Study: Treat MGD before cataract surgery to prevent worsening

We’re seeing more, and more, and more about this, and it’s a good trend. It’s not just about “dry eye” in general, it’s honing in on MGD.

Remember all those years when LASIK patients who got MGD afterwards had no answers? To see discussion of MGD in even a cataract surgery context now lends even more credibility to the reality of our experiences. Who knows how many of us may have had undiagnosed MGD flying under the radar before an eye surgery. It’s good to see standards slowly improving. Visual outcomes are still probably the main thing driving the trend, but preventing a worsening of dry eye or MGD is a good thing whatever drives it and that is exactly what this particular study focuses on.

Preoperative Management of MGD Alleviates the Aggravation of MGD and Dry Eye Induced by Cataract Surgery: A Prospective, Randomized Clinical Trial. Song et al, Biomed Res Int. 2019 Apr 11

Abstract

PURPOSE:

To investigate the effect of preoperative treatment and postoperative enhanced anti-inflammatory treatment on alleviating meibomian gland dysfunction (MGD) and dry eye induced by cataract surgery.

DESIGN:

Prospective, randomized clinical trial.

METHODS:

A total of 120 cataract patients with moderate obstructive-MGD were enrolled and randomized with 60:30:30 number of patients in cohorts I, II, and III, respectively: Cohort I: routine postoperative anti-inflammatory treatment; Cohort II: preoperative treatment (warming compress, lid hygiene, and anti-inflammatory treatment) and routine postoperative anti-inflammatory treatment; Cohort III: enhanced postoperative anti-inflammatory treatment.

MAIN OUTCOMES MEASURES:

All participants were examined preoperatively and postoperatively for ocular symptom score (OSS), noninvasive keratographic tear break-up time (NIKBUT), corneal fluorescein staining, Schirmer I test, lid margin, meibum quality and expressibility, and meibomian gland dropout.

RESULTS:

Ocular surface disorders and MGD showed aggravated status at 1 month postoperatively in Cohort I and Cohort III, and the aggravated MGD resolved by 3 months postoperatively. At 1 month postoperatively, Cohort II and Cohort III presented high NIKBUT and low OSS, lid margin, and meibum quality and expressibility (Cohort II vs Cohort I: all P<0.001, respectively; Cohort III vs Cohort I: P=0.011, P=0.024, P=0.046, P=0.045, and P=0.012, respectively). Additionally, Cohort II had better outcomes of lid margin and meibum quality and expressibility than Cohort III at 1 month postoperatively (P=0.031, P=0.026, and P<0.001, respectively). At 3 months postoperatively, Cohort II presented a significantly higher NIKBUT than Cohort I and Cohort III (P<0.001 and P=0.001, respectively).

CONCLUSION:

Preoperative management of MGD is effective and optimal in alleviating obstructive-MGD and dry eye induced by cataract surgery.

ASCRS on addressing dry eye before eye surgery

I am happy to see more and more attention to the implications of dry eye for people facing eye surgeries. This has long been an issue in elective surgeries such as LASIK, of course, but in recent years it’s becoming more widely understood to bean issue for cataract surgery and other procedures.

What’s at stake? Both vision and dry eye, because your dry eye status before surgery (whether you have symptoms or not) affects your vision outcome from the surgery, and of course surgery can make dry eye worse (at least temporarily).

ASCRS (American Society of Cataract and Refractive Surgery - that’s a major professional body for cornea specialists and in general ophthalmologists who do vision correction surgeries, and it’s their annual meeting that I have been blogging about so much) finds that a lot of surgeons, while they may know it’s important, aren’t necessarily up to speed on what to do about it, so they’ve come up with some specific standards for this. Great way to get more attention to the topic and more conversations going.

An algorithm for the preoperative diagnosis and treatment of ocular surface disorders (Starr et al, J Cataract Refract Surg. 2019 May)

Any ocular surface disease (OSD), but most commonly, dry-eye disease (DED), can reduce visual quality and quantity and adversely affect refractive measurements before keratorefractive and phacorefractive surgeries. In addition, ocular surgery can exacerbate or induce OSD, leading to worsened vision, increased symptoms, and overall dissatisfaction postoperatively. Although most respondents of the recent annual American Society of Cataract and Refractive Surgery (ASCRS) Clinical Survey recognized the importance of DED on surgical outcomes, many were unaware of the current guidelines and most were not using modern diagnostic tests and advanced treatments. To address these educational gaps, the ASCRS Cornea Clinical Committee developed a new consensus-based practical diagnostic OSD algorithm to aid surgeons in efficiently diagnosing and treating visually significant OSD before any form of refractive surgery is performed. By treating OSD preoperatively, postoperative visual outcomes and patient satisfaction can be significantly improved.

ARVO Sunday afternoon - more posters

More poster session notes

Moved over to Section B. There are acres of posters… there really are… and I get to start over tomorrow and Tuesday!

I couldn’t help noticing how many people over here in the retinal research sections had white canes, and a service dog or two even. Definitely a lot of personal interest going on in vision research, and this would definitely be the place to catch up on what’s going on.

