Patients with coexisting inflammatory disease are at increased risk of delays in visual recovery and complications after cataract surgery. It is imperative that ophthalmologists diagnose during the preoperative examination inflammatory conditions that may complicate patients' postoperative recovery. Common examples include aqueous tear-deficient dry eye disease (DED), meibomian gland dysfunction (MGD), and uveitis.
AQUEOUS Tear-deficient DED
The visual recovery after cataract surgery of patients with aqueous tear-deficient DED is often delayed, especially if corneal staining is evident preoperatively. Aggressive management before surgery is therefore preferable to postoperative treatment, when the patient is likely to be frustrated and unhappy.
The level of matrix metalloproteinase-9 has consistently been shown to be elevated in the tears of patients with inflammatory DED.1 Testing for this inflammatory marker is extremely sensitive and specific. InflammaDry (Rapid Pathogen Screening Inc.; not available in the United States) is a new, accurate, in-office immunoassay that detects elevated levels of matrix metalloproteinase-9 in tears in 10 minutes. This test allows the clinician to more effectively diagnose inflammatory DED and begin appropriate therapy.
Initial treatment should include the frequent instillation of unpreserved artificial tears and a lubricating gel or ointment at night. Therapy with topical cyclosporine A (Restasis; Allergan, Inc.) also deserves strong consideration, because DED is a progressive condition that often worsens after cataract surgery. Although several weeks may elapse before cyclosporine therapy produces a significant response, treatment should continue during the postoperative period. An improved tear film often increases patients' satisfaction and quality of vision.
Punctal occlusion is a valuable technique for treating severe DED. We prefer the punctal plugs from Odyssey Medical, Inc., for their comfort and stability. Plugs can be placed preoperatively or at the time of cataract surgery. Thermal cautery for permanent punctal occlusion merits consideration in cases of Sjögren syndrome.
Patients with significant conjunctival injection and discomfort from DED may benefit from topical corticosteroids preoperatively. Combined with cyclosporine A, a corticosteroid will provide immunomodulation, decrease ocular burning, and more rapidly relieve DED. Loteprednol (Lotemax; Bausch + Lomb) is an excellent option in these cases due to its high efficacy on the ocular surface and inside the eye. Moreover, the safety parameters of this ester steroid reduce the risk of IOP elevation.2 The availability of loteprednol as an ointment makes it particularly helpful in patients with ocular surface disease who need a steroid after cataract surgery. Applying the drug at night lubricates the surface and increases anti-inflammatory coverage.
If the preoperative workup identifies severe DED, it may be appropriate to delay cataract surgery until the ocular surface improves.
MEIBOMIAN GLAND DYSFUNCTION
Patients with MGD often have a difficult postoperative course. Their most frequent complaint is a fluctuation of vision due to an unstable tear film, which ultimately leaves them frustrated with their surgery. Treating MGD and improving the quality of the tear film before the cataract procedure is therefore critical to satisfying these patients.
Preoperative management should include a protocol for lid hyperthermia and hygiene treatment. Patients often do not comply with this regimen for long periods of time but will perioperatively if the surgeon stresses its importance to the surgical outcome. The LipiFlow Thermal Pulsation System (TearScience, Inc.) is a new device that applies heat to the palpebral surfaces of the upper and lower eyelids directly over the meibomian glands, while simultaneously delivering graded pulsatile pressure to the outer eyelid. The heat helps to liquefy the contents of the meibomian glands. The pulsation transiently decreases blood flow to the tissue surrounding the meibomian glands, thus increasing the efficiency of heat transfer and resulting in the evacuation of the glands' liquefied contents to alleviate the obstruction. Another first-line therapy for MGD is oral omega-3 nutritional supplements. The recommended dose is 3 g per day. In our experience, topical azithromycin (AzaSite; Merck & Co., Inc.) q.d. for long-term therapy is also very beneficial for these patients. The drug is best applied as a drop in the cul-de-sac and then massaged into the lids.3 Many patients benefit from prolonged therapy postoperatively, either as long-term maintenance or cycled as a few months on and off.
