While participating in the Academia Global Forum in Dubai, Ahmad Fahmy, OD, FAAO, recognized that effectively treating dry eye disease (DED) prior to procedures was top of mind for a majority of the attendees. Many of the cornea specialists in attendance were very excited about the ocular surface disease sessions.
According to Dr. Fahmy, “The topic of optimizing the ocular surface before surgery is something that is really catching on in the Middle East as well [as the United States]. It was a common thread in a lot of our discussions.”
And though discussions are happening and awareness is increasing, both doctors in today’s video feel clinicians could be more proactive in addressing ocular surface issues prior to cataract and refractive surgery (e.g., PRK, LASIK, SMILE).
Dr. Fahmy stated, “Thanks to the work that Dr. William Trattler and others have done, I definitely think there is a greater awareness. But, unfortunately, in clinical practice, I still see dry eye not really treated aggressively enough before surgery.”
In this episode of Dry Eye Fireside Chat, he and host Damon Dierker, OD, FAAO, share their experiences and offer timely tips to ensure a compromised ocular surface does not result in compromised vision post-surgery.
ODs own the onus of DED detection
Although nearly 35% of all adults suffer from DED, the incidence of DED in cataract surgery patients tends to be even higher. Studies have shown that nearly 50 to 70% of patients presenting for cataract surgery can have signs of DED on clinical examination and testing. Almost 50% of these patients are unaware that they have an underlying condition.1,2
However, if not identified prior to surgery, DED can significantly impact measurements used for cataract surgery. Errors in keratometry and biometry can lead to unexpected and unwanted post-operative refractive errors due to inaccurate intraocular lens (IOL) power selection.
When compared with patients without hyperosmolarity, individuals with hyperosmolar ocular surfaces had significant variability in keratometry readings and astigmatism measurements.3 Small degrees of refractive inaccuracy can significantly degrade the quality of vision, especially when premium IOL technology is at play.
Between post-operative care instructions and fielding patient questions, surgeons often do not have the bandwidth or chair time to delve into DED. Therefore, it is important for optometrists to take the lion’s share of responsibility in identifying and treating dry eye.
Ideally, a thorough history followed by diagnostic tests should be completed by a Doctor of Optometry specialized in ocular surface disease (OSD) on the front end. Treatment should be prescribed, and any existing problems should be addressed before scheduling surgery. It is especially important to make certain there is no trace of central punctate epithelial keratitis (PEK).
Inquire about variability in vision
Prior to sending a patient with a visually significant cataract into the hands of the surgical team, it is imperative to take a detailed history to establish exactly what is currently happening with their vision beyond the typical complaints of contrast, glare, and halos.
Often, fluctuating vision is indicative of ocular surface issues, so ask specifically about variability in vision. Questioning can be as simple as, “Are there times throughout the day that you see more clearly than others?” or “Do you ever find your vision worsens as the day progresses?”
Assess the tear film
Both doctors feel very strongly about thoroughly assessing the tear film. Knowing whether the tear film is evaporating too quickly or breaking up too rapidly can help guide next steps. Dr. Fahmy said, “It gives you a clue on how to treat that dry eye more efficiently before their surgery.”
After adding fluorescein to the eye, examine the tear breakup time, tear meniscus, and, specifically, how it is breaking up and the patterns involved to determine the nature of the insufficiency. For example, an immediate spot break pattern could point to goblet cell deficiency, which is common in glaucoma patients on topical pressure-lowering drops.
In cataract patients who are also being treated for glaucoma, certain medications—non-selective beta-blockers (timolol and levobunolol) and drops containing benzalkonium chloride (BAK) as a preservative—can play a role in reduced goblet cell density, so this can be an excellent option for patients to help reduce dependence on topical pressure lowering drops after surgery.
The goal should be to replenish basal tear secretion in these patients pre-operatively and re-establish healthy surface mucin levels. In addition to topical medications (perfluorohexyloctane, cyclosporine, etc), neurostimulation is one of the most effective means to do so.
According to Dr. Fahmy, “I want to make sure that the tear film is as pristine as we can get it and knock out any PEK, especially more central PEK, before surgery.”
Manage meibomian gland dysfunction
In addition to the tear film, it is important to understand the role of meibomian gland dysfunction (MGD) in dry eye disease. Dr. Fahmy urges optometrists to become comfortable manipulating the eyelids and performing the appropriate diagnostic tests to identify potential obstruction.
Once MGD is identified, a treatment regimen can ensue. This may entail warm compresses, prescription medications, eye hygiene, and/or in-office procedures, such as LipiFlow Thermal Pulsation System, BlephEx, and intense pulsed light (IPL). Managing MGD is a crucial part of ocular surface optimization.
Refer to a dry eye specialist when necessary
Today, there are a plethora of tools available to treat dry eye disease, including artificial tears, prescription medications, punctal plugs, and advanced point-of-care treatments. In-office treatments such as IPL, radiofrequency (RF), Lipiflow, TearCare, iLux, BlephEx, NuLids Pro, and others offer targeted interventions to address causes of evaporative dry eye, in addition to other elements of DED as well.
However, not all Doctors of Optometry have access to all treatments. If you feel your patient could benefit from a procedure you cannot complete in-office, it is preferable to make a referral to a fellow OD who specializes in dry eye and has the technologies at hand.
Remember: The ultimate goal is a successful surgical outcome and patient satisfaction.
Opt for early education
The earlier you can educate the patient on the importance of a healthy ocular surface and the value of treatment, the more likely they are to follow instructions and be compliant.
Oftentimes, patients are preoccupied with just having their cataract removed as quickly as possible and do not want delays. It is critical that patients understand the relationship between pre-surgical measures to address DED and post-surgical complications.
Final thoughts
When optometrists and ophthalmologists work together with the mission of achieving superior surgical results—from the initial consultation through the operation to post-operative follow-ups—patients are the ultimate winners.
“This model of optometry and ophthalmology working together for the patients produces the best, best outcomes,” Dr. Fahmy said.
In closing, he reiterated, “If there's one thing I've learned in treating ocular surface disease, it is that identifying it [OSD] early and treating it appropriately is really important for success.”
