Eyeworld

JULY 2019 | SUPPLEMENT TO EYEWORLD | 5 New direction for ocular surface disease diagnosis by Preeya Gupta, MD New tool provides step-by-step guidance for diagnostic process T he new ASCRS Preop- erative OSD Algorithm developed by the ASCRS Cornea Clinical Com- mittee provides surgeons in busy surgical practices with an easy-to-use framework for diagnosing and treating OSD. 1 With this tool, surgeons can address OSD as part of the process for evaluating presur- gical patients. The literature provides extensive evidence showing that a high percentage of patients arriving for cataract surgery consults have OSD, and we can assume that this is true for refractive surgery patients as well. 2,3 To deliver premium out- comes and achieve high-qual- ity vision, it is imperative for clinicians to address OSD. 4 Essential tests The OSD algorithm was designed to assess symptoms and signs of OSD in all patients being evaluated for refractive or cataract surgery. After noninvasive preop refractive measurements are performed, we administer the ASCRS SPEED II question- naire, which assesses patients' symptoms. This incorporates questions from the SPEED questionnaire (Johnson & Johnson Vision) and questions regarding additional OSD subtypes, along with questions about patient expectations, personality traits, and will- ingness to pay out-of-pocket costs to reduce spectacle de- pendence, which were adapt- ed from Dr. Steven Dell's Cataract and Refractive Lens Exchange Questionnaire. 5 Subsequently, the techni- cian performs point-of-care tear osmolarity and matrix metalloproteinase-9 testing to identify signs of OSD. 6,7 Determining OSD subtypes If all of these tests have negative results, OSD is unlikely; if any have positive results, additional testing is recommended to determine the stage of OSD and which aspects of OSD are present. Assessments may include mei- bography, corneal topography, optical coherence tomography tear meniscus measurements, ocular scatter index, aber- rometry, lipid layer thickness, noninvasive tear breakup time, or others. 1 Meibography enables the clinician to examine the un- derlying structure of the mei- bomian glands, which is very helpful in staging meibomian gland disease. It is difficult to determine at the slit lamp whether patients have meibo- mian gland atrophy (Figure 1). The next step is the clinical examination, includ- ing LLPP (look, lift, pull, and push) (Figure 2). The surgeon looks at the lashes, eyelids, in- terpalpebral surface, and blink; lifts the upper lids to examine the superior surface; pulls the lid to determine whether the patient has lid laxity; and gen- tly pushes on the meibomian glands to assess function and the meibum expressed. The algorithm guides clinicians in identifying sub- Figure 1. Meibomian gland dysfunction and fine telangiectasia along the lid margin continued on page 6 Preeya Gupta, MD Figure 2. LLPP (look, lift, pull, and push) Clinical exam (LLPP) Look: Lift: Pull: Push: Blink, lids, lashes, interpalpebral surface Upper lid, examine superior surface Assess lid laxity 'floppy eyelids', fornices Meibomian gland expression Stain (dye instillation): corneal staining? TBUT? +/–Schirmer's

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