP-9) offer efficient ways to screen the tear film and, in turn, may act as predictors of whether preoperative measurements will be accurate. Studies show that cataract patients with abnormal tear film osmolarity have highly variable keratometric readings (up to nearly 3.5 D, taken 2 weeks apart).

With treatment and stabilisation of the tear film, more accurate measurements are captured, reducing residual refractive error.

 Here is a look at how I screen my cataract patients, aggressively treat them before surgery and initiate long-term therapy postoperatively for chronic dry eye disease.

Given the prevalence of dry eye disease in the cataract age group, we have to look at every cataract patient as a dry eye consultation. This is true even when patients are asymptomatic or do not recognise mild symptoms of dry eye disease.

Patients might have intermittent blurred vision that they blame on the cataracts or fatigue, when in fact the problem is tear film instability. If we do not treat the condition before surgery, dry eye symptoms often worsen from the stress of surgery, at which point patients blame their surgeon for “giving them dry eye”.

Objective tests make dry eye screening accurate and efficient. I use an osmolarity test (TearLab Osmolarity System, TearLab Corporation), in which a score above 308 mOsm/L and/or an interocular difference of 8 mOsm/L or higher indicates an abnormal tear film. When the two eyes exhibit different numbers, the diagnosis and treatment decisions are based on the higher number.

In addition to osmolarity testing, I also perform meibography (TearScience LipiView, Johnson & Johnson Vision) to show patients their missing or architecturally abnormal gland structures. Another point-of-care test that our technicians perform is an MMP-9 test for inflammation (InflammaDry, Quidel Corporation). If this test shows a stripe ranging from faint pink to bright red, inflammation is present. We need to treat the inflammation before cataract surgery.

Finally, I educate patients about dry eye and their diagnostic test results. It is so important to make believers of them and engage them in their own treatment process before surgery.

I give patients a card with their osmolarity number and a scale on the back with the colour-coded interpretation of their number. I explain to them, “We have to tune your ocular surface to get the best results from cataract surgery,” and typically they are highly motivated to adhere to their customised treatment for the next few weeks.

When patients are ready for cataract surgery, they do not want to wait months for their dry eye treatment to work, but they do not mind waiting a few weeks to ensure a better outcome. I treat the tear film aggressively and schedule patients to return this for their measurements in about 3 weeks, depending on disease severity. I explain that they must be adherent, or I will not be able to acquire reliable data for surgery.

I start patients on a topical corticosteroid for 2 weeks to quell the inflammation (either Alcon’s Eysuvis or loteprednol if there are insurance coverage issues for Eysuvis). Patients start oral omega supplements, sometimes starting with a liquid formula before transitioning to capsules long term.

If meibography shows impacted meibomian glands, I perform thermal pulsation (TearScience LipiFlow, Johnson & Johnson Vision) to evacuate the inspissated meibum and allow the ingested omega fatty acids to filter through the cleaned meibomian gland orifices onto the ocular surface. If patients have blepharitis, I recommend microblepharoexfoliation of the lid margins (BlephEx, Alcon) to debulk the debris, break up the biofilm, and minimise the risk of infection and endophthalmitis.

With the tear film stabilised, as evidenced by an osmolarity score below 308 mOsm/L and an absent red line on the MMP-9 test, I am ready to take measurements, calculate the implant powers and proceed with surgery.

Post-op: Transition to long-term treatments

Ocular surface disease is chronic; patients will need to use customised therapies long term. I explain to patients that to get the most from their new implants, they need to keep their tear film healthy. Postoperatively, patients continue with their omegas, a heated moisture mask, lid scrubs and an annual thermal and evacuation treatment if warranted.

For patients with meibomian gland dysfunction, I often perform intense pulsed-light therapy (Lumenis OptiLight or ESW Vision’s E-Eye). This four-session treatment is scheduled every 2–3 weeks and can then be repeated as a single treatment semi-annually for maintenance. Most patients perceive the benefits, with decreased lid margin hyperaemia and increased ocular comfort, after the sessions are complete.

