In this interview, Preeya K. Gupta, MD, and Brandon Baartman, MD, from Vance Thompson Vision, discuss how to integrate dry eye treatments, specifically therapies for meibomian gland dysfunction (MGD), into a surgically-focused ophthalmology practice.
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Incorporating dry eye therapies into a surgically-focused practice
Dry eye disease (DED) can significantly impact the measurements used for many ocular surgeries and, if left untreated, can lead to postoperative refractive errors. As a result of this, Dr. Baartman highlighted that dry eye therapies are a natural fit into a surgically-focused practice because maintaining the ocular surface goes hand in hand with optimizing surgical outcomes.
In order to seamlessly integrate the two, part of the strategy at Dr. Baartman’s practice is to promote education on diagnosing and managing dry eye to their referral network and the broader eyecare community. In this manner, the patients they receive tend to have already started the dry eye treatment process and are prepped for surgery.
To advocate for education on managing dry eye, members of the Vance Thompson Vision team make visits to the offices of referring practices to establish a relationship and review impactful tips. It is vital that referring partners know exactly what kind of patient profiles Dr. Baartman and his practice can best treat. Additionally, part of the goal is to push objective testing further upstream in the process so patients can walk into the clinic either ready for a specific procedure or, minimally, with baseline knowledge of the underlying cause of their dry eye symptoms.
Pearls on objective testing for ocular surface disease
To ensure that the patient’s ocular surface is primed for surgery, Dr. Baartman uses the Preoperative OSD Algorithm from the American Society of Cataract and Refractive Surgery (ASCRS) to guide the process from patient intake to the procedure.
He starts by providing all patients that come to the clinic with a SPEED questionnaire. The results of the questionnaire then direct the team towards objective testing, such as evaluating tear osmolarity, MMP-9 levels, or other tear film analysis tests.
Dr. Baartman mentioned that he most frequently uses topography and wavefront aberrometry to evaluate dry eye. For example, all of his preoperative patients have their topography measured, and he checks for any ocular surface irregularities such as epithelial basement membrane dystrophy (EBMD) or Salzmann's nodules. This facilitates the process of identifying dry eye and promptly switching gears to manage the signs and symptoms before these conditions cause possible complications.
The “1-2-3 punch” for treating dry eye in pre-surgical patients
To broadly treat potential underlying causes, Dr. Baartman targets three key factors for dry eye: tear volume, tear quality, and inflammation. If a quick recovery of the ocular surface is necessary for a surgical procedure, clinicians can focus on treating tear volume either by adding artificial tears or placing collagen plugs prior to surgery to retain the patient’s tear film.
The key to treating dry eye is understanding that these factors are not necessarily mutually exclusive, so if the priority is quickly treating the ocular surface, treating all three simultaneously accelerates symptom relief and improvements in topography and biometry measurements. To emphasize this, Dr. Gupta added that ASCRS algorithm stresses the importance of aggressive treatment for patients with pre-existing dry eye.
Integrating TearCare into your surgical practice
Patients with evaporative or MGD-related dry eye can be treated in-office with TearCare or Lipiflow or at home with palliative treatments like warm compresses. TearCare is Dr. Baartman’s go-to for in-office MGD therapies, as many of his patients are pre-surgical and, more specifically, pre-refractive, so the goal is to prime the ocular surface for the procedure. He also uses a meibography unit such as LipiScan to analyze the health of the meibomian glands to check if there are notable signs of MGD, particularly for premium cataract surgery or LASIK patients.
Integrating TearCare into a surgically-focused ophthalmology practice is a balancing act with the staff and team to refine the process. To facilitate this, at Dr. Baartman’s practice there is a dedicated room for the TearCare machine to create a soothing and relaxing environment for patients. One of the challenges is timing the treatment correctly to when the doctor can come in and check the glands before they cool. To prevent this, Dr. Baartman gets a text message 10 minutes into the TearCare treatment, signaling to him that he has 5 minutes to get to the room to express the patient’s meibomian glands.
To optimize the treatment process one step further, Dr. Baartman prefers to express meibomian glands with a high-definition slit lamp camera in the same room as the TearCare machine. While performing this technique, Dr. Baartman records a video or takes pictures to show the patient afterward. This provides feedback and information that the patient can use to better understand the treatment process since they can visualize the results. Of note, some patients might experience instantaneous symptom relief while others may have a ramp-up period that could take several weeks.
Conclusion
The value of having refractive and cataract surgeons adopt dry eye therapies in their practices to proactively treat the ocular surface before surgery is in helping patients understand that they have two concomitant diseases. On top of the cataract or refractive error that the patient is aware of, there is additional baseline dry eye.
As dry eye management often requires long-term treatment, for surgically-focused practices, adding dry eye therapies doesn't necessarily mean that they have to treat the patients long-term as well. By maintaining a strong referral network, you can point patients to primary care optometrists or other practices that focus on dry eye management to cultivate and strengthen relationships in your eyecare community.
