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New Evidence and Insights on the
From Ocular Surface Disorders to Surgery
Highlights from a Continuing Medical Education Symposium held
during the American Academy of Ophthalmology 2012 Meeting*
ORIGINAL RELEASE: March 15, 2013
LAST REVIEW: February 22, 2013
EXPIRATION: March 31, 2014
Jointly sponsored by The New York Eye and Ear Infirmary
and MedEdicus LLC
This continuing medical education activity is supported through an
unrestricted educational grant from Bausch + Lomb Incorporated.
*This CME symposium was not affiliated with the official program of the AAO/APAO Joint Meeting.
Richard L. Lindstrom, MD
(Program Chair and Moderator)
Founder and Attending Surgeon
Minnesota Eye Consultants, PA
Adjunct Professor Emeritus
Department of Ophthalmology and Visual Neurosciences
University of Minnesota
Eric D. Donnenfeld, MD
Ophthalmic Consultants of Long Island
Rockville Centre, New York
Clinical Professor of Ophthalmology
New York University
New York, New York
Geisel School of Medicine at Dartmouth
Hanover, New Hampshire
Stephen S. Lane, MD
Associated Eye Care
University of Minnesota
St. Paul, Minnesota
Terrence P. O’Brien, MD
Professor of Ophthalmology
Charlotte Breyer Rodgers Distinguished Chair in Ophthalmology
Director, Refractive Surgery Service
Bascom Palmer Eye Institute
Palm Beach Gardens, Florida
Learning Method and Medium
This educational activity consists of a supplement and ten (10) study questions.
The participant should, in order, read the learning objectives contained at the
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This continuing medical education (CME) activity captures content from a
CME symposium held on November 10, 2012, in Chicago, Illinois.
This activity intends to educate ophthalmologists.
Upon completion of this activity, participants will be better able to:
• Summarize key efficacy and safety attributes of new anti-inflammatory
• Demonstrate best-practice regimens for reducing inflammation risk for
patients undergoing cataract, refractive, or glaucoma procedures
• Demonstrate best-practice regimens for the management of inflammation in
patients with inflammatory conditions such as dry eye, blepharitis, allergy,
and/or anterior uveitis
• List anti-inflammatory therapies in development
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Essential Areas and Policies of the Accreditation Council for Continuing
Medical Education (ACCME) through the joint sponsorship of The New York
Eye and Ear Infirmary and MedEdicus LLC. The New York Eye and Ear
Infirmary is accredited by the ACCME to provide continuing medical
education for physicians.
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The New York Eye and Ear Infirmary designates this enduring material for
a maximum of 1.5 AMA PRA Category 1 Credits. Physicians should claim
only the credit commensurate with the extent of their participation in
This continuing medical education activity is supported through an
unrestricted educational grant from Bausch + Lomb Incorporated.
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It is the policy of The New York Eye and Ear Infirmary that the faculty and
anyone in a position to control activity content disclose any real or apparent
conflicts of interest relating to the topics of this educational activity, and also
disclose discussions of unlabeled/unapproved uses of drugs or devices during
their presentation(s). The New York Eye and Ear Infirmary has established
policies in place that will identify and resolve all conflicts of interest prior to
this educational activity. Full disclosure of faculty/planners and their
commercial relationships, if any, follows.
Eric D. Donnenfeld, MD, had a financial agreement or affiliation during the
past year with the following commercial interests in the form of Consultant/
Advisory Board: Abbott Medical Optics; AcuFocus, Inc; Alcon, Inc; Allergan, Inc;
AqueSys, Inc; Bausch + Lomb Incorporated; Better Vision Network; Cataract
and Refractive Surgery Today; ELENZA, Inc; Glaukos Corporation;
LacriPen/LacriSciences LLP; LenSx Lasers/Alcon Inc; Merck & Co, Inc;
NovaBay Pharmaceuticals; Odyssey Pharmaceuticals; Pfizer Inc; PRN Physician
Recommended Nutriceuticals; QLT Inc; SARcode Bioscience, Inc; TearLab
Corporation; TLC Laser Eye Centers; TrueVision; and WaveTec Vision.
Richard L. Lindstrom, MD, had a financial agreement or affiliation during
the past year with the following commercial interests in the form of
Consultant/Advisory Board: Abbott Medical Optics; AcuFocus, Inc; Adoptics;
Advanced Refractive Technologies; Alcon, Inc; AqueSys, Inc; Bausch + Lomb
Incorporated; Bio Syntrx, Inc; Calhoun Vision, Inc; Clarity Ophthalmics;
Clear-Sight Inc; CoDa Therapeutics, Inc; EBV Partners; EGG Basket
Ventures; ELENZA, Inc; Encore; e-Vision Photography, Inc; Eyemaginations,
Inc; Foresight Venture Fund #3; ForSight Labs; Glaukos Corporation; High
Performance Optics; Hoya Surgical Optics; Improve Your Vision, LLC; ISTA
Pharmaceuticals, Inc; LensAR; LenSx Lasers, Inc; LifeGuard Health LLC;
Lumineyes, Inc; Minnesota Eye Consultants, PA; NuLens Ltd; Ocular Optics
Co, Ltd; Ocular Surgery News/Slack Inc; Ocular Therapeutix, Inc; OmegaEye
Health; Omeros Corporation; PixelOptics, Inc; Quest; Refractec, Inc;
RevitalVision, LLC; Schroder Life Science Venture Fund; Seros Medical, LLC;
Sightpath Medical; Strategic Pharmaceutical Advisors; Surgijet/Visijet; 3D
Vision Systems LLC; TLC Vision Corporation; TearLab Corporation; Tracey
Technologies; Transcend Medical, Inc; TrueVision Systems, Inc; Versant
Corporation; and Vision Solutions Technologies; Ownership Interest: Abbott
Medical Optics; AcuFocus, Inc; AqueSys, Inc; Bausch + Lomb Incorporated;
Bio Syntrx, Inc; Calhoun Vision, Inc; Clarity Ophthalmics; Clear-Sight Inc;
CoDa Therapeutics, Inc; Confluence Acquisition Partners I, Inc; CurveRight
LLC; Cxl Ophthalmics, LLC; EBV Partners; EGG Basket Ventures; Encore;
e-Vision Photography, Inc; Evision Medical Laser; Eyemaginations, Inc;
Foresight Venture Fund #3; FzioMed; Glaukos Corporation; Healthcare
Transaction Services; HEAVEN Fund; High Performance Optics; Improve
Your Vision, LLC; LensAR; LenSx Lasers, Inc; LifeGuard Health LLC;
Minnesota Eye Consultants, PA; Nisco; NuLens Ltd; Ocular Optics Co, Ltd;
Ocular Therapeutix, Inc; OmegaEye Health; OnPoint Medical Diagnostics,
Inc; One Focus Ventures; PixelOptics, Inc; Quest; Rainwater Healthcare, Inc;
Refractec, Inc; ReVision Optics, Inc; RevitalVision, LLC; Sarbox NP, Inc;
SARcode Bioscience, Inc; Schroder Life Science Venture Fund; Sightpath
Medical; SolBeam, Inc; Surgijet/Visijet; 3D Vision Systems LLC; TLC Vision
Corporation; TearLab Corporation; Tracey Technologies; Transcend Medical,
Inc; TriPrima Inc; TrueVision Systems, Inc; Viridax Corporation; Vision
Solutions Technologies; and Wavefront Systems Ltd; Medical Director:
Refractec, Inc; Sightpath Medical; and TLC Vision Corporation.
