Kendall E. Donaldson, MD, MS: In most ophthalmology practices, the majority of patients who present with ocular surface disease (OSD) are women. Our female patients are usually our largest OSD subgroup. In fact, as shown in the Beaver Dam Offspring Study, OSD is nearly twice as common in women as in men.¹ Here, we discuss how we can provide women with the best possible medical care, including diagnosis and treatment for the effects of OSD, and we will discuss why this condition is such a problem among female patients. For example, women may develop certain systemic conditions that involve the eyes, such as autoimmune diseases, at higher rates than men; hormonal changes associated with menopause as well as hormone therapy can affect their ocular surface health;² and they typically have a greater tendency compared with men to use cosmetics or undergo elective cosmetic procedures. All of these characteristics and pre-disposing conditions may be associated with OSD.

In 2014, 125.9 million adult women — compared with 119.4 million adult men — resided in the United States. Twice as many women as men, 4 million vs. 2.1 million, were age 85 or older. In 2008, approximately 56% of Medicare’s 45.4 million enrollees were female. Knowing these numbers, I still wondered whether the majority of my patients are female simply because I’m a female physician. I analyzed the composition of my male OSD-cornea specialist colleagues and found that their clinics are also female dominant.

What is the composition of the patient population in your practice?

Elizabeth Yeu, MD: I can definitely appreciate the gender predilection that exists for various reasons. In addition, in the past, I might have said my older patients were suffering from OSD in the greatest numbers, but in the 10 years I’ve been practicing, dry eye has been encompassing a younger age group, as well as both genders. Not only do we know so much more today about etiology, diagnosis, and therapies, but patients are coming in for second and third opinions because of their symptoms. Gaming, computer use, and other modern risk factors have made dry eye ubiquitous.

Neda Shamie, MD: Absolutely. Like the rest of the panel, I have a medical-surgical practice. The mix is approximately 50/50. In the past, the dry eye segment of the practice was the nonsurgical segment. Now, I’m seeing dry eye encompass the entirety of the practice, the surgical as well as the nonsurgical patients. Maybe we’re paying more attention, or perhaps patients are more educated, or a little bit of both, but dry eye is increasingly common among all of my patients.

As far as the female-male ratio, I feel as though I’m seeing OSD in the great majority of my male and female patients, but often find that the dry eye related symptoms are not the primary reasons my male patients seek care. In contrast, the women tend to present with the classic complaints of burning, blurring, gritty sensation, and so on, while the men tend to describe their symptoms differently, often rejecting the notion that they may have dry eyes, even after my evaluation. At the risk of generalizing, many of the men tend to think somewhere beyond OSD, often insisting to me, for example, that their symptoms may be a sign that it’s time for cataract surgery. I find myself trying to convince them that they have dry eye.

Dr. Donaldson: Females are much higher utilizers of the medical system. Also, as we mentioned, if you look at the population age 85 and older, there are twice as many women as there are men. Therefore, among those older patients, certainly many more are women.

Dr. Gupta, in your practice you have an OSD center that’s separate from your main clinic. However, do the patients, perhaps the surgical patients, overlap?

Preeya K. Gupta, MD: Academic centers such as ours typically serve as referral centers, which means we have no shortage of patients who suffer from dry eye, both male and female. But to answer your question, I do have quite a bit of overlap between the dry eye center and the main clinic. Quite often, patients who come to see me for a dry eye evaluation also have cataracts and/or other ocular diseases. This is one of the shifts that has occurred in the past few years. We’re taking the entire patient into account — regardless of the reason he or she came to see us. That’s partly because today we have better tools for diagnosing dry eye than we did in the past. We can detect it more easily, and it’s on our minds; we’re paying attention to it. Also, our surgical patients have high expectations and high demands that require us to address OSD. Dry eye is definitely more prevalent in our population today, but we’re better at identifying it, too, which is part of what accounts for the high incidence.

