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EW SHOW DAILY 54 Sunday, May 8, 2016 Meeting Reporter This is particularly significant in light of the fact that DED is "ex- tremely common in the preoperative cataract patient," he said. Darrell White, MD, Westlake, Ohio, even went so far as to say, "Every patient has dry eye until proven otherwise." Surgeons should concern them- selves with this fact as, Dr. Starr em- phasized, surgery will worsen DED, whether the procedure be a cataract or refractive surgery. Vital signs Dr. Starr thus recommended test- ing all patients—"You have to look for it, you have to find it"—at the point of care, and the ASCRS Cornea Clinical Committee is creating an algorithm to help ophthalmologists in their approach to these patients. As the committee continues to "hammer out" the algorithm, Dr. Starr offered a few preop pearls. "If it is a preop refractive surgery visit, with or without DED symptoms, we recommend tear testing along with standard refractive tests," he said. In particular, Dr. Starr recom- mended testing for tear hyperosmo- larity and inflammation—2 of what Preeya Gupta, MD, Durham, North Carolina, called "ocular vital signs": objective data gathered from the tear film that allows earlier diagnosis and facilitates clinical differentiation from "masqueraders of dry eye." Masqueraders, she said, in- clude anterior basement membrane dystrophy, superior limbic kerato- conjunctivitis, floppy eyelids, and conjunctivochalasis. Hyperosmolarity can now be evaluated using a device such as the TearLab Osmolarity Test (San Diego) while inflammation is reliably diagnosed by detecting the presence of matrix metalloprotein- ase 9 (MMP-9) using a device such as the InflammaDry (RPS Diagnostics, Sarasota, Florida). The doctors' full presentations from this symposium are available at Presentations.EyeWorld.org. EW Editors' note: This event was supported by educational grants from Alcon (Fort Worth, Texas), Allergan (Dublin), Shire Pharmaceuticals (Lexington, Massa- chusetts), TearLab, and TearScience (Morrisville, North Carolina). by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer The ocular surface in ophthalmic surgery A surgical society's fascination over the ocular surface may seem strange at first, but a closer look reveals just how pertinent it is to ophthalmic surgeons. The tear film, Dr. Starr said, is arguably the most important refract- ing interface in the eye, with the cornea and tear film accounting for two-thirds of the optical power. The greatest change in refrac- tive index occurs between air and the pre-corneal tear film, and any change to the tear film thus has a significant impact on visual qual- ity. In fact, Dr. Starr said that tear film irregularities have been shown to reduce retinal image quality up to 40%, while hyperosmolarity can lead to variability in Ks and IOL errors—even in asymptomatic patients. Visual quality, he said, is worse with dry eye disease (DED). In fact, visual fluctuations are pathogno- monic of DED. on which tests to perform, what primary treatments to use, or when to initiate therapy. Nevertheless, Dr. Donnenfeld said, point of care testing "is the future." In fact, he said, in terms of both diagnostics and therapeutics, "the pipeline on dry eye is full." In the last 10 years, agreed Christopher Starr, MD, New York, there has been an explosion of new understanding of OSD following the publication of the results of landmark studies, followed by the development of novel diagnostic tests and treatments. The ASCRS Clinical Surveys from 2013 to 2015, he added, revealed that there was much confusion over this explo- sion—that the information as well as the diagnostic and therapeutic developments were "too much too soon," with many ophthalmologists feeling overwhelmed. The ASCRS Cornea Clinical Committee thus made ocular surface disease a major educational initia- tive in 2016. I n 2015, the majority of oph- thalmologists believed that less than 20% of patients who present for cataract surgery have significant ocular surface disease (OSD), according to Eric Donnenfeld, MD, Rockville Centre, New York. Meanwhile, to date, the tools most commonly used at point of care to diagnose OSD are more than a hundred years old and "don't have much utility"—this despite the availability of tools that evaluate objective parameters for the diagno- sis of OSD. Dr. Donnenfeld took this data on OSD diagnosis and care from the 2015 ASCRS Clinical Survey, present- ing it at an EyeWorld CME Educa- tional Symposium on "Optimizing Ocular Surface Diagnosis and Care for Successful Surgical Outcomes." According to the data, cost is perceived to be the biggest barrier in implementing new point of care diagnostic tools. Dr. Donnenfeld observed that OSD remains under-recognized in the surgical population, and there remains no significant consensus Optimizing the ocular surface Dr. Starr explains why anterior segment ophthalmic surgeons should be thinking about the ocular surface.

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