Strategies for the Successful Perioperative Management of OSD

As a primary care optometrist with an emphasis in ocular surface disease (OSD), I’ve found it encouraging that surgeons have become increasingly aware of the need to treat OSD perioperatively. Surgeons today understand that OSD is sometimes invisible, so we must screen everyone and treat them appropriately, rather than simply addressing only the obvious cases.

This is true for patients undergoing both cataract and refractive surgeries, regardless of their age. One study found that one in three patients who visited an eye doctor had complaints of OSD.¹ Another found that 24.1% of asymptomatic patients had dry eye.² In that same study of 400 participants, dry eye was present in 54.3% of patients older than 40 years and 67.3% of those 71 years or older.² Further, in another study, among 120 patients referred for cataract surgery, 80% had at least one abnormal result on objective OSD tests.³

OSD: PRESENT UNLESS DISPROVED

Given the above, my assumption with the surgical patients I comanage is that OSD is present unless examination proves otherwise. It is therefore essential to diagnose and treat OSD perioperatively because the condition can affect postoperative outcomes in both refractive accuracy and patient satisfaction.

Keratometry readings, and therefore IOL power calculations, are less reliable in patients with OSD than in patients with a healthy ocular surface, but treating OSD before biometric measurements are taken can help ensure repeatable and consistent measurements and, therefore, better visual outcomes.⁴ Additionally, surgery can potentially disrupt corneal nerves on the ocular surface and decrease the quantity and quality of tears during the healing process.⁵ We expect to see temporary inflammation and decreased tear breakup time (TBUT) postoperatively, both of which result in patients experiencing greater discomfort.⁵

For patients with preoperative OSD, surgery can exacerbate the signs and/or symptoms of the condition, and if patients are not educated preoperatively, they will blame the surgery—and the surgeon—for their increased discomfort. A recent study of patients who received toric IOLs during cataract surgery found that 57% of those who were dissatisfied with the result attributed their dissatisfaction to refractive error, and 35% pointed to OSD.⁶ When OSD is treated preemptively, surgeons can obtain repeatable and accurate measurements, potentially maximizing objective and subjective satisfaction.

THE GOAL: A STABLE OCULAR SURFACE

When we screen patients for OSD before surgery, we’re generally looking for common conditions such as aqueous deficiency, evaporative dry eye disease in the form of meibomian gland dysfunction (MGD), blepharitis, or some combination of these. We may also find more acute ocular surface conditions such as superficial punctate keratitis.

In most instances, we can treat OSD within a timeframe of 4 weeks to avoid a significant delay in surgery. The goal is not to cure OSD before proceeding to surgery (most conditions are chronic and patients will require ongoing therapy), but rather to stabilize the ocular surface to allow accurate preoperative measurements, to ensure greater postoperative comfort, and to make the patient aware of the effect OSD can have on his or her comfort and vision.

Although there are several algorithms at our disposal, I typically rely on the treatment guidelines established by the Tear Film & Ocular Surface Society Dry Eye Workshop (TFOS DEWS II) study.⁷ For diagnostic purposes, I follow guidelines from the American Society of Cataract and Refractive Surgery,⁸ starting with use of the verified Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire. I consider anyone with a score of 8 or higher on that questionnaire to be a suspect for OSD.

To add to this subjective information, I perform initial screening using corneal topography, which provides further analysis of the mucin, aqueous, and lipid layers of the tear film, plus imaging of the meibomian glands. Additional screening methods include TBUT, which gives me a better idea of whether the patient has an adequate functioning tear film, and staining to ascertain the health of the ocular surface, cornea, and conjunctiva.

If a patient has significant OSD symptoms, tear osmolarity measurements (TearLab Osmolarity System, TearLab), inflammatory marker testing (InflammaDry, Quidel), and corneal epithelial cell mapping can all provide further valuable information.

The second part of the process is setting the patient’s expectations for realistic outcomes. We evaluate the situation and do our best to optimize the ocular surface before surgery, but we must make sure the patient understands the situation.

