Eyeworld

advancing surgical outcomes: Algorithm launches new era in preoperative OSD management 4 | SUPPLEMENT TO EYEWORLD | JULY 2019 keratometry readings and IOL calculations. 5 In addition, undiagnosed and untreated OSD can reduce satisfaction among pa- tients who had uncomplicated surgery. For all of these reasons, it is critical to take the time to diagnose and treat OSD before surgery. Building a mindset Before integrating the algo- rithm into a surgical practice, surgeons themselves need to recognize the impact of OSD in treating cataract and refrac- tive patients. They also need to make it clear to everyone in the practice who is involved in patient care that it is necessary to implement this algorithm or another system to evaluate every cataract and refractive surgery patient for OSD and treat it. In response to some med- ical professionals and patients who question the importance of diagnosing and treating OSD, we remind them that it is essential to perform corneal topography before refractive surgery or optical biometry before cataract surgery. We would never skip these tests on patients, who have high expectations of cataract and refractive surgery. Preopera- tive OSD management is the next step in trying to improve preoperative measurements, surgical outcomes, and patient satisfaction. If we do not try to imple- ment an OSD diagnostic and treatment system or show our passion for it, the office staff will not be on board. It is es- pecially important to educate technicians and physician ex- tenders about its importance because they play a major role in its implementation. Simplified process The new algorithm is easy to perform. Essential tests include the ASCRS SPEED II questionnaire, tear osmolarity, and matrix metalloprotein- ase-9. Data from these tests are provided to the surgeon, who then performs the LLPP (look, lift, pull, and push) step of the examination. Additional tests may be added if available, but we designed the algorithm to be accessible and inexpensive. 1 The algorithm standard- izes diagnosis of meibomian gland dysfunction, which accounts for 86% of cases of dry eye disease. 1,6 At the beginning of the process, the technician assesses tear osmo- larity, and ultimately, the sur- geon examines the meibomian glands. The algorithm also enables practices to include tests specifically focusing on meibomian gland dysfunction, such as meibography. Surgeons may consider ways to manage OSD testing expenses. If patients answer any questions positively on the ASCRS SPEED II questionnaire, testing will be reimbursed. However, even if patients have negative results, they may have asymptomatic OSD, so additional testing is important. Practices may include a portion of unre- imbursed test expenses in premium packages for cataract surgery, whether the patient is having femtosecond laser cataract surgery or receiv- ing toric, extended depth of focus, pseudoaccommodat- ing, or multifocal intraocular lenses. Conclusion When integrating the ASCRS Preoperative OSD Algorithm, surgeons need to embrace this process and emphasize its importance to staff. It is important to educate staff about the benefits of OSD management, stressing that it will improve postoperative outcomes and patient satisfac- tion, which will have a positive impact on the practice. n References 1. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669–684. 2. Nettune GR, Pflugfelder SC. Post- LASIK tear dysfunction and dysesthe- sia. Ocul Surf. 2010;8:135–145. 3. Naumann GO, Schlötzer-Schrehardt U. Amantadine-associated corneal ede- ma. Ophthalmology. 2009;116:1230– 1231; author reply 1231. 4. Chuck RS, et al. Refractive Errors & Refractive Surgery Preferred Practice Pattern. Ophthalmology. 2018;125:P1– P104. 5. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratom- etry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672– 1677. 6. Lemp MA, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472-478. Dr. Mah is director, cornea and external disease, and co-director, refractive surgery, Scripps Clinic, La Jolla, California. He can be contacted at mah.francis@ scrippshealth.org. Figure 1. Anterior staphylococcal blepharitis Figure 2. Inspissated meibomian glands continued from page 3

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