Impact of Thermal Pulsation Treatment on Astigmatism Management and Outcomes in Meibomian Gland Dysfunction Patients Undergoing Cataract Surgery

Impact of thermo-mechanical skin treatment on refraction and keratometry in patients with dry eye disease and the implications for cataract surgery

PURPOSE

To determine the changes in keratometry measurements and refraction in patients having the thermo-mechanical periorbital skin treatment, Tixel®, to treat dry eye disease (DED).

METHODS

A multi-centre, prospective, non-masked study was conducted. DED patients were recruited in 3 international centres and were evaluated in 5 visits separated by an interval of 2 weeks except for the last visit which took place after 18 weeks from visit 1. The same clinical examination was performed at all visits: OSDI questionnaire, tear stability, keratometry, best corrected visual acuity and refraction. Tixel® treatment was applied at the first 3 visits.

RESULTS

89 participants (24 males/65 females; mean age: 55.0 ± 14.2 years) were included: 20 presented moderate DED symptoms and 69 severe DED symptoms. Significant differences were found for the spherocylindrical refraction (vector analysis) between visit 1 and visits 2 and 3. Following cumulative analysis, 11.86 % and 16.94 % of participants had more than 0.5 dioptre (D) change in mean keratometry and keratometric astigmatism, respectively, at 3 months post-treatment. A total of 5.40 % had a sphere and cylinder change greater than 0.50D and 16.21 % had the axis changed more than 10 degrees (vector analysis). These changes were particularly significant in patients with severe DED symptoms.

CONCLUSIONS

Keratometry readings and refraction can change following thermo-mechanical skin treatment for DED, especially in those patients with severe DED symptoms. This should be considered as potential errors in intraocular lens calculations may be induced.

Repeatability of biometry in patients with meibomian gland dysfunction before and after vectored thermal pulsation therapy: A randomized, controlled trial

PURPOSE

To evaluate the effect of vectored thermal pulsation therapy (VTPT) on the repeatability of biometry readings of two different optical biometers in patients with meibomian gland dysfunction (MGD).

METHODS

Patients affected by MGD were included in this prospective, randomized, controlled, investigator-masked study. One eye was randomized to VTPT (LipiFlow®, Johnson & Johnson), and the contralateral eye served as a control. Three visits were scheduled at baseline, 2 weeks and 3 months after the treatment. The main outcome parameter of the study was the repeatability of three calculations of emmetropic intraocular lens power (EIOLP) at the 3 months visit as compared to baseline using an optical biometer (IOLMaster® 700, Carl Zeiss Meditec AG). Repeatability of different keratometry values obtained by the optical biometer and a Placido-disc topographer (MS-39®, CSO) served as secondary outcome parameters.

RESULTS

Twenty-nine patients were included in the final analysis. While tear film parameters improved in the study eyes, there were no significant differences regarding the repeatability of three EIOLP measurements between baseline and 3-months-visit in both eyes (p > 0.05) and keratometry measurements in both the optical biometer and the Placido-disc topographer. Remarkably, throughout all study visits, there were some outliers regarding the repeatability of measurements.

CONCLUSION

While both devices showed high repeatability regarding EIOLP and keratometry, future studies are needed to detect high-risk patients for poor repeatability.

Prevalence of Meibomian Gland Atrophy in Patients Undergoing Cataract Surgery

PURPOSE

The aim of this study was to determine the prevalence of meibomian gland (MG) atrophy in a US-based population of patients presenting for cataract surgery.

METHODS

In this retrospective study, case records of 391 patients aged 50 years or older, who had undergone a preoperative cataract surgery workup with meibography, were included. The amount of atrophy in the lower eyelid was graded as described by Arita et al (grade 0 = no atrophy, grade 1 = 1%-33% atrophy, grade 2 = 34%-66% atrophy, and grade 3 = >66% atrophy), and the prevalence of MG atrophy was determined. Associations between MG atrophy and demography, comorbidities, and risk factors were evaluated.

RESULTS

Overall, 95.1% of patients (372/391) had MG atrophy ≥grade 1, with 50.4% (197/391) having grade 1, 25.8% (101/391) grade 2, and 18.9% (74/391) grade 3. MG atrophy had a statistically significant correlation with MG expressibility (R = 0.22; P = 0.001), but not with meibum grade (R = 0.103; P = 0.123) and telangiectasia (R = 0.014; P = 0.787). The prevalence of MG atrophy (≥grade 1) was comparable among patients who had previously been diagnosed with dry eye disease (DED) versus those who had not; however, the severity of MG atrophy was higher in patients with previous DED diagnosis (grade 2/3: 59% vs. 30.9%). Among patients with no previous history of DED, 18% (35/194) had moderate and 13% (25/194) had severe MG atrophy.

