Presbyopia / SPO - 3.2.1.5. Crystalline lens surgery and dry eye

3.2.1.5. Crystalline lens surgery and dry eye

Itziar Martínez-Soroa (1,2), Leire Galdós (1) and Javier Mendicute (1,2)

Hospital Universitario Donostia, Donostia-San Sebastián, Spain
Innova Begitek Clínicas Oftalmológicas, Donostia-San Sebastián, Spain

INTRODUCTION

Cataract surgery and in extension, crystalline lens surgery, has increased the number of its indications in recent years. Such increase in indications and number of procedures has been a consequence, among other factors, of the standardization of the surgical procedure, of the decrease of intra and postoperative complications and of the excellence of the refractive and visual results based on the technological development implicit in the new models of intraocular lenses.

However, the presence of dry eye and/or ocular surface disease can alter the accuracy of the equipment used in preoperative assessment and overshadow postoperative visual results and visual quality after surgery. It is also true that the surgery itself or the postoperative treatment may favor the appearance of postoperative signs and symptoms of dry eye that may have gone unnoticed preoperatively1,2.

The exacerbation of symptoms (foreign body sensation, eye irritation, burning, heavy eyelids and also alterations in visual quality) can cause dissatisfaction and frustration, and compromise the excellence of potential visual results.

PHYSIOPATHOLOGICAL MECHANISM

The prevalence of dry eye increases with age. And age is also a recognized factor that makes the population more susceptible to developing cataracts. The lens surgery itself causes alterations in the ocular surface and, in patients with risk factors, it can exacerbate the symptoms of ocular dryness3.

It has been demonstrated that phacoemulsification increases the instability of the tear film4. The increase of the squamous metaplasia and the decrease of the goblet cells in the conjunctiva have been related to the time of exposure to the light of the microscope, to the profuse irrigation with serum during surgery, to the own desiccation by ocular exposure5 and to the topical anesthesia and eye drops applied both intra and postoperatively1.

Although the mechanism is not known exactly, these same agents could alter the secretion of the Meibomian glands and increase the instability of the lacrimal film2.

The surgical trauma itself is associated with the production of free radicals, proteolytic enzymes, prostaglandins, leukotrienes and other inflammatory cytokines that alter the characteristics of the tear film on the ocular surface6,7. Along with tear instability, studies have shown a decrease in tear production8, caused in part by a neuropathic effect in relation to the corneal incision9, as well as the heat released by the ultrasonic energy of phacoemulsification10. The use of the aspiration speculum during surgery has also been associated with an increase in the symptoms of ocular dryness11.

But the greater iatrogenicity of cataract surgery seems to be related to the use of the topical anesthetic during the procedure as well as in the use of eye drops in the immediate postoperative period.

The squamous metaplasia observed after cataract surgery is accentuated in the lower conjunctival sector, where the instillation of eye drops provokes greater toxicity1. Certain active principles, such as aminoglycosides and NSAIDs12, can damage epithelial cells, but it is the preservatives (mainly benzalkonium chloride) that accompany these eye drops that have been shown to alter the ocular surface to a greater extent13,14.

In general, these symptoms last between 2 and 3 months and at 6 months the ocular surface assessment indexes return, in general, to preoperative values1,13.

Patients who underwent femtosecond laser-assisted lens surgery (FLACS) also present with dry eye symptoms and increased fluorescein uptake on the surface during the first postoperative week due to the use of the suction ring15.

Although there are no long-term studies, there is no evidence that these patients present more dry eye symptoms six months after the intervention.

PREOPERATIVE STUDY

Although a significant percentage of patients affected with dry eye disease have not presented or manifested symptoms of dryness before lens surgery, it is advisable to identify during the anamnesis those patients who are at greater risk for developing such a disease.

Preoperative diagnosis is essential to anticipate the possible effects of dry eye after surgery, to warn patients preoperatively and to anticipate a possible worsening of symptoms.

The preoperative diagnosis will allow us to anticipate and establish the appropriate treatment16.

But, perhaps, there is no ocular pathology in which such discordance between symptoms referred by the patient and signs observed by the doctor is observed. Increasing emphasis is placed on the sensorineural alteration of the ocular surface that accompanies the dry eye. Such alteration would explain this discordance between the symptoms and signs of this disease17.

ANAMNESIS

During the clinical interview it would be advisable to ask the patients for possible symptoms of ocular dryness such as the sensation of grit, burning, stinging, its variation throughout the day and environmental triggering situations (Table 1).