Taking Gender into Account

Dr. Donaldson: Our female patients have some different concerns when they come into our offices. They have some special issues that relate to women specifically, such as makeup use and cosmetic procedures, including LASIK or eyelid surgeries that they tend to undergo at a higher incidence than male patients. Also, as we reviewed at the beginning of the discussion, women develop systemic conditions that involve the eyes, such as autoimmune diseases, at high rates, and they experience hormone imbalances in menopause, which may contribute to the onset or worsening of OSD. Nine out of 10 people who have Sjögren’s syndrome, which is a major cause of dry eye, are women.³ What types of issues do you see that are unique to women?

Dr. Yeu: Makeup can be a concern from a therapeutic standpoint. Because not all of it is waterproof, instillation of artificial tears may cause it to run, which can be a nuisance because it blurs the vision. Something like that could be detrimental to compliance with a treatment recommendation. With regard to cosmetic surgery or any kind of eyelid surgery that might be done, either functionally or for a cosmetic reason, ocular surface exposure can be an issue. The morphologic changes that occur from having the lid margin, tarsus, or underlying tissue adjusted can have exposure or mechanical effects that are responsible for dry eye. It can be devastating in some cases. Meibography has changed the way we understand the causes and evolution of dry eye disease. I’ve seen patients who have had permanent eyeliner applied, which is essentially a tattoo, and their meibomian glands are obliterated. So, for reasons of vanity or efficiency, these patients — who otherwise might have been just fine — opted for a procedure that can lead to fairly significant sequelae and implications for the future.

As clinicians, we need to recognize that these gender-specific issues are very important. They’re important because all of these patients are coming into our practices. No matter what type of practices we have, we’re going to see these patients. We should be aware of potential issues and causes of OSD so we can address them properly.

Dr. Gupta: That’s a good point about eyelid surgery and postoperative eyelid position. In my opinion, mechanical issues such as these are one of the most under-recognized, under-diagnosed issues among dry eye patients. Blepharoplasty significantly changes the blink function and how the tear film is spread across the ocular surface. Some of these patients haven’t necessarily seen an ophthalmologist prior to undergoing blepharoplasty and may not have been screened for preexisting lid margin disease. An eyelid procedure is likely to compound that. All of us should be asking our dry eye patients about past eyelid surgery, looking for blepharoplasty scars, or otherwise tracking down these issues, which, as we’ve stated, have a higher likelihood of being present in our female patients.

Dr. Donaldson: Yes, and it may be that we really have to tease that information out of them.

Dr. Shamie: In Los Angeles, we have a high concentration of plastic surgeons within a 5-mile radius. A few years ago, I was asked by their local meeting organizer if I would be willing to present on dry eyes because they see the condition so often. I found that to be a wonderful opportunity to educate my plastic surgery colleagues, who are performing these surgeries, such as blepharoplasty, that sequelae can occur at some point down the line. I really encourage ophthalmologists to partner with the plastic surgeons and cosmetic surgeons in their area to educate them the same way we need to be educated by physicians in other specialties when our work could potentially affect their patients.It was great for me to present on the importance of screening prior to eye-related cosmetic procedures. Now, I’m seeing patients prior to their blepharoplasties and other procedures and screening them for dry eye and meibomian gland dysfunction (MGD). If necessary, these patients can be pretreated, much like we pretreat our cataract surgery patients, to restore the health of the ocular surface and eyelids before they undergo a procedure. We have innovative products, such as Avenova (NovaBay), at our disposal. Avenova, which is the only pure hypochlorous acid available, comes in a spray solution that helps to normalize extra-ocular microorganisms and debris that contribute to dry eye, MGD, blepharitis, and ocular allergy.

Also, because, in general, women are more cognizant of cosmesis than men, they may be more likely to want contact lenses. Screening is critical here as well. Patients seeking to start contact lens wear should not only be screened for dry eye, but also educated about OSD symptoms. They should understand why their lenses might become less comfortable over time, and know that they need to come in for an evaluation. At that point, we would examine the lid margins, perform tear osmolarity testing (TearLab), and also test for inflammatory byproducts in the tear film using InflammaDry (Quidel Corporation).

