Eyeworld

C OCTOBER 2025 | EYEWORLD BONUS ISSUE | 19 Reference 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. Relevant disclosures Gupta: Alcon, Azura, Bausch + Lomb, Harrow, Sight Sciences, Tarsus Starr: AbbVie, Alcon, Aldeyra, Azura, NuVissa Contact Gupta: preeyakgupta@gmail.com Starr: drstarr@gmail.com refractive surprises, decreasing patient satisfac- tion and reducing visual quantity, quality, and performance postoperatively. It could also lead to a post-surgical infection like endophthal- mitis and/or non-visually significant OSD that may worsen after surgery and become visually significant. In assessing dry eye disease and OSD, phy- sicians need to inquire about symptoms, how- ever, signs are more important preoperatively (especially since many of these patients may be asymptomatic). To aid in symptom assessment, a new pre-surgical OSD questionnaire was cre- ated for the algorithm. The algorithm also points to the impor- tance of a slit lamp exam to assess the patient for VS-OSD. The LLPP technique—look, lift, pull, push—is critical in this step. It can also be important to test for corneal sensation and staining. After assessing for OSD, the physician needs to determine if it's visually significant and could potentially impact the surgical outcome. If VS-OSD is detected, it should be treated aggres- sively and ideally reversed before proceeding with surgery. Treatment options for VS-OSD are numerous, including prescription medications and procedural treatments. Dr. Starr noted that the algorithm took mul- tiple iterations and a few years to get it right. In the 6 years since the paper was first pub- lished, there have been many advances in re- search, diagnostics, and treatments in the OSD and surgical spaces, Dr. Starr said, adding, "We thought that the time was right to update the algorithm and consensus recommendations." Dr. Gupta said the new paper will be in a similar format to the previous publication and will include an updated review of the literature. "We will dive into the algorithm, discuss prev- alence and negative consequences of visually significant OSD, and review treatment strate- gies," she said. While Dr. Starr said it's still a work in prog- ress and far from being finalized, overall, the algorithm and questionnaire will be iteratively refined, and the paper will be updated to reflect the new knowledge and various FDA approvals since the first publication. "We will be highlight- ing the changes to the algorithm, questionnaire, consensus recommendations, and overall methodology," he said. ASCRS Clinical Commit- tee educational initiatives are largely driven by the annual ASCRS Clinical Survey responses, he said, adding that recent survey data showed that 15% of respondents think the prevalence of dry eye disease/OSD in their cataract patients is zero, and 18% would implant a multifocal or extended depth of focus IOL in a patient with preoperative OSD and "manage the OSD postoperatively." "Clearly, we still have some educational work to do, and this is why we are updating the algorithm," he said. For those physicians just getting started with implementing the OSD algorithm into practice, Dr. Gupta stressed that "practice makes perfect." "The beauty of this algorithm is that it is adaptable to whatever diagnostic tools you have in your clinic," she said. "We think that anyone can screen for OSD in their periopera- tive patients, and simple diagnostic equipment and questionnaires can be used to find patients in need of treatment." "Our algorithm was designed to be easy to follow and easy to integrate into the pre-surgi- cal evaluation, and many surgeons do follow it faithfully, partially, or have adapted their own version of it, and all of that is fine with us," Dr. Starr said. "Our goal was to raise awareness on the importance of the ocular surface on surgical outcomes and to provide an easy framework for routinely managing these patients efficiently and successfully." Corneal staining can adversely affect the accuracy of pre-surgical refractive measurements. Source: Christopher Starr, MD

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