CONCLUSIONS

MG atrophy is common in patients presenting for cataract surgery evaluation, indicating potential underdiagnosis. Routine use of meibography during preoperative screening in cataract surgery patients may facilitate more timely and effective diagnosis and treatment.

Preoperative Treatment of Meibomian Gland Dysfunction with a Vectored Thermal Pulsation System Prior to Extended Depth of Focus IOL Implantation

INTRODUCTION

Patients implanted with a range-of-vision intraocular lens (IOL) (multifocal or extended depth of focus, EDOF) may be more susceptible to visual disturbances from poor tear film quality, and prophylactic treatment of meibomian gland dysfunction (MGD) has been recommended. The purpose was to evaluate whether vectored thermal pulsation (LipiFlow™) treatment prior to cataract surgery with a range-of-vision IOL safely improves postoperative outcomes.

METHODS

This is a prospective, randomized, open-label, crossover, multicenter study of patients with mild-to-moderate MGD and cataract. The test group underwent LipiFlow treatment prior to cataract surgery and implantation of an EDOF IOL, while the control group did not. Both groups were evaluated 3 months postoperatively, after which the control group received LipiFlow treatment (crossover). The control group was re-evaluated 4 months postoperatively.

RESULTS

A total of 121 subjects were randomized, with 117 eyes in the test group and 115 eyes in the control group. At 3 months after surgery, the test group had a significantly greater improvement from baseline in total meibomian gland score compared with the control group (P = 0.046). At 1 month after surgery, the test group had a significant decrease in corneal (P = 0.04) and conjunctival (P = 0.002) staining compared to the control group. At 3 months after surgery, the test group had significantly lower incidence of being bothered by halos compared with the control group (P = 0.019). The control group had a significantly lower incidence of being bothered by multiple or double vision compared with the test group (P = 0.016). After crossover, patients had significant improvement in vision (P = 0.03) and total meibomian gland score (P < 0.0001). No safety concerns or relevant safety findings were uncovered.

CONCLUSION

Presurgical LipiFlow treatment of patients implanted with range-of-vision IOLs improved meibomian gland function and postoperative ocular surface health. This supports guidelines recommending proactive diagnosis and management of MGD in patients with cataracts to improve patient experience.

TRIAL REGISTRATION

The study was registered on www.

CLINICALTRIALS

gov (NCT03708367).

Dry Eye Disease as a Cause of Refractive Errors After Cataract Surgery - A Systematic Review

Dry eye disease (DED) is a multifactorial ocular surface disorder characterized by loss of tear film homeostasis with associated ocular symptoms, like dryness, foreign body sensation, and inflammation. Numerous reports confirm an increase in dry eye symptoms after cataract surgery. DED also significantly disturbs preoperative biometric measurements, mainly by changes in keratometry measurements. The purpose of this study is to evaluate the effect of DED on biometric measurements before cataract surgery and postoperative refractive errors. PubMed database was searched for keywords: cataract surgery, dry eye disease, refractive error, refractive outcomes, keratometry, and biometry. Four clinical studies evaluating the effect of DED on refractive errors were included. In all studies, biometry was performed before and after dry eye treatment, and the mean absolute error was compared. Various substances have been used to treat dry eye, such as cyclosporin A, liftitegrast, and loteprednol. The refractive error was significantly lower after treatment in all studies. The results unanimously indicate that refractive errors can be reduced by proper treatment of DED before cataract surgery.

Efficacy of vector thermal pulsation treatment in reducing postcataract surgery dry eye disease in patients affected by meibomian gland dysfunction

PURPOSE

To evaluate the effect of a single LipiFlow vector thermal pulsation treatment performed before cataract surgery in reducing signs and symptoms of postoperative dry eye disease (DED) in patients with mild-moderate meibomian gland dysfunction (MGD).

SETTING

Eye Clinic, Careggi Hospital, University of Florence, Florence, Italy.

DESIGN

Prospective unmasked randomized controlled clinical trial.

METHODS

This study included patients affected by age-related cataract and mild-moderate MGD, who were randomized into 2 groups: (1) a single LipiFlow treatment performed at 5 preoperative weeks and (2) warm compresses and eyelid massages twice a day for 1 preoperative month (control group). Noninvasive break-up time (NI-BUT), Schirmer test, Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, and MG functionality parameters were evaluated at visit 0 (5 preoperative weeks), visit 1 (1 preoperative week), and visit 2 (1 postoperative month). Confocal microscopy of the MG of lower eyelids was performed at visit 0 and visit 2.

