With an aging population and rising expectations from patients on the surgical outcomes of cataract surgery, understanding how two distinct disease entities, namely meibomian gland dysfunction (MGD) and cataract surgery, intertwine into one treatment journey for patients is crucial for the ophthalmic community.
This episode of Interventional Mindset outlines clinical pearls from Drs. Parekh, McGee, and Ayres for co-managing cataract surgery in ocular surface disease (OSD) patients and the necessity for tandem action with tuning up the ocular surface prior to cataract extraction to optimize the surgical outcome.
Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.
Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.
Managing patient expectations around cataract surgery
Considering the influx of new technological developments in refractive and cataract surgery, it is worth taking stock of these innovations, such as light adjustable lenses (LALs) along with advanced technology intraocular lenses (IOLs), including presbyopia-correcting IOLs (multifocal, trifocal, extended depth of focus [EDOF]) and toric IOLs that offer patients many different approaches to vision correction.
This constant evolution in cataract surgery has even impacted how surgeons understand the procedure, as cataract surgery is now seen as a longer-term journey that factors in any medical treatments in the time prior to and following cataract extraction, explained Dr. Parekh.
Similarly, Dr. Ayres emphasized the importance of discussing visual goals upfront with patients. This can aid surgeons in narrowing down the broad array of technology available to what is appropriate for the patient and bring them closest to their desired outcome. Interestingly, because the technology for measuring biometry and IOLs has developed so rapidly, now other problems have begun to move to the forefront, such as how to record quality biometry measurements and optimize the ocular surface prior to cataract surgery.
Dr. Ayres noted that a trap some surgeons may fall into is selecting a lens for a patient without performing a thorough pre-operative workup, unfortunately causing the surgical outcome to suffer.
How to factor in the ocular surface during the cataract surgery journey
A pristine ocular surface is critical from the time the patient walks in for a cataract consult through the follow-up period, and it is beneficial to focus on first setting clear treatment expectations with the patient and communicating these expectations in an accessible fashion.
As an optometrist who works closely with referring ophthalmologists, Dr. McGee explained that at her clinic, the moment it becomes clear that a patient will need cataract surgery, she begins developing a plan for how to treat the ocular surface before the patient even visits the co-managing ophthalmologist. Once the patient is referred to the surgeon, she shifts to creating a treatment plan that factors in how to maintain the ocular surface during the post-operative period.
Dr. McGee emphasized that some eyecare practitioners (ECPs) make the mistake of not "front-loading" the ocular surface treatment prior to surgery and subsequently planning it through the end. Treating patients proactively is beneficial to the overall process, as she can make time to record any information that could be relevant or impactful for the surgeon to help ease the patient while they transition care to the co-managing ophthalmologist for a cataract surgery consultation.
This is especially true for an unstable ocular surface since biometry measurements can vary widely up to a 3.0D differential, explained Dr. McGee. She highlighted that her goal is to ensure that the patient’s measurements going into the cataract consult are as accurate as possible to help the patient potentially achieve an optimal surgical outcome.
Preventing delays with thorough pre-operative workups
As part of her ocular surface optimization protocol, Dr. McGee always starts patients off with a questionnaire, fluorescein staining, and assessing meibomian gland function. She explained that this efficient process was borne out of seeing how unmanaged ocular surface damage can cause significant delays in cataract surgery. In her professional medical opinion, she envisions the role of optometrists in cataract surgery as being focused on treating any ocular surface dysfunction as early as possible so that when the patient sees the cataract surgeon, the treatment has already been initiated prior to the consultation.
Dr. Parekh added that his colleagues Eric Donnenfeld, MD, and Paul Karpecki, OD, FAAO, stated that if surgeons ignore the ocular surface before cataract surgery, it will become their problem post-operatively. However, if the ocular surface is dealt with pre-operatively, and the surgeon and optometrist work as a team with the patient, it becomes an “us” problem everyone can work towards resolving.
