Dry eye disease is a pervasive concern, with an estimated 16 million adults in the U.S. already having a diagnosis and another 30 million reporting symptoms without a formal diagnosis. In order to ensure pre- and postoperative success, dry eye must not only be diagnosed, but treated ahead of surgery.

There’s no question that ocular surface disease must be identified preoperatively, says Cynthia Matossian, MD, FACS, founder and medical director of Matossian Eye Associates, with locations in Pennsylvania and New Jersey. “We have known for quite some time that a healthy ocular surface is essential to achieve the best visual outcomes in cataract patients,” Dr. Matossian says. “Presurgical treatment is essential to maximize postoperative outcomes and patient satisfaction. In 2015, I published a paper with Dr. Alice Epitropoulos and other colleagues showing that hyperosmolar patients demonstrated significantly greater variability in average K readings and anterior corneal astigmatism, with the result that there was a higher probability of the IOL power calculation being off by a diopter or more.”

Part of the Pre-Op Workup

Marguerite McDonald, MD, FACS, clinical professor of ophthalmology at New York University and Tulane University and a cataract, refractive, and corneal surgeon with the Ophthalmic Consultants of Long Island in New York, says that in order to identify dry eye, she uses the classic stains (fluorescein and lissamine green) as well as the use of tear osmolarity, MMP-9 testing, and the SPEED questionnaire. If a patient checks off even a single “yes” on the questionnaire and/or has an elevated tear osmolarity or positive MMP-9, everything stops—the patient is not dilated, and she is brought in.

“I’ll perform a quick slit-lamp exam and let the patient know we’ve detected significant dry eye, which is going to impact the surgical outcome,” she says. “We avoid putting the patient through the entire exam, which they appreciate. It may sound cliché, but when you diagnose dry eye before surgery, it’s the patient’s problem. If you diagnose it after—when they’re miserable—it’s your problem. It saves a lot of time, expense, and frustration to stop things short. Our technicians are trained to know this. I finish the cataract evaluation (IOL Master, OCT of the macula, Pentacam, and dilated exam) on their second visit, when they have had several weeks of treatment for their ocular surface disease.”

Dr. Matossian utilizes the SPEED or the SANDE questionnaires. Following the results, the technicians perform three tests—tear osmolarity, MMP-9, and meibomian gland imaging. She says these tests, along with a slit-lamp exam, help to identify a broad range of ocular surface disease from mild to severe.

“When I come into the exam room, I have all of this information in front of me,” she continues. “I proceed by using lissamine green to evaluate the lid margin, conjunctiva and cornea, and fluorescein to further look at the cornea. Each dye staining pattern provides important information. I also examine the lid margins, the meibomian gland orifices and press on them with a cotton swab or with a meibomian gland evaluator to assess meibum quality and quantity. All of these steps don’t even add a minute to my normal exam, yet they allow me to better grade the level of existing surface disease.”

Because a primary symptom of dry eye disease is fluctuating vision, Dr. Matossian advises being on the lookout for that—and to be prepared to distinguish it from cataract-induced blurry vision. Topography, along with the black and white placido disc rings, can be other critical tools to help identify surface problems, a potently strong indicator of tear film instability in this population.

All of this is important, as most patients who present for cataract evaluation may not be aware of having meibomian gland dysfunction or ocular surface disease, explains Dr. Matossian.

“This puts the responsibility to identify dry eye disease squarely on our shoulders as refractive cataract surgeons,” she adds.

Dr. McDonald agrees.

“I would say that half of my patients have significant dry eye with no symptoms, so you need objective criteria, like tear osmolarity,” Dr. McDonald says. “This silent half will be just as miserable with their postoperative outcome as those who are currently exhibiting symptoms.”

Prioritizing Patient Education

Treatment for dry eye should start with education. Dr. McDonald says that many patients have an initial reaction of, “just fix it,” so she uses an analogy to diabetes, explaining that dry eye can’t be cured, but it can be controlled. Most patients will understand this comparison.

“It’s so important to make patients understand that it is a lifetime commitment to maintain a healthy ocular surface or else they’re going to be unhappy with their surgery and perhaps their IOL choice,” she says.