Stephen S. Lane, MD, had a financial agreement or affiliation during the
past year with the following commercial interests in the form of Honoraria:
Alcon, Inc; and Bausch + Lomb Incorporated; Fees for promotional, advertising
or non-CME services received directly from commercial interest or their Agents
(eg, Speakers Bureaus): Alcon, Inc; and Bausch + Lomb Incorporated.
Terrence P. O’Brien, MD, had a financial agreement or affiliation
during the past year with the following commercial interests in the form of
Consultant/Advisory Board: Alcon, Inc; Allergan, Inc; Abbott Medical
Optics; Bausch + Lomb Incorporated; and ISTA Pharmaceuticals, Inc.
Peer Review Disclosure
Ted Gerszberg, MD, has no relevant commercial relationships to disclose.
Editorial Support Disclosures
Cheryl Krader Guttman; Cynthia Tornallyay, RD, MBA, CCMEP;
Kimberly Corbin, CCMEP; Barbara Aubel; and Vivian Fransen, MPA,
have no relevant commercial relationships to disclose.
The contributing physicians listed above have attested to the following:
1) that the relationships/affiliations noted will not bias or otherwise influence
their involvement in this activity; 2) that practice recommendations given
relevant to the companies with whom they have relationships/affiliations will
be supported by the best available evidence or, absent evidence, will be
consistent with generally accepted medical practice; and 3) that all reasonable
clinical alternatives will be discussed when making practice recommendations.
This educational activity includes off-label discussion of topical azithromycin
for meibomian gland dysfunction (MGD), loteprednol etabonate gel and
ointment for inflammation other than that related to cataract surgery, and
doxycycline for MGD.
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A recent case-based continuing medical education
symposium focused on a spectrum of inflammatory
disorders that can compromise the success of cataract and
laser vision correction surgery. This continuing medical
education monograph includes the cases presented and
highlights from the faculty’s discussions covering the
diagnosis, treatment, and prevention of various
inflammatory disorders. We hope the information it
contains will be helpful to clinicians as they strive to
minimize surgical complications and optimize outcomes
for their patients.
—Richard L. Lindstrom, MD
Case 1: Cystoid Macular
—Richard L. Lindstrom, MD
A 73-year-old male presents with a chief complaint of decreased
visual acuity and vision difficulty while driving and reading. He
has an 18-year history of diabetes that is controlled with oral
medication. Best corrected visual acuity (BCVA) is 20/60 OU,
and ophthalmic examination shows bilateral 3+ nuclear sclerotic
cataracts and 1+ background diabetic retinopathy.
The patient undergoes uneventful cataract surgery and is
prescribed a topical fluoroquinolone for 2 weeks plus
prednisolone acetate 1% 4 times a day for 2 weeks, then
prednisolone acetate 1% twice a day until gone. BCVA improves
initially to 20/25, but at 1 month postoperatively, the patient
presents with BCVA of 20/40 and reports he ran out of his
medication 1 week earlier. Central foveal thickness on optical
coherence tomography (OCT) is 543 microns (Figure 1).
Figure 1. Case 1: Optical coherence tomography image with readily apparent
Photo courtesy of Richard L. Lindstrom, MD
Dr Lindstrom: Is fluorescein angiography needed to diagnose
cystoid macular edema (CME) in this patient?
Dr Lane: The risk of postcataract surgery CME is increased in
patients with diabetes. So, in this case, the patient’s history and
OCT seem sufficient for diagnosing CME.
Dr Lindstrom: What about the differential diagnosis? Is there
anything that might have been missed preoperatively?
This continuing medical education activity is copyrighted to MedEdicus LLC ©2013.
All rights reserved.
Dr O’Brien: Surgeons should maintain suspicion for subtle
vitreomacular interface abnormalities, including epiretinal
membrane and vitreomacular traction, in patients with diabetes.
Since the cataract can obscure visualization, it is useful to
perform OCT prior to surgery.
Dr Lindstrom: This patient may have had edema from
diabetic macular edema or possibly an epiretinal membrane
preoperatively. Possible causes for decreased or blurry vision
after cataract surgery include ocular surface disease, regular and
irregular astigmatism, and age-related macular degeneration.
Since this patient ran out of his steroid early, postcataract
surgery CME was diagnosed and treated as such.
Do you modify your medication regimen for cataract surgery
patients at high risk for CME?
Dr O’Brien: Yes. These individuals at higher risk for CME
need a longer duration of treatment with a nonsteroidal
anti-inflammatory drug (NSAID) preoperatively and
postoperatively. 1,2 I instruct the patient at higher risk for CME to
initiate the NSAID 1 week preoperatively and continue it for at
least 6 to 8 weeks after surgery and sometimes, when indicated,
even as long as 3 months.
Dr Lindstrom: My bias is that if we are going to give the
antibiotic plus NSAID preoperatively, there is no reason not to
start the steroid at the same time. I think it helps clean up the
ocular surface, and the more anti-inflammatory therapy on
board at the time of the surgical insult, the better. The steroid
also seems to protect the corneal endothelium. Dr Donnenfeld,
please tell us about your research in that area.
Dr Donnenfeld: Traditionally, NSAIDs are used preoperatively
and steroids are used postoperatively. However, based in part
on evidence from randomized controlled clinical trials of patients
undergoing various major surgical procedures that preoperative
administration of a steroid has benefits for reducing edema and
pain, 3 we conducted a study comparing difluprednate 0.05%
and prednisolone acetate 1% in which both medications were
started 2 hours prior to cataract surgery, pulse dosed in the
perioperative period, and then tapered. 4 The steroid was started
2 hours preoperatively since its mechanism is to inhibit the
release of arachidonic acid that only occurs after there has been
tissue damage. The pulse dosing regimen was used because the
effect of the steroid is dose-dependent, and then it is tapered
quickly after surgery.
