Eyeworld

3 Supported by unrestricted educational grants from TearLab, TearScience, and RPS by Eric Donnenfeld, MD New ocular surface therapeutics to optimize surgical outcomes Diagnostic technologies guide treatment of ocular surface dysfunction T he many advanced technologies we use to deliver increasingly better visual outcomes after cataract surgery, such as femtosecond lasers and aspheric, multifocal, and toric intraocu- lar lenses (IOLs), fail to deliver optimal outcomes if patients have a compromised ocular surface. Our repeatability and accuracy in choosing the correct IOL decreas- es, as does patient satisfaction. However, more than one- third of respondents to the 2015 ASCRS Clinical Survey reported that they are not familiar with the International Dry Eye WorkShop (DEWS)/Delphi guidelines for treatment of aqueous deficient dry eye and meibomian gland dysfunction, and roughly another third think they are following them but are not certain. It is important to keep in mind that the key to success as a cataract surgeon is managing the ocular surface. New diagnostic technologies To treat dry eye disease (DED), we first must identify it. The future of dry eye diagnostics is evidence-based ophthalmology— point-of-care testing that allows us to diagnose DED seamlessly and accurately. We begin with tear film questionnaires. If patients' responses indicate possible dry eye, the technician can order the appropriate tests to make the diagnosis. We test all of our cataract patients with tear osmolarity and MMP-9 testing, which provide ob- jective evidence of DED, leading to better therapeutic decisions. However, these tests are only a starting point, leading me to per- form more diagnostic testing to confirm my diagnosis. If a patient has positive results, I perform tests such as lissamine green staining and tear break-up time, examine the ocular surface, and use dynamic meibomian gland imaging. Negative results indicate that the patient does not have DED, but I need to look for con- ditions that mimic DED, such as ocular allergy or a lid disease such as conjunctivochalasis, entropion, ectropion, and floppy eyelid syn- drome. When these tests confirm my diagnosis, I can develop a targeted therapeutic plan. Individualized treatment If cataract surgery patients have mild DED, we treat them and schedule them for surgery. When cataract surgery patients have keratitis and ocular surface damage evident on to- pography or fluorescein staining, we delay surgery, treat them, and perform presurgical testing later. Resolving the ocular surface also provides more accurate keratom- etry, which is often the limiting step in determining the correct IOL power. Although patients with ocu- lar surface dysfunction (OSD) may be surprised that surgery is post- poned, they need to understand that we have their best interests at heart. Looking beyond the cataract and examining the ocular surface allows me to be a better clinician and a better surgeon. Patients understand this and em- brace the fact that we are doing more than they anticipated. Objective evidence-based point-of-care testing allows us to show patients exactly what we see so they understand the mag- nitude of the disease and how it needs to be treated. Achieving satisfaction There is a misconception that dry eye patients are our most unhap- py patients after cataract surgery. Our patients who are marginally compensated and have borderline dry eye, with an increased blink rate or need to close their eyes more may shift to overt dry eye after cataract surgery, and these are our most unhappy patients. More than one-third of respondents to the 2015 ASCRS Clinical Survey think that 21% or more of their patients have no OSD symptoms before surgery but they develop after surgery (Figure 1). By preoperatively diagnos- ing the marginally compensated patient with tear osmolarity, for example, we can identify these patients. After we talk to patients about their disease and treat it, they are more likely to be satisfied with their outcomes. Dr. Donnenfeld practices with Ophthalmic Consultants of Long Island and Connecticut and is clinical professor of ophthalmology, New York University, and trustee, Dartmouth Medical School. Figure 1. Respondents to the 2015 ASCRS Clinical Survey reported what percentage of their cataract patients present as asymptomatic of any ocular surface disease before surgery but develop symptoms after surgery. 70% 60% 50% 40% 30% 20% 10% 0 0% 1–20% 21–40% 41–60% 61–80% 81–99% 100% Average Pct All 20% U.S. 19% Non U.S. 22% All U.S. Non U.S. Eric Donnenfeld, MD

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