Most of that is outside my areas of interest, but I did browse most aisles of posters just to get a sense of some of the trends.

One thing that I saw a little bit more of this time was mentions of patients. You know, US. And what we want and how we feel about things. Considering the push at the NIH & elsewhere to start at least making some effort to involve patients’ voices, though, I was surprised not to see more evidence of this in the poster sessions. At least today’s. We’ll see what the next couple of days bring.

Minor tidbit from the glaucoma section. A poster mentioned, in its background information, that long-term benzalkonium chloride exposure is a risk factor for dysfunctioning blebs. Just what I needed, another reason to dislike BAK.

Then came cataract surgery: I browsed this section for anything dry eye related. Usually when I think of cataract and dry eye, I think of dry eye after cataract surgery, but this time I was noticing things like increased efforts to detect and treat dry eye before cataract surgery, not but because of dry eye concerns per se but because of how undiagnosed dryness could interfere with calculating the intraocular lens power. There was a poster from Melbourne on using the axis of astigmatism to identify subclinical dry eye, and another on tear osmolarity because of how a poor tear film can affect keratometry readings.

And more cataract: A poster from Central South University in China studied MGD patients before and after cataract surgery and determined that while they may have worse symptoms after cataract surgery, the MGD itself doesn’t get worse following surgery.

Then I meandered back to the other section where most of the cornea stuff was, in case I missed anything, and sure enough!

New! HL-036 (HanAll BioPharma): Phew, I didn’t even have this one on the radar, but I looked it up and I see that they recently started recruiting for a Phase 3 clinical trial! Just added it to the pipeline page. In the poster presented today, they compared two different concentrations with placebo. The lower one had results similar to placebo (in terms of clinical signs) while the higher was much better.

Then there were two posters on slow release cyclosporine. One had too much of a crowd for too long and I lost patience. The other one, I allowed the author to talk me through the entire store. Very nice young man and he’ll never know quite how much of it was over my head. It was actually really interesting, but the particular work he was doing was nowhere near human studies.

Missing in action: There was a poster I was really looking forward to and it had been highlighted as a “hot topic” in the press office… It was about an OCT imaging process to quantify inflammation. I was so disappointed to find that the presenter had withdrawn from the meeting at the last minute. But I looked up the paper in our app, and here’s the gist of the conclusion: “Magnetic nanoparticles can be visualized using OCT… The high sensitivity suggestions that the visualization of inflammatory cells labeled by functionalized nanoparticles is possible…” It’s in very early stages but sounds promising. From a patient’s standpoint, “inflammation” too often sounds rather nebulous and subjective. The idea of imaging for it sounds fascinating.

I always forget…

…how hard convention centers are on the eyes. Exhibit halls especially, but maybe I just noticed it more there because I spent so much time there in the poster sessions. Cool, dry, blowing air everywhere. I love coming to these things, but by halfway through the day, my lenses get so uncomfortable and my eyes are so light sensitive I want to screen.

Anyway, I made it a relatively short day today - left when my laptop battery and my eyes had both given out. Tomorrow will be quite full - back to back presentations most of the day plus a dinner tomorrow night.

Study: Effect of cataract surgery on meibomian gland dysfunction

Influence of cataract surgery on Meibomian gland dysfunction [Translation]

J Fr Ophtalmol. 2018 Jun 7. pii: S0181-5512(18)30197-9. doi: 10.1016/j.jfo.2017.11.021.
[Article in French]
El Ameen A, Majzoub S, Vandermeer G, Pisella PJ.

Abstract:

PURPOSE:

To evaluate the influence of cataract surgery on meibomian gland dysfunction, in particular on postoperative functional symptoms.

PATIENTS AND METHODS:

Thirty patients who underwent cataract surgery were included in the study. A clinical examination (OSDI questionnaire, measurement of tear break up time [TBUT], corneal staining, meibomian gland expressibility test) and a paraclinical evaluation (loss of Meibomius glands [LMG] measured using ImageJ on meibography, conjunctival redness and non-invasive tear break up time [NIK-BUT]) were performed preoperatively and at 1 month and 3 months after phacoemulsification.

RESULTS:

TBUT and meibomian gland expressibility were worsened at 1 month and 3 months postoperatively (P<0.05). LMG was significantly more important for the upper eyelid and the mean at 1 month (33.1±15.2 P=0.02; 28.5±15.6 P=0.025, respectively) and 3 months postoperatively (36.5±17.4 P=0.0005; 31.2±17.4 P=0.0002, respectively) than preoperative values (29.4±15.3; 26±15, respectively). There was a significant correlation between LMG on the upper eyelid preoperatively and the OSDI score at 1 month postoperatively (R=0.37; P=0.05).

CONCLUSION:

The meibomian gland loss in the upper eyelid is associated with an increased postoperative ocular discomfort score. Alterations in the meibomian gland expressibility and TBUT persist for up to 3 months postoperatively suggesting a direct role of cataract surgery by an obstructive mechanism.