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Ocular Surface Cataract/Refractive Ocular Surface Disorders and Cataract and Refractive Surgery Success Carlos Vergés Professor and Chairman of Ophthalmology, Area Oftalmológica Avanzada, Universidad Politécnica de Cataluña, Barcelona, Spain Abstract Many ophthalmologists stress the importance to success of considering the state of the ocular surface in cataract and refractive surgery. The problem is that surgeons do not always attach the same required attention and there is not a well-defined protocol for diagnosis and treatment of ocular surface disorders. This article aims to highlight these facts and provide a guide, both simple and practical, for both diagnosis and for treatment. Keywords Dry eye, ocular surface disorders, meibomian gland dysfunction, refractive surgery, cataract surgery, diagnosis, treatment Disclosure: The author has no conflicts of interest to declare. Received: 12 January 2013 Accepted: 5 March 2013 Citation: European Ophthalmic Review, 2013;7(1):28–30 Correspondence: Carlos Vergés, C/Dalmases 42 08021 Barcelona, Spain. E: cverges@cverges.com Dry eye syndrome (DES) is a multifactorial ocular surface disease (OSD), 1–3 the incidence of which is about 16 %, 4–7 and is one of the most common reasons why people visit their ophthalmologist – approximately one in three patients seek treatment from a specialist. 8 Many cases of dry eye are associated with other disorders such as meibomian gland disease (MGD), conjunctivochalasis or even allergy. Recently, the International Dry Eye Workshop (DEWS) 1 and the Meibomian Gland Dysfunction Workshop 9 redefined these conditions. It is relevant and somewhat novel that in both definitions, DES and MGD, inflammation appears as a major factor in the pathogenesis. This will be important in providing a more definitive approach to diagnosis and treatment. Cataract or refractive surgery often aggravate the symptoms of DES, 11 and there is evidence to show how these patients have poorer outcomes after surgery. 11 In patients with DES undergoing laser-assisted in situ keratomileusis (LASIK) surgery, a worsening of symptoms or onset of discomfort in patients who were previously asymptomatic, 12 or even a reduction of functional visual acuity, 13 have been described. We also know that MGD is the most prevalent cause of evaporative dry eye. 14 Pre-existing MGD can double a patient’s risk of developing DES, 15 especially after ocular surgery, which can negatively affect outcomes. 15–19 For these reasons it is important for ophthalmologists to consider DES and OSD whenever they approach surgical patients in order to identify and treat these conditions pre-operatively and thus optimise surgical outcomes. Diagnosis Traditional tests to diagnose OSD provide limited practical information. 20 Fortunately this has changed recently and the combination of clinical history, subjective symptoms and, especially, data provided by new technologies, help us with a given diagnosis. We emphasise the value of the patient’s clinical history. The presence of other diseases, ocular 28 and systemic, as well as certain medications are fundamental factors in the onset and course of the disease. According to the DEWS report, risk factors for dry eye to be taken in account before surgery include: • Increasing age; • Female gender, especially women who are post-menopausal and taking oestrogen; • Deficiencies of omega-3 and omega-6 fatty acids and vitamin A; • Oral medications, including antihistamines, betablockers, tricyclic antidepressants and diuretics; • Topical medications, especially those containing preservatives, such as benzalkonium chloride; • Systemic diseases, namely autoimmune disease, including Sjögren syndrome and diabetes; • Ocular surgery, in particular, laser vision correction and cataract surgery, especially when limbal relaxing incisions are used; and • Stem-cell transplantation, especially when graft versus host disease occurs. To achieve a complete approach to OSD, diagnosis should include a standardised questionnaire, such as the Ocular Surface Disease Index (OSDI); McMonnies; Schein; Dry Eye Questionnaire (DEQ); Ocular Comfort Index (OCI); or the Standard Patient Evaluation of Eye Dryness (SPEED), followed by non-invasive objective testing. New technologies include: • New corneal topography: measure tear break-up time and tear meniscus height objectively (Keratograph, Oculus). • New optical coherence tomography (Fourier domain OCT) objectively quantifies the tear meniscus height and volume. • Dynamic Wavefront aberrometry (the Oral Controlled Absorption System [OCAS]) measures the inter-blink change in higher-order aberrations and, thus, provides a quantitative assessment of tear-film quality and stability. © Touc h ME d ic al ME d ia 2013