It is inevitable that, at some point, one of your patients may need to undergo surgery. Although you, the practitioner, may not necessarily be the one performing the surgery, it is still your responsibility to appropriately optimize the health of the patient’s ocular surface ahead of time to achieve the best surgical outcomes. This should start with addressing any lingering ocular surface issues.
In this article, we will discuss the technologies that should be employed to accurately and efficiently assess your patients’ ocular surface criterion preoperatively, how to treat their condition(s) accordingly, and how to create a helpful discourse with an ophthalmologist in the case of a referral. Such preparation will no doubt improve your patient’s quality of life pre- and post-surgery, and will help to provide a more comprehensive service to your patients. Lastly, these types of preemptive groundwork will help keep your patients coming back to you as their primary eye care practitioner.
Preoperative Care
Ocular surface disease can encompass a multitude of issues including dry eye, meibomian gland dysfunction (MGD), allergy, blepharitis, infection and inflammation. Each corneal surface problem should be addressed individually in order to accurately treat the entirety of your patient’s problem. Why is it important to acknowledge and treat the ocular surface preoperatively? Approximately 20% of cases presented to eye care practitioners are cases involving ocular surface disease.1
A recent study by George M. Salib, M.D., and colleagues found that, in 21 dry eye patients, preoperative cyclosporine treatments provided a greater refractive predictability three and six months post-operatively.2 All patients over the age of 55 who plan to undergo cataract surgery should be routinely tested for dry eyes, whether or not they report symptoms.3 Additionally, dry eye can affect corneal topography and ocular biometry readings, which may negatively affect surgical outcomes. Ultimately, the patient is more prepared for surgery and has a better outcome if you optimize the corneal surface ahead of time.
Look for signs and symptoms of OSD before your patient undergoes surgery.
Diagnosing the Condition
How do you know what to look for? How can you properly diagnose what you may not see? In the dry eye arena, there are a number of diagnostic tests that can be employed to accurately assess the quality of your patient’s tear film.
The first and primary diagnosis tool typically has been the use of fluorescein or lissamine green dyes in standardized corneal and conjunctival staining. These dyes are an efficient and noninvasive method to identify damage in the ocular surface at a cellular level.
Certain methods of analysis coupled with a standard slit lamp examination can help to accurately assess your patient’s signs of disease including redness, swelling, and discharge. For dry eye analysis, Michael A. Lemp, M.D., and John R. Hamill, M.D., initially reported that the TFBUT cut-off for dry eye diagnosis was less than 10 seconds.4 By reducing the quantity of fluorescein used, we now have a more accurate threshold of five seconds. In addition, the Ocular Protection Index (OPI) was developed to quantify the interaction between blinking and the tear film, providing a framework to assess the effects of tear film instability associated with dry eye.5
Conducting a Verbal Discourse
In addition to using the aforementioned diagnostic technologies, the preoperative assessment of your patient’s ocular surface also needs to include a verbal dynamic between you and your patient. Asking the right questions and understanding your patient’s history are extraordinarily important for an accurate diagnosis. Beyond a comprehensive patient history, this includes learning what your patient’s occupational needs and hazards are, as environmental elements can play a determining role in their ocular health. Working in front of a computer all day, or gardening, can make your patient susceptible to dry eye or allergy. If it is difficult to read or work in front of a computer for an extended period of time without experiencing a burning sensation in your eyes, that is a definitive sign of dry eye, even if the pain is just minor discomfort.
Most likely, you will be referring your patient to a specialist for cataract or refractive surgery. It is crucial to start a dialogue with all involved practitioners to appropriately comanage the patient. This includes providing information on your past treatments, and the past and current conditions of the ocular surface disease (OSD). Open and honest communication will help facilitate a better post-operative treatment plan, as dry eye or other pre-existing issues may worsen or new complications may arise. Comanagement will help to create an increased level of trust with your patient as well, while re-enforcing your position as the primary eye care practitioner.
Once your patient has been identified as having OSD, many treatments can come into play. For dry eye, an increased regimen of artificial tears will help treat the condition and should be continued postoperatively. Getting your patients on an artificial tear routine early on will not only prepare their ocular surface, but also will help postoperatively as their tear film will be compromised. In addition, discontinuing oral antihistamines pre-operatively and adjusting anti-allergy therapies may be necessary; postoperatively, a combination of an antibiotic and steroid may be helpful for an allergy patient. Beyond artificial tears, treating preoperatively can include lubricating tears, topical drugs, systemic medications, anti-inflammatories, antibiotics, nutritional supplements and/or punctal plugs.
Overall, understanding your patient and having an accurate understanding of diagnostic technologies will be your most valuable tools concerning pre-surgical considerations. Preemptively assessing and treating your patient for OSD will prepare your patient and undoubtedly reassure confidence in their eye care practitioner.
1. Lemp M, Marquardt R. The dry eye. A comprehensive guide. Berlin: Springer-Verlag; 1992.
2. Salib GM, McDonald MB, Smolek M. Safety and efficacy of cyclosporine 0.05% drops versus unpreserved artificial tears in dry-eye patients having laser in situ keratomileusis. J Cataract Refract Surg. 2006 May;32(5):772-8.
3. Trattler W. The Impact of dry eye on cataract and refractive surgical outcomes. Advanced Ocular Care. 2011 Jul/Aug(Suppl).
4. Lemp MA, Hamill JR Jr. Factors affecting tear film breakup in normal eyes. Arch Ophthalmol. 1973 Feb;89(2):103-5.
5. Ousler GW, 3rd, Hagberg KW, Schindelar M, Welch D, Abelson MB. The Ocular Protection Index. Cornea. 2008 Jun;27(5):509-513.
