Eyeworld Daily News

EW SHOW DAILY 50 Meeting Reporter Sunday, April 15, 2018 by Rich Daly EyeWorld Contributing Writer to look for duct dilation, curling and shortening, hazy appearance, and dropout. She noted that such imaging is a powerful tool to moti- vate patients to accept or perform preventative care. Then the office can add ther- apeutics, such as professional lid cleaning, microblepharoexfoliation, and thermal pulsation therapy. Practices can add technologies as needed. Such efforts likely will lead growing numbers of extreme dry eye patients to seek out care at your practice, Dr. McDonald said. In addition to helping your patients who are suffering and improving your surgical outcomes, the center of excellence approach can bolster practice income. For in- stance, Dr. McDonald has found she obtains as much revenue from each thermal pulsation treatment as she does from performing a LASIK pro- cedure. Such treatments also have minimal medicolegal risks, unlike other private pay procedures. Cataract surgeons are likely to face two broad types of OSD that should drive different responses, Dr. McDonald said. Cases of mild OSD should lead them to perform biometry and schedule the cataract surgery. Such patients' OSD treat- ments should last 2–4 weeks before surgery. The second group of OSD patients—those with worse than mild conditions—should not pro- ceed to surgery. Instead, they require at least 4 weeks of treatments before performing biometry. Tips from her practice include stopping the cataract workup if the osmolarity is greater than 325 or if there is breakup of the Placido rings. In such cases, Dr. McDonald said not to dilate or obtain biometry; instead she starts lifitegrast or cyclosporine, using plugs or other approaches. Additionally, she uses BlephEx (Franklin, Tennessee) or LipiFlow (Johnson & Johnson Vision, Santa Ana, California) as indicated. EW Editors' note: This event was supported by educational grants from Johnson & Johnson Vision, Santen (Osaka, Japan), Shire (Lexington, Massachusetts), and Sun Pharmaceuticals (Mumbai, India). with minimal to no symptoms on the SANDE questionnaire, 75% had abnormal MMP-9 testing, 45% had abnormal tear osmolarity, and 40% were abnormal on both tests. One approach surgeons can take is to develop a dry eye center of excellence within their practice, Dr. McDonald said. The approach starts with informing your staff that it is a priority, then visiting other dry eye centers of excellence to learn from them. Clinical approaches should start with questionnaires and osmolarity, which she described as objective, easy, and inexpensive to implement. Next steps include adding MMP- 9 testing for patients with symptoms and osmolarity, and bringing in meibography. In meibomian gland imaging, Dr. McDonald urged physicians posium. Another 30% cited their limited time during preop workups. Keys to treating patients with OSD, according to Marjan Farid, MD, Irvine, California, include understanding that the conditions are multifactoral, early identification and management are important, no single treatment works for all, and treatments should break the cycle of inflammation and restore tear homeostasis. Marguerite McDonald, MD, Lynbrook, New York, urged cata- ract and refractive surgeons to treat every patient as a dry eye patient, regardless of the chief complaint. That approach was driven by several studies finding the lack of symp- tomology among various types of OSD patients. For instance, a prospective study presented at the 2017 ASCRS•ASOA Symposium & Congress found that among patients C ataract surgeons have tremendous potential to expand their care in ocular surface disease, but they frequently must overcome obstacles to do so. Ocular surface disease (OSD) is prevalent but often undiagnosed in cataract patients, said Alice Epi- tropoulos, MD, Columbus, Ohio. The importance of OSD stems from its ability to decrease surgical predictability and adversely affect surgical outcomes. Comprehensive detection, however, requires eval- uating asymptomatic patients, Dr. Epitropoulos said. The leading obstacle to evaluat- ing tear film, lids, and meibomian glands in preop patients is a lack of access to advanced tear film or other office-based diagnostic testing, according to 36% of respondents at an EyeWorld CME Educational Sym- Ocular surface disease opportunities and obstacles for cataract surgeons Dr. McDonald discusses the steps needed to build a dry eye center of excellence.

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