\n<\/figcaption><\/figure>\nEspecially if Brent Saunders sticks around.<\/p>\n
As I have previously noted here and elsewhere, I am the son and grandson of English teachers. Writing comes easily to me, especially if I am allowed to write in my own \u201cvoice.\u201d In addition to my family\u2019s early influence, I am fortunate to have several friends who write for a living. From them I receive an almost endless stream of advice and good-natured ribbing about my \u201camateur\u201d status. The columnists among this group uniformly suggest having a couple of themes or schemes that come up periodically. You may have noticed that I have taken this to heart with my annual \u201cNew Years Resolutions\u201d and Sits and Thinks columns.<\/p>\n
When I look back at my collected columns, it seems that I never go much longer than 12 or 15 months between offerings that address some aspect of DED in the surgical setting. Perhaps not on any schedule, like my themed columns, but nonetheless with enough frequency that I wonder if I should just make DED and surgery an annual topic. Indeed, like anti-inflammatory treatment, each year brings subtle and not-so-subtle changes in how we address this and why.<\/p>\n
Last fall, I took part in several fascinating meetings during which we discussed all things dry eye and, specifically, cataract surgery. Assembled were some of the most thoughtful cataract surgeons in the United States. And me. Among the attendees were surgeons practicing in boutique settings where 90+% of their cases were upgraded IOLs, surgeons doing more than 3,000 cases per year, predominantly traditional IOLs, and everything in between. Some of the surgeons saw every postop and preop exam while others met their patients under the microscope.<\/p>\n
Each meeting brought us together to talk about the impact of DED on cataract surgery outcomes. How does it affect biometric accuracy preop? What do we see postop when DED arises after surgery? When DED is present, what do our patients experience, and how do they tell us about it? Was there a consensus in the room about how to address DED discovered during preop evaluations? Is there any correlation between such things as practice \u201cstyle\u201d or case volume and the practice\u2019s approach to diagnosing and treating DED? In the event that this heterogenous group found some common ground, how might we gently educate our fellow surgeons?<\/p>\n
There was one universal priority among the cataract surgeons in the meetings: All had designed their preop protocols to maximize the likelihood that patients would choose an advanced-technology IOL for their surgery. Everyone expressed interest in having a higher percentage of their surgical candidates choose a toric, multifocal or extended depth of focus lens. Not much of a surprise there.<\/p>\n
What, if anything, did surprise us?<\/p>\n
Let me start with the things that surprised me. Right off the jump, I was surprised by how many of the practices delegated most or all of the patient exam and the review of preop testing to optometric colleagues who were part of the surgical practice. I cannot remember the over\/under, but this was the rule with the higher-volume practices regardless of where the patient came from. Likewise, the larger the surgical volume, the greater the likelihood that most or all of the surgical counseling and education on IOL choice was provided by counselors. Whether or not the surgeon visited with the patient in the office was determined by practice style and not strictly volume.<\/p>\n
The larger the practice and the lower the likelihood that the surgeon would see the patient preop, the less likely established protocols were in place to proactively diagnose DED. Having said that, 50% of the smaller \u201cboutique\u201d practices were without standing protocols, too. Those practices with at least one surgeon who proactively treated patients with DED uniformly had formal protocols to proactively diagnose and treat perioperative DED. Only one practice routinely checked tear osmolarity preop or postop (guess who?!).<\/p>\n
But the biggest surprise was the finding that only three practices routinely used fluorescein staining preoperatively to look for visually significant DED in all patients, regardless of symptoms.<\/p>\n
When we turned our attention to our postop protocols, pretty much all the practices moved in lockstep when it came to our approach to DED discovered postop. Clues from patient symptoms (intermittent blur, unexpected postop refractive errors, discomfort and frank pain) uniformly trigger what we would all recognize as a standard DED workup: symptom surveys, slit lamp examination, fluorescein staining, tear breakup time. Every single surgeon in the meetings agreed that patient discomfort was their greatest concern, the thing that made the surgeon unhappiest in the postop period.<\/p>\n
Which brings us to the \u201chow might we educate\u201d part. Starting with the universal desire to perform more surgeries with advanced-technology IOLs, we can share some data about Xiidra (and likely by extension other immunomodulators) pre- and postop. John Hovanesian and coauthors published a study in which Xiidra (lifitegrast ophthalmic solution 5%, Bausch + Lomb) was used for 28 days preop, held over early perioperative period and then resumed 28 days postop. One hundred percent had corneal staining preop, down to 63% postop. Referring to the desire to do more advanced-technology IOL surgery, patient candidacy for these IOLs increased 60% in the treated study group.<\/p>\n
Lesson for the surgeon: You can increase the percentage of patients who are candidates for advanced-technology IOLs by doing fluorescein staining during the preop exam and achieve a timely effect by treating positive findings with Xiidra. Implication for the class: highly likely with Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical), possible with Vevye (cyclosporine ophthalmic solution 0.1%, Harrow), historically unlikely with Restasis (cyclosporine ophthalmic emulsion 0.05%, AbbVie).<\/p>\n
Our other universal finding was the discomfort felt by all the surgeons in the meetings when their patients had postop discomfort following otherwise unremarkable cataract surgery regardless of IOL. Surgeons practicing in all style settings and performing any volume of cases were in agreement: Patients complaining of discomfort universally called them into the postop exam. John Hovanesian also published a study in which Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) was prescribed to treat DED diagnosed preop in the same pattern as Xiidra in the above study. Not only was total corneal fluorescein staining improved (5 to 1.9 on a scale of 9), preop Ocular Surface Disease Index and eye dryness visual analog scale were dramatically improved postop, 51.9 to 11.9 and 62.3 to 25.9, respectively.<\/p>\n
Lesson for the surgeon: You can prevent postop discomfort associated with DED by asking about symptoms and doing fluorescein staining, treating positives with Miebo.<\/p>\n
There is a pattern here, my friends. Whether we are seeking the carrot (increased advanced-technology IOL volume) or avoiding the stick (called into the postop exam room), ultimate success lies in making the diagnosis of DED (ask about symptoms and perform fluorescein staining) and actively treating positive findings. For staining alone, Xiidra was found to be effective in a timely manner, consistent with clinical trials. Other immunomodulators might also work. For patients with symptoms as well, the Hovanesian data for Miebo were highly favorable; Miebo is in a class n = 1.<\/p>\n
This year\u2019s bottom line for mitigating the negative effects of DED in cataract surgery: Someone should ask about symptoms, someone should do fluorescein staining, and someone should prescribe a real DED medication to treat it. Still.<\/p>\n
For More Information:<\/h2>\n
Darrell E. White, MD, <\/strong>of SkyVision Centers in Westlake, Ohio, can be reached at dwhite2@skyvisioncenters.com.<\/p>\n\n
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