Dr. Donaldson: You raise a great point. Contact lens wearers are often the people who go on to have LASIK and then perhaps later undergo a lid procedure. The tendency for these types of choices often clusters together, raising the risk that any preexisting problems related to OSD could be compounded significantly, or that new problems could emerge.

The Value of Objective Testing and New Imaging Technologies

Dr. Donaldson: I’ve been in practice for 13 years now, and it’s interesting that during my residency and fellowship, we didn’t talk about any of this. We didn’t talk about evaluating patients for dry eye or examining the eyelids or meibomian glands. Our understanding, and, therefore, our protocols, have evolved over the past decade, and particularly over the past 5 years. We’ve had an explosion of awareness. What changes have you noticed since you’ve been in practice?

Dr. Shamie: Like you, I finished my fellowship almost 14 years ago. I think Schirmer’s was our primary dry eye diagnostic test back then, and we thought fluorescein and other types of corneal staining made us quite advanced. Our understanding of dry eye was limited to lacrimal insufficiency, and we had very little appreciation for structures such as the meibomian glands, the mucin layer, and the goblet cells. We knew the anatomic nature of the ocular surface, but we didn’t really grasp the anatomy of the tear film or the contributions of inflammation in the tear film to OSD, let alone conjunctival chalasis.

Today, we recognize the importance of the meibomian glands and are able to use imaging devices, such as LipiView (TearScience), to assess their health and monitor the effects of treatment. We can actually measure the thickness of the lipid layer and analyze the quality of the blink, meaning we’re taking into account structure and function. This type of anatomic knowledge, and all of the knowledge that’s yet to emerge, empowers us as physicians. Our improved understanding also allows us to educate and empower our patients. It’s much more satisfying to treat dry eye now than it was a decade ago.

Dr. Donaldson: It was certainly more challenging when we didn’t have the tools we have today. Speaking of tools, let’s talk about how you screen and diagnose OSD patients in your practice.

Dr. Gupta: When patients come in with typical dry eye complaints, such as irritation, blurry vision, redness, and so on, it triggers our protocol. The staff performs a tear osmolarity test and the InflammaDry test, which measures the matrix metalloproteinase-9 (MMP-9) marker of inflammation in the tears, and obtains meibomian gland images using the Lipiview II (TearScience). These three tests aid in the differential diagnosis, and if the diagnosis is dry eye, we categorize the patient based on disease severity. As we know, not all patients with foreign body sensation, redness, and irritation have dry eye. Other conditions can masquerade as dry eye, and these tests help by streamlining and adding precision to the diagnosis. Furthermore, we’re all scientists; we like the objective data the tests provide. We like to know what’s happening at the molecular level, and the tests also give us a way to follow patients over time.

Years ago, it used to be somewhat frustrating when patients had dry eye complaints because we couldn’t tell them much about their condition or do very much to help them. Thankfully, today we know not to wait to see corneal staining or meibomian glands that are notched and dragging posteriorly before we intervene. We can assess the signs of OSD ahead of the disease, which, to me, really is the key differentiator for being successful with our treatments.

Dr. Donaldson: Yes, the objective measurements and images we can obtain now are so useful, and we can share the information with our patients. They love to see numbers, and they love to see images they can understand. These tools serve three main functions: diagnosis, patient education, and treatment tracking.

Dr. Yeu: Our attention to the lid margin is much, much more acute now than it used to be. Also, the quality of the meibum is very important, as is looking for signs of inflammation, which may or may not be the etiology of meibomian gland dysfunction in a given patient. The cause isn’t necessarily primary rosacea blepharitis. Sometimes, the cause is mechanical; it’s a congestion, which is less obvious.

We pay close attention to the tear film as well. There is so much that can be happening to give us insight into the biofilm. We may see little suds, which indicate saponification as a result of bacterial lipases. It may contain debris. We know that lid margin flora can have implications for both anterior and posterior blepharitis.

