Treating dry eye in the surgical patient: One doctor’s simple algorithm

Incorporating an effective dry eye protocol means the surgeon must have the ability to disrupt a previously successful set of procedures.

Issue: June 25, 2016

ByDarrell E. White, MD

Dry eye disease, or DED, has made the ultimate breakthrough into the consciousness of ophthalmology. We are now talking about DED as it relates to surgery. All eye surgery. Even retinal doctors are talking about the challenges that their patients face from DED and other ocular surface diseases around both retinal surgeries and the now ubiquitous anti-VEGF injections for age-related macular degeneration. Can you imagine? Retinal surgeons are talking about the need to treat DED. That is truly something big.

At the recent American Society of Cataract and Refractive Surgery meeting in New Orleans, the topic that dominated all others was the diagnosis and treatment of DED. Key opinion leaders among us stood before standing-room only crowds to talk about the kinds of things you and I have been chatting about here in Ocular Surgery News for a couple of years. The topic of greatest interest was diagnosing and treating DED in the setting of impending cataract or refractive surgery. That should not be too surprising, of course. It is the Society of Cataract and Refractive Surgery, after all.

During the meeting, I had the honor and pleasure to share a symposium stage with four accomplished DED experts: Drs. Chris Starr, Preeya Gupta, Marjan Farid and Alice Epitropoulos. My charge was to discuss how a busy surgeon could incorporate the evaluation and treatment of DED into the perioperative process. While preparing my talk, I realized that we have a two-tiered system when it comes to DED and anterior segment surgery. Unlike other medical systems in which the tiers are driven by transactional forces (you pay more, you get something better), diagnosing and treating DED as part of the surgical experience appears to be driven by the degree to which the surgeon has control over the entirety of the patient’s preop and postop experience. Allow me to explain.

Surgeon control

Cataract and refractive surgeons have been conditioned to partition our world along rather obvious, traditional lines. High-volume surgeon vs. low-volume surgeon. Private practice or employed (corporate or academic). Surgical volume generated by an optometric referral group or organically from inside the practice. Even the classic early-, mid- and late-adopter labels can accurately be applied across the spectrum of our specialty when we seek to describe ourselves. What it takes to diagnose and treat DED in the surgical patient is something we have not really thought about previously: How much control do you have over the patient, whether that is real or perceived, especially before surgery?

We cannot ignore the fact that it takes time to both diagnose DED and achieve an effect on the ocular surface. I think the universe of surgeons can be divided into two distinct camps: “very high control” and “little or no control.” In order to assimilate an effective DED protocol into the preop time frame, it is necessary to have the ability to disrupt a previously successful set of procedures in your practice. Surgeons who are employed may not have the ability to make these changes no matter how important they may feel it is to treat DED. Indeed, some of the largest-volume cataract surgeons in the U.S. do not offer presbyopia-correcting IOLs because of the time it takes to discuss them in the office and the associated disruption in patient flow. Their effective control is nil.

Control also means being assured that your patient will stick around and follow through on surgery with you if you delay scheduling in order to treat DED. Surgeons in highly competitive markets may fear losing patients to another surgeon if they do not schedule them promptly following an examination. A practice that generates its surgery from an optometric referral group may also receive pushback from the referring doctors when a patient remains with the surgeon for care that is not considered directly surgical.

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Treatment algorithm

For those enlightened surgeons who have come to the realization that treating DED will enhance their outcomes and also have the control necessary to do this in their practice, here is a simple algorithm that can be followed. This is essentially what we do at SkyVision, where we have a busy surgical practice but one in which the surgeon has total control over the patients’ perioperative experience. It is a condensed version of our everyday DED process that takes into account the diagnostic and therapeutic treatments that are available to us all today.

Just like every other patient in our practice, every staff member is on the lookout for any indication that a pre-surgical patient has concomitant DED. We include a SPEED test or OSDI as part of the history taking in every surgical patient. This is largely a billing issue in this case, however, because we are going to test every preop cataract or laser vision correction patient in an attempt to uncover low-grade or asymptomatic DED (we know all of our surgeries will make DED worse postop). A patient who expresses any symptoms of DED allows us to bill for the tear osmolarity and MMP-9 testing that is done as a standard part of our pre-surgical evaluation. You can still do them for anyone without symptoms, but you just really cannot bill for them that first time. (Once the diagnosis is made, follow-up testing is billable.)

Who gets treated is now driven by IOL choice and DED severity. Any patient with severe DED will have treatment initiated. Every patient who opts for an advanced IOL (presbyopia correcting, toric) will have treatment of DED of any degree initiated preop. Treatment is chosen based on a simple matrix that includes the slit lamp exam, tear osmolarity and MMP-9 results. All treatment is initiated at that first visit.

A patient with elevated or asymmetric osmolarity and a positive InflammaDry (RPS) is started on Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). A low osmolarity and positive InflammaDry will produce a sample and a prescription for AzaSite (azithromycin ophthalmic solution 1%, Akorn). A negative InflammaDry with a high or asymmetric osmolarity and fluorescein staining of the conjunctiva or cornea means treatment with Restasis. Because we have the entire TearScience diagnostic and therapeutic suite, we will offer LipiFlow to advanced IOL patients who have obvious meibomian gland dysfunction. This should be considered an optional arm of the protocol, one that is much more reasonable now following the 50% price reduction that TearScience announced at OSN New York 2015.

That is all there is. Simple and straightforward, the key lies in testing and evaluating every preop patient and then treating those who will suffer a poor quality outcome if you do not tend to the DED. If you, the surgeon, have the ability to add these steps to the surgical evaluation, and if you are confident that your patient will stay with you as you treat them before surgery, you can pick and choose whom to treat. You will save yourself (and your patient) the aggravation of suffering a less than satisfactory outcome. The technology is easily accessible, affordable and mostly reimbursable. Treatment is well known, straightforward and accessible. Newer treatments will eventually come online as well.

The surgeon’s attention has shifted to the ocular surface in cataract and refractive surgery. Our SkyVision algorithm can be your entry into the perioperative diagnosis and treatment of DED. Treating DED as part of your surgical protocol makes everything look better.

Especially you.

For more information:
Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.

Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.