Eyes treated with difluprednate had clearer corneas on day 1
postoperatively, less CME at 2 and 4 weeks, and higher
endothelial cell density at 4 weeks, as compared to eyes not
treated with difluprednate.
A topical corticosteroid also helps control pain after cataract
surgery. 5 Patients can have 20/20 vision on day 1
postoperatively, but if they are uncomfortable, they view the
surgery as a failure.
Dr Lindstrom: The difluprednate-treated patients in your study
also had better vision on the first day postoperatively, and
anecdotally, I think the preoperative use of a steroid with an
NSAID helps to maintain pupillary dilation intraoperatively.
We agree that patients at high risk for CME should be treated
with a steroid preoperatively and be treated for a longer duration
with an NSAID. My short list of patients at high risk for CME
includes those with diabetes, vascular occlusion, epiretinal
membranes, a history of uveitis, CME in the same or fellow eye,
previous ocular surgery, prolonged operating time, and vitreous
loss. However, sometimes you do not know preoperatively who
is at high risk for CME. So, do you use an NSAID in all patients?
Dr Lane: You can get an idea about the risk for CME from the
patient’s history, but in the United States, most cataract
surgeons are routinely using an NSAID.
It is useful to have 2 regimens—1 for “routine patients” and
another for the group of patients at high risk for CME who use the
same medications, but more intensively. Since you do not always
know who the patient at high risk for CME is, having some
coverage with both the NSAID and steroid makes good sense.
I use difluprednate with an NSAID for controlling inflammation
after cataract surgery in the eyes of patients at high risk for
CME, but loteprednol combined with an NSAID is my treatment
of choice in routine cases. In a study we conducted with Edward
J. Holland, MD, in which patients who were having routine
cataract surgery received an NSAID postoperatively and were
randomized to prednisolone acetate 1% or loteprednol
etabonate 0.5% suspension, inflammation control was
equivalent in the 2 groups, but the loteprednol-treated group
had less intraocular pressure (IOP) fluctuation than the
prednisolone-treated group. 6
Dr Lindstrom: If you see a patient who had CME after his or
her first eye cataract surgery, what will you do differently when
operating on the second eye?
Dr Donnenfeld: Patients are counseled about their risk for CME
and told what will be done to try to give them the best possible
surgical outcome. I would obtain a preoperative OCT, and if
there is significant macular edema, I would refer the patient to a
retinal surgeon for possible intravitreal steroid injection prior
If the CME was not significant, I would treat the patient before
surgery with an NSAID plus a steroid. I use bromfenac 0.09%,
which is recommended for once-daily dosing, but I would
prescribe it for use twice a day in a patient with diabetes,
starting 1 week preoperatively and continuing it for 2 to
3 months postoperatively. I would also have the patient start
difluprednate 1 day before surgery and, importantly, begin pulse
dosing difluprednate right before surgery. The patient should be
followed closely postoperatively.
If there is any intraoperative complication, I like to use
intracameral triamcinolone acetonide, not only to recognize
vitreous loss, but also to reduce inflammation. I am very
aggressive with the use of steroids in these patients.
Dr O’Brien: I would agree and also have a low threshold for
intraocular corticosteroid therapy. I use intracameral preservativefree
dexamethasone in patients at risk for CME and intravitreal
preservative-free triamcinolone acetonide in patients who have
complications or are at high risk for CME. Perhaps in the near
future, we will have sustained-delivery vehicles for the longer-term
release of corticosteroids with zero-order pharmacokinetics to
control inflammation for an extended period.
Dr Lindstrom: The point here is that steroids work
synergistically with NSAIDs to minimize postoperative
inflammation and thus can be used aggressively.
CME is more common than people think. If postcataract surgery
CME is defined as any leakage or thickening of the retina on
OCT, its rate is near 90% in patients having uneventful cataract
surgery, according to a study by Lobo and colleagues. 7 Among
the 32 eyes included in the trial, 88% of the eyes had evidence
of retinal vascular leakage at 12 weeks postoperatively.
If the goal of cataract surgery is to provide patients with the best
possible visual acuity, surgeons need to focus on preventing
CME. OCT is becoming a critical tool for identifying patients at
high risk for CME, and we have drugs that work synergistically
to help prevent CME.
slit-lamp reveals trace collarettes and scales on the lashes. She
has a clear cornea, rapid tear break-up time (TBUT), and foamy
tear film (Figure 2), along with a 2+/3+ nuclear sclerotic
cataract and 1+ posterior capsular cataract OU. The fundus
examination is unremarkable, and the patient wants a
presbyopia-correcting intraocular lens (IOL).
Dr Lane: Something I have come to realize in treating patients
with CME is that while visual acuity usually comes back to
20/20, visual quality may still be reduced. Since we do not
know who is going to develop CME, the use of medications to
prevent CME makes good sense.
Dr Donnenfeld: My partner, John Wittpenn, MD, was the lead
author of a paper that provided evidence-based information in
this area. 8 He and his colleagues randomized approximately
550 cataract surgery patients to receive a steroid alone or
combined with an NSAID postoperatively. Retinal thickening of
more than 10 microns occurred in twice as many eyes in the
steroid-only group than in the NSAID-plus-steroid group, and
having more than 10 microns of retinal thickening was
associated with lower contrast sensitivity.
Extrapolating these data to the more than 3 million cataract
surgeries performed in the United States annually suggests
about 150,000 patients would suffer visual deficit if they were
not treated with this combination of an NSAID plus steroid.
That is a staggering number.
Dr Lindstrom: Indeed, we must think about the prevention of
CME, and today we have more effective steroid options than in
the past for controlling postoperative inflammation with
difluprednate 0.5% emulsion as well as loteprednol 0.5%, which
now includes preservative-free ointment and a gel formulation in
addition to the suspension. Our NSAID options have also been
expanding with the development of formulations that have
reduced dosing frequency relative to their predecessors. In
addition to once-daily bromfenac 0.09%, there has been the
introduction of ketorolac tromethamine 0.45% solution, which
is preservative-free and has a dosing frequency of twice-daily
administration. Nepafenac 0.3% suspension was very recently
approved by the US Food and Drug Administration with a oncedaily
regimen for the treatment of pain and inflammation
associated with cataract surgery, and it received approval in
Europe for the prevention of CME in patients with diabetes. In
addition, a New Drug Application has been filed for a lowerconcentration
preparation of bromfenac that was shown
effective as a once-daily treatment for pain and inflammation
associated with cataract surgery. 9
Case 2: Preoperative Management
of Comorbidities in Cataract
Surgery—Blepharitis and Dry Eye
—Stephen S. Lane, MD
A 75-year-old female who had been using artificial tears 5 times
a day for comfort presents with a complaint of decreased visual
acuity. BCVA is 20/80 OD and 20/70 OS. Examination at the
Figure 2. Case 2: Slit-lamp findings in a patient with combined anterior and
posterior blepharitis show scurf at the base of the lashes (A), inspissation and
plugging of the meibomian glands (B), foam in the tear film (C), and irregular
tear film break-up (D).
