Eyeworld

I NOVEMBER 2019 | EYEWORLD | 47 widely from test to test, then DED or anoth- er form of visually significant OSD would be highly suspected," Dr. Starr said. Some of these diagnostic tools, such as the topography, enable surgeons to see other ocular surface disorders, including pterygium, Salzmann's nodules, and central corneal anterior basement membrane dystrophy (ABMD), said Brandon Ayres, MD. Topography also can warn surgeons about their prospective lens choice. "If I see irregular astigmatism on topography, then I'm not going to trust the keratometry and lens choice I'm getting on biometry. It'll often lead me down the wrong path," Dr. Farid. Whether OSD is likely or unlikely, the algo- rithm advises that surgeons conduct a clinical exam using their handy mnemonic, LLPP. The algorithm also recommends at this point that surgeons may want to perform tear break-up time, corneal staining, and a Schirmer's test. Although that may seem like a large battery of tests to conduct, they are complementary in the quest to assess for cataract, dry eye, and astigmatism, Dr. Ayres added. If OSD is ruled out after these tests, surgeons can proceed with their plans. If OSD is present, then treatment should take place preoperatively. Treatment before surgery If you see a patient with DED who is not hav- ing surgery, you may add treatments method- ically. However, if it's a preop patient who is eager to have a cataract removed, trying several questionnaire used should ask about dry eye in different ways, as patients may initially say no if you only ask, "Do you have dry eye?" "They won't say they have dry eye, but they will say they have vision fluctuation or have some other way of commenting on the symptoms," he said. If a patient has a positive response regarding symptoms, you can bill for some of the diag- nostic tests. At the office of Alice Epitropoulos, MD, technicians are empowered to perform point- of-care testing on symptomatic patients scoring above 6 on the SPEED questionnaire, she said. The diagnostic tests for DED may vary from surgeon to surgeon, but there are similar themes. The algorithm advises the use of a tear osmolarity test and inflammatory marker (spe- cifically, MMP-9). Those two tests have good data to back up their results, and they can be re- imbursed, Dr. Mah said. Patients with abnormal tear osmolarity have been shown to have greater variability in their keratometry readings and IOL power calculations compared to normal osmolar patients. 5 "If any one of those is abnormal, then there is a high likelihood of the presence of OSD and potentially visually-significant OSD," Dr. Starr said. Refractive tests commonly performed at the preoperative visit (e.g. keratometry, optical biometry, and topography) not only help in selecting the appropriate IOL, they also provide useful information on the status of the ocular surface. "When irregular astigmatism is pres- ent on topography, especially when 'irregularly irregular' astigmatism is seen or it fluctuates Dry eye disease with diffuse punctate epithelial erosions (PEE) About the doctors Brandon Ayres, MD Cornea specialist Wills Eye Hospital Philadelphia Alice T. Epitropoulos, MD Ophthalmic Surgeons & Consultants of Ohio The Eye Center of Columbus Clinical assistant professor, The Ohio State University Columbus, Ohio Marjan Farid, MD Director, cornea, cataract, and refractive surgery Vice-chair of ophthalmic faculty Professor of ophthalmology Gavin Herbert Eye Institute, University of California, Irvine Irvine, California Francis Mah, MD Scripps Health La Jolla, California Christopher E. Starr, MD Associate professor of ophthalmology Director, Cornea Fellowship, Refractive Surgery Service, and Ophthalmic Education, Weill Cornell Medicine, New York Presbyterian Hospital New York continued on page 48 Epithelial basement membrane dystrophy (EBMD) and punctate epithelial erosions; both conditions can reduce accuracy of preoperative measurements

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