The existence of previous and current systemic diseases and the use of oral medication should be recorded in the clinical history.

The latest report from the International Dry Eye Workshop (DEWS II) includes a series of consistent risk factors18 (Table 2) that is advisable to take into account to detect these patients. Among them, old age, being a woman, suffering from a connective tissue disease, having Sjögren’s syndrome, having been transplanted with hematopoietic cells and taking anxiolytic, antidepressant, antihistamine medication or having been treated with isotretinoin against acne are important aspects for having a dry eye.

SPECIFIC HEALTH QUESTIONNAIRES

The inclusion of specific dry eye health questionnaires such as the DEQ-5 (Dry Eye Questionnaire) (Figure 1) or the OSDI (Ocular Surface Disease Index)19 (Figure 2), during the waiting time, for example, would identify in a simple way symptomatic patients who are therefore more susceptible to worsen after the procedure of cataract surgery.

Figure 1. DEQ-5 questionnaire.

Figure 2. OSDI questionnaire.

BIOMISCROSCOPY

As of today, there is not a single test that could be considered a gold standard and that would help us identify patients with dry eye disease. The symptomatology of the patient as well as the slit lamp examination, are the most useful diagnostic tools to study patients susceptible to worsening dryness after lens surgery. Conjunctival folds (Figure 3), which become trapped with the blinking, can be the basis of many symptoms in the postoperative period 20.

Figure 3. Conjunctival folds. The conjunctival folds at the eyelid margin are very symptomatic in the postoperative period of lens surgery.

The malposition of the eyelid margin, the lack of apposition against the eyeball of the lacrimal point, the existence of sebaceous secretion or scales on the eyelashes, as well as the presence of telangiectasias and obturations in the exit of the Meibomian glands, are biomicroscopic data to be taken into account in the clinical history because they suppose a greater risk to present dry eye of evaporative type.

SPECIFIC TESTS

Of all the studies to be performed in the context of a dry eye, the Tear Break-Up Time (TBUT) is the most sensitive test to study lacrimal instability18.

Vital stains are also essential in studying this tear instability and the state of the corneo-conjunctival epithelium. The lysine green is more sensitive for the study of the ocular surface because it stains in those areas where there is no mucin layer, while fluorescein stains those areas of epithelial cell loss.

All these explorations require a study methodology that, on occasions, is difficult to complete due to the limited consultation times assigned by the healthcare system. Hardten suggests a simple test as a stress test to identify patients susceptible to dry eyes21. It proposes that after the waiting period, following the instillation of mydriatic drops, the presence of a punctate keratopathy or epithelial irregularity, can help identify those patients at greater risk of presenting dry eyes after the surgical procedure. In any case, in starting the exploration of the patient who is going to undergo this type of surgery, both symptomatic patients of dry eye as well as asymptomatic ones should be considered, paying great attention to the clinical findings of the ocular surface to warn of the risk of ocular dryness in the postoperative period, This way we can avoid that in the presence of contributing factors, ocular dryness manifestations worsen, and the good refractive and visual results that we have promised are overshadowed.

Tear osmolarity. From the DEWS I it is already pointed out that hyperosmolarity22 is the main mechanism that triggers inflammation of the ocular surface in dry eye disease23. There is a proven positive correlation between the severity of dry eye and the osmolarity values24. Patients with tear osmolarity greater than 312 mOsm/L have greater symptoms of ocular dryness. The possibility of performing an osmolarity test on patients before cataract surgery can identify patients susceptible to worsening after surgery. In any case, it has not been demonstrated that the cataract surgery procedure increases tear osmolarity25.

RECOMMENDATIONS AND MANAGEMENT

Diagnosis constitutes the basis for avoiding manifestations of dry eye after lens surgery. In any case, there are universal measures to be taken to avoid either exacerbating a pre-existing dry eye, or contributing to the manifestation of symptoms in the postoperative period.

