Eyeworld

4 Navigating OSD treatments, technologies, and techniques for today's refractive cataract practice Integration of new ocular surface testing and therapeutics into routine practice by Edward Holland, MD sions because additional incisions in the cornea can increase neuro- trophic trauma to the cornea. Potential multifocal IOL candidates are even more chal- lenging. Patients with a less than optimal tear film and corne- al epithelium will have more complaints of decreased contrast sensitivity than a monofocal IOL patient. With aggressive OSD treat- ment, the corneal epithelium can be improved, and in many pa- tients with mild to moderate dry eye a multifocal IOL implantation will be successful. In potential multifocal IOL patients, I definite- ly manage OSD before surgery, and I must be confident that they have a healthy surface before I recommend this IOL option. Conclusion If we do not diagnose and treat OSD before cataract surgery, patients' visual outcomes will fall short of their expectations. They will believe the surgery failed, but the failure occurred in not diag- nosing and treating OSD before surgery. Dr. Holland is director of the cornea service, Cincinnati Eye Institute, and professor of clinical ophthalmology, University of Cincinnati, Ohio. Undetected dry eye may negatively impact cataract surgery outcomes W hen we evaluate patients for cataract surgery, a major component of that examination is the ocular surface. A healthy ocular surface is critical to successful out- comes—particularly in patients having refractive cataract surgery. When patients are unhappy with their outcomes, it usually is not because we missed our refractive target. More commonly patients are dissatisfied with their vision because the ocular surface was not managed. New ocular surface thera- peutics can help us treat patients with aqueous tear deficiency and meibomian gland dysfunction (MGD) to deliver optimal out- comes. Targeting ocular surface disease Our first step in screening for ocu- lar surface disease (OSD) is to ask all refractive and cataract surgery patients to complete a question- naire regarding ocular surface symptoms. Based on their responses, technicians know which point- of-care tests to perform. New point-of-care testing modalities make us faster, better, and more efficient clinicians compared with old technologies, which were not very effective or efficient. We begin ocular surface test- ing with tear osmolarity, which is helpful in diagnosing early signs of dry eye. Levels are elevated in both aqueous tear deficiency and MGD, indicating that patients have OSD even if they have no symptoms. We also perform MMP-9 testing, which helps us to deter- mine whether inflammation plays a key role and whether we should prescribe anti-inflammatories to manage dry eye. I think that in the future we will have inflammatory markers that we can quantify, which also will allow us to monitor treatment response and help patients under- stand that their OSD is improving. Asymptomatic patients may not realize they have OSD. When OSD becomes chronic, neurotrophic change occurs on the ocular surface so patients may not experience burning, pain, and discomfort. Vision fluctuation is a common symptom of OSD in an elderly patient, even in patients without the typical dry eye symp- toms of pain or burning. Another valuable new diagnostic technology is mei- bomography to detect MGD. Many patients do not under- stand the presence and function of the meibomian glands and the importance of the tear lipid layer. Meibomography allows patients to directly visualize their own meibomian glands and the pathology that is contributing to their dry eye. Treating OSD Because OSD is a progressive disease, we should discuss the diagnosis and available treatments with patients with findings of OSD. If patients have OSD without corneal staining, we can perform topography and biometry and obtain good data. In these cases, we simultaneously plan cataract surgery and treatment of their OSD, explaining to patients that this will provide better vision after surgery. However, corneal stain- ing indicates severe disease. We explain to patients that because of OSD, we may not be as accurate in selection of intraocular lenses (IOLs) or management of astig- matism. We recommend delaying surgery and treating OSD first to obtain a quality tear film and corneal epithelium and achieve better outcomes. Patients may be disappoint- ed to learn that we need to delay surgery. However, if we do not treat OSD before surgery, they often blame the surgeon for sub- optimal results. OSD and premium IOLs We should not use toric IOLs or perform relaxing incisions in patients with corneal irregular- ities and irregular astigmatism that may be secondary to OSD. In these cases, it is best to manage OSD and obtain consistent pre- operative data and possibly more regularity of astigmatism measure- ments. If we cannot get consistent readings, we sometimes choose to not manage the astigmatism. In the dry eye patient, a toric IOL is more desirable than relaxing inci- Edward Holland, MD Practice pearls • Ocular surface disease is a very common disorder that is often ignored and underdiagnosed by clinicians. • Ocular surface disease can have a significant impact on your patients' vision, comfort, and quality of life and your surgical outcomes. • New technologies will improve the clinicians' ability to properly and efficiently diagnose ocular surface disease.

• Cover