Eyeworld Daily News

MAY 4, 2019 | EYEWORLD DAILY NEWS | 15 ASCRS NEWS by Ellen Stodola EyeWorld Senior Staff Writer/ Meetings Editor We chose those two tests because they're good tests for dry eye and ocular surface disease, he said, and they're relatively inexpen- sive. Objective testing is import- ant, and you'll pick up a lot that you otherwise would have missed. However, Dr. Starr stressed that the ASCRS algorithm doesn't have to be followed rigidly, which is the same with other algorithms. It's more of a suggestion, which helps provide a low-cost, low-risk process to adopt those things into a practice. Editors' note: Dr. Starr has finan- cial interests with various ophthalmic companies. and severity. Overall, it's more aggressive therapy than routine OSD, and Dr. Starr added that you should start at TFOS DEWS II step 2 or 3, then prescription med- ication, procedural treatments, and follow-up in 2 to 4 weeks. He said to proceed with surgery only when VS-OSD is converted to non-visu- ally significantly OSD. In conclusion, Dr. Starr said, whether one adopts these algorithms faithfully, partially, or not at all, ASCRS encourages all refractive surgeons to pay close attention to the visually important ocular surface prior to surgery. During a follow-up panel dis- cussion, Dr. Starr commented on "what if you don't have osmolarity or MMP-9?" The goal of the ASCRS Cornea Clinical Committee was to create a "true algorithm" that was consensus- and evidence-based, that could be integrated into preoperative surgery visits, had reliance on tech and objective test- ing to reduce chair time, and that identified all visually significant subtypes of OSD prior to surgery. Dr. Starr described the long evolution of the ASCRS algo- rithm, ending with the current iteration that was just released. He described the key steps of this algorithm. It begins on the preoperative visit, and the first step is nonin- vasive refractive surgical planning tests (there is a possibility that these tests will need to be repeated later if VS-OSD is detected). The second step is an OSD screen, looking at symptoms and signs. To look at symptoms, Dr. Starr said a novel questionnaire can be used, and to look for signs, he mentioned using the osmolarity and MMP-9 tests. If any is abnor- mal, OSD is likely, he said, adding that any subtype of OSD can potentially be visually significant. Osmolarity is used primarily as an assessment for DED, and MMP- 9 is a non-specific inflammatory marker. Step 3 of the algorithm is a direct, quick exam to assess for VS-OSD. Dr. Starr said to use "LLPP": look, lift, pull, push, then stain. The next step is that OSD is ruled in or out, and if it's ruled in, you need to determine visual significance. If there is non-visu- ally significant OSD, surgery can proceed, and the refractive plan can be finalized. However, if there is VS-OSD, the surgery and refrac- tive plan should be delayed, the patient should be counseled on OSD impact on surgery, and you should start aggressive treatment to minimize delay, Dr. Starr said. Step 5 of the algorithm is to treat VS-OSD based on subtypes A n afternoon Cornea Day session focused on preparing the ocular surface for cataract surgery. During the session, Chris Starr, MD, New York, shared a review of current OSD/DED algorithms. We are living in an era of al- gorithms, he said. There has been a rise in OSD in the last 15 years and with that, a rise in interest in algorithms. Dr. Starr noted that dry eye disease literature doubled between 2007 and 2017, and the TFOS DEWS II came out in 2017 as well. This gave us the first diag- nostic algorithm, he said. It started with triaging questions, then diagnosis of DED. If DED was ruled in, the primary subtype was identified and treated based on severity. The overall goal was to restore homeostasis. Dr. Starr also mentioned the CEDARS paper from 2017, which was an evidence- and consen- sus-based overview of all treat- ment and diagnostic tools, and it offered a detailed protocol for identifying and treating dysfunc- tional tear syndrome based on subtype rather than severity. Dr. Starr highlighted the ASCRS Preoperative OSD Algo- rithm, which was created by the ASCRS Cornea Clinical Commit- tee and was just unveiled. Dr. Starr noted that ocular surface disease is common but often asymptomatic in cataract patients. He added that it can also be visually significant. Visually significant ocular surface disease (VS-OSD) reduces accuracy of preoperative refractive measure- ments, reduces visual quality and quantity pre- and postoperatively, and blepharitis may increase the risk of endophthalmitis. Cornea Day features presentation of the ASCRS Preoperative OSD Algorithm Dr. Starr discusses the ASCRS Preoperative OSD Algorithm.

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