The importance of the patient handoff between ECPs
In addition, Dr. Ayres highlighted the value of a thorough patient handoff, in which ECPs put in the extra leg work to start addressing OSD before the patient meets with the ophthalmologist. He ruminated that Dr. McGee’s protocol is not a well-established practice for many optometrists and that, hopefully, with time, it will become an expected part of any patient handoff to improve the overall clinical workflow, surgical experience for the patient, and surgical outcomes.
Further, he observed that the handoff back from the surgeon to the optometrist is also equally critical, and similarly, it is the responsibility of the ophthalmologist to ensure the patient has guidance on how to continue to manage the ocular surface post-operatively; otherwise, their OSD will progress, and their eyesight might be negatively impacted.
Ultimately, cataract surgery requires a treatment journey with clear communication back and forth between both optometrists and ophthalmologists to ensure the best possible surgical outcome and to get as close as possible to the patient’s vision goal.
Where does managing MGD fit into the treatment paradigm of cataract surgery?
Meibomian gland dysfunction is a critical part of any discussion surrounding the ocular surface, as most patients have multifactorial dry eye, and the majority of pharmaceutical treatments for dry eye target aqueous-deficient dry eye. As such, many of the treatments for MGD are interventional, as opposed to medical.
Dr. Ayres added that he believes that expensive imaging systems such as LipiView, while helpful, are not always necessary to screen patients for MGD. At a minimum, he explained, eyecare practitioners can evaluate patients’ meibomian glands using the “Look, Lift, Pull, Push” exam developed by the American Society of Cataract and Refractive Surgeons (ASCRS) as part of their Pre-Operative OSD Algorithm.
He noted that following the assessment, if the patient has an MGD component to their OSD, it is necessary to move forward with treatment. He prefers to recommend a procedure that heats the lids followed by manual compression and potentially combined with lid debridement.
In his clinical experience, he has found TearCare to be simple to integrate and perform, noting many of his patients respond well to treatment relatively quickly. Dr. Parekh mentioned that he also likes to prescribe TearCare to his patients as it allows for a targeted approach to the disease, which often does not present homogeneously across the general population who suffer from lid disease.
Using intense pulsed light therapy for dry eye patients
For patients with ocular rosacea, Dr. McGee recommends prescribing both TearCare and intense pulsed light (IPL) therapy. She prefers to initiate a course of IPL and, towards the end of the treatment cycle, segue into TearCare, as much of the inflammation initially present has been calmed by then. She found that adding TearCare helped improve the treatment results more than starting with it.
Dr. McGee then explained that having an IPL machine is most helpful for practices with many ocular rosacea patients, as the heating and expression of the eyelids and meibomian glands do not sufficiently address the telangiectatic vessels that cause inflammation. As such, depending on the patient population of the practice, IPL is beneficial for targeting the ocular rosacea component of dry eye more efficiently than most lid margin treatments.
Further, she added that she always performs the first treatment of IPL to identify clear clinical endpoints for the patient. Once the treatment protocol has been outlined, she has an ocular hygienist that she personally trained to assist her in administering the subsequent treatments. Additionally, Dr. McGee emphasized that she is keeping a close watch on the results of the Titan study for TP-03. She hypothesized that treating Demodex could be another approach to managing ocular rosacea.
This new research is part of an evolution of treating dry eye with both pharmaceutical and procedural treatments to efficiently intervene and address one of the root causes.
The time frame for MGD treatment before cataract surgery
Subsequently, Dr. McGee asked Drs. Parekh and Ayres to discuss their preferred time frame and protocol for performing MGD treatments and when to have the patient return for cataract surgery. When using a lid margin treatment, Dr. Ayres explained that he anecdotally has seen rapid improvement as early as 2 weeks, with the effects lasting for 6 months.
He has found that with the quick onset of the treatment and the length of time that it provides symptom relief, he recommends doing the treatment at least 2 weeks prior to cataract surgery, though he has waited after a month as well and still had positive results.
Conclusion
With the broad array of dry eye and MGD treatments, as well as technological advancements in cataract surgery techniques, the ophthalmic community currently has a multitude of options available in their armamentarium to identify a collaborative, targeted treatment plan that best fits the needs of OSD patients set to undergo cataract surgery.