Photos courtesy of Stephen S. Lane, MD
What are the striking findings in her slit-lamp images?
Dr O’Brien: She exhibits typical signs of combined anterior
blepharitis and posterior blepharitis with inflammation at the
anterior lid margin, collarettes, and crusting, along with a
glistening from oil reflection of light off the lid skin and lid
margin telangiectatic vessels.
Dr Donnenfeld: The soap-like material along the lid margin is
the result of saponification. It is caused by lipase hydrolysis of
the meibomian gland lipids to soaps and fatty acids, and those
breakdown products cause burning and tear film instability with
a shortened TBUT. Inspissation of the glands is also present and
is pathognomonic for meibomian gland dysfunction (MGD).
Normally, the meibum has an olive oil-like appearance, but with
MGD, the thickened secretions block the glands.
Dr Lane: We do corneal topography routinely for patients
receiving advanced technology IOLs to check the ocular surface.
This patient has irregular astigmatism secondary to an irregular
ocular surface (Figure 3).
Figure 3. Case 2: Corneal topography with irregular astigmatism.
Photo courtesy of Stephen S. Lane, MD
Dr Donnenfeld: There are a few things that can account for the
type of topographic irregularity seen in this patient, but it is
important not to operate in this situation because the
keratometry will be irregular and result in IOL power selection
error. The black areas seen at the bottom of the topographic
image represent frank dropout because of the surface
irregularity. That should tell a surgeon there is a problem that
needs to be rectified before operating.
Dr O’Brien: The quality of the topographic image is adversely
impacted in this patient by the film instability and overall poor
quality of the tear lake, and the use of the information obtained
will lead to spurious keratometry and inaccurate IOL power
selection. This is a clear case of the “garbage in will yield
garbage out” principle in terms of IOL power selection and
Dr Lane: Yes. Implanting a multifocal IOL in this patient is a
formula for disastrous results. Not only will the IOL power be
wrong, but the image quality will be reduced postoperatively
because of the tear film irregularity (Figure 4). MGD needs to
be treated aggressively prior to surgery.
Figure 4. Reduction in visual quality due to tear film abnormality.
Photo courtesy of Stephen S. Lane, MD
Do patients present with pure MGD, pure aqueous deficient dry
eye, or pure anterior blepharitis?
Dr Lindstrom: There certainly are cases of true aqueous
deficient dry eye, as in patients with Sjögren’s syndrome.
However, according to a study by Lemp and colleagues, 10 86%
of dry eye is evaporative, and it is also my impression that more
patients have MGD with secondary evaporative dry eye than
true aqueous deficient dry eye, especially seniors.
Dr O’Brien: With respect to the lid margin disease, some
patients have a clearly defined clinical picture where the anterior
lid margin is principally involved, and others have involvement
that is more exclusively limited to the posterior lid margin.
However, the majority of the patients have a combination of
anterior and posterior lid margin involvement, and both
components need to be addressed for effective control. The
involvement of the posterior lid margin adds to the poor quality
of meibum, an unstable lipid layer, and accelerated evaporative
tear loss with resultant aqueous tear layer insufficiency.
Dr Donnenfeld: I have found an overwhelming association
between a chief complaint of tired eyes and MGD or dry eye
disease. The reason is that as these patients attempt to maintain
image quality, they may double or triple their blink rate.
Consequently, the levator muscles tire. Other than a slightly
shortened TBUT, they may have no other signs of dry eye.
However, their borderline condition may be converted to an
acute dry eye state after surgery. Then, they might be very upset
and blame the surgery for a preexisting problem that was
Dr Lane: I think we would all agree to postpone surgery in
these patients. How should they be managed?
Dr Lindstrom: Because MGD is so common, all patients deserve
what I call “ocular surface preparation.” The regimen I use is
influenced by a study in which Dr Lane was an investigator that
showed improvements were achieved in patients with moderateto-severe
blepharitis/blepharoconjunctivitis after 1 week of
treatment with a fixed combination of topical antibioticcorticosteroid.
11 My approach is to use a fixed combination
antibiotic-corticosteroid, tobramycin-loteprednol, or tobramycindexamethasone,
together with lid hygiene and artificial tears for
1 week prior to surgery.
I think these eyes remain more vulnerable to intraoperative
trauma, and so I put some dispersive viscoelastic on the eye for
protection during surgery. For long-term maintenance therapy, I
am a big advocate of omega-3 fatty acids, but there is no reason
not to start that preoperatively.
Dr. O’Brien: I certainly agree that particular attention to and
proper preparation of the ocular surface preoperatively can lead
to less instability and faster recovery postoperatively from the
stress that cataract surgery inevitably poses to any ocular
surface. One cautionary note about viscous surface protectants
is to be certain to apply the antiseptic and antibiotic agents for
antimicrobial prophylaxis prior to placing the viscous agent.
This order of use allows sufficient time for effective antimicrobial
action that can be blocked by the viscous lubricant substance.
Ocular nutriceuticals, including sources of essential omega-3
fatty acids and related nutrients, play an important role in ocular
surface management, but may require a more extended course
to achieve significant and lasting improvements of the tear film
and ocular surface. Cyclosporine may also take several weeks to
months to gain control of ocular surface inflammation. Thus, a
corticosteroid preparation that is ocular surface friendly,
effective, and safe provides a tool to rapidly reduce ocular
surface inflammation preoperatively.
Dr Lane: Many patients are already taking omega-3 fatty acids,
but often it is not the right kind or enough. The preparation
needs to contain the triglyceride form to assure good
absorption. 12 Results of a randomized clinical trial of patients
with blepharitis and MGD showed improvements in objective
and subjective measures after 1 year of treatment with
approximately 3 g/d of omega-3 fatty acids. 13
To treat MGD and ocular surface disease prior to surgery, I like
to use a fixed combination of loteprednol-tobramycin because of
the safety of loteprednol. Loteprednol ointment might also be
considered to decrease inflammation when initiating treatment
for more severe inflammatory anterior blepharitis and MGD.