I might explain, for example, that our tests show that the lipid layer in the patient’s tears is deficient, but that we are going to treat the problem in an attempt to optimize the surface of his or her eye before surgery. I’ll admit that we may not be able to treat it completely, and that these are the challenges that the patient might experience if his or her tear film is not optimized. I then explain the potential postoperative consequences such as transient blurred vision during the healing time frame, and point out the additional challenges for cataract patients considering multifocal lenses. Considerations such as glare, halos, or starbursts can be exacerbated by poor tear quality and lead to decreased satisfaction with surgical results. This conversation helps patients make good choices and avoids surprises if there are ocular surface problems after surgery.

TREAT AGGRESSIVELY

In the context of surgery, the short preoperative timeline makes it essential to treat OSD aggressively and get results quickly, after which patients may remain on chronic therapy. In some instances, such as severe dry eye with superficial punctate keratitis right through the visual axis, the patient should have surgery delayed for additional therapy until the ocular surface is stable enough to provide reliable and repeatable measurements.

Patients with minimal OSD receive education, recommendations for environmental modification, artificial tears, and possible changes to their existing medications. Those with mild OSD may receive nonpreserved lubricating drops, punctal occlusion, moisture goggles, topical immunomodulatory drops (a number of commercial formulations of cyclosporine are available from different vendors), moist heat compresses, and recommended use of lifitegrast ophthalmic solution 5% (Xiidra, Novartis) for symptom relief. If MGD is suspected, we add omega-3 fatty acid supplements.

In patients with moderate to severe OSD, we can add an autologous tear, biologic drops, or amniotic membrane to the aforementioned therapies. For those with MGD, we consider adding Demodex treatment, one of several available in-office therapies that heat and express the meibomian glands, a topical antibiotic such as azithromycin (we use a preservative-free compounded formulation, PF Klarity-A, from ImprimisRx) or antibiotic-steroid combination for blepharitis, and/or oral doxycycline/azithromycin.

Although we might recommend a heat mask and prescribe a topical immunomodulator, the preoperative time frame doesn’t necessarily give us time for those measures to work. As a result, I rely more heavily on a short-term topical steroid such as loteprednol etabonate ophthalmic suspension 0.25% (Eysuvis, Kala Pharmaceuticals) or fluorometholone acetate ophthalmic suspension 0.1% (Flarex, Eyevance Pharmaceuticals) to bring down the inflammation and use an in-office procedure to restore meibomian gland function and improve the tear lipid layer.

Treatment can also be tailored to both the patient’s condition and the surgery. For example, if a cataract patient is planning to get a multifocal IOL, even a subtle ocular surface problem can interfere with image quality. We would set the bar for success even higher than for a monofocal IOL (longer TBUT or better osmolarity, for example) and treat more aggressively.

Finally, to reach our goal of stabilizing the ocular surface as the clock ticks down to surgery, patients must be compliant with therapy. This is another reason to lean toward in-office procedures and fast-acting steroids rather than chronic at-home therapies. Another challenge for patients is the out-of-pocket costs for therapies and procedures, which may or may not be covered by insurance. However, patients are invested in the success of their surgeries, so I experience little pushback on costs.

CONTINUE THERAPY

For patients recovering from cataract or refractive surgery, our clinic prescribes a preservative-free compounded antibiotic/steroid/nonsteroidal antiinflammatory drop (prednisolone acetate 1%, moxifloxacin 0.5%, nepafenac 0.1%; LessDrops, ImprimisRx) once daily for a month after surgery.

After healing is complete in both eyes, it’s important to continue chronic therapy and keep tracking OSD against baseline testing. I continue to manage patients based in our practice with 6-month follow-up visits to maintain stability throughout the seasons. For comanaged patients referred to us for surgery, I include a letter to the referring doctor detailing OSD treatment.

Some optometrists continue therapy and follow up with the patient on their own schedule, whereas others prefer to comanage these patients. The important thing is to ensure that patients understand that OSD is an ongoing problem that must be managed, and that you, as their eye doctor, can help them accomplish this either by diagnosing and treating their condition appropriately or by comanaging their care with a colleague.