When we have these signs top of mind, we can choose the appropriate treatments. For MGD, LipiFlow (TearScience) has become a go-to option in my practice, and using it in conjunction with Avenova, creates synergy that maximizes the effects of each individual treatment.

All of this tear film, eyelid, and gland-related evaluation has become a crucial component of the OSD examination because, as Dr. Lemp and colleagues elucidated for us,⁴ approximately 86% of cases of dry eye have a connection with MGD.

Dr. Donaldson: I believe the imaging, in particular, is especially useful for educating patients. They can actually see and, thus, better understand the problems they’re having, which helps to create a stronger partnership between physician and patient. It’s great for compliance with treatment recommendations, too, because it’s motivational.

Dr. Gupta: Meibomian gland and tearfilm imaging also enable disease stratification. Before the development of devices, such as LipiView or LipiScan (TearScience), we had no way to determine whether patients had gland atrophy. We could see only the top, external portion of the gland structure. Therefore, we didn’t know whether we were seeing the residual effects of atrophy or congestion obscuring normal anatomy below. Meibography provides a clear answer to that question and indicates where a patient is in the course of the disease. That information, in turn, guides our treatment choices and helps us set patient expectations.

Dr. Shamie: Yes, disease stratification via imaging and objective testing is the first step in appropriately choosing first-line and subsequent treatments. It provides the basis for initiating a progression of treatments. We start at treatment level A and evaluate the results both objectively and subjectively by talking with the patient and using an OSDI-type symptoms questionnaire. If improvement is insufficient, we switch to or add the level B treatment, and so on. The availability of all the new diagnostic tools and treatments is really what makes dry eye centers of excellence possible.

With a thoughtful focus on OSD, both patients and practices can thrive. Patients are quite grateful to have their symptoms addressed in such a thorough manner.

Meibography will remain an exciting and useful tool well into the future because of what it will add to our body of knowledge. Although we know so much more about OSD than we did a decade ago, we have more questions. For example, do different types of MGD — congestion versus gland dropout — have different pathophysiologies and courses of progression? Does congestion lead to dropout? Are the cases that involve saponification and bacterial overgrowth the ones that result in dropout? Does MMP-9 lead to faster gland dropout? These answers and others will, again, help us to further improve the targeting of our therapies.

Streamlined Diagnosis and Management

Dr. Donaldson: In my practice, we have patients complete an OSDI-type questionnaire and we perform the InflammaDry test and the TearLab osmolarity test on all of our new and follow-up OSD patients (dry eye patients and suspects) and all of our preoperative patients. So that does amount to quite a bit of testing. How do you accomplish these necessary tests efficiently so they can be incorporated into your clinic without obstructing clinic flow?

Dr. Yeu: First, I would say the time and costs involved with dry eye testing are certainly tempered by the benefits it provides, which are:

1. greater insight
2. determination of disease level or severity
3. ability to take a thoughtful, customized approach.

All of these benefits actually make us more efficient. Contrast this with the days when our main test was Schirmer’s. That test took some time to complete, was uncomfortable for patients, and provided very little actionable information.

It’s easy to give an example of how the currently available testing and imaging streamlines my evaluation and treatment decision-making. And just to make it that much more interesting, let’s say I started with a normal tear osmolarity test result. One might think a normal result would not make sense in a patient who presents with dry eye symptomology and is perhaps also exhibiting corneal or conjunctival staining. In fact, it can be just as important a clue as an abnormal result.

Many of us have begun to appreciate this over time, and doctors at Weill Cornell Medical College recently presented the results of a study that support this.⁵ In a group of 50 consecutive patients, all of whom had at least one dye eye symptom and a normal tear osmolarity test result, they were able to identify an alternate primary diagnosis, such as allergic conjunctivitis, anterior blepharitis, computer vision syndrome, or epithelial basement membrane dystrophy, in all 50 cases. In other words, when we see a normal tear osmolarity level in conjunction with other factors indicative of dry eye, it suggests for us the presence of some type of OSD, just not the chronic, progressive, “classic” dry eye that we may have been expecting.