It is a nice formulation because it is not greasy and contains
To decrease inflammation related to MGD, cyclosporine might
also be considered.
Dr Donnenfeld: Patients coming for surgery want something
that is rapidly effective, and they do not want to wait 3 months
for the benefit from omega-3 fatty acids. For these patients,
loteprednol rapidly optimizes the ocular surface, 14 has a good
safety profile, and works synergistically with cyclosporine, which
also has a delayed onset of efficacy and causes irritation. We
found starting loteprednol first and initiating cyclosporine after
1 to 2 weeks increases the patient’s comfort and tolerability with
cyclosporine. 15 I start loteprednol 4 times a day for 2 weeks,
then twice a day for 2 weeks.
Dr Lindstrom: A lot of patients are unhappy if they are started
on cyclosporine alone. I tell my patients that if we start
cyclosporine, it is a lifetime treatment, but I find I can sometimes
go from twice-a-day to once-a-day administration after 6 to 12
months. In a randomized study, Su and colleagues reported that
most patients with dry eye disease treated with cyclosporine
twice a day for a year could maintain control when switched to
once-daily dosing. 16
Dr Donnenfeld: We also decrease the dosing frequency of
cyclosporine to once a day for some patients with dry eye.
However, it depends on the underlying etiology, and patients
have to be monitored for potential worsening that would
necessitate a return to twice-daily dosing.
Dr Lane: In terms of the patient in this case, surgery was
postponed, and the patient was instructed to perform lid
hygiene and to start omega-3 fatty acids at 3 g/d. Treatment
also included loteprednol 0.5% ointment since the inflammatory
component of the mixed blepharitis was significant enough to
necessitate a steroid, and she started taking doxycycline. There
was a significant improvement after 2 weeks. The patient had
surgery and did well. For long-term control, she was started on
maintenance therapy with topical azithromycin every other
month and continued oral omega-3 fatty acids supplementation
and lid hygiene.
Dr Lindstrom: I also find topical azithromycin effective for
long-term maintenance therapy in patients with MGD.
Dr O’Brien: Azithromycin, an advanced macrolide agent,
is well-suited for MGD management because it has both
immunomodulatory properties conferring anti-inflammatory
activity and is antimicrobial. Anterior blepharitis is not an
infectious process, but it is associated with excessive
For lid hygiene, I like to use a foaming lid scrub that contains
linalool, a tea tree oil derivative that has some anti-inflammatory
and antimicrobial properties, including activity against methicillinresistant
Staphylococcus aureus and Staphylococcus epidermidis. 17
We also caution the sometimes obsessive-compulsive patients
with MGD blepharitis to not use detergent-containing lid scrubs
excessively as this may result in further breakdown of abnormal
meibum into free fatty acids, and triglyceride soaps may also add
to the ocular surface irritation.
Case 3: Ocular Allergy and
—Terrence P. O’Brien, MD
A 61-year-old male presents with IOPs of 36 mm Hg OD and
38 mm Hg OS as well as early glaucomatous changes in his
visual field and retinal nerve fiber layer. Previously, he had been
a suspect for primary open-angle glaucoma with a cup-to-disc
ratio of 0.7 OU, borderline high IOP, and a family history of
glaucoma. He is a patient with a moderately high degree of
myopia who has worn rigid gas-permeable contact lenses
successfully for many years.
He was placed on a prostaglandin analogue once nightly. IOP
decreased only to the mid-20s, and an alpha adrenergic agent
(brimonidine) was added twice a day. The patient complained of
itching, occasional redness, and episodic mucus discharge, and
he was developing contact lens intolerance. Photographs from
his external examination are shown in Figure 5. What is your
Figure 5. Case 3: Clinical findings of giant papillary conjunctivitis with tarsal
hyperemia in a patient with long-term rigid gas-permeable contact lens wear.
Fluorescein sodium outlines the giant papillae on the upper eyelid.
Photos courtesy of Terrence P. O’Brien, MD
Dr Donnenfeld: Given the appearance and history of contact
lens wear, I would diagnose giant papillary conjunctivitis.
Dr O’Brien: Talking in general about patients with glaucoma
plus ocular surface disease, what are the issues to consider when
using topical medications?
Dr Lane: IOP-lowering agents can be a double-edged sword
because of the risks for an allergic reaction to some medications
and for toxicity from the medications themselves or from
preservatives, especially benzalkonium chloride. 18,19 In this
patient who needs a steroid to treat inflammation, the potential
for an IOP response also needs to be considered.
Dr O’Brien: How do you differentiate whether the conjunctival
redness in this patient is a sign of allergy or irritation?
Dr Donnenfeld: With a prostaglandin analogue, there can be
irritation from the preservative or from the active ingredient.
Switching to a preservative-free medication might be a reasonable
thing to try. Sometimes I prescribe an oral glaucoma medication
for a few weeks to treat the IOP and leave such patients on 1
topical medication in 1 eye only. If the redness in the fellow eye
improves, I know which topical medication was the cause.
Brimonidine can cause allergic reactions. 20 Patients with an
allergic reaction to brimonidine tend to rub their eyes a lot. The
rubbing perpetuates the redness by causing mast cell
degranulation, and the rubbing is also detrimental in patients
with glaucoma because the rubbing increases IOP.
Dr Lindstrom: When a patient has an allergic reaction, there is
itching, often right over the caruncle, and there might be some
erythema of the skin as well. Blepharitis burns, and dry eyes
typically are associated with a foreign body gritty sensation.
Dr O’Brien: To manage this patient, we suspended the contact
lens wear and treated him with a pulse dosing regimen of
loteprednol etabonate 0.5%. Loteprednol has a safety
advantage in the patient with glaucoma because it has a reduced
potential for IOP elevations relative to other steroids, 21 and this
case was managed using the suspension formulation. Now,
however, loteprednol gel 0.5% is available and would have been
a good choice because it contains 70% less preservative than
the suspension, 0.003% vs 0.01%. Therefore, it is friendlier to
the ocular surface. The vehicle is a “smart” polymer and
contains the demulcents polyethylene glycol and glycerin. It
dispenses as a liquid and converts to a gel on the eye, but causes
Dr Lane: I think gel formulations are going to bring a paradigm
shift in treating ocular surface disease because of their potential
for increased dwell time on the ocular surface.
Chronic contact lens wearer
Dr Lindstrom: The gel formulation of loteprednol etabonate is
also a non-settling suspension so that a uniform dose is
delivered with each drop and without a need for shaking.
