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therapeutic solutions: Ocular surface disease and episodic flares of dry eye disease Case study 3 • 65-year-old male presenting for cataract surgery • On topical anti-inflammatory therapy • Burning and irritation every month • Vision fluctuates with burning/irritation • Osmolarity = 316 and 305 • Lissamine green conjunctival staining = 2+ • Inferior corneal staining = 1+ Meibomian gland dysfunction = 3+ sation as well. "I would start the patient on omega-3s and a topical loteprednol steroid. By doing that, I would get the patient comfortable and have him return in 1 to 2 weeks hopefully ready for cataract surgery," he said. n Moderately severe MGD; thickened meibum with poor expressibility Moderate MGD; accelerated TBUT with some inferior corneal staining Presence of OSD means the cataract surgery will be postponed until the ocular surface is restored to health. Elizabeth Yeu, MD, explained that she would take note of if the patient has other systemic comorbidities, what medica- tions he is on, and what other risk factors may be contrib- uting to the patient's acute inflammation. The panel agreed that quieting the eye should be the immediate goal and that once that is accomplished punctal occlusion might be the con- comitant therapy needed for maintenance. Terry Kim, MD, said that cataract surgery can be a flare trigger. "The patient is already on topical anti-inflammatory therapy, so he is obviously experiencing flare," Dr. Kim said. "I think you need to control that flare prior to pro- ceeding with cataract surgery because the surgery can exac- erbate the flare and you want the patient comfortable." Dr. Gupta said she would start the patient on lotepred- nol because it is gentle on the ocular surface but very effica- cious in terms of its ability to quiet inflammation and allow surface repair. Richard Lind- strom, MD, suggested every- one on the panel would treat with a topical steroid. "Some of us might use erythromycin or azithromycin at bedtime as well," he said. All concurred that it is important to have a conver- sation with the patient about his dry eye because of its potential impact on his post- operative cataract results. Dr. Donnenfeld said he would do hot compresses, lid hygiene, and micro-blepharoexfolia- tion, and perhaps thermal pul- A 65-year-old male presenting for cataract surgery evaluation has monthly episodes of burning, irritation, and vision fluctuation and is already on topical anti-inflammatory therapy. Osmolarity is elevated at 316 and 305, and he has 2+ lissamine green conjunctival staining, 1+ inferior corneal staining, and meibomian gland dysfunction (MGD). The ocular surface disease panel agreed that the patient will undergo topography because he is being seen for a cataract evaluation, and Preeya Gupta, MD, pointed out that topography patterns will reveal the patient's dry eye disease. Dr. Holland noted that in a patient like this, if the manual keratometry readings, the topography, and the biom- etry do not agree, it is almost certainly due to OSD. Copyright 2019 ASCRS Ophthalmic Corporation. All right reserved. The views expressed in this publication do not necessarily reflect those of the staff and leadership of EyeWorld and ASCRS, and in no way imply endorsement by EyeWorld and ASCRS.

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