So, to continue with this diagnostic example, if tear osmolarity testing is normal, I know to look in a different direction for another cause of signs and symptoms. That cause can be any number of issues, such as early MGD, ocular allergy, or a mechanical abnormality, such as conjunctival chalasis. And whether the tear osmolarity test results are normal or abnormal, the next step is to combine that with LipiView meibography to determine whether there is mild, moderate, or severe gland dropout.

From that point, I can decide on the most appropriate first-line therapy. It might be a lid margin intervention, for example, or a steroid to quiesce an inflammatory flare-up. Then, as we discussed, I can move in a step-wise fashion through any additional therapies, if necessary. That’s the typical thought process I go through with my OSD patients, and the point-of-care diagnostics and the imaging technology allow it to unfold more smoothly and logically than was possible in the past.

Dr. Donaldson: Throughout the process, we also want to ensure we take into account systemic diseases, either diagnosed or undiagnosed, in our female patients in particular, given the female predominance of inflammatory/autoimmune issues. We should be looking at everything that might be going on in their lives, including any systemic medications or topical glaucoma medications they might be using. These issues in addition to lid malposition issues can be easily overlooked and their effects can be underestimated. Nothing that could have a possible connection with OSD, all the way down to any potential ocular effects of their occupations, should be overlooked.

Screening and Pretreating Surgical Patients

Dr. Donaldson: Let’s talk more about the therapies and baseline regimens we use for our OSD patients, including patients whose ocular surface we want to prepare for surgery.

Dr. Gupta: Once I’ve performed all of my diagnostic testing and narrowed down the type of dry eye that a patient has —for example, MGD, eyelid abnormalities, poor blink reflex — I really try to figure out if significant inflammation is present. If so, it’s necessary to treat it. Much of the inflammation I see comes from bacterial overgrowth on the eyelid, which makes lid cleaning and lid hygiene very important. To address this, I’ve incorporated Avenova into my practice. This is a prescription product, and it’s easy for them to use. They spray the cleanser onto a cotton pad and gently wipe the base of the upper lashes and the base of the lower lashes horizontally. The process is repeated with a fresh cotton pad for the other eye.

We know that bacteria gravitate toward the oil on the lids and lashes and bacterial overgrowth is a common problem in patients with rosacea. I find that Avenova is particularly helpful in rosacea patients for calming down the propensity toward the formation of biofilms along the eyelids and underlying inflammation.

Dr. Donaldson: I’ve been prescribing Avenova frequently for my OSD patients and have been very pleased with the response in my patients.

Dr. Yeu: I have, too, and it is making a significant difference.

Dr. Shamie: Some of my rosacea patients use Avenova on their faces, which has been quite effective. In any case where I see evidence of anterior blepharitis at the eyelid margins, any crusting of the lashes or saponification, or MGD, I’ve found it to be very important to take advantage of that cleansing to improve the biofilm.

Dr. Gupta: Certainly, for our surgical patients, infection is something we all take very seriously. Anything we can do to help lower the bacterial counts we should be doing, and lid hygiene is a relatively simple way to accomplish this.

Dr. Yeu: When I have a surgical candidate for whom I’m particularly concerned about anterior blepharitis, which, as we know, is associated with bacterial overgrowth at the base of the eyelashes, my number-one regimen is Avenova daily lid and lash hygiene. There are other products that contain its active ingredient, hypochlorous acid, but Avenova is the only one designed to be free of impurities that can be toxic to cells. When I prescribe this, I schedule the patient’s surgery for 4 to 6 weeks later, which allows time to ensure the bacterial load is sufficiently reduced.