Dr O’Brien: That is an excellent point as, despite frequent
instruction, few patients properly agitate the eyedrop bottle to
achieve a uniform suspension of the active ingredient with
drop delivery. 22
In addition to loteprednol etabonate 0.5%, this particular patient
was also started on a dual-acting anti-allergy agent (olopatadine)
twice daily and was switched to daily disposable soft contact
lenses. Brimonidine was stopped. The patient’s IOP increased
to above 30 mm Hg, but was controlled with the addition of a
beta-blocker. The patient did well but returned 14 months later
with even worse dryness, irritation, itching, hyperemia, and
We referred this patient for consultations with both the
refractive surgery and glaucoma services, hoping that refractive
surgery would eliminate his need for contact lenses and the
glaucoma surgery would minimize the need for topical
medications. He was also restarted on a pulse dosing regimen of
loteprednol 0.5%. He continued the anti-allergy agent, used
preservative-free artificial tears, and returned for a refractive
surgery evaluation after 6 weeks.
At the Bascom Palmer Eye Institute, we developed an
algorithmic approach to rationally manage the candidate for
LASIK (laser-assisted in situ keratomileusis) who has comorbid
allergy (Figure 6). 23 Just as it is important to control
inflammatory conditions prior to performing cataract surgery, it
is important to have ocular allergy under control prior to LASIK.
Dual action anti-allergy agents have become our mainstay for
treating ocular allergy. However, it is important to realize that
they may differ in their effects on the tear film due to differences
in histamine receptor binding affinity profiles. 24
Dr Lindstrom: In a contact lens wearer or patient with known
dry eye, I am using bepotastine besilate 1.5%. Bepotastine is a
highly selective H1 receptor antagonist with low binding affinity
for muscarinic receptors, 24 and therefore it has a low likelihood
for exacerbating dry eye.
Loteprednol etabonate 0.2% is also an effective option for ocular
allergy management, 25 and it has been reported to be safe when
used on a long-term basis in patients with chronic allergy. 26
Dr O’Brien: This patient had LASIK performed in 2 stages.
First, the flap was created with a femtosecond laser, but the
excimer laser photoablation was delayed for 6 weeks after
Slit lamp exam
Tear breakup time
green, rose bengal)
KCS TFD VKC GPC AKC PAC SAC
Optimization of Ocular Surface
Mast cell stabilizers
Tear film osmolarity
RPS inflammatory dry eye
Re-evaluate Ocular Surface (4 weeks)
Figure 6. Preoperative workup for LASIK candidates with a history of allergy. 23
Reprinted with permission from Lippincott Williams & Wilkins.
Peak flow spirometry
trabeculectomy with mitomycin-C so that it would correct any
astigmatism induced by the glaucoma surgery.
Postoperatively, the patient had excellent unaided visual acuity,
20/20 OD and 20/15 OS, with very little residual refractive error
and no need for contact lenses. He continued the preservativefree
artificial tears for 6 months and the dual action anti-allergy
agent as needed. The hyperemia and papillae in this patient
gradually improved, although it took about a year, and the
persistence of the papillae can be associated with exacerbations
and recurrences. However, the patient was delighted to no longer
need contact lenses, IOP was controlled in the low teens, and the
visual field and nerve fiber layer were stable.
Dr Donnenfeld: Dr Lindstrom has published on the benefit of
cataract surgery for glaucoma control. 27,28 Therefore,
phacoemulsification, perhaps combined with a trabecular microbypass
stent, might have been an alternative to trabeculectomy
in this patient.
In patients with milder glaucoma who have ocular irritation
associated with their topical medication, laser trabeculoplasty is
also a reasonable procedure for trying to eliminate topical
Dr Lindstrom: Most 60-year-olds have early cataracts. If a patient
has what I call the 3G syndrome—glare from cataract, glasses,
and glaucoma—I often think of a refractive lens exchange.
Case 4: Inflammation and
Surviving a Toxic Anterior
Segment Syndrome Epidemic
—Eric D. Donnenfeld, MD
A 71-year-old female underwent uneventful cataract surgery in
2005 and received the standard postoperative medication
regimen that included a fourth-generation fluoroquinolone, an
NSAID, and prednisolone acetate 1%. She presents on the first
postoperative day without pain, minimal lid swelling, and a
relatively quiet eye, but complains about decreased vision.
A slit-lamp photo of her eye is shown (Figure 7). What are the
Figure 7. Case 4: Sterile hypopyon
in a patient with TASS.
Photo courtesy of
Eric D. Donnenfeld, MD
Dr O’Brien: The corneal edema is diffuse. It is not just adjacent
to the incision, but is limbal to limbal, horizontally and vertically.
That suggests a toxic response.
Dr Lane: However, unless you have a reason to suspect toxic
anterior segment syndrome (TASS) because of an ongoing
outbreak, your first obligation is to rule out infectious
Dr O’Brien: The time course also provides diagnostic clues.
Significant hypopyon within 24 hours of surgery suggests it may
be triggered by a toxic response rather than infection. Despite
these suggestive clues, I certainly agree that it is incumbent upon
the surgeon to perform the requisite diagnostic tests to rule
Dr Donnenfeld: TASS was suspected in this patient because I
learned a TASS epidemic had started the day before. Other
patients seen by other surgeons had a similar presentation, and
some had an anterior chamber tap with nothing found on Gram
stain. How do you manage TASS?
Dr Lane: I would do an anterior chamber washout, prescribe an
intracameral antibiotic, and treat TASS with an aggressive
Dr O’Brien: The possible sequelae of TASS include CME,
endothelial damage, and damage to the trabecular meshwork
leading to uncontrollable glaucoma. The pupil may also be
affected by the toxins and become permanently mydriatic
Based on my experience with TASS cases seen on referral, I think
early anterior chamber irrigation plus washout is an important
maneuver to prevent permanent intraocular damage, especially in
this case where the inflammation is so severe. TASS is a toxic
insult to the intraocular milieu, and the solution to pollution is
dilution. We need to be aggressive in irrigating the toxins away
and then start the patient on high-dose corticosteroids.
Dr Lindstrom: I think of TASS in much the same way as I think
of diffuse lamellar keratitis (DLK). If I see DLK on the first day
after LASIK, I do not immediately lift the flap and irrigate, but
usually give patients an opportunity to respond to aggressive
topical steroids while monitoring them very closely.
Dr Donnenfeld: Nick Mamalis, MD, a professor of
ophthalmology at the John A. Moran Eye Center, University of
Utah, Salt Lake City, and co-chairman of the American Society
of Cataract and Refractive Surgery TASS Task Force, is against
using antibiotics, and I think washout is also controversial.
