24 | OCTOBER 2021

� COVER FOCUS THE SURGICAL ADVOCATE

As a primary care optometrist with an emphasis in ocular surface disease (OSD), I’ve found it encouraging that surgeons have become increas-

ingly aware of the need to treat OSD perioperatively. Surgeons today under-stand that OSD is sometimes invisible, so we must screen everyone and treat them appropriately, rather than simply addressing only the obvious cases.

This is true for patients undergoing both cataract and refractive surgeries, regardless of their age. One study found that one in three patients who visited an eye doctor had complaints of OSD.1 Another found that 24.1% of asymptomatic patients had dry eye.2 In that same study of 400 participants,

dry eye was present in 54.3% of patients older than 40 years and 67.3% of those 71 years or older.2 Further, in another study, among 120 patients referred for cataract surgery, 80% had at least one abnormal result on objective OSD tests.3

OSD: PRESENT UNLESS DISPROVEDGiven the above, my assumption

with the surgical patients I comanage is that OSD is present unless examina-tion proves otherwise. It is therefore essential to diagnose and treat OSD perioperatively because the condition can affect postoperative outcomes in both refractive accuracy and patient satisfaction.

Keratometry readings, and therefore IOL power calculations, are less reliable

in patients with OSD than in patients with a healthy ocular surface, but treating OSD before biometric mea-surements are taken can help ensure repeatable and consistent measure-ments and, therefore, better visual outcomes.4 Additionally, surgery can potentially disrupt corneal nerves on the ocular surface and decrease the quantity and quality of tears during the healing process.5 We expect to see temporary inflammation and decreased tear breakup time (TBUT) postopera-tively, both of which result in patients experiencing greater discomfort.5

For patients with preoperative OSD, surgery can exacerbate the signs and/or symptoms of the condi-tion, and if patients are not educated

STRATEGIES FOR THE SUCCESSFUL PERIOPERATIVE MANAGEMENT OF OSD

To avoid surprises after cataract or refractive surgery, stabilize the ocular surface first.

BY THOMAS CHESTER, OD, FAAO

OCTOBER 2021 | 25

COVER FOCUS THE SURGICAL ADVOCATE �

preoperatively, they will blame the surgery—and the surgeon—for their increased discomfort. A recent study of patients who received toric IOLs during cataract surgery found that 57% of those who were dissatisfied with the result attributed their dis-satisfaction to refractive error, and 35% pointed to OSD.6 When OSD is treated preemptively, surgeons can obtain repeatable and accurate mea-surements, potentially maximizing objective and subjective satisfaction.

THE GOAL: A STABLE OCULAR SURFACE

When we screen patients for OSD before surgery, we’re generally looking for common conditions such as aqueous deficiency, evaporative dry eye disease in the form of meibomian gland dysfunc-tion (MGD), blepharitis, or some combi-nation of these. We may also find more acute ocular surface conditions such as superficial punctate keratitis.

In most instances, we can treat OSD within a timeframe of 4 weeks to avoid a significant delay in surgery. The goal is not to cure OSD before proceeding to surgery (most conditions are chronic and patients will require ongoing ther-apy), but rather to stabilize the ocular surface to allow accurate preoperative measurements, to ensure greater post-operative comfort, and to make the patient aware of the effect OSD can have on his or her comfort and vision.

Although there are several algo-rithms at our disposal, I typically rely on the treatment guidelines estab-lished by the Tear Film & Ocular Surface Society Dry Eye Workshop (TFOS DEWS II) study.7 For diagnostic purposes, I follow guidelines from the American Society of Cataract and Refractive Surgery,8 starting with use of the verified Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire. I consider anyone with a score of 8 or higher on that question-naire to be a suspect for OSD.

To add to this subjective informa-tion, I perform initial screening using

corneal topography, which provides further analysis of the mucin, aqueous, and lipid layers of the tear film, plus imaging of the meibomian glands. Additional screening methods include TBUT, which gives me a better idea of whether the patient has an adequate functioning tear film, and staining to ascertain the health of the ocular sur-face, cornea, and conjunctiva.

If a patient has significant OSD symptoms, tear osmolarity measure-ments (TearLab Osmolarity System, TearLab), inflammatory marker testing (InflammaDry, Quidel), and corneal epithelial cell mapping can all provide further valuable information.

The second part of the process is setting the patient’s expectations for realistic outcomes. We evaluate the situation and do our best to optimize the ocular surface before surgery, but we must make sure the patient understands the situation.

I might explain, for example, that our tests show that the lipid layer in the patient’s tears is deficient, but that we are going to treat the problem in an attempt to optimize the surface of his or her eye before surgery. I’ll admit that we may not be able to treat it completely, and that these are the challenges that the patient might experience if his or her tear film is not optimized. I then explain the potential postoperative consequences such as

transient blurred vision during the healing time frame, and point out the additional challenges for cataract patients considering multifocal lenses. Considerations such as glare, halos, or starbursts can be exacerbated by poor tear quality and lead to decreased satisfaction with surgical results. This conversation helps patients make good choices and avoids surprises if there are ocular surface problems after surgery.

TREAT AGGRESSIVELY In the context of surgery, the short

preoperative timeline makes it essen-tial to treat OSD aggressively and get results quickly, after which patients may remain on chronic therapy. In some instances, such as severe dry eye with superficial punctate keratitis right through the visual axis, the patient should have surgery delayed for addi-tional therapy until the ocular surface is stable enough to provide reliable and repeatable measurements.