PREOPERATIVE CARE

Although exact figures are difficult to establish, it is believed that up to 70% of patients who undergo lens surgery have dry eye symptoms of varying intensity26. It would be advisable to identify patients with symptoms and/or signs of ocular dryness to warn them of an eventual worsening with surgery. An improvement in lacrimal homeostasis would prevent this aggravation, so it would be beneficial to arrive at the surgery in the best possible conditions. In patients with obvious signs of dry eye, the instillation of 0.05% Cyclosporin A every 12 hours one month before the intervention and several months later has shown improvement in tear stability, conjunctival staining as well as visual quality in those patients who had been implanted with a multifocal lens27. The existence of blepharitis, beyond causing alterations of the ocular surface, has been shown to increase the risk of postoperative endophthalmitis28. The use of topical antibiotics can reduce the growth of the staphylococcal flora and in turn improve the symptomatology29. It is advisable to perform eyelid hygiene in these patients, although not in the pre and postoperative periods close to surgery to avoid the mobilization of germs. Oral doxycycline is an excellent treatment to improve the flora and also the symptoms30 and signs31 of patients suffering from meibomian gland dysfunction, especially in the context of a rosacea.

INTRAOPERATIVE CARE

It is advisable to keep in mind, during lens surgery, that the time of exposure of the eye to the light of the microscope, the drying and the topical anesthetic can influence the cornea-conjunctival epithelium. The best care of the ocular surface is achieved with the use of a viscous solution, such as 2% hydroxy methyl(propyl) cellulose, which has been shown to be effective for the preservation of the exposed epithelium32.

In relation to the incisions, it is advisable to perform them as small as possible and in a single plane, avoiding deep pre-incisions. Corneal pre-incisions in lens surgery have been associated with greater alteration in corneal sensitivity33 and greater risk of accumulating secretions at their level.

POSTOPERATIVE CARE

As for the postoperative period, the modification of guidelines in the protocols, improves the clinical symptoms of ocular dryness.

The preservative-free eye drops are more respectful of the ocular surface34, so it is advisable to include topical corticosteroids and anti-inflammatory agents free of preservatives.

Topical NSAIDs can alter the corneal epithelium and cases of corneal defects have been described in relation to these medications35,36. In cases of patients with severe dry eyes, for example Sjögren’s syndrome, it is advisable to avoid or reduce as much as possible the time of application of this active ingredients.

Once warned of the possibility of the appearance of adverse effect of dryness, patients with greater risk of presenting them should be instructed in the administration of artificial tears without preservatives during the postoperative period, being more recommendable the formulations that include hyaluronic acid or carboxymethylcellulose37,38.

The worsening of symptoms after the withdrawal of corticosteroids sometimes requires prolonging the use of corticosteroids with lower potency ones (like fluorometholone or rimexolone) for several weeks39.

If recovery is delayed and if the symptoms are moderate or severe, Ciclosporin A 0.05% can be applied for 3-6 months with a dose scheduled every 12 hours27,40. It has even been shown to be effective in once a day applications41.

The results obtained by the tetrasodium diquaphosol secretagogue (Diquas®, Santen, Osaka, Japan) are encouraging for patients affected by dry eye. It is a purinergic P2Y2 receptor agonist that stimulates the secretion of the aqueous component and mucin by the conjunctival epithelial cells and goblet cells, which in turn leads to better stability of the tear film in the dry eye42. Its use in Japan and South Korea is approved and several randomized controlled trials have shown that the application of topical diquaphosol significantly improves the objective markers of dry eye disease, as well as cornea-conjunctival fluorescein staining, TBUT and Schirmer test43-45.

CONCLUSIONS

When considering surgery of the crystalline lens, we should be aware of the possibility of aggravating dry eye symptoms or of precipitating their appearance in patients who previously had no symptoms or signs. The success of surgery is based not only on visual results or implanted optics but above all on patient satisfaction.

To warn, in the interview prior to surgery, about the possible appearance of symptoms of dry eyes, can make its subsequent treatment more acceptable.

In case of symptoms of dry eye, it is convenient to explain the generally self-limiting nature of the condition with resolution of it in several months, helping the patient to cope better with the symptoms and thus avoid overshadowing the visual and refractive results obtained.

Identifying, during the clinical interview with the appropriate work system, those patients with greater risk, can contribute to anticipating the aggravation of symptoms, improving lacrimal homeostasis and performing the lens surgery in the best possible conditions of the ocular surface.

It would also be desirable to generalize the use of preservative-free eye drops in the postoperative period to reduce the toxicity on the ocular surface.

If the recovery of symptoms and signs of dry eye is prolonged, topical treatment with corticosteroids can be done for several weeks to reduce the clinical symptoms or to instill eye drops of Ciclosporin A 0.05% for as long as it may be necessary.

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