Targeting OSD before surgery

Careful pre-op planning can help avoid post-op ocular surface disease surprises.

By Vanessa Caceres, Contributing Editor

The more time focused on finding, then treating, ocular surface disease before cataract or refractive surgery, the odds rise on two events: The patient’s chance of having an accurate pre-op biometry, and an excellent surgical outcome. Why? The OSD was met, and defeated, on the playing field. Or, as Vince Lombardi would have said: “The best defense is a good offense.”

“If you can diagnose it in advance, the patient will sail through the post-op period,” says Marguerite B. McDonald, MD, Ophthalmic Consultants of Long Island, Lynbrook, NY, and clinical professor, Department of Ophthalmology, NYU Langone Medical Center.

Dr. Starr’s patient with inferior corneal staining, high osmolarity and cataract. The patient wanted a multifocal IOL, so Dr. Starr treated the dry eye disease aggressively first and then proceeded with surgery once the cornea cleared.
COURTESY: CHRISTOPHER STARR, MD

Over the past decade, cataract and refractive surgeons have switched from sweeping OSD under the rug to shining a spotlight on it. Although surgeons have devoted more attention in the past to OSD pre- and post-refractive surgery, they are now monitoring for it before or after cataract surgery. Having a frank talk with patients is a big part of the OSD diagnosis and treatment, says Deepinder K. Dhaliwal, MD, LAc, director, Cornea and External Disease and Refractive Surgery Services, University of Pittsburgh Medical Center; and associate professor, University of Pittsburgh School of Medicine. One reason: It may take weeks or months to treat someone with lagophthalmos or other significant OSD conditions.

“With newer IOLs and doctors promising perfect vision, this topic comes to the forefront,” says Robert Latkany, MD, founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York. “I think it’s become more the norm to address dry eye, although not everyone is doing it the same way.”

It also helps that ophthalmologists have a greater understanding of how the ocular surface works, says Dr. Dhaliwal.

Even with greater awareness of the ocular surface and the importance of treating it, physicians sometimes will overlook it with their singular focus on surgery, says Christopher Starr, MD, associate professor of ophthalmology and director of refractive surgery at New York-Presbyterian Hospital, Weill Cornell Medical Center in New York. “Yet even subtle dry eye can lead to unhappy patients.”

Seeking clues: OSD tests

Although a patient’s experience of dry eye, blepharitis and various forms of OSD can be subjective, the battery of available, measurable tests have made diagnosis easier, Dr. Latkany says.

The first step to targeting OSD is assessing patient symptoms via a careful history and validated questionnaires. Surgeons should also examine for signs of dry eye and other OSD, as many patients with disease can be asymptomatic. For example, corneal punctate epithelial keratitis is a common sign of OSD, but some patients may not have complaints, Dr. Starr says. He uses one of the various questionnaires to assess OSD symptoms, such as the Ocular Surface Disease Index, Symptom Assessment in Dry Eye, or the Standard Patient Evaluation of Eye Dryness.

One test that Dr. McDonald performs on any patient with related dry eye symptoms is the TearLab Osmolarity Test (TearLab). She also will use InflammaDry (Rapid Pathogen Screening), which measures for the MMP-9 protein; and the Keratograft 5M (Oculus) if she suspects clinically significant dry eye.

By having positive results from those tests before examining the patients, Dr. Starr feels he has enough objective information to be certain of a diagnosis. “A negative test result is just as useful. That tells me to look for other diagnoses to explain the symptoms,” he says, noting that other forms of OSD with overlapping dry eye symptoms include:

• corneal epithelial basement membrane dystrophy

• allergic conjunctivitis

• medication toxicity

• conjunctivochalasis.

Tests such as LipiView (TearScience) that detect lid-related issues like blepharitis and meibomian gland dysfunction are also given in some cases. Physicians do not need to perform every OSD test, but they should do at least a handful of such measurements, Dr. Latkany advises. “If there’s any question about whether there’s OSD, proceed with further testing.”

The patient education factor

Surgeons may appreciate having these OSD diagnostic tests at the ready, but how about patients? Even if some patients are annoyed at submitting to so many tests, surgeons can’t let patients’ impatience win out; besides, most patients appreciate the surgeon’s complete and thoughtful evaluation, Dr. McDonald says. Remind patients that finding and eliminating OSD before surgery will only benefit them.

Most insurers cover OSD tests, although some of the lid hygiene diagnostic tools are cash-only, Dr. Latkany says. Practices may need to justify to patients why a self-pay test might be necessary.

Pre-op treatment

Naturally, the treatment for dry eye varies according to severity, and treatments are tailored for each patient. “Depending on a patient’s level, I’ll use tears, nutritional supplements, Restasis [cyclosporine emulsion, Allergan] and lid soaks and scrubs if they have blepharitis as well. I’ll recommend the whole treatment algorithm for at least a month. Usually, patients are vastly improved,” Dr. McDonald says. Dr. Starr usually gives patients two to four weeks to see how their OSD treatments fare.