Dr. Donaldson: Screening cataract surgery patients for OSD is increasingly the norm, given its importance in achieving the best possible outcomes. I screen at the time of the consultation, which is generally 4 to 6 weeks before surgery. At that point, if necessary, I can start the patient on Avenova, along with an additional treatment, which, depending on the particular situation, may be lubricant eyedrops, a steroid, cyclosporine (Restasis, Allergan), or lifitegrast (Xiidra, Shire) to pretreat the ocular surface prior to making all of the measurements for IOL power calculation.

Epitropoulos and colleagues published an informative study recently in which they grouped patients by tear osmolarity, >316 mOsm/L (hyperosmolar) or < 308 mOsm/L (normal), and measured K values at baseline and again within three weeks. Then they compared variability between the two groups in average K, corneal astigmatism, and IOL sphere power calculations.⁶ The hyperosmolar group had higher variability in the average K reading, a higher percentage of eyes with a 1.0D or greater difference in the measured corneal astigmatism, and a higher percentage of eyes with an IOL power difference of more than 0.5D, all statistically significant.

Heat treatments are another potential OSD intervention. Are you recommending these in your practice?

Dr. Gupta: Our patients find the Bruder Moist Heat Eye Compress (Bruder Healthcare Company) easy to use. It’s microwaved for 20 to 25 seconds and applied for 5 to 10 minutes. It holds the heat well and is washable and reusable.

Dr. Donaldson: I’m recommending the Bruder compress frequently as well. When we tell patients about it, we also give them a two-page printout that explains how to use the compress mask, and we have a staff member demonstrate.

Dr. Gupta: We have the Bruder Moist Heat Eye Compress available at the practice with other OSD treatments to provide patients with “one-stop shopping.”

Dr. Shamie: It’s beneficial for patients to leave the practice with the recommended treatment options in hand. Once patients leave the office, they’re right back to living their lives, and they may forget what’s been recommended. So even if you’re not ready to offer a full dry eye retail segment in your practice, you can send patients home with a care package, or survival kit, of products. That way, they can start treatment right away and at least become familiar with the specific products.

Dr. Yeu: Adding a retail component to a practice can be a bit challenging, especially if you’re just beginning to focus on dry eye. We do offer products at our practice. However, we’ve found that sometimes, it’s not easy for our patients to come in to pick up, for example, refills of their omega-3 supplements, so we also have an online dry eye store. It’s linked with our website, but it’s managed by a third party. So online is another way to help patients with access to treatment recommendations, and it doesn’t require an upfront capital investment. Practices can learn how to set this up from Dry Eye University, which has been created by Bowden Eye & Associates out of Jacksonville, FL. They host courses to share and teach their systematic approach to integrating ocular surface disease management effectively into the daily flow of practice.

How to Make Dry Eye Care a Priority in a Busy Surgical Practice

Dr. Donaldson: As Dr. Yeu mentioned, the courses offered by Dry Eye University lead practices toward the best practices for creating a dry eye center of excellence, which all of us have done. Additionally, visiting a practice with a dry eye center of excellence can help you create an effective model for your own practice. What pearls can you share for practices that have a desire to start moving toward that goal?

Dr. Gupta: The first and most crucial step in having a dry eye center of excellence, or ocular surface center, is buying into the fact that you’ll be embracing this group of patients. Providing quality care for them doesn’t have to be complicated when you’re taking advantage of all the diagnostic and treatment tools that are available. You want to go all in as far as having these tools at your disposal so you can really customize the treatment approach for each patient.

Dr. Shamie: It’s important to realize that, as ophthalmologists with surgical practices, we can’t ignore OSD. Ignoring it would be like saying we’re internists but we don’t want to monitor blood pressure. OSD is the most common reason people seek eye care. It’s become an epidemic among younger patients, too, and they will eventually become our cataract surgery patients. It’s our responsibility to address ocular surface health in all of our patients to prevent severe problems. Really, we’re past the point of asking whether we should buy into embracing this issue. We would be obsolete if we didn’t accept that dry eye is a real issue to be addressed. This is our field. We need to embrace it, or we won’t have the best results surgically either. Those who don’t embrace it continue to have unhappy patients. Those who do embrace it have happy patients who feel their concerns have been heard, and, as a bonus for the practice, they’re more likely to keep coming back and possibly refer others to you.