RESULTS

A total of 46 patients (46 eyes) were enrolled. In the LipiFlow group (n = 23), NI-BUT, SPEED questionnaire, and MG functionality parameters significantly improved at visit 1 ( P < .05) and visit 2 ( P < .05) compared with baseline and remained stable postoperatively. In the control group (n = 23), they did not significantly improve after treatment, while worsened postoperatively. Moreover, the changes in all parameters from baseline were significantly different between the 2 groups. Confocal microscopy imaging highlighted lower postoperative MG alterations in the LipiFlow group.

CONCLUSIONS

A single preoperative LipiFlow treatment was effective in preventing postcataract surgery DED in patients with mild-moderate MGD. Postoperatively, treated patients displayed a better ocular surface status compared with warm compresses.

Impact of Thermal Pulsation System Therapy on Pre-Operative Intraocular Lens Calculations before Cataract Surgery in Patients with Meibomian Gland Disfunction

In patients with eye surface disorders such as dry eye syndrome or Meibomian gland dysfunction (MGD) it is necessary to improve the tear film condition in order to obtain visual system measurements before cataract surgery. The aim of the project was to analyze the Thermal Pulsation System (TPS) impact on the visual system parameters used in cataract surgery qualification. The study included six patients (11 eyes) with MGD diagnosis. All patients were treated with TPS. The obtained results were compared and used to calculate the power and type of the intraocular lens (IOL). As a treatment result, the power of astigmatism has changed in 64% of the eyes. Planned surgical treatment type has changed in 27% of cases. TPS also affected the cylinder axis in three eyes, which was 27% of cases. Based on the calculations, power of the recommended IOL has changed in five eyes (46%). Stabilization of visual system parameters after TPS allowed to improve the accuracy of the results. It also ensured the proper astigmatism treating method during cataract surgery and allowed selection of the proper IOL power and type.

ESCRS Clinical Trends Survey 2016-2021: 6-year assessment of practice patterns among society delegates

PURPOSE

To evaluate clinical opinions and practice patterns of delegates to the ESCRS.

SETTING

Clinical Trends Surveys were administered during annual ESCRS congresses held between 2016 and 2021, and data collected online and in-person.

DESIGN

Survey questions addressed several specialty areas, including cataract surgery, presbyopia-correcting and toric intraocular lenses (IOLs), ocular surface disease, and glaucoma.

METHODS

Survey results were compared and analyzed across 6 years. 4 main profile questions were used for cross-tabulation analyses of questions pertaining to refractive surgery-practice location, years in practice, primary surgery setting, and average annual volume of cataract surgery.

RESULTS

The highest number of responses (3019) was collected in 2019, with the lowest (569) received in 2020. The use of presbyopia-correcting and toric IOLs has increased significantly from 2016 to 2021, with certain respondent segments using them more frequently than others. Although optical biometry remains the preferred method for obtaining preoperative measurements, the use of tomography (Scheimpflug) has significantly increased. In 2021, 61.1% and 44.9% of respondents always performed preoperative checks of the ocular surface before refractive and cataract surgery, respectively. The number of respondents who perform glaucoma surgery has significantly decreased over the years, with an increasing number of delegates reporting having only a medical glaucoma practice. On average, 5.4% of patients with cataract and glaucoma underwent combined minimally invasive glaucoma surgery and cataract procedures in 2021.

CONCLUSIONS

Evaluation of the Clinical Trends Survey data provides valuable insights into the shifting practice patterns and clinical opinions of ESCRS delegates.

Systane iLux Thermal Pulsation System in the Treatment of Meibomian Gland Dysfunction: A Post-Hoc Analysis of a 12-Month, Randomized, Multicenter Study

Purpose

This study aimed to demonstrate the effectiveness of Systane iLux, a thermal pulsation device, in patients with MGD, over 12 months post-single treatment.

Methods

This is a post-hoc analysis of a previous prospective, assessor-masked, parallel-group, multicenter study (NCT03956225) that compared the effectiveness and safety of iLux with LipiFlow in subjects with MGD. The original study included subjects with meibomian gland score (MGS) ≤12 in lower eyelids, Impact of Dry Eye on Everyday Life-Symptom Bother (IDEEL-SB) module score &gt;16, and non-invasive tear break-up time (NITBUT) &lt;10 seconds. Subjects were randomized (1:1) to receive a single bilateral treatment of iLux or LipiFlow. In this post-hoc analysis, mean changes in MGS, NITBUT (first break-up; seconds), IDEEL-SB module score, and corneal staining, from baseline to 12 months were analyzed post-single treatment with iLux.