Lid hygiene is also crucial to debulk the bacterial milieu, Dr. Dhaliwal says. Those with blepharitis, MGD and Demodex will benefit from better lid hygiene. In patients with dry eye and lid issues, Dr. McDonald uses LipiFlow (Tear Science). Doxycycline is also useful, Dr. Dhaliwal says. She is not a fan of warm compresses, as patients usually do not use them thoroughly enough for them to work.

Drs. Starr and McDonald will also use AzaSite (azithromycin) off-label for MGD because of its anti-inflammatory and antibacterial properties. Dr. McDonald recommends using it twice daily, finger-rubbed into the lid margins immediately after the twice-daily soaks and scrubs.

In patients with inflammatory dry eye that needs to be cleaned up as soon as possible, Drs. Starr and McDonald will use a topical steroid like Lotemax (loteprednol etabonate). Dr. Starr will also insert punctal plugs if necessary once inflammation is controlled.

Don’t overlook allergy

Another treatment area that comes up frequently before surgery and requires a lot of detective work is allergy, Dr. Dhaliwal says. If physicians don’t treat ocular allergy effectively before surgery, it can affect outcomes. Allergy treatment usually involves switching patients to topical eye drops and corticosteroid nasal sprays instead of the notoriously drying oral antihistamines. If asthma is involved and a patient needs additional treatment, Dr. Dhaliwal recommends montelukast, which does not have drying effects. There’s also a discussion with patients about what could be triggering their allergies. “You have to talk to these patients for a long time,” she says. “I tell them we want the best outcome for them, and sometimes that takes weeks to months of optimization. If they’re not willing to do the work, it’s OK, they don’t have to have LASIK.”

Think ahead

Dr. Dhaliwal has designed a post-cataract surgery treatment protocol to help patients steer clear of any OSD surprises. For one week, patients use an antibiotic and steroid. At week 1, she stops the antibiotic and then starts an NSAID. Her aim is to limit the number of drops a patient may use at a time, to increase compliance. In LASIK patients, Dr. Dhaliwal will start cyclosporine emulsion ahead of time if the OSD shows an anti-inflammatory component. She anticipates that most patients will have transient worsening of signs and symptoms after LASIK due to corneal nerve transection.

Before proceeding to pre-op measurements and eventual surgery, Dr. Starr will ensure that the tear film, ocular surface and corneal epithelium are normalized. Although he won’t tell cataract surgery patients that they cannot have surgery due to refractory OSD, he will often advise patients against multifocal IOLs. Because laser vision correction surgery is largely elective and dry eye disease can worsen afterward, it is prudent to indefinitely delay surgery if there are persistent signs of OSD, Dr. Starr says.

“I won’t do LASIK if there’s punctate corneal staining,” Dr. Dhaliwal says. “With cataract surgery, I’m a little more lenient, but I still want to get the patient optimized as much as I can.”

When there’s OSD post-op

By devoting more time and attention to OSD before surgery, physicians say its occurrence postoperatively has been greatly reduced.

Still, exceptions exist. Dr. McDonald had a female patient with Sjögren’s syndrome who was treated with virtually everything possible before surgery, including ointment and autologous serum. While the surgery itself was uneventful, one-day post-op the patient sloughed off a 100-mm sheet of central corneal epithelium. Her vision was counting fingers 20/400.

However, Dr. McDonald had told the patient her case would be more challenging, and she was prepared. Within 1 week, after her epithelium had healed with a bandage contact lens, the patient was 20/25 without correction.

Dr. Dhaliwal had a referral with Sjögren’s syndrome and cataract surgery. The referring surgeon had prescribed generic antibiotics and a generic NSAID. The physician saw the patient at day 1 post-op but did not see her again until 1 month. Although the patient felt no pain, she knew something was wrong. She had corneal melting with 50% thinning and was referred to the UPMC Eye Center.

When Dr. Dhaliwal performed cataract surgery on the second eye, she occluded the puncta pre-operatively and had the patient use omega 3 supplements, doxycycline and autologous serum.

Dr. Dhaliwal says the pearl here is to follow at-risk patients more frequently after surgery.

Worth a pound of cure

Dr. Latkany, who specializes in dry eye, sees the unhappy patients who have post-op OSD and weren’t properly vetted before surgery. “Ophthalmologists need to do a better job of screening patients preoperatively to reduce the number of postoperative unhappy ones,” he says.

Treating patients with OSD takes patience, Dr. McDonald emphasizes. Should a surgeon lack that attribute, she recommends collaborating with someone who doesn’t, perhaps an optometrist. Another recommendation she makes is collaborating with staff members to determine how to fit the various tests and treatments into the practice pattern.

Says Dr. McDonald: “We have all these wonderful devices we can use for these patients now. We just have to be willing to use what we have.” OM