Most patients whose MGD does not respond to the aforementioned treatments will experience significant anti-inflammatory effects from oral doxycycline.3 A regimen of 50 mg per day avoids the frequent gastrointestinal complications of the typical, higher anti-infective dosing.
A combined antibiotic-steroid may help MGD patients who have concomitant anterior blepharitis or who require the short-term treatment of significant inflammation. Tobradex ST (Alcon Laboratories, Inc.) delivers a broad-spectrum antibiotic (tobramycin) and a powerful steroid (dexamethasone) in a new preparation that adheres well to the eyelids. The product contains xanthan gum, which forms an ionic interaction with tobramycin and reduces the settling of dexamethasone. The agent's viscosity increases sevenfold from the bottle to the tears, extending retention time.
Patients with corneal involvement of MGD or a significant conjunctival reaction should undergo treatment with a topical steroid. We prescribe loteprednol suspension during the day and loteprednol ointment at night for these patients. The latter reduces inflammation in the lids and meibomian glands while delivering anti-inflammatory treatment to the ocular surface.
UVEITIS
The patient with a history of uveitis is at significant risk for an exacerbated inflammatory reaction after cataract surgery. The normal trauma of the procedure can precipitate a severe uveitic reaction and postoperative complications such as cystoid macular edema (CME), the formation of anterior and posterior synechiae, and secondary glaucoma. Postoperative treatment with oral corticosteroids 1 mg/kg starting on the day of surgery is a powerful prophylactic regimen. These agents can be tapered over 2 to 3 weeks.
Topical steroids should be used more frequently during the immediate postoperative period in patients with uveitis. Because the goal is to suppress inflammation before its occurrence, we also treat uveitic patients with a topical corticosteroid prior to surgery. The most powerful topical agent available is difluprednate ophthalmic emulsion 0.05% (Durezol; Alcon Laboratories, Inc.). In a trial of uveitic patients, this drug dosed q.i.d. controlled inflammation better than prednisolone acetate dosed eight times a day.4 Difluprednate achieves its increased efficacy and strength in part from its fluorination at both the C6 and C9 positions, making it a difluorinated prednisolone derivative. Dermatologists have used fluorinated corticosteroids for decades, and these agents are well established as the most potent topical anti-inflammatory medications available. Durezol is formulated as an emulsion, which, unlike a suspension, does not require shaking and maintains an even distribution of its active ingredient.
Topical nonsteroidal anti-inflammatory drugs also play an important role in achieving successful outcomes in cataract surgery, and these agents are critical for uveitic patients. They should begin using nonsteroidal anti-inflammatory drugs 5 to 7 days preoperatively and continue them for at least 2 to 3 months postoperatively to help reduce the risk of CME. For individuals with significant vitritis, an intravitreal injection of triamcinolone (Triesence; Alcon Laboratories, Inc.) can provide long-term control of inflammation, reduce the risk of CME, and improve cataract surgical outcomes.5
CONCLUSION
The aggressive treatment of DED and MGD prior to cataract surgery will increase both its success and patients' satisfaction. Managing patients with cataracts and uveitis requires expert surgical care with minimal trauma to the eye. Anti-inflammatory therapy should continue significantly longer than after conventional cataract surgery. An aggressive treatment plan to suppress inflammation preoperatively and control it postoperatively will dramatically improve surgical results.
Eric D. Donnenfeld, MD, is a professor of ophthalmology at NYU and a trustee of Dartmouth Medical School in Hanover, New Hampshire. Dr. Donnenfeld is in private practice with Ophthalmic Consultants of Long Island in Rockville Centre, New York. He is a consultant to Abbott Medical Optics Inc.; Alcon Laboratories, Inc.; Allergan, Inc.; Bausch + Lomb; and Merck & Co., Inc. Dr. Donnenfeld may be reached at (516) 766-2519; eddoph@aol.com.
Edward J. Holland, MD, is a professor of ophthalmology at the University of Cincinnati in Ohio and the director of cornea at the Cincinnati Eye Institute. He is a consultant to Abbott Medical Optics Inc.; Alcon Laboratories, Inc.; Allergan, Inc.; and Bausch + Lomb. Dr. Holland may be reached at (859) 331-9000, ext. 3064; eholland@holprovision.com.