Dr. Donaldson: As physicians, we certainly have to embrace providing proper care for dry eye and OSD overall, and bringing our staff members on board is just as important. Just as we’re educating our patients about these conditions and treatments, we should be making sure staff members understand the difference we can make for patients and why we’re adopting new tests and protocols. Also, changes in our knowledge and new treatments and diagnostics come online fairly regularly, so staff and physicians must be sure to keep up.

Dr. Shamie: Exactly. To encourage buy-in at our practice, we spent a half day having staff members go through our dry eye protocol as if they were patients. Not surprisingly, about half of them had positive findings and are now feeling better with treatment. Even those who didn’t have dry eye were able to see how their colleagues and friends who did were able to be helped. Therefore, it was a positive experience and very effective for helping them see why focusing on OSD is a priority.

Dr. Donaldson: We’ve done that at our practice as well. It really is such an effective team-building experience. It works on several levels, by providng a chance for the group to bond and learn more about dry eye. Also, it’s fun and it encourages better patient care.

Dr. Yeu: Staff buy-in is certainly important, and beyond that, a practice has to account for the cost center component, maintaining efficiency, and various other aspects of focusing on OSD. A standardized protocol is needed to guide the whole process. It’s not necessarily easy to create this, and this is a great point at which to utilize some sort of help in training not only the physician but staff members as well. This is where something like Dry Eye University can be helpful.

In addition, making use of objective testing, specifically tear osmolarity testing and meibography, has made me a more efficient and proficient dry eye doctor and surgeon. I employ meibography in 100% of my cataract evaluations. I have five LipiScan devices, one in every office. With 50% of my patients being advanced technology IOL patients, I can’t afford to miss dry eye or MGD. Adding tear osmolarity testing and meibography to the clinical examination creates a much smoother process. Fewer follow-up visits are necessary because diagnosis is tried and true, not just trial and error.

Dr. Donaldson: It’s helpful for an ocular surface center to rely on physician extenders and staff members in the day-to-day operations. We have an optometrist who runs our center, and we have several technicians who are really interested in dry eye care. The technicians have created a specialty of sorts, and these patients have really bonded with them as they’re performing the LipiFlow treatments, the manual gland expression, and other treatments. This takes away any time pressure from me. I don’t have to personally increase the time I spend with each patient, yet the practice has been able to forge a bond with these patients through the physician extenders.

Dr. Gupta: Efficiency related to dry eye care is also important as it applies to our surgical patients. In addition to doing a better job of identifying dry eye and MGD, it’s been crucial that we have the treatments to address them. Incorporating LipiFlow thermal pulsation into our practice has actually helped us to get patients to cataract surgery faster. They don’t want to wait months to have their cataract surgery while treating OSD, and with effective dry eye and MGD treatments, like thermal pulsation, they don’t have to. If MGD is identified in the pre-surgical evaluation, I spend time explaining to the patient that they have two disease processes — not just one — going on. Patients understand the diagnosis of dry eye or MGD if brought to their attention before surgery. We know that OSD symptoms can worsen after cataract surgery, so I find it critical to treat not only for patient comfort and satisfaction, but also because in my refractive cataract surgery population, I can’t afford to have a refractive miss which is much more likely in a patient with OSD.

Dr. Donaldson: They don’t want to wait very long to have their cataract surgery, but at the same time, seeing their meibomian gland images and having their tear osmolarity number makes it clear to them that they have a condition that needs to be treated before we place the intraocular lens that’s going to be with them for the rest of their lives. Objective measures and images help create a partnership with patients to achieve the best compliance and, thus, the best patient outcomes.