Additionally, for many patients’ long-term care, I prescribe ciclosporin (Allergan’s Restasis or Sun Pharmaceutical Industries’ Cequa), or lifitegrast ophthalmic solution (Xiidra, Novartis Pharmaceuticals Corporation) 5% eye drops, or varenicline solution (Tyrvaya, Oyster Point Pharma) nasal spray 0.03%. Each patient’s treatment needs must be customised and carefully monitored.

When we stabilise the tear film, refractive surprises become less frequent. Moreover, patients do not suddenly experience dry eye symptoms postoperatively and blame their surgeon.

For the process to work, we have to ensure adherence by engaging patients in their surgical journey. I find this empowers them. They like tracking their osmolarity number. In addition, by starting a dry eye care routine leading up to surgery, patients are well prepared to continue their maintenance therapy after surgery.

Dr Matossianspecialises in refractive cataract surgery and dry eye disease.Sheis the founder of Matossian Eye Associates, located in Pennsylvania and New Jersey, United States.

1. Epitropoulos AT, Matossian C, Berdy GJ, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. 

2. Matossian C. Impact of thermal pulsation treatment on astigmatism management and outcomes in meibomian gland dysfunction patients undergoing cataract surgery. 

Articles

Correcting abnormal tear film osmolarity before cataract surgery enables more accurate measurements to be captured, reducing residual refractive error.

Cataract predictability: Screen and treat unstable tear film in weeks

Topical cyclosporine A (CsA) has long been a mainstay of treatment for dry eye disease. In fact, for many years, CsA 0.05% (Restasis, Allergan) was the only treatment available to our patients, other than steroids or palliative artificial lubricants. More recently, we have seen the introduction of lifitegrast 5% (Xiidra, Novartis), multiple treatments for underlying meibomian gland dysfunction, and higher-concentration CsA formulations (Cequa, Sun Pharmaceutical Industries; and Klarity-C, ImprimisRx), all of which have given rise to a more robust armamentarium of treatment options for dry eye disease.

CsA is an immunosuppressant that inhibits T-cell-mediated inflammation and cytokines, stimulates tear production and increases goblet cell density.

 Despite its success in the marketplace and in many of our practices, there are still challenges with its use, including the high cost of the prescription solution for patients and burning or stinging on instillation, which can discourage patients from continuing the drops long enough to see an effect. Additionally, it is challenging to formulate a topical CsA preparation because this molecule is not very water soluble.

I have been involved in a study to evaluate efficacy in a real-world clinical practice setting of a higher-dose (0.1%) cyclosporine (Klarity-C) in a unique chondroitin sulfate formulation.

 Chondroitin sulfate, a compound developed decades ago by Dr Richard Lindstrom, Dr Herbert Kaufman and others, is the key ingredient in OptiSol-GS (Bausch + Lomb) and is used in several viscoelastic products.

It has some unique properties in that it is lubricating, anti-inflammatory, cell membrane-stabilising and corneal oedema-reducing.

 Klarity-C, the drug used in our study, is a preservative-free drop compounded in a 503B United States Food and Drug Administration (FDA)-regulated outsourcing facility. 503B pharmacies have to follow stringent quality and manufacturing requirements and are subject to the same FDA inspection and oversight as large pharmaceutical companies. However, compounded medications are typically more affordable than other branded drugs.

This was a retrospective, multicentre study which I conducted with Dr Jennifer Loh and Dr William Trattler. Adult patients with a dry eye diagnosis who were treated with Klarity-C twice daily were included. We reviewed patients’ charts to determine the change from baseline in ocular surface disease index (OSDI) scores and corneal staining after 3 months of treatment.

Fifty-one patients with dry eye (102 eyes) were enrolled. Patients ranged in age from 27 to 80 years, with a mean age of 62 years and 76% were women.

The OSDI questionnaire measures dry eye symptoms, including visual symptoms and ocular discomfort. Patients are asked to indicate whether they experienced any of the 12 symptoms all, most, half, some or none of the time during the previous week, and the answers are scored from 0 to 100, with a lower score being ideal.

