Algorithm establishes protocol for preoperative ocular surface disease patients

Several algorithms for managing ocular surface disease (OSD) have been published, but none had specifically addressed the preoperative OSD surgical patient until 2019. After identifying this gap via its annual surveys, the ASCRS Cornea Clinical Committee, of which I was a member, initiated a collaborative, consensus-based project culminating in the paper, “An algorithm for the preoperative diagnosis and treatment of ocular surface disorders.”¹

Overview

The algorithm provides an objective data-based protocol for identifying and reversing visually significant OSD prior to refractive and cataract surgery. It is comprised of:

• A focused questionnaire. None of the common validated dry eye disease (DED) questionnaires were designed with the surgical patient in mind, so a new one was created combining elements of the Standardized Patient Evaluation of Eye Dryness (SPEED) and Dell questionnaires, with additional items for identifying non-DED OSD subtypes, such as allergic and infectious conjunctivitis.
• Slit lamp exam.
• Non-invasive refractive preoperative measurements. These are optical biometry, topography and keratometry, among others.
• OSD screening battery. This consists of tear osmolarity and MMP-9 tests. Osmolarity is useful in diagnosing and staging DED, while MMP-9, as a non-specific inflammatory marker, can be elevated in many OSD subtypes (e.g. DED, allergic and infectious conjunctivitis, etc.). OSD is likely present if any abnormality is detected on the questionnaire (symptoms) or tear testing (signs). A variety of objective tests (e.g. meibography, non-invasive tear break-up time, OCT, light scatter etc. can also be incorporated into the algorithm, depending on availability and office workflow: Meibography would help diagnose meibomian gland dysfunction.

  

  
  At this point, the technician has collected ample data to help the surgeon quickly assess the quality and consistency of the refractive measurements, as well as performed an objective analysis of the ocular surface and the likelihood, severity, and potential visual significance of any OSD subtypes.
• Look, Lift, Pull, Push (LLPP). This stands for look at the interpalpebral ocular surface and lid margins, lift the upper lid to examine the superior cornea and conjunctiva, pull the upper lid to assess laxity and floppiness, and push the meibomian glands to assess meibum quality.
  As a brief yet related aside, the algorithm can be utilized for managing OSD in any clinical scenario.

Value

Any OSD subtype that reduces the precision of preoperative refractive measurements, reduces postoperative visual performance, and/or increases the risk of surgical infection is considered visually significant and should be treated prior to finalizing the measurements and proceeding with surgery. The consensus of the ASCRS clinical committee is to treat aggressively with a multifaceted approach emphasizing prescription medications and procedural interventions to minimize potential surgical delays. If non-visually significant OSD is detected, the patient should be informed and educated, and, because it can worsen postoperatively, prophylactic treatment instituted.

Since its publication, “An algorithm for the preoperative diagnosis and treatment of ocular surface disorders”¹ has been translated into multiple languages, presented at major meetings, and is widely cited and referenced in the global literature. By raising awareness of the importance of ocular surface health prior to surgery, both patients and surgeons benefit. CP

References

1. Starr CE, Gupta PK, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684.

DR. STARR is an associate professor of ophthalmology and director of Cornea Fellowship, Refractive Surgery and Ophthalmic Education at Weill Cornell Medicine in New York, where he has a special interest in dry eye and ocular surface disease and performs cataract, cornea and refractive surgery. He is a consultant for Alcon, Allergan, BlephEx, Bruder, Dompé, Eyevance, Johnson & Johnson Vision, Kala, Novartis, Quidel, and TearLab.