Eyeworld Supplements

continued on next page Ocular surface treatment plans Dr. Ayres discussed ocular surface treatment plans, which he described as "drinking from the firehose" in terms of all the options available. There is so much information and so many new medications. Dr. Ayres specifically discussed treatments following the ASCRS algorithm for a patient who is coming in for cataract surgery. He noted patients with exposure/lid malposition, dry eye disease, lumps and bumps, and conjunctivitis as typical patients you might see. Dr. Ayres discussed several categories of treatment options. Medications include cyclosporine A 0.05%, cyc- losporine A 0.09%, cyclosporine A 0.1%, lifitegrast, and loteprednol 0.25%. He noted lotilaner 0.25%, perfluorohex- yloctane, and varenicline solution. There are also options like lid scrubs, artificial tears, nutritional supplements, warm compresses, and warming masks. Finally, there is a category including intense pulsed light therapy, thermal lid pulsations, lid heating and manual expression, microbleph- aroexfoliation, and punctal occlusion. He shared a case of a 67-year-old man referred in for cataract surgery who worked as an architect and wanted to be free of glasses after his surgery. The patient had evapo- rative dry eye and a strong lid margin component. Consider perfluorohexyloctane, which has been shown to be effective for treatment. Lifitegrast is traditionally thought to be a fast-acting medication, Dr. Ayres said, adding that it might take a few weeks to help. You can't ignore topical steroids, particularly for the flares, and they tend to work quickly. He also mentioned varenicline nasal spray. There are some other procedure-based treatments that can be employed, like intense pulsed light therapy, mi- croblepharoexfoliation, automated thermal pulsation, and automated heating with manual expression. Dr. Farid said in cases like this, her go-to has become MIEBO when she wants to get vision stabilized. Dr. Starr said he could see the thickening of the lid margin in the patient and what looked like a biofilm. When using thermal pulsation, he likes to do microblepharoexfoliation at the same time, which helps make the thermal pulsation more effective and also to knock down the bacterial load. Dr. Ayres suggested perfluorohexyloctane, topical steroids to reduce inflammation, and interventional dry eye treatment of your choice as primary treatments in this case. As a secondary treatment, consider a chronic anti-inflamma- tory for long-term stability. His second case was a 73-year-old woman with a history of glaucoma who experienced a severe reduction of vision. She was fine with reading glasses but wanted to be free of glasses for distance activity. Dr. Ayres questioned if it was aqueous tear deficiency, but he also thought there was a strong component of toxici- ty from years of glaucoma drops. There is evidence showing the more drops you use, the worse the ocular surface gets; this could be because of the use of benzalkonium chloride. Dr. Ayres mentioned targeted treatments. He questioned the "myth" that you can't use punctal occlusion in a patient with an inflamed eye, and he said that this is not actually the case. Punctal occlusion may work synergistically with cyclosporine. Placement of plugs still gives symptomatic release and reduced corneal staining even in eyes with inflammation. For this patient, Dr. Ayres suggested primary treatment options could include reducing toxicity and considering pre- servative-free glaucoma medications, using modern chronic anti-inflammatories or neurostimulation, and using preser- vative-free artificial tears. He suggested punctal occlusion as a secondary treatment option. Lastly, Dr. Ayres shared a case of an 85-year-old man who presented for surgical evaluation. He had put off sur- gery for several years but now had fluctuating and reduced vision and was worried about driving. Dr. Ayres noticed collarettes and thought there was likely Demodex. We know this can worsen the ocular surface, he said, and it can wors- en after cataract surgery. He noted treatments that are not FDA approved for Demodex, like oral or topical ivermectin, metronidazole, tea Relevant disclosures Contact Pharmaceuticals, Sight Sciences, Sun Ophthalmics, Tarsus Pharmaceuticals, Viatris, Zeiss Mah: Alcon, Aldeyra, Allergan, Avellino, Bausch + Lomb, Dompé, Johnson & Johnson Vision, Kala, Novartis, Ocular Therapeutix Ayres: Alcon, Bausch + Lomb, CorneaCare, CorneaGen, Dompé, Glaukos, Sight Sciences, Sun Pharma, Théa, Tarsus, Zeiss Farid: AbbVie, Alcon, Aurion, Bausch + Lomb, Bio-Tissue, CorneaGen, Glaukos, Harrow, Johnson & Johnson Vision, Kala Pharmaceuticals, Orasis Ayres: BAyres@oppdoctors.com Farid: mfarid@hs.uci.edu Mah: Mah.Francis@scrippshealth.org Starr: drstarr@gmail.com Starr: AbbVie, Aerie, Alcon, Allgenesis, Aldeyra, Amgen, Azura, Bausch + Lomb, BlephEx, Bruder, CSI Dry Eye, Dompe, Essiri Labs, Eye Care International, Glaukos, Johnson & Johnson Vision, Kala, Novaliq, NuVissa, Oyster Point Pharmaceuticals, Quidel, Sofia Biologics, Sun Pharma, Tarsus, Théa

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