Results

Data from 119 patients (n=238 eyes) treated with iLux were analyzed. The mean±SD age of the subjects was 58.4±13.4 years, with majority being female (79.0%). MGS (mean±SD) for both eyes improved significantly from baseline to 12 months (OD [baseline: 6.9±3.69; month 12: 22.8±11.31; change: 15.9±11.57, p&lt;0.0001]; OS [baseline: 6.4±3.66; month 12: 23.0±11.33; change: 16.7±11.40, p&lt;0.0001]). Similarly, significant improvements were observed in NITBUT (OD [baseline: 5.2±1.97; month 12: 7.0±3.68; change: 1.9±3.69, p&lt;0.0001]; OS [baseline: 5.6±1.96; month 12: 7.9±4.58; change: 2.3±4.59, p&lt;0.0001]) and IDEEL-SB score (p&lt;0.0001). Corneal staining reduced significantly from baseline to 12 months (OD [baseline: 2.1±2.96; month 12: 0.7±1.56; change: -1.4±2.65, p&lt;0.0001]; OS [baseline: 2.1±2.94; month 12: 0.7±1.44; change: -1.4±2.75, p&lt;0.0001]). Improvements in MGS, NITBUT, IDEEL-SB module score, and corneal staining were seen as early as week 2, and at months 1, 3, 6, and 9 (all p&lt;0.001).

Conclusion

A single treatment with iLux significantly improved clinical parameters of MGS, NITBUT, and corneal staining, and patient-reported symptom assessment with IDEEL-SB in patients with MGD over 12 months.

Thermal Pulsation with or without Dexamethasone Intracanalicular Insert for Meibomian Gland Dysfunction: A Prospective, Masked Trial

Significance

Meibomian gland dysfunction (MGD) is among the most common causes of dry eye disease worldwide. Few studies have compared treatment options, and the basis for an evidentiary approach to MGD management is lacking. We have conducted a non-randomized trial evaluating the additive benefit of a recently developed therapy.

Purpose

To compare the efficacy of thermal pulsation therapy alone or combined with the dexamethasone intracanalicular insert (Dextenza) on the signs and symptoms of MGD.

Methods

This was a prospective, patient-masked, sham-controlled, non-randomized trial. All subjects underwent thermal pulsation therapy using the LipiFlow system. The dexamethasone intracanalicular insert was placed in the inferior canaliculus of the more symptomatic eye (DEX group), while sham punctal dilation of the fellow eye was performed to preserve patient masking (SHAM group). Key outcomes were improvement in meibum expressibility at 1, 4, and 12 weeks and patient treatment preference at week 12.

Results

Nineteen subjects underwent thermal pulsation therapy and received the DEX insert. Meibomian gland expressibility scores improved significantly in both groups at 1, 4, and 12 weeks, with significantly greater improvement in DEX eyes than SHAM eyes at 12 weeks (P=0.027). Improvement from baseline in TBUT was significant at all time points in DEX eyes and only at week 4 in SHAM eyes, with significantly greater improvement in DEX eyes over SHAM eyes at week 12 (P=0.028). Mean best-corrected visual acuity and intraocular pressure remained unchanged from baseline throughout follow-up in both groups, and no adverse events were noted. Combined therapy with DEX was preferred by 61% of subjects.

Conclusion

This study demonstrated a significant benefit of combining thermal pulsation therapy with the dexamethasone intracanalicular insert on signs of MGD including TBUT and meibomian gland expressibility score. Consequently, a majority of patients preferred combination therapy to thermal pulsation therapy alone.

Efficacy of the Systane iLux Thermal Pulsation System for the Treatment of Meibomian Gland Dysfunction After 1 Week and 1 Month: A Prospective Study

OBJECTIVES

To assess 1-week and 1-month efficacy of Systane iLux thermal pulsation treatment for meibomian gland dysfunction (MGD).

METHODS

This prospective, nonrandomized, open-label, multicenter study enrolled 30 adult patients (60 eyes) who had a Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire score greater than 6 and total meibomian gland secretion (MGS) score equal to or less than 12 in each eye. All participants received thermal pulsation treatment bilaterally. Primary efficacy measures included MGS score (sum of grades for 15 glands graded on a scale of 0-3; 0 [no secretion], 1 [inspissated], 2 [cloudy], and 3 [clear liquid]) and tear breakup time (TBUT). Secondary efficacy measures were SPEED and Ocular Surface Disease Index (OSDI) scores.