At 3 months, our patients’ mean OSDI score improved from 37.57 to 23.83 (

 < 0.001). Before starting treatment, 61% of the patients had OSDI scores in the “severe” range (33–100). By 3 months, patients scoring in the severe range declined to 20%, and more than one third of patients reported improvements in symptoms that put them in the normal (0–12) range (see Figure 1).

Fluorescein staining of the entire cornea was evaluated for each eye (N = 102). The mean staining grade improved from 3.57 pre-treatment to 2.17 (

 < 0.001) at 3 months. I find corneal staining with vital dyes to be an excellent diagnostic tool. In the PHACO study, Trattler 

showed that staining is extremely common in older patients, with 77% of those presenting for cataract surgery demonstrating some corneal staining (central or peripheral), including 50% with central staining.

One patient I treated in this study was a 71-year-old man who complained of blur, light sensitivity and irritation, which he described as a “sandy, gritty feeling.” He thought he needed stronger glasses because he had a hard time focusing to read.

He was not on any ocular medications, including artificial tears. His medical history was significant for hypertension, controlled on lisinopril 10 mg and metoprolol 25 mg. He went through a full dry eye evaluation.

Tear osmolarity (TearLab) was normal (300 oculus sinister and 301 oculus dexter), but an MMP9 test (InflammaDry, Quidel) was positive for the inflammatory marker in the tear film.He had 1+ central and inferior staining in both eyes and his OSDI score was 22.7, putting him in the mild-to-moderate category.

I also like to look at topography images in evaluating dry eye. Prior to treatment, the axial maps on the OPD-Scan III (Nidek Inc) revealed that this patient had tear film instability (see Figure 2). We could also see missing and warped squares on the Cassini ocular surface qualifier, supporting the finding of an unstable tear film.

After 3 months of treatment with Klarity-C, this patient’s tear film was still not perfect, but the topography images were better; his OSDI score had improved from 22.7 to 6.25—well into the normal category—and he now had only trace inferior staining, with no staining centrally. His symptoms improved, including the visual fluctuations that made him feel like something was wrong with his vision. He had no problems tolerating the drops.

CsA is a time-tested, effective treatment for inflammation in dry eye. Twice daily instillation of Klarity-C results in statistically significant improvement in OSDI scores and improvement in corneal staining while offering patients a favourable tolerability and cost profile.


Dr Matossian is the founder and medical director of Matossian Eye Associates, an integrated ophthalmology and optometry group practice with three offices in Pennsylvania and New Jersey, United States. Dr Matossian Eye is an affiliate of Prism Vision Group. She also serves as a clinical instructor in the Department of Ophthalmology at Temple University Lewis Katz School of Medicine. Dr. Matossian is a consultant to Allergan, Bausch + Lomb, ImprimisRX, Shire/Novartis and Sun Pharmaceuticals.

Sall K, Stevenson OD, Mundorf TK, Reis BL. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000;107:631-639.

Kunert KS, Tisdale AS, Gipson IK. Goblet cell numbers and epithelial proliferation in the conjunctiva of patients with dry eye syndrome treated with cyclosporine. Arch Ophthalmol. 2002;120:330-337.

Matossian C, Loh J, Trattler WB. Efficacy of topical 0.1% cyclosporine in chondroitin sulfate ophthalmic emulsion in patients with dry eye. Paper presented at: 2020 American Society of Cataract and Refractive Surgery Virtual Annual Meeting; 16-17 May 2020.

Lindstrom RL, Kaufman HE, Skelnik DL, et al. Optisol corneal storage medium. Am J Ophthalmol. 1992;114:345-356.

Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The prospective health assessment of cataract patients’ ocular surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017:11;1423-1430.

In recent years, ophthalmologists have seen several new therapeutics for the treatment of dry eye disease. 

Author | Cynthia Matossian; Special to Ophthalmology Times®

Articles

Cataract predictability: Screen and treat unstable tear film in weeks

Novel chondroitin formulation contributes to cyclosporine efficacy