Expert opinions on complex cases

Should every toric patient be treated for dry eye even if it is not visible? Should NSAIDs be avoided after surgery in cases with dry eye? What is the best IOL power calculation formula is such situations? These were among the many questions addressed during one of the 25th ESCRS Winter Meeting Virtual 2021 ‘Meet The Experts’ discussions, where key ESCRS opinion leaders tackled the latest issues in anterior segment surgery while audience members asked questions during 30-minute Zoom sessions. During one of these very useful and practical sessions, on complicated cataract cases (glaucoma, extreme ametropias and dry eye) Professor Ewa Mrukwa-Kominek MD, Poland, outlined a number of such cases and discussed the best approaches while taking questions. Discussing a complex case that involved dry eye disease and a shallow anterior chamber where it is more difficult to calculate the IOL power, her session co-host Guy Sallet MD, Belgium, said he always uses fluorescein staining for preoperative assessment. “For every patient now, which I did not do always, when they come in for biometry, I have the topography and the calculation, and I always see every patient with fluorescein staining of the cornea. It is very simple, and this might show irregularities like the beginning of Bowman’s dystrophy, which otherwise with the slit lamp might be overlooked. I think this is quite helpful and very easy, he said.” They both agreed that carefully managing patient expectations is also important in cases of cataract surgery with ocular surface disease, as the surgery will not cure that; just the cataracts. During the session Dr Sallet went outlined an unusual case of his where there was a refractive surprise caused by dry eye disease in the patient. It prompted some interesting questions and discussion, including whether patients with mild dry eye disease should be given lubricants before implanting a toric IOL. Both Dr Sallet and Prof Mrukwa-Kominek agreed that dry eye should be treated before surgery. It is very important to moisten the anterior surface before calculating intraocular lenses, especially premium IOLs, as this will help to avoid unpleasant refractive surprises.For moderate or severe dry eye, Prof Mrukwa-Kominek said she also uses cyclosporin and keeps the patient on it through the surgery period, which also addresses acute inflammation. However, cyclosporin is not commercially available in all countries, including Belgium, noted Dr Sallet, who said he uses a low-dose steroid in these cases, although Prof Mrukwa-Kominek noted they can increase the symptoms of dry eye. Prof Mrukwa-Kominek also noted that dry eye symptoms can increase during post-cataract surgery prophylaxis, such as antibiotics and steroid treatment. In relation to the use of NSAIDs in these patients post-surgery, Dr Sallet said he prescribes NSAIDs in every case, even dry eyes. Ewa Mrukwa-Kominek: emrowka@poczta.onet.pl Guy Sallet: dr.sallet@ooginstituut.be