RESULTS

The mean age of patients was 52.9±11.9 years. After 1 week, the mean MGS score improved significantly from 4.1±3.1 to 15.8±7.1 (right eye, OD) and 3.7±3.1 to 16.7±7.6 (left eye, OS); mean TBUT improved significantly from 4.9±4.1 to 8.4±3.6 (OD) and 5.2±4.2 to 8.9±3.9 (OS); and mean SPEED and OSDI scores improved significantly from 16.1±5.3 to 7.2±6.1 and 45.2±21.3 to 19.0±16.8, respectively (all P<0.001). After 1 month, the mean MGS score improved to 18.3±8.2 (OD) and 18.6±7.3 (OS); mean TBUT improved to 9.7±3.8 (OD) and 9.6±3.5 (OS); and mean SPEED and OSDI scores improved to 7.0±5.6 and 16.7±14.5, respectively (all P<0.001). No adverse events were reported.

CONCLUSIONS

Systane iLux thermal pulsation treatment for MGD resulted in a statistically significant increase in meibomian gland secretion, improvement in tear film stability, and reduction in dry eye symptoms as early as both 1 week and 1 month.

The Prevalence of Demodex Blepharitis in US Eye Care Clinic Patients as Determined by Collarettes: A Pathognomonic Sign

Purpose

Patients and Methods

Results

Conclusion

The Effect of Rebamipide on Refractive Accuracy of Cataract Surgery in Patients with Dry Eye

Introduction

Refractive accuracy is crucial for increasing patient satisfaction after cataract surgery. Tear film instability caused by dry eye can lead to inaccurate measurement of corneal power, which is one of the most important factors for postoperative refractive calculation. This study investigated the effect of 2% rebamipide ophthalmic suspension on the predicted refractive accuracy for cataract surgery in patients with dry eye.

Methods

This single-center, prospective, open-label study included 35 dry eyes (with tear breakup time < 5 s) who underwent cataract surgery. The patients were treated with rebamipide for 4 weeks before the preoperative examination. In addition to the usual evaluation of biometric variables essential for cataract surgery, tear breakup time (TBUT), superficial punctate keratopathy in the central part of the cornea (C-SPK), corneal higher-order aberrations (HOAs), and predicted postoperative spherical equivalent (P-SE) were evaluated at baseline and 4 weeks after dry eye treatment. The patients’ subjective spherical equivalent (S-SE) was evaluated 1 month postoperatively. The difference between S-SE and P-SE was used to assess the accuracy of the P-SE. Improvement in TBUT, C-SPK, HOA, and the accuracy of P-SE after dry eye treatment were analyzed.

Results

The accuracy of the biometry readings for the achieved P-SE was within 0.25 D in 42.9% and 54.3%; within 0.5 D in 71.4% and 88.6%; and within 0.75 D in 88.6% and 97.1% of eyes before and after rebamipide treatment, respectively (p < 0.01). TBUT, C-SPK, and HOAs significantly improved after rebamipide treatment (p < 0.01).

Conclusion

Rebamipide significantly improved the corneal surface condition and accuracy of the predicted postoperative refraction in dry eyes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00457-3.

Optimizing the ocular surface prior to cataract surgery

PURPOSE OF REVIEW

Ocular surface disease can significantly impact the outcomes of cataract surgery. Recent studies have examined the efficacy of several new dry eye disease (DED) therapies, the extent to which epithelial debridement affects keratometric measurements in epithelial basement membrane dystrophy (EBMD) and Salzmann nodular degeneration (SND), and the predictability of refractive error following combined pterygium and cataract removal. This review aims to incorporate these newer studies in updating and further emphasizing the need for careful management and optimization of common ocular surface conditions prior to cataract surgery.

RECENT FINDINGS

Common ocular surface conditions such as DED, EBMD, SND, and pterygium can cause significant irregular astigmatism and higher-order aberrations. Their resolution can substantially alter biometry measurements in preparation for cataract surgery, affecting the final visual outcome. Newer therapies for DED, such as topical lifitegrast and thermal pulsation treatment, can aid in this optimization process. If superficial keratectomy or excisions of lesions on the ocular surface are performed, sufficient healing time is needed to allow the ocular surface to reach stability prior to biometry measurements.

SUMMARY

Ocular surface optimization is key to successful cataract surgery planning and reaching desired outcomes.