For a mild case, I start treatment for the patient with a potent
topical steroid, but when there is severe corneal edema, I wash
out the eye and inject steroid intracamerally. I use preservativefree
dexamethasone sodium phosphate because it works more
quickly than triamcinolone and does not stay around as long.
Then I start the use of topical difluprednate because of its
potency. In a study of patients with severe anterior uveitis, the
use of difluprednate 4 times a day was more effective than
brand-name prednisolone acetate 1% 8 times a day. 29
This case was part of a nationwide epidemic that included
37 cases at our surgery center over 6 weeks. An investigation
led by Dr Mamalis identified endotoxin in one manufacturer’s
balanced salt solution as the cause. What are some other causes
Dr Lane: Residue in inadequately cleaned reusable cannulas is a
Dr O’Brien: Some detergent residues used in processing
surgical instruments are also a cause.
Dr Donnenfeld: The lessons we learned from this TASS
outbreak were that you have to scrupulously examine the
process of cleaning and processing instruments; document lot
numbers for all products coming in contact with the eye; keep
records of all staff and equipment used; communicate early
within and outside your facility; and identify TASS early, treat
aggressively with steroids, and avoid vitreous taps and
The first 9 cases at our center were sent to a retinal specialist
for evaluation, and the 2 most severe cases had a vitreous tap
with intravitreal antibiotics, but you do not want to do those
maneuvers if you know it is TASS. These patients need to be
watched very carefully, and you have to certainly be willing to
see them every 4 to 5 hours until you know what is going on.
The patient was treated with cyclopentolate 1% and
prednisolone acetate because difluprednate was not available at
the time. She did well with the clearing of her corneal edema,
fibrin, and hypopyon over 3 weeks, but she had low-grade
inflammation with chronic iritis, CME, and photophobia, and
was maintained on a long-term basis with loteprednol.
TASS can be associated with long-term smoldering
inflammation. How would you manage this patient who
presents 2 months later with low-grade iritis?
Dr Lane: The goal for long-term treatment for low-grade
iritis is to use an agent that is potent enough to control the
inflammation, but has a high enough safety margin so that you
do not have to be concerned about adverse effects of chronic
treatment. Loteprednol fits that description and would be an
appropriate choice. I would start treatment for low-grade iritis
with the gel formulation, taper it to once or twice a day, and
instead of discontinuing the steroid altogether, switch to
loteprednol 0.2% for longer-term use.
There are published reports of patients using loteprednol 0.2%
daily for up to 3 years without developing cataracts or IOP
elevation. 26 I find it is very helpful for managing mild
inflammation for the long term.
Dr Donnenfeld: Loteprednol is a strong steroid with minimal
side effects, and it is my corticosteroid of choice for long-term
maintenance treatment, such as following a penetrating
keratoplasty. I also use loteprednol for everything anterior to
Descemet membrane—anything involving the ocular surface,
anterior cornea, conjunctiva, pterygia, or lid margin. My early
experience with loteprednol gel is that it is even more potent
than the suspension and may be used for intraocular
inflammation. I use difluprednate when I need a potent steroid
for rapid inflammation control. I use it in pulse dosing for TASS,
for acute graft rejection, and in cataract surgery when I want to
completely suppress inflammation.
1. Heier JS. Preventing post-cataract extraction CME: early identification of
patients at risk and prophylactic treatment may avert vision loss. Ophthalmol
Manage. October 2004:63-72.
2. O’Brien TP. Emerging guidelines for use of NSAID therapy to optimize cataract
surgery patient care. Curr Med Res Opin. 2005;21(7):1131-1137.
3. Holte K, Kehlet H. Perioperative single-dose glucocorticoid administration:
pathophysiologic effects and clinical implications. J Am Coll Surg. 2002;195(5):
4. Donnenfeld ED, Holland EJ, Solomon KD, et al. A multicenter randomized
controlled fellow eye trial of pulse-dosed difluprednate 0.05% versus
prednisolone acetate 1% in cataract surgery. Am J Ophthalmol. 2011;152(4):
5. Korenfeld MS, Silverstein SM, Cooke DL, Vogel R, Crockett RS; Difluprednate
Ophthalmic Emulsion 0.05% (Durezol) Study Group. Difluprednate ophthalmic
emulsion 0.05% for postoperative inflammation and pain. J Cataract Refract
6. Lane SS, Holland EJ. Loteprednol etabonate 0.5% versus prednisolone acetate
1.0% for the treatment of inflammation after cataract surgery. J Cataract Refract
7. Lobo CL, Faria PM, Soares MA, Bernardes RC, Cunha-Vaz JG. Macular
alterations after small-incision cataract surgery. J Cataract Refract Surg.
8. Wittpenn JR, Silverstein S, Heier J, et al. A randomized, masked comparison of
topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery
patients. Am J Ophthalmol. 2008;146(4):554-560.
9. Klier SM, Pearce JH, Goldberg DF, Gow JA, McNamara TR, Low-
Concentration, Modified Bromfenac Ophthalmic Solution Once Daily Study
Group. Efficacy of low-concentration, modified bromfenac ophthalmic solution
administered once daily for ocular inflammation and pain associated with
cataract surgery. Poster presented at: Association for Research in Vision and
Ophthalmology Annual Meeting; May 10, 2012; Fort Lauderdale, FL.
10. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of
aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a
retrospective study. Cornea. 2012;31(5):472-478.
11. Torkildsen GL, Cockrum P, Meier E, Hammonds WM, Silverstein B, Silverstein
S. Evaluation of clinical efficacy and safety of tobramycin/dexamethasone
ophthalmic suspension 0.3%/0.05% compared to azithromycin ophthalmic
solution 1% in the treatment of moderate to severe acute blepharitis/
blepharoconjunctivitis. Curr Med Res Opin. 2011;27(1):171-178.
12. Dyerberg J, Madsen P, Møller JM, Aardestrup I, Schmidt EB. Bioavailability of
marine n-3 fatty acid formulations. Prostalgandins Leukot Essent Fatty Acids.
13. Macsai MS. The role of omega-3 dietary supplementation in blepharitis and
meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc. 2008;
14. Pflugfelder SC, Maskin SL, Anderson B, et al. A randomized, double-masked,
placebo-controlled, multicenter comparison of loteprednol etabonate ophthalmic
suspension, 0.5%, and placebo for treatment of keratoconjunctivitis sicca in
patients with delayed tear clearance. Am J Ophthalmol. 2004;138(3):444-457.
15. Donnenfeld E, Sheppard JD, Holland EJ. Prospective, multicenter, randomized
controlled study on the effect of loteprednol etabonate on initiating therapy with
cyclosporine A. Presented at: American Academy of Ophthalmology Annual
Meeting; November 2007; New Orleans, LA.
