At the completion of this article, the reader should be able to…
- Understand that while prevalence rates are debated, true accommodative dysfunction is uncommon in children who have good visual acuity and are otherwise healthy.
- Integrate a child’s aesthenopic complaints into the context of their overall ocular and general health, including identifying any differences in symptoms between their recreational habits and compulsory tasks.
- Identify limitations, difficulties, and pitfalls in diagnosing accommodative defects in children.
- Educate patients and caregivers that measures of accommodation can be unreliable and often improve without treatment, making observation and monitoring an appropriate initial course of action.
Shon Prasad
B Vis Sci, M Optom
The Eye Health Centre Spring Hill
Helen Gleave
BScOpt(Hons) MCOptom
Senior professional education
and development manager,
Alcon Vision Care ANZ
Queensland optometrist SHON PRASAD has seen firsthand how patients with seemingly good cataract surgery outcomes can become dissatisfied with their vision due to dry eye disease – something that can be avoided with strong peri-operative management.
Optometrists play a key role in the diagnosis and referral pathway for cataract surgery. This role provides opportunities to educate patients about progression, treatment and possible outcomes. As dry eye can be exacerbated, or even present for the first time after cataract surgery, optimising the tear film and ocular surface peri-operatively is an important consideration.
Optometrist Mr Shon Prasad, who has worked in a variety of practices and recently joined an ophthalmology practice in Brisbane, shares his insights with Alcon’s senior professional education and development manager, Ms Helen Gleave.
Helen Gleave (HG): Has this new role given you a different perspective on managing dry eye?
Shon Prasad (SP): About 10 years ago, I was a humble optometry student unaware of all the havoc dry eye disease would cause to the world. The pain it put patients through, the complications that arose from it. I thought, ‘it’s just dry eye, toughen up, throw in some drops and get on with life’.
Fast forward a few years later and in this role I find myself being on the frontline against a hidden enemy who is ready to ruin someone’s day. Not only the patient’s day, but also the surgeon who is just
about to operate on the owner of the eye. This hidden enemy is just about to be awoken from its deep slumber.
After encountering firsthand how dry eye disease can affect my patients, their quality-of-life (QoL) and their experiences of cataract surgery, it’s become my standard practice to keep up-to-date with the latest research and make recommendations for the best outcomes.
HG: How important is it to manage dry eye disease in general?
SP: It is important to remember dry eye is a disease. It is a disease as classified by the TFOS DEWSII Report published in 2017.1 In the early stages it may seem dormant, the symptoms may be mild and consequently go unnoticed, until it strikes. It may be due to a new medication, potentially reaching a certain birthday, changing environments, or in the cases I see today, undergoing surgery.
As frontline eyecare providers, taking dry eye disease seriously is important. It has been shown to be a burden on patients’ mental and physical QoL. Such studies consistently show that dry eye disease has a measurable impact on several aspects of patients’ QoL, including pain, vitality, ability to perform certain activities requiring sustained visual attention (e.g. reading, driving), and reduced productivity in the workplace.2 Understanding the impacts dry eye has on society serves as a real call to action.
HG: What do you use to guide your dry eye diagnosis and management?
SP: The TFOS DEWS II Report Executive Summary3 highlights the various ways dry eye disease can come about. I love this illustration; I find it a fantastic visualisation on how symptoms of dry eye can come about from a combination of contributing factors.
I tell my patients, sometimes you can be on the edge of dry eye without knowing it, and then a surgery can push you over the edge into the vicious cycle of dry eye disease.
The outer circle highlights all the various etiologies that can lead to a loss of homeostasis. Identifying those risk factors in patients is the first key. Remember, you can’t change or control all factors for a patient. You can’t change the weather or a patient’s age, although we can highlight the importance of managing these risk factors in our patients’ everyday life.
Why is this important? Have you ever come across a patient with good vision, but they keep telling you it’s not clear? Have you performed your best refraction and it doesn’t seem good enough? The answers keep changing, every blink gives a different visual acuity recording. The macular appears to be fine, and you think, what is going on? The thought is that it must be the cataracts, so off they go with their referral to see the best local ophthalmologist.
A few weeks go by, and they return with 6/5 vision right and left and they say their vision is terrible. They complain they can’t see clearly, and they want to take this further with the surgeon. I’ve seen this firsthand.
All of a sudden, this surgery has woken the hidden enemy. They’ve been tipped over the edge and now surgery has set off a cascade of events leading to poor quality vision, maybe some pain and a disgruntled patient.
Remember, the first surface that light from the world hits as it travels towards your retina is your tear film. Imagine a cracked car windscreen in the rain with some old worn-out wipers. Good luck trying to see clearly when driving. The same goes for your ocular surface. With surgery and the subsequent inflammation that the patient experiences, they might have been tipped over the edge.
HG: When referring patients for cataract surgery, how could patient dissatisfaction due to dry eye disease be avoided?
SP: I have thought, if only we could simply turn back time and recommend a product and management to quieten the enemy before it comes to bite us.
Looking at the research, studies have shown the efficacy of the combination of hydroxypropyl guar (HPG) and hyaluronic acid (HA) in dry eye management. One study it is most prominently featured in is Clinical Ophthalmology, entitled: ‘Protecting the ocular surface in cataract surgery: The efficacy of the perioperative use of a hydroxypropyl guar and hyaluronic acid ophthalmic solution’.4
I encourage everyone to read the study in detail, but for those who work in a busy practice, fully booked every day, I can let you know the study recommends one way to disarm the hidden enemy of dry eye is through Systane HYDRATION.4
According to Alcon, Systane HYDRATION lubricant eye drops combine HA* with the company’s unique formulation of HP-guar and borate which crosslink to form a meshwork to increase retention of demulcents. This has been shown to increase tear break-up time (TBUT) compared to lubricating eye drops containing HA alone,6 and support ocular surface healing.7π
The study (Figures 1-3) compared a cohort of 419 patients, divided into three groups:4
low-grade staining at the levels of grade 0 and 1, and that group C post-operatively had higher levels
of grades (>1). At four weeks, group A had significantly less staining overall (p=0.013) and at higher
levels (>1) than group B.4 Images: Alcon.
