Eyeworld

2 Navigating OSD treatments, technologies, and techniques for today's refractive cataract practice may be reluctant to manage these conditions. However, ophthalmol- ogists will save time in the long run if they educate patients about their condition and treat it fully. If refractive surgery is performed without properly managing DED, more time will ultimately be spent managing dissatisfied patients postoperatively. Reference 1. Trattler WB, et al. Cataract and dry eye: Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) Study. San Diego: ASCRS•ASOA Symposium & Congress, March 2011. Dr. Starr is associate professor of ophthalmology, director of the refractive surgery service, and director of the cornea, cataract, and refractive surgery fellowship, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York. Increasing patient satisfaction To ensure patient satisfaction, the informed consent process should include information about their condition and recommend- ed treatment options. We need to establish reasonable patient expectations, and patients need to understand that it is often import- ant to continue DED treatments after surgery. For patients with significant DED, I usually prescribe cyclospo- rine (often with other adjunctive treatments such as punctal plugs, topical steroids, antibiotics, and lubricants) before surgery and continue for at least 6 months after cataract surgery or laser vi- sion correction. Corneal incisions and surgery itself can affect the corneal sensation for 6 months or longer. As a result of gray areas in OSD and DED and the time re- quired to diagnose and treat these disorders, some ophthalmologists be ruled out in any patient, espe- cially young female patients, with suggestive symptoms. Many of these novel point-of- care diagnostics can be performed by a trained physician extender long before the patient sees the ophthalmologist. This saves the clinician a significant amount of time. A closer look Despite these modern advanc- es, many OSD cases still remain undetected. In the 2015 ASCRS Clinical Survey, the majority of respondents said less than 20% of their preoperative cataract surgery patients required treatment for DED beyond artificial tears (Figure 1). By contrast, in the multicenter Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) Study by Trattler et al., only approximately 22% of pa- tients scheduled for cataract sur- gery had a prior diagnosis of DED, despite about 80% having signif- icant signs of DED. 1 More than 75% had corneal staining, and 50% had central corneal staining during their preoperative cataract surgical appointment. This is strik- ing data since any corneal staining could lead to potential errors in IOL selection. Ophthalmologists need to be on high alert for DED in this de- mographic since patients may not report symptoms and may not car- ry a DED diagnosis. Some patients with more advanced disease may not have significant symptoms because of the neurotrophic effect on the corneal nerves. Patients also need to know that if we do not postpone surgery to fully treat and reverse DED, it can adversely affect visual outcomes. tee is developing a protocol to help clinicians manage patient flow and determine which tests to use. Efficient protocols Preoperative refractive mea- surements such as keratometry, topography, aberrometry, IOL calculations, and final refraction are all significantly affected by the tear film—probably the most important refractive surface in the eye. Therefore, it is essential to optimize the ocular surface and tear film before performing final presurgical measurements. Each practice should train its technicians to identify dry eye disease (DED) and other common ocular surface disorders and then establish a protocol to maximize office efficiency and diagnostic reproducibility. We recommend all laser vision correction and cataract sur- gical patients receive a standard- ized questionnaire (OSDI, SANDE, SPEED, to name only a few possi- bilities). When DED/OSD patients are identified, technicians then perform tear osmolarity testing first, before the tear lake is disrupt- ed by bright lights, dilating drops, and anesthetics, followed by the MMP-9 tear test. The diagnostic sensitivity and specificity of this combination of tests is very high for identifying or ruling out DED. Optical coherence tomography of the tear film, tear lactoferrin, lipid interferometry, meibography, noninvasive tear break-up time, as well as traditional diagnostics like Schirmer's, lid expression, and staining, among others, also can be performed to help distin- guish between aqueous deficient and evaporative forms of DED. Sjögren's syndrome, a potentially fatal autoimmune disease, should continued from page 1 " Many of these novel point-of-care diagnostics can be performed by a trained physician extender long before the patient sees the ophthalmologist. " –Christopher Starr, MD

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