Jodi Luchs, MD Carlos Buznego, MD William Trattler, MD Asymptomatic or Minimally Symptomatic Blepharitis in Patients Having Cataract Surgery Jodi Luchs, MD Carlos Buznego, MD William Trattler, MD The authors of this poster have received research funding and travel expense reimbursement from Inspire Pharmaceuticals. Jodi Luchs, MD , Carlos Buznego, MD and William Trattler, MD are consultants for Inspire Pharmaceuticals.

Abstract Title: Asymptomatic or Minimally Symptomatic Blepharitis in Patients Having Cataract Surgery Authors: Jodi I. Luchs, Carlos Buznego, William B. Trattler Purpose: This sub-analysis of previously reported data analyzed the prevalence of asymptomatic or minimally symptomatic blepharitis and the tear film status in patients preparing to undergo cataract surgery. Methods: A sub-analysis of our previously reported cohort of 100 Patients was performed to assess the prevalence of minimally or asymptomatic blepharitis (mean symptom score or 1 or 0), and the tear film break-up time (TFBUT) in those patients. Results: 59/100 (59%) of patients had blepharitis. 45 of the 100 patients (45%) were asymptomatic or minimally symptomatic for ocular surface disease (mean symptom scores or 0 or 1), 26 of which had blepharitis (44.1%). 15/45(33.3%) of these patients had TFBUT scores of ≤5 seconds in at least one eye. Of these, 12 of the 15(80%) had blepharitis. Similarly, 31/45(68.9%) had TFBUT scores of ≤7 seconds in at least one eye. Of these, 19 of the 31 (61.3%) had blepharitis. 19/ 26 patients (73.0%) with minimally or asymptomatic blepharitis had TFBUT of 7 seconds or less. Conclusion: This sub-analysis reveals that minimally symptomatic/asymptomatic blepharitis is common in patients undergoing cataract surgery. The mild or absent symptoms may contribute to the condition being overlooked. However, this condition may have important effects on the TFBUT/ocular surface, which may have important pre/post-operative implications for patients undergoing ocular surgery.

Introduction Both Anterior and posterior blepharitis are common ocular surface disorders, which may be frequently overlooked, yet may have a significant impact on the outcomes of ocular surgery. Our previously reported data1 suggests that there is a high prevalence of blepharitis in patients preparing to undergo cataract surgery, yet the average clinical sign and symptom scores were mild-moderate. This sub-analysis evaluated the prevalence of minimally symptomatic or asymptomatic blepharitis and the status of the tear film in patients undergoing routine cataract surgery.

Methods A sub-analysis of data from a previously performed prospective, multicenter observational study which assessed the incidence of blepharitis in 100 patients scheduled to undergo cataract surgery was performed1. Minimally symptomatic patients were defined as those with a mean clinical symptom score of 1 (scale 0-4) Asymptomatic patients were defined as those with a symptom score of 0 Primary outcome measures in the original study: The presence or absence of blepharitis (presence of at least 2 clinical signs of blepharitis, at least one of which had a severity score of ≥2 on a scale of 0-4) Total blepharitis symptom severity score (summed symptom scores for itch, foreign body sensation, dryness, burning or pain, and swollen/heavy eyelids (scale 0-4 for each symptom)) Blepharitis clinical sign severity scores for lid debris, lid swelling, meibomian gland plugging, and quality of meibomian gland secretions (scale 0-4) Degree of ocular surface fluorescein staining (NEI grading system1) Tear film break up time (TFBUT)

Patient Demographics 59% of patients were diagnosed with blepharitis Mean age was 72.4 years (range: 52-88)

Prevalence of Blepharitis in the Study Population

Prevalence of Blepharitis in Symptomatic and Min/Asymptomatic Subjects

TFBUT Distribution of Asymptomatic/Minimally Symptomatic Subjects

Rapid TFBUT (≤ 7 Seconds) in Symptomatic and Min/Asymptomatic Blepharitis Subjects

Discussion Blepharitis is one of the most common conditions encountered by eye care professionals, although it may be frequently overlooked. It is important to recognize and treat this condition pre-operatively in patients about to undergo ocular surgery in order to potentially reduce the risk of post-operative infection,3-5 as well as to stabilize the tear film in order to ensure accurate pre-operative keratometry, topography or wavefront analysis. Post-operatively, untreated posterior blepharitis may also contribute to worsening of post-operative dry eye, fluctuating vision or a slower recovery of vision. Our original study found that 59% of patients undergoing routine evaluation for cataract surgery had clinical signs of blepharitis, making it a commonly occurring condition. However, the overall clinical sign and symptom scores were low for this cohort of patients, suggesting that this condition may be frequently overlooked. In this sub-analysis, we determined that almost half (45%) of the patients in the original study were asymptomatic or minimally symptomatic for ocular surface disease, yet more than half of those patients (26 of 45, 57.8%) had blepharitis. Conversely, of the 59% of patients who had blepharitis in this study, almost half (26 of 59, 44.1%) had minimal or no symptoms. However, there is a real disturbance to the tear film, even in these patients with minimal or no symptoms. One third of patients with minimal or no symptoms (15 of 45, 33.3%) had a TFBUT of 5 seconds or less in at least one eye. Of these, 12 of the 15 (80%) had blepharitis. Similarly, 68.9% of patients with little or no symptoms had a TFBUT of ≤ 7 seconds in at least one eye, and most of these patients (61.3%) also had blepharitis. Of the 26 patients with minimally or asymptomatic blepharitis, 73% had a TFBUT of ≤ 7 seconds. This suggests an association between the presence of blepharitis and a disturbance of the tear film, even in the presence of little or no symptoms. This may have important implications for patients undergoing ocular surgery. It should be noted that this observational study did not control for the presence of other ocular surface diseases such as dry eye in either group, which might confound these results.

Conclusions Blepharitis is common in patients preparing to undergo cataract surgery. Mild or absent symptoms may contribute to the condition being frequently overlooked. However, there is a real disturbance of the ocular surface as evidenced by the more rapid TFBUT in these minimally symptomatic or asymptomatic patients. This can have potentially important implications for pre-operative measurements and post-operative outcomes of cataract and refractive surgery. REFERENCES: 1Luchs JI, Buznego C, Trattler W: Prevalence of Blepharitis in Patients Scheduled for Routine Cataract Surgery. Poster presented at the American Society of Cataract and Refractive Surgery annual meeting, Boston, MA 2010 2Lemp MA. Report of National Eye Institute/Industry Work shop on clinical trials in dry eyes. C L A O J 1995;21:221-232 3EVS Study Group: Arch Ophthalmol 1995;113(12):1479-1496 4Solomon et. al.: J Cataract Refract Surg. 2003;29:2001-2006 5Speaker MG et al.: Ophthalmology 1991;98(5):639-649