16. Su MY, Perry HD, Barsam A, et al. The effect of decreasing the dosage of
cyclosporine A 0.05% on dry eye disease after 1 year of twice-daily therapy.
17. Gilbard JP, Douyon Y, Huson RB. Time-kill assay results for a linaloolhinokitiol-based
eyelid cleanser for lid hygiene. Cornea. 2010;29(5):559-563.
18. Epstein SP, Chen D, Asbell PA. Inflammatory response by ocular surface
epithelia upon exposure to prostaglandin analogs. Invest Ophthalmol Vis Sci.
19. Baudouin C. Labbé A, Liang H, Pauly A, Brignole-Baudouin F. Preservatives in
eyedrops: the good, the bad and the ugly. Prog Retin Eye Res. 2010;29(4):
20. Blondeau P, Rousseau JA. Allergic reactions to brimonidine in patients treated
for glaucoma. Can J Ophthalmol. 2002;37(1):21-26.
21. Comstock TL, Decory HH. Advances in corticosteroid therapy for ocular
inflammation: loteprednol etabonate. Int J Inflam. 2012;2012:789623.
22. Apt L, Henrick A, Silverman LM. Patient compliance with use of topical
ophthalmic corticosteroid suspensions. Am J Ophthalmol. 1979;87(2):
23. Bielory BP, O’Brien TP. Allergic complications with laser-assisted in situ
keratomileusis. Curr Opin Allergy Clin Immunol. 2011;11(6):483-491.
24. Wade L. Bielory L, Rudner S. Ophthalmic antihistamines and H1-H4 receptors.
Curr Opin Allergy Clin Immunol. 2012;12(5):510-516.
25. Elion-Mboussa A, Gong L, Roy L, Zhu B, DeCory H, Chu E. Loteprednol
etabonate ophthalmic suspension, 0.2% is as safe as olopatadine hydrochloride
ophthalmic solution, 0.1% with superior relief of signs and symptoms in the
treatment of seasonal allergic conjunctivitis. Presented at: Proceedings of the
Annual Meeting of the American Academy of Allergy Asthma and Immunology;
March 2012; Orlando, FL.
26. Ilyas H, Slonim CB, Braswell GR, Favetta JR, Schulman M. Long-term safety of
loteprednol etabonate 0.2% in the treatment of seasonal and perennial allergic
conjunctivitis. Eye Contact Lens. 2004;30(1):10-13.
27. Poley BJ, Lindstrom RL, Samuelson TW, Schulze R Jr. Intraocular pressure
reduction after phacoemulsification with intraocular lens implantation in
glaucomatous and nonglaucomatous eyes: evaluation of a causal relationship
between the natural lens and open-angle glaucoma. J Cataract Refract Surg.
28. Poley BJ, Lindstrom RL, Samuelson TW. Long-term effects of
phacoemulsification with intraocular lens implantation in normotensive and
ocular hypertensive eyes. J Cataract Refract Surg. 2008;34(5):735-742.
29. Foster CS, Davanzo R, Flynn TE, McLeod K, Vogel R, Crockett RS. Durezol ®
(difluprednate ophthalmic emulsion 0.05%) compared with Pred Forte ®
Ophthalmic Suspension in the treatment of endogenous anterior uveitis.
J Ocul Pharmacol Ther. 2010;26(5):475-483.
CME Post Test Questions
To obtain AMA PRA Category 1 Credit for this activity, complete the CME Post Test by writing the best answer to each
question in the Answer Box located on the Activity Evaluation/Credit Request form on the following page. Alternatively, you
can complete the CME Post Test online at http://www.MedEdicus.com, Educational Activities tab, and click the Post-Test &
CME Certificate button.
See detailed instructions at To Obtain AMA PRA Category 1 Credit on page 3.
1. All of the following are risk factors for postcataract surgery
cystoid macular edema, except:
B. Vitreous loss
C. History of LASIK (laser-assisted in situ keratomileusis)
D. Epiretinal membrane
2. In a published study by Lobo and colleagues of patients
undergoing uneventful cataract surgery, the percentage of
eyes found to have evidence of retinal vascular leakage after
12 weeks was near:
3. In a study by Wittpenn and colleagues comparing postcataract
surgery treatment with a steroid alone or combined with an
NSAID, retinal thickening of more than 10 microns:
A. Occurred more often in the combination treatment
B. Was associated with reduced contrast sensitivity
C. Was prevented by combination treatment
D. Was associated with reduced uncorrected visual acuity
4. Depending on the intraocular pressure and other ocular
findings, all of the following might be a reasonable surgical
strategy for minimizing medication use in patients with
glaucoma plus ocular surface disease, except:
C. Laser trabeculoplasty
D. Any of the above might be reasonable, depending on
5. All of the following may be signs of meibomian gland
A. Low Schirmer test score
B. Rapid tear break-up time
C. Lid margin telangiectasia
D. Foamy tear film
6. Initial treatment for dry eye associated with meibomian gland
dysfunction might include all of the following, except:
B. Punctal plugs
C. Topical corticosteroid-antibiotic combination
D. Lid hygiene
7. A benefit of using bepotastine besilate to treat ocular allergy
in contact lens wearers is:
A. Its receptor selectivity profile confers a reduced
likelihood of exacerbating dry eye
B. It is recommended for once-daily dosing
C. It contains no preservatives
D. It can be instilled without removing the contact lenses
8. Adverse sequelae of toxic anterior segment syndrome (TASS)
may include all of the following, except:
A. Cystoid macular edema
B. Permanent miosis
D. Endothelial damage
9. Which of the following should be absolutely avoided in an eye
A. Vitreous tap
B. Topical corticosteroid treatment
C. Anterior chamber washout
10. All of the following ophthalmic nonsteroidal
anti-inflammatory drugs are recommended for
once-daily dosing, except:
A. Bromfenac 0.09%
B. Ketorolac tromethamine 0.45%
C. Nepafenac 0.3%
D. All 3 products are recommended for once-daily dosing
Activity Evaluation/Credit Request
New Evidence and Insights on the Inflammation Panorama: From Ocular Surface Disorders to Surgery
ORIGINAL RELEASE: March 15, 2013
LAST REVIEW: February 22, 2013
EXPIRATION: March 31, 2014
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• Demonstrate best-practice regimens for reducing inflammation risk for patients 5 4 3 2 1
undergoing cataract, refractive, or glaucoma procedures
• Demonstrate best-practice regimens for the management of inflammation in patients 5 4 3 2 1
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1. Please list one or more things, if any, you learned from participating in this educational activity that you did not already know. ____________________________
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