Effective Diagnosis and Treatment of Ocular Surface Disease in Cataract and Refractive Surgery Patients

Effective Diagnosis and Treatment of Ocular Surface Disease in Cataract and Refractive Surgery Patients Duke Cornea Specialists Contribute to new ASCRS OSD Algorithm

Failure to treat ocular surface dysfunction (OSD) prior to cataract surgery can have a significant adverse effect on surgical planning and outcomes. However, despite the poor correlation between the symptoms of OSD and objective measures of the condition, presurgical testing is not typically performed in the absence of patient-reported symptoms. Recent findings suggest that more patients should be screened. In a 2018 study published in the Journal of Cataract & Refractive Surgery 1 , found that as many as 80 percent of patients who present for cataract surgery evaluation have ocular surface dysfunction. “There are a number of studies showing that ocular surface dysfunction can negatively affect outcomes at the time of cataract surgery,” explains the study’s first author, Preeya K. Gupta, MD, associate professor of ophthalmology and corneal specialist at Duke Eye Center. “We’re trying to identify who’s more likely to have this problem, and, if someone is susceptible, treat them beforehand by doing a better job of diagnosing.” The study included 120 patients from two physicians’ practices at Duke and Weill Cornell Medicine. Researchers examined several measures of OSD: slitlamp evaluation findings of the corneal surface, OSDI or SANDE questionnaire score, tear osmolarity, and tear matrix metalloprotease-9 (MMP-9) test results. The overall prevalence of OSD was 80 percent. Of the 56.7 percent of patients who had no preexisting diagnosis of the condition, 81 percent had at least one abnormal tear film test. Interestingly, traditional methods of screening, such as looking for corneal staining or using questionnaires, failed to identify many cases of the condition. By contrast, 83 percent of patients who scored “normal” on their questionnaire had either an abnormal osmolarity or abnormal MMP-9 test (or both). These results confirm that newer point-of-care tests such as tear osmolarity and MMP-9 allow for rapid and objective assessment of the ocular surface. Based on this study and other previously published data, a new consensus-based practical diagnostic OSD algorithm has been developed to specifically address this population, aiding surgeons in diagnosing and treating visually significant OSD before any form of refractive surgery is performed. The algorithm, presented by the American Society of Cataract and Refractive Surgery (ASCRS) Cornea Clinical Committee at the 2019 ASCRS Annual Meeting 2 , emphasizes the use of efficient point-of-care testing for assessing OSD preoperatively. While a number of tests are available, it may not always be clear how clinicians should incorporate these tests into practice. Preeya K. Gupta, MD Associate Professor of Ophthalmology Terry Kim, MD Professor of Ophthalmology

ASCRS Preoperative OSD Algorithm

The ASCRS Cornea Clinical Committee includes Gupta and Terry Kim, MD, professor of ophthalmology and chief of cornea, external disease and refractive surgery at Duke Eye Center.

ASCRS OSD Evaluation Recommendations The tear osmolarity and the inflammatory marker MMP-9 tests are recommended because they are readily available and streamlined. These tests are easy and efficient and take less than a minute for a technician to do. There is value in conducting more advanced testing in patients. For example, meibography shows through an infrared image what percentage of the meibomian glands are atrophied or lost. The ASCRS SPEED II Pre-Op Questionnaire that screens for dry-eye disease and helps identify the patient’s visual needs as it relates to cataract surgery planning is also recommended. Following this algorithm is important to improve patient outcomes. With cataract surgery, there are many different intraocular lens implant options, and to be successful with the premium category of technology, you really need a pristine ocular surface. By diagnosing and treating dry-eye disease properly and earlier, there is an inherent improvement in the refractive outcomes of the cataract surgery, and the patient’s satisfaction and visual quality will be higher as a result. Gupta says it is reasonable to recommend that cataract surgeons screen all patients prior to cataract surgery. “Ocular surface dysfunction due to dry eye disease is highly prevalent, and a lot of patients are undiagnosed,” she says. “If we’re not screening for them, we’re missing the opportunity to not only help patients’ eyes feel better but also to help them see better.” The new ASCRS algorithm will aid surgeons in diagnosing and treating visually significant OSD before any form of refractive surgery is performed, improving cataract surgery outcomes.

Impact of Other Ocular Surface Disorders “Eye care providers should also be aware of other ocular surface disorders that can affect pre-operative measurements taken in cataract and refractive surgery patients,” says Kim. In another study undertaken at Duke, lead author and Duke third-year resident, Mark Goerlitz-Jessen, MD, along with Gupta and Kim, found that corneal lesions like epithelial basement membrane dystrophy and Salzmann nodular degeneration can significantly alter keratometry measurements and recommend that these lesions also be addressed prior to surgery to obtain more reliable biometry results for surgical planning. 3

1  Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. 2018 Sep;44(9):1090-1096.

2  An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. Starr CE, Gupta PK, Farid M, Beckman, KA, Chan CC, Yeu E, Gomes JAP, Ayers BD, Berdahl JP, Holland EJ, Kim T, Mah FS, ASCRS Cornea Clinical Committee. 2019 May;45(5):669-684.

3  Impact of epithelial basement membrane dystrophy and Salzmann nodular degeneration on biometry measurements. J Cataract Refract Surg. Goerlitz-Jessen MF, Gupta PK, Kim T. 2019 Aug; 45(8): 1119-1123.

Opposite page: The ASCRS preoperative OSD algorithm developed by the ASCRS Cornea Clinical Committee. Abbreviation Glossary: (ADDE = aqueous-deficient dry eye; CL = contact lens; DED = dry-eye disease; EBMD = epithelial basement membrane dystrophy; EDE = evaporative dry eye; IOL = intraocular lens; LLPP = Look, Lift, Pull, Push; LLT = lipid layer thickness; LRI = limbal relaxing incisions; LVC = laser vision correction; MGD = meibomian gland dysfunction; MMP-9 = matrix metalloproteinase-9; NI-TBUT = noninvasive tear breakup time; NVS-OSD = nonvisually significant ocular surface disease; OCT = optical coherence tomography; OSD = ocular surface disease; OSI = ocular scatter index; SPEED = Standard Patient Evaluation of Eye Dryness; TBUT = tear breakup time; TMH = tear meniscus height; VS-OSD = visually significant ocular surface disease).