– Group A who instilled a HPG/HA solution three times a day pre-operatively for one week and then for eight weeks post-operatively.
– Group B who instilled HPG/HA solution only eight weeks post-operatively.
– Group C who did not instill any drops peri-operatively.
They all followed the same post-surgery regime of topical anti-inflammatory and antibiotic treatment which consisted of dexamethasone and tobramycin four times a day for 10 days, nepafenac 0.1% eye drops three times a day for one month. The three groups were evaluated for the scores of SPEED (Standard Patient Evaluation of Eye Dryness) questionnaire, TBUT and corneal fluorescein staining (CFS, Oxford scale).
The results from the study found:
In groups A and B, the SPEED scores were significantly lower than group C in the whole postoperative period. In Group A, the SPEED scores were significantly lower than group B one and four weeks after surgery. In Group C, 25% of patients reported symptom scores corresponding to mild-moderate dry eye four and eight weeks after surgery.
Clearly this highlights the importance of managing the ocular surface appropriately before and after ocular surgery.
Furthermore, the results showed the fluorescein tear BUT in groups A and B was significantly higher than group C in the whole postoperative period. Remembering, a higher TBUT means tears are stable for longer on the ocular surface. In addition, TBUT in group A was significantly higher than even group B after surgery.
Lastly, when comparing CFS over the weeks post-surgery, more patients showed no CFS in Groups A and B than Group C at all the postoperative visits.
Therefore, I believe suggesting peri-operative ocular lubrication, especially with HPG/HA eye drops should really become the gold standard in eyecare.^
HG: What does your patient assessment look like?
SP: If I’m going to evaluate a patient and consider them for a referral for cataract surgery, I want their experience to be successful. Neither I nor the surgeon want any surprises. This begins in our optometry consult room. Identify those risk factors early and look for the signs: poor TBUT or ocular surface staining. Usually the symptoms won’t be there, but if they are, listen out for them.
HG: Would you share the outcome for the disgruntled patient you spoke of previously?
SP: In reality the patient had 6/6 vision unaided post cataract surgery, but her vision was fluctuating. Understandably she was frustrated and disappointed with the outcome of the fabulous lens implants she had been given. She had a history of breast cancer, rhinitis, sinusitis, cat/dog/dust mite allergies, rheumatoid arthritis. Her list of medications included an anti-hypertensive, oral prednisone, methotrexate, an anti-depressant and a breast cancer medication. Clearly the risk factors were there!
After many weeks of dry eye treatment and management, she was finally happy with her vision and she reported feeling emotionally better too.
In retrospect, this whole situation could have possibly been avoided with a proactive dry eye management plan. In addition, her pre-operative evaluation may have been enhanced with more accuracy in the biometry measurements with a stable tear film and improved TBUT.
What are your final thoughts?
Moving forward in our dry eye management is a key consideration. The hidden enemy lurks, only to emerge from the shadows causing despair, distress and disappointment.
Dry eye disease is everywhere and in a busy practice we could consider disregarding it for the time being, but evidence-based practice shows we should manage dry eye and include Systane HYDRATION peri-operatively to reduce dry eye symptoms post operatively4 and help optimise the chance of a successful outcome along with that referral.”^
Shon Prasad received an honorarium for his time in contributing to the article.
Key:
*Systane® HYDRATION Lubricant Eye Drops contain sodium hyaluronate, the salt form of hyaluronic acid.
π Based on an animal model
^ Results may vary
References:
1.Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. The Ocular Surface. 2017;15(3):276–283
2. Uchino M, Schaumberg DA. Dry Eye Disease: Impact on Quality of Life and Vision. Curr Ophthalmol Rep. 2013;1(2):51-57.
3. Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II Report Executive Summary. Ocul Surf. 2017;15(4):802-812
4. Favuzza E, Cennamo M, Vicchio L, et al. Protecting the Ocular Surface in Cataract Surgery: The Efficacy of the Perioperative Use of a Hydroxypropyl Guar and Hyaluronic Acid Ophthalmic Solution. Clin Ophthalmol 2020 Jun 26;14:1769-1775
5. Springs C. Novel Ocular Lubricant Containing an Intelligent Delivery System: Details of its Mechanism of Action. Dev Ophthalmol 2010; 45:139-147.
6. Fluorescein tear break-up time was measured following fluorophotometry assessment. Based on measurement of eye drop retention time using a fluorophotometer; Alcon data on file, 2024
7. Carlson et al. Impact of Hyaluronic Acid-Containing Artificial Tear Products on Reepithelialization in an In Vivo Corneal Wound Model J Ocul Pharmacol Ther 2018; 34(4): 360-364
8. Adapted from Baudouin C. A new approach for better comprehension of diseases of the ocular surface.
J Fr Ophtalmol. 2007;30:239-246.
9. Adapted from Baudouin C, Messmer EM, Aragona P, et al. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction.
Br J Ophthalmol. 2016;100:300-306.
10. Adapted from Baudouin C, Aragona P, Van Setten G, et al; ODISSEY European Consensus Group. Diagnosing the severity of dry eye: a clear and practical algorithm.
Br J Ophthalmol. 2014;98:1168-1176.