Dr. Shamie: The meibography and tear osmolarity number have been useful additions to my explanation of why I need to pre-treat OSD prior to surgery. I tell patients that our goal is to optimize their outcomes. I don’t want them to invest in something, especially a premium surgery, unless we’re taking every step we can to ensure our result is the best it can be. The sports car analogy is one that I use. I explain that if we buy a sports car, we also want to have access to the best roads for driving it. Similarly, I say, for a multifocal or toric IOL to function the way it’s intended, we need that first layer of the eye to be in tip-top shape. The light has to travel through that first layer before it does its job anywhere else in the visual system.

Dr. Yeu: And it’s not just the patients’ investment we’re talking about. Our practices have invested hundreds of thousands of dollars in capital equipment for cataract surgery, femtosecond lasers, and so forth, none of which will work unless the patient has a healthy tear film and ocular surface. It’s essential to identify and treat OSD prior to surgery. Otherwise, postoperative vision is likely to be unsatisfactory. Elements of the surgical procedure itself, such as the incisions, the time, the drops, can turn an asymptomatic eye into a symptomatic eye. When that happens, when we fail to prophylactically treat what is a preexisting condition, we can only blame ourselves for a subpar outcome.

Dr. Shamie: It’s been clear to us for quite some time that a significant proportion of patients presenting for cataract surgery have OSD,^7,8 whether or not they have symptoms, and cataract surgery can exacerbate the condition.⁹ Furthermore, according to a retrospective review published last year, the most common causes of patient dissatisfaction after cataract surgery with a presbyopia-correcting IOL are residual refractive error and dry eye.¹⁰ There’s no doubt how important it is that surgeons pay attention to optimization of the ocular surface prior to operating.

Dr. Donaldson: While women may be disproportionately affected by dry eye and OSD, everything we’ve discussed applies to other subgroups as well. All of our patients, surgical and otherwise, deserve to have the appropriate treatment for OSD, which in addition to compromising cataract surgery outcomes can be quite an uncomfortable and life-altering condition.

A relatively new area of interest is whether a relationship may exist between dry eye and chronic pain syndromes. Findings in this area suggest that a central pain disorder may underlie both.^11,12

Managing OSD in the Ophthalmology Practice

Dr. Yeu: Because dry eye disease is such an exploding field, with a fairly recent expansion of diagnostic and treatment options, it may seem overwhelming to begin to focus on it in your practice. However, I can attest to the fact that the new tools make this easier. We can identify MGD and inflammation as contributors to OSD, we can customize treatment for each patient based on imaging and objective testing, and we have more effective treatment options than ever before. With some education and development of protocols, any practice can be proactive about dry eye in an efficient manner. Taking advantage of the courses offered by Dry Eye University is a smart way to begin.

Dr. Shamie: In addition to physician and staff education, patient education is key. Patients should feel comfortable complying with the steps to address their OSD. It’s incumbent upon us to communicate to them the progressive nature of the disease, the importance of early diagnosis to prevent damage and maximize surgery outcomes, and that treatment may be a process, which often begins with quieting inflammation. Patients should understand that like diabetes or any other chronic disease, we’re striving to keep OSD in check, and we’re here to help them every step of the way.

Dr. Donaldson: Yes, creating trust and a therapeutic partnership is important for dealing with a chronic condition.

Dr. Gupta: My advice to other physicians and practices is this: don’t make dry eye care complicated. Pay attention to the anatomy. If you see gland obstruction, treat that. If you see irregularities in the cornea or conjunctiva, treat that. And go back to the basics of how we were all trained. Look for the abnormality, and if you can treat that structure and make it functional again, your patient is going to be happy.

Dr. Donaldson: We’re lucky to be practicing in 2017, because we have so many helpful diagnostic tests and treatment options. We can effectively relieve symptoms and take steps to ensure our surgery patients benefit as well. Our female patients deserve special emphasis due to several factors that make them more susceptible to OSD. Sharing our knowledge and experience surrounding these issues will better help us to identify more patients who need OSD care so we can treat them more effectively and help to avoid post-operative decompensation that can lead to unhappy patients. Vigilant screening for OSD improves clinical outcomes in surgical and non-surgical patients alike.

References

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