Eyeworld

FALL 2025 | EYEWORLD | 37 C by Liz Hillman Editorial Co-Director About the physicians Tal Raviv, MD Eye Center of New York New York, New York William Trattler, MD Director of Cornea Center for Excellence in Eye Care Miami, Florida later for repeat measurements. "We did this for a few years," he said. "I was just getting my practice going, so we had the capacity to do it, but I did notice that a large majority of these patients came back, we repeated the biometry, and it was the same." Dr. Raviv said that perhaps the testing para- digm for ocular surface disease was a "little too sensitive" for what was needed to proceed with cataract surgery for most patients. So, as his practice matured, he started to figure out which patients actually needed optimization vs. which ones didn't. As in the ASCRS Preoperative OSD Algo- rithm, which separates dry eye into visually significant vs. non-visually significant, Dr. Raviv said visually significant dry eye cases were the ones where keratometry measurements im- proved after surface optimization therapies. "The ones that were not visually signif- icant, meaning patients may have had some symptoms, some blepharitis, or some abnormal point-of-care testing, but they did not have corneal staining, we found a way to be more specific," he said. "The topography looked nor- mal, and there were multiple keratometries that we did on biometric devices lined up. Those patients did just fine going with those initial measurements for surgery." A significant number of patients presenting for cataract surgery have signs or symptoms of dry eye. 1 In recent years, there has been a concerted education effort on the importance of ocular surface optimization to ensure accurate IOL calculations and candidacy for advanced-technology IOLs, when desired. In addition, there are now more treatments avail- able for dry eye and ocular surface conditions. With an increase in education and treat- ment options, however, some questions can arise. Who really needs surface optimization vs. who is essentially ready to schedule for surgery now? What's reasonable in terms of treatment? When is a patient who needed ocular surface optimization ready for surgery? Targeting optimization Tal Raviv, MD, said about a decade ago he began to practice based on refractive cataract surgery. It was a time when the impact of the ocular surface on refractive outcomes became widely publicized. At that time, he said, the practice was performing surface optimization measures on 70% of their patients. "We were bringing them back for any ab- normality," Dr. Raviv said of putting patients on a surface optimization protocol before repeating biometry for IOL calculations. Over time, how- ever, the practice found that for many patients, this aggressive optimization didn't move the needle in terms of outcomes. "We did (and still do) dry eye screening questionnaires for any new patient," he said. "We empowered our staff members to do further diagnostic tests, such as osmolarity or MMP-9 testing or meibomian gland imaging. Then we would do the slit lamp examination and other diagnostic cataract devices. With all that, I used to find just about everyone had something off. Whether they had symptoms of dry eye on the SPEED questionnaire or signs of dry eye, one of their point-of-care tests was a little off." As such, the practice began patients on a protocol that could include a range of sur- face optimization therapies—over-the-counter tears, supplements, heat and massage therapy, prescription eye drops, or even in-office proce- dures—before seeing them back several weeks Surface optimization—what's reasonable? continued on page 38 Corneal topography revealed marked irregular astigmatism characterized by central flattening and superior steepening, with slit lamp examination identifying EBMD as the underlying cause of the irregular corneal shape Source: William Trattler, MD

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