Dr. Matossian says that it’s important to educate patients that they have two distinct medical conditions: one being age-related lens opacification and the other being ocular surface disease. She uses a patient script that goes somewhat like this: “You have two diseases. The cataract, which I can ‘cure’ by removing it and it will never grow back. But dry eye is progressive, chronic, and cannot be ‘cured.’ However, we can work together to find therapies to address this life-long disease.”

Although identifying and treating dry eye adds extra chair time on the front end of cataract surgery, it has an added benefit of reducing chair time postoperatively, Dr. Matossian adds. If a patient’s condition flares up after surgery and his or her vision fluctuates a little—or the quality of vision changes—you can reference the pre-existing dry eye diagnosis.

“By tuning up the ocular surface preoperatively, you’ll also get closer to your refractive target and will likely have fewer IOL exchanges, PRK, or LASIK tune-ups. Overall, chair time post-surgery is minimized when you focus on the ocular surface on the front end,” notes Dr. Matossian.

To make that patient education time as memorable as possible, she suggests making it experiential with plenty of hands-on “show-and-tell.” This might include utilizing clinical images and walking the patient through what the images mean.

Targeted Presurgical Treatment

When it comes to pre-op treatment protocols, our experts note that the approaches can be varied.

“Treating ocular surface disease in a preoperative patient is a little different than maintenance therapy,” says Dr. Matossian, “because the goal is rapid tear film homoeostasis to enable reliable measurements for surgery. As such, pre-op treatment is more aggressive if the patient desires surgery in a few weeks.”

Depending on the patient’s condition, a combination approach may be necessary, she says.

“Dry eye disease and meibomian gland dysfunction are complex, multifactorial processes. Therefore, in order to treat the underlying root cause, combination therapeutic approaches may be required,” notes Dr. Matossian. “The end goal is to address ocular surface inflammation and meibomian gland dysfunction while regenerating the ocular surface epithelium and restoring the tear film.”

Handling Cost of Dry Eye Interventions With Premium Cataract Surgery Patients

When patients are told that advanced technology implants are not covered by insurance, an additional dry eye diagnosis—which may require a cash-pay office procedure—can catch them off guard. Dr. Matossian says that this is where the education on having two distinct diseases is critical.

“Patients need to be encouraged to understand this important distinction, because without keeping their tear film healthy, the results of their premium surgery may not only be less than ideal, they may not be sustained due to their unhealthy tear film,” warns Dr. Matossian. “Consequently, a presurgical regimen that includes aggressive treatment with prescription medications, including a short course of steroids, in-office procedures coupled with at-home remedies, along with the initiation of chronic medication treatment with immunomodulators have to be factored into the premium surgical equation.”

She says that financing options need to be discussed for dry eye treatments in the same way as premium implants are, as both are not covered by insurance. Moreover, because dry eye is not a “once and done” approach, folding the dry eye treatment costs into the premium package may not help the patient understand the chronicity of the disease state.

“However, every practice has to select the option that works best for their patients and aligns best with their work philosophy,” she adds.

Working in a large practice, Dr. McDonald sees different doctors pricing these services in different ways—and they all seem to work. Whether you’re offering them as a bundle or à la carte, she says it boils down to being very clear why these procedures are necessary as well as what’s included and what’s not.

“Patients don’t want surprises,” she says. “The more transparent you can be, the better. Also, let your surgical coordinator know exactly how you want to bill for these services—particularly if you’re at a large practice with more than one provider. It all comes down to being clear and being honest and providing as much communication as possible with the patient.”

Reworking Your Pre-Op Workup

The goal of every ophthalmic surgeon is to provide the patient with the best vision possible post-surgery, and to take whatever steps are necessary for positive surgical outcomes. Therefore, screening and treating patients’ dry eye issues before surgery must become part of your plan in order to set up not only your patients but your practice for success. ■

REFERENCES

1. Movahedan A, Djalilian AR. Cataract surgery in the face of ocular surface disease. Curr Opin Ophthalmol. 2012 Jan;23(1):68-72.
2. Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41(8):1672-1677.