“A premium eye procedure requires a premium eye.” In our refractive cataract surgery practice, we’ve built our philosophy around this incredible insight from Dr. Roger Zaldivar. We think of vision hollistically and, therefore, take a holistic approach to treating our patients.

In general, this means we aim to take care of patients’ eyes through every stage of their lifetimes using a “retain and hold” model as opposed to a “catch and release” model. In refractive cataract surgery, it means we address not only the opacity caused by the cataract, but also the focusing issue (astigmatism), and dry eye (Figure 1).

It’s now possible to show objectively that an unstable tear film degrades vision. A double-pass imaging technique (HD Analyzer) can be used to determine what’s known as an objective scatter index. This reveals how a point source of light is imaged on the retina dynamically over time. In dry eye, poor retinal image quality is observed between blinks. A blink restores the point spread function to some degree, which quickly dissipates until restored again by the next blink in the case of dry eye (Figure 2).

Inside Our Dry Eye Center

A significant part of our holistic approach to eye care is our dry eye center. There, we have an ocular surface optimization program that consists of four pillars:

• LipiFlow thermal pulsation (TearScience/Johnson & Johnson Vision)
• medical-grade oral supplements and fish oil to help LipiFlow treatments to work effectively (HydroEye, ScienceBased Health; BioTears, Biosyntrx; Dry Eye Omega Benefits, PRN)
• immunomodulatory drops: cyclosporine (Restasis, Allergan) and lifitegrast (Xiidra, Shire)
• punctal occlusion, in stages from collagen plugs to polymer plugs
• heat eye compress/mask (Bruder)
• eyelid cleansers (Avenova, NovaBay)

In more severe cases of dry eye, adjunctive therapy may include:

• viscous lubricants
• topical steroids
• amniotic membrane
• conjunctival cautery
• serum tears
• scleral contact lens
• acetylcysteine
• Low-concentration steroids

We’re in the process of adding two new options to our armamentarium, neurostimulation with TrueTear (Allergan) and amniotic membrane extract (Ocular Science). A question I’m often asked is why I include lubrication with artificial tears on my adjunctive therapy list. My answer is that although artificial tears are a necessary first-line therapy for insurance purposes, it’s more important that we fix the root problems in dry eye, such as meibomian gland dysfunction, inflammation, and missing nutrients.

Furthermore, I expect we’ll increasingly use our treatment options earlier rather than later in the disease process and disease severity. We saw this with Restasis. At first, its main use was in moderate and severe dry eye. However, now that we know more about it, we use it much sooner. LipiFlow is another example. I’d venture to say LipiFlow is on the same trajectory. I think in the future it will be used prophylactically for most patients.

Communicating the Holistic Approach to Patients

As we engage patients with our ocular surface optimization program, we set the stage to help them understand that we treat the ocular surface so that we’ll be working in an ideal state at the time of surgery. We explain that doing so isn’t a quick fix — it’s a journey. We make a pact with them that we’ll take the journey together. Patients already understand the meaning of holistic approaches to health and wellness; therefore, we can talk in those terms.

A typical conversation begins along these lines: “Imagine, Mr. Smith, if we wanted to lose 50 pounds together. It wouldn’t happen overnight, right? We need a verbal contract that we’re going to work on this together over time. It’s not a quick fix. There’s no silver bullet. We have to address it from every single aspect. We have to eat well, exercise, and get enough rest. I’ll be your personal trainer, and we’ll do this together. And we’ll keep in mind that if we exercise but also eat pizza all day, it’s probably not going to work. We have to make a real commitment.”

We also talk with patients in terms of prophylaxis to convey the importance of holistic care for the eyes. For a model of this, we can look to our dental colleagues. We have so much to learn from them ­— they’ve mastered the prophylaxis educational message. It’s not difficult to draw the parallels between dental care and dry eye care.

We use dental analogies, for example, when we discuss LipiScan high-definition meibography (TearScience/Johnson & Johnson Vision) and LipiFlow with our patients. The dentist X-rays the teeth to look for cavities. We image the meibomian glands with LipiScan to look for problems. If a cavity is present, the dentist can’t reverse it, but he can clean the teeth on a regular basis to prevent future cavities. We can’t reverse meibomian gland atrophy detected by LipiScan, but we can recommend periodic LipiFlow treatments and other therapies to prevent future gland atrophy.

When we put our approach in dental terms, it makes sense to our patients. They’re also more accepting of the fact that not all of our treatments are covered by insurance, just like at the dentist’s office.

We spread the word about the importance of dry eye care in our community, too. Staff members routinely attend health fairs where they perform dry eye screening as a public service. Our tables are usually full of people who really want to know if their eyes are healthy, and, if not, we invite them to our institute for ocular surface evaluation and optimization. This is also a wonderful way to evaluate patients for cataract and refractive needs as well. Local media outlets often cover our health fair screenings, and the information naturally makes its way onto the internet.

Vision for a Lifetime Paradigm

Today’s refractive cataract surgery practices may have varying philosophies, but ours is the retain and hold model. It’s a long-term vision for a lifetime paradigm in which we take a holistic approach to eye wellness. We address all aspects of vision, including dry eye, because the ocular surface is the most important refractive surface. ■