Patients with minimal OSD receive education, recommendations for envi-ronmental modification, artificial tears, and possible changes to their existing medications. Those with mild OSD may receive nonpreserved lubricating drops, punctal occlusion, moisture goggles, topical immunomodulatory drops (a number of commercial for-mulations of cyclosporine are available from different vendors), moist heat

s

In one study, among 120 patients referred for cataract surgery, 80% had at least one abnormal result on objective ocular surface disease (OSD) tests.

s

Keratometry readings, and therefore IOL power calculations, are less reliable in patients with OSD than in patients with a healthy ocular surface.

s

Treating OSD before biometric measurements are taken can help to ensure repeatable and consistent measurements and, therefore, better visual outcomes.

AT A GLANCE

26 | OCTOBER 2021

� COVER FOCUS THE SURGICAL ADVOCATE

compresses, and recommended use of lifitegrast ophthalmic solution 5% (Xiidra, Novartis) for symptom relief. If MGD is suspected, we add omega-3 fatty acid supplements.

In patients with moderate to severe OSD, we can add an autolo-gous tear, biologic drops, or amniotic membrane to the aforementioned therapies. For those with MGD, we consider adding Demodex treatment, one of several available in-office therapies that heat and express the meibomian glands, a topical antibi-otic such as azithromycin (we use a preservative-free compounded formu-lation, PF Klarity-A, from ImprimisRx) or antibiotic-steroid combination for blepharitis, and/or oral doxycycline/azithromycin.

Although we might recommend a heat mask and prescribe a topical immunomodulator, the preoperative time frame doesn’t necessarily give us time for those measures to work. As a result, I rely more heavily on a short-term topical steroid such as loteprednol etabonate ophthalmic suspension 0.25% (Eysuvis, Kala Pharmaceuticals) or fluorometholone

acetate ophthalmic suspension 0.1% (Flarex, Eyevance Pharmaceuticals) to bring down the inflammation and use an in-office procedure to restore mei-bomian gland function and improve the tear lipid layer.

Treatment can also be tailored to both the patient’s condition and the surgery. For example, if a cataract patient is planning to get a multifocal IOL, even a subtle ocular surface prob-lem can interfere with image quality. We would set the bar for success even higher than for a monofocal IOL (longer TBUT or better osmolarity, for example) and treat more aggressively.

Finally, to reach our goal of stabilizing the ocular surface as the clock ticks down to surgery, patients must be compliant with therapy. This is another reason to lean toward in-office procedures and fast-acting steroids rather than chronic at-home therapies. Another challenge for patients is the out-of-pocket costs for therapies and procedures, which may or may not be covered by insur-ance. However, patients are invested in the success of their surgeries, so I experience little pushback on costs.

CONTINUE THERAPYFor patients recovering from

cataract or refractive surgery, our clinic prescribes a preservative-free compounded antibiotic/steroid/nonsteroidal antiinflammatory drop (prednisolone acetate 1%, moxifloxa-cin 0.5%, nepafenac 0.1%; LessDrops, ImprimisRx) once daily for a month after surgery.

After healing is complete in both eyes, it’s important to continue chronic therapy and keep tracking OSD against baseline testing. I continue to manage patients based in our practice with 6-month follow-up visits to maintain stability throughout the seasons. For comanaged patients referred to us for surgery, I include a letter to the refer-ring doctor detailing OSD treatment.

Some optometrists continue therapy and follow up with the patient on their own schedule, whereas others prefer to comanage these patients. The impor-tant thing is to ensure that patients understand that OSD is an ongoing problem that must be managed, and that you, as their eye doctor, can help them accomplish this either by diag-nosing and treating their condition appropriately or by comanaging their care with a colleague. n

1. Farrand KF, Fridman M, Stillman IO, et al. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol. 2017;182:90-98.2. Shah S, Jani H. Prevalence and associated factors of dry eye: our experience in patients above 40 years of age at a tertiary care center. Oman J Ophthalmol. 2015;8(3):151-156.3. Gupta PK, Drinkwater OJ, VanDusen KW, et al. Prevalence of ocular surface dysfunc-tion in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018;44(9):1090-1096.4. Chuang J, Shih KC, Chan T, et al. Preoperative optimization of ocular surface disease before cataract surgery. J Cataract Refract Surg. 2017;43(12):1596-1607.5. Donnenfeld ED, Solomon K, Perry HD. The effect of hinge position on corneal sensa-tion and dry eye after LASIK. Ophthalmology. 2003;110(5):1023-1030.6. Gibbons A, Ali T, Waren D, Donaldson K. Causes and correction of dissatisfaction after implantation of presbyopia-correcting intraocular lenses. Clin Ophthalmol. 2016;10:1965-1970. 7. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II definition and classification report. Ocul Surf. 2017;15(3):276-283.8. Starr C, Gupta P, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684.

THOMAS CHESTER, OD, FAAOn Clinical Director, Cleveland Eye Clinic, Brecksville, Ohion drchester@clevelandeyeclinic.comn Financial disclosures: Consultant (Novartis, Kala

Pharmaceuticals, Allergan, Sun Pharma, Sight Sciences, Johnson & Johnson Vision)

MY ASSUMPTION WITH THE SURGICAL

PATIENTS I COMANAGE IS THAT OSD IS PRESENT

UNLESS EXAMINATION PROVES OTHERWISE.

IT IS THEREFORE ESSENTIAL TO DIAGNOSE

AND TREAT OSD PERIOPERATIVELY BECAUSE

THE CONDITION CAN AFFECT POSTOPERATIVE

OUTCOMES IN BOTH REFRACTIVE ACCURACY

AND PATIENT SATISFACTION.