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OSN round table, part 2: Optimization of the ocular surface

Dry eye is a multifactorial progressive disease that worsens with time. At the European Society of Cataract and Refractive Surgeons meeting in Barcelona, Ocular Surgery News convened anterior segment surgeons from both sides of the Atlantic to address the challenges of diagnosing and treating ocular surface disease, particularly before and after ophthalmic procedures. In this second of two parts led by OSN Technology Section Editor William B. Trattler, MD, the round table participants delve into their suggested regimens for optimizing the ocular surface with respect to dry eye, giving their thoughts on eyelid hygiene, use of punctal plugs, pterygium surgery and consequences of cross-linking for keratoconus.

Lid hygiene

William B. Trattler, MD: There have been a number of innovations in diagnostics as well as therapies for lid margin disease. What new technologies have you incorporated into your practice to improve care for your patients?

Jennifer Loh, MD: When assessing eyelid disease in terms of treating dry eye, we know that eyelids are a big foci for inflammation that contributes to decreased lipid layer and poor tear film, and so we want to treat the blepharitis and inflammation of the eyelids. A popular eyelid treatment now is something called Avenova (hypochlorous acid, NovaBay). It works well for cleaning the eyelids and getting rid of debris and inflammatory markers. If a patient cannot afford that, I often will use a product in the United States called OcuSoft, which is a pre-moistened towelette with lid cleanser.

After pterygium surgery, William B. Trattler, MD, treats the ocular surface aggressively to reduce inflammation, which is a risk factor for recurrence.

Image: Trattler WB

Béatrice Cochener, MD, PhD: Do they need to warm it?

Loh: Yes. They should warm the eyelids first and then do the cleansing. Another point is that, sometimes, if someone has severe telangiectasias or redness, I will use oral doxycycline temporarily to help decrease the inflammation. I do not use it in all patients, but if they have severe rosacea or signs of that, I will. Sometimes I even give erythromycin ointment after the cleansing to keep the bacterial load at a minimum.

Trattler: What products or technologies do you use in Europe?

Cochener: The strategy is according to the compliance of the patients. Sometimes people forget or do not do the routine every day. So we start always with a simple and cheap process, just using warm and moist towelettes in the morning. Then we go for a warming mask that is put in the microwave or more sophisticated electric warming glasses. Patients do that every day and then two or three times per week. Of course, it needs to be associated with perfect cleaning of the eyes right after.

You may also use LipiFlow (TearScience), which is a therapeutic step that uses a thermopneumatic eyecup that gets warm and that works on just the lids. It is popular in the States because American patients are ready to pay. In Europe, it is more of the last choice when people get tired of the repeated treatment and/or still feel uncomfortable with their eyes, and they make then the decision to pay for one single treatment. But based on the media, some even come to the office and ask for it specifically. The key advantage is that it should work on average for 3 to 6 months. That is the average, 3 to 6 months. In between treatments, the patient does not have to do all this repetitive treatment.

Roundtable Participants

  • Moderator

  • William B. Trattler
  • Beatrice Cochener, MD
  • Béatrice Cochener
  • Aylin Kilic, MD
  • Aylin Kiliç
  • Jennifer Loh, MD
  • Jennifer Loh
  • Wolfgang Riha, MD
  • Wolfgang Riha