Eyeworld

38 | EYEWORLD | FALL 2025 ATARACT C Contact Raviv: talraviv@eyecenterofny.com Trattler: wtrattler@gmail.com Reference 1. Trattler WB, et al. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: the ef- fect of dry eye. Clin Ophthalmol. 2017;11:1423–1430. Relevant disclosures Raviv: Johnson & Johnson Vision Trattler: AbbVie, Alcon, Bausch + Lomb, BVI, Cassini Technologies, Harrow, Oculus, Sun Pharma, Zeiss these patients and waits 3 months for the re-ep- ithelialization and smoothing before proceeding with measurements for IOL calculations. "I'm really looking for a regular ocular surface with repeatable biometry on multiple devices to be comfortable that we can get close to the refractive outcome that the patient and I are desiring," Dr. Raviv said. Homework up front reduces postop work William Trattler, MD, said he brings back a lot of patients for surface optimization and repeat measurements. Patients in his practice, he clarified, are not counseled or pre-treated with anything prior to their first exam. If patients were advised, when they called in for their initial consultation, to use hypo- chlorous acid and artificial tears prior to their in-person exam, Dr. Trattler said it would result in better readings and reduce the need for bringing patients back after surface optimiza- tion measures. "Is the dry eye going to be solved for everyone, no … but it might be that only 20% of patients need a second set of readings," he said. Dr. Trattler said he obtains three measures of astigmatism prior to cataract surgery: a Cassini, a Pentacam (Oculus), and an IOLMaster 700 (Zeiss). If the astigmatism axis and power measurements align, he knows the readings are good. "As Dr. Raviv shared, in the presence of dry eye, if the three astigmatism results align, we can be confident that the measurements will provide reliable information for calculating our IOL power as well as our astigmatism power and axis," he said. "However, when there are significant differences in the three astigmatism measurements, I will initiate therapy for the ocular surface and have the patient return for repeat measurements." If you're only using one device for your astigmatism readings you can potentially miss these inconsistencies. Dr. Trattler emphasized that ocular surface optimization is important even for patients receiving basic monofocal IOLs. "These patients may not be selecting a premium IOL, but they're still undergoing surgery and have high expecta- tions," he said. "Our goal is to deliver the best refractive outcomes possible. While they under- stand they may need glasses afterward, it's criti- cal to avoid leaving them significantly off target. Every patient we treat becomes an ambassador Dr. Raviv clarified that this doesn't mean he didn't discuss or treat dry eye with these pa- tients, it just didn't delay the patients' surgeries. Dr. Raviv said he uses three keratometric devices and reflection topography (Placido disc) or an LED light topography. "We obtain two late generation biometries, an auto-K, and the Cassini topographer [Cassini Technologies], and that gives us four sets of Ks to look at, four sets of astigmatic axis of certain magnitude and direction. If those are variably off, we know that something's up on the ocular surface; we can't go forward," he said. "If they all line up nicely and the topographic picture looks regular, either bowtie astigmatism or spherical, I am com- fortable proceeding typically without further optimization of the surface." If a patient is optimized for severe or even moderate dry eye and they improve, Dr. Raviv said he still might avoid a diffractive multifocal IOL for this patient in favor of blended or mono- vision. "If it's just a mild dry eye, and they come back and look pretty good, I might use one of the newer generation multifocals," he said. "But if they're pretty dry and it took a while to get them to be optimized, I'm going to recommend a monofocal." With the number of cataracts going up, Dr. Raviv said efficiency is key. He has found that focusing optimization on only visually signifi- cant dry eye patients is more efficient. "I find that focusing on the more critical subset of dry eye patients that I mentioned, the visually significant dry eye patients, those are the ones we really don't want to miss, and we want to be able to bring those people back. For the ones who may have mild symptoms but they don't have visually significant dry eye, we want to ad- dress it, we want to know about it, but we're a little more confident in our biometry and those patients. The whole point is you're not delaying your surgery because of this." Finally, he said it's important to note that there are patients with conditions that typical surface optimization won't fix. There are many conditions that can result in irregular topogra- phy that are not dry eye. "You treat them like crazy, they come back, and it looks the same." This is where he finds OCT epithelial thickness mapping helpful. Their tear film is fine but their epithelium is not. Dr. Raviv said this is subclin- ical EBMD that may not be seen on slit lamp exam. He performs a superficial keratectomy on continued from page 37

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