Preop Visually Significant OSD: Treatment Strategy and Outcomes

EP: 1.Detecting Demodex Blepharitis during preop cataract surgical visit

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EP: 2.Preop Visually Significant OSD: Treatment Strategy and Outcomes

EP: 3.Demodex Blepharitis in a Contact Lens Wearer

EP: 4.Demodex Blepharitis in a Contact Lens Wearer: Treatment Plan and Outcomes

Treatment Protocols and Clinical Outcomes for Preoperative Demodex Blepharitis

The management of visually significant ocular surface disease in the preoperative cataract patient requires a multimodal approach targeting inflammation, infection, and tear film instability. In the presented case, treatment involved topical antibiotics to address the elevated gram-positive bacterial load frequently associated with Demodex infestation, alongside topical corticosteroids to rapidly control the documented inflammation (MMP-9 positive). The regimen included perfluorohexyloctane drops to address corneal epithelial disruption and stabilize the tear film, mechanical blepharoexfoliation to remove biofilm and collarettes, and thermal pulsation to treat meibomian gland dysfunction (MGD). To prevent postsurgical OSD flare, a topical immunomodulator was initiated preoperatively. Most significantly, a 6-week course of FDA-approved lotilaner ophthalmic solution was prescribed to eradicate the Demodex mites. This comprehensive approach aligns with current evidence suggesting that untreated Demodex blepharitis increases risk of bacterial load and potential surgical complications.

The clinical outcome after 6 weeks of targeted therapy demonstrated remarkable improvement in both subjective symptoms and objective metrics. Complete resolution of collarettes was observed, lid margins appeared healthy, and bacterial burden was presumably reduced. Critically, refractive measurements between biometry, topography, and autokeratometry showed consistency, enabling accurate toric IOL placement planning. The corneal surface regularized, with elimination of the previously observed "irregularly irregular" pattern. The patient's SPEED questionnaire score decreased significantly, osmolarity normalized, and MMP-9 testing returned to negative. Although best-corrected visual acuity remained 20/50 due to nuclear sclerosis, the patient reported elimination of diurnal fluctuations and complete resolution of lid margin symptoms, including crusting, erythema, and pruritus. Most notably, corneal epithelial staining completely resolved, confirming the transition from visually significant to non-visually significant OSD.

Research data supports the prevalence and clinical significance of ocular surface disease in preoperative cataract patients. A collaborative study between major academic centers found that among asymptomatic preoperative patients, 85% had at least one abnormal diagnostic test (osmolarity or MMP-9), while approximately 50% exhibited abnormalities in both parameters—consistent with visually significant OSD despite absence of symptoms. This asymptomatic presentation creates diagnostic challenges and underscores the importance of objective testing. The transformation from visually significant to non-visually significant OSD in this case enabled optimal surgical outcomes, including the successful implementation of a multifocal IOL—a lens choice that would have been contraindicated in the presence of untreated ocular surface disease. This case illustrates the critical importance of preoperative Demodex eradication and comprehensive OSD management to achieve optimal visual outcomes, particularly when premium IOLs are planned.