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Dry eye disease in the surgical patient
The harsh truths about perioperative dry eye.
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“If you diagnose dry eye before you operate, it is your patient’s problem. If you diagnose it postoperatively, it is your problem.” –Eric Donnenfeld
“You can’t handle the truth.” – Col. Jessup, A Few Good Men
For most of us who practice in the anterior segment, surgery is what we do best. Not only that, but most of us would choose to spend more time in the OR if we could. Reality for most of us is that we must spend as much or more time in the office engaged in not only pre- and postoperative examination and testing, but we must also spend quite a bit of time in conversation with our patients about both what they should expect from surgery and why they got the outcome they ended up getting. The first harsh truth of being any kind of surgeon whatsoever is that you must see your surgical patients before you operate on them, and then you are responsible for everything that happens to them afterward, even if you never see them again.
Everyone has dry eye
Your default position when you are contemplating anterior segment surgery of any kind whatsoever is that your patient has a DED of some sort. Really and truly. Every single one. If you enter each preop evaluation with this assumption, you are less likely to miss a dry eye that you would otherwise have treated. Sometimes your patient makes it very easy for you by declaring that their eyes are dry. Other times it is a staff member who saves your bacon by highlighting some other historical clue in your patient’s narrative. Most of the time, though, you are on your own.
Knowing that Eric is a very smart guy who has only your best interest at heart, you are going to do everything in your power to make a diagnosis of DED in as many operative candidates as you possibly can. Mind you, this is all comers and includes cataract patients, LASIK, Raindrop (ReVision Optics) or Kamra (AcuFocus) candidates, or glaucoma patients referred to get your MIGS flavor of the day. All of them. Strictly speaking, all of you retina folks should be doing this, too, but I understand you probably will not because, you know, retina.
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At this point, the easiest thing to do is simply turn on your DED protocol for your preop patients. At SkyVision we do a tear osmolarity on every preop, even if they are completely asymptomatic. Yes, I know, we are unable to bill for that tear osmolarity chip if they do not show up with a prior diagnosis or symptoms, but tear osmolarity is the best way to uncover an otherwise difficult-to-find case of DED in a patient who does not have any DED complaints. Any exam signs that are discovered — staining, rapid tear breakup time, low tear meniscus, “sticky” conjunctiva — should be noted and used to make a supportable DED diagnosis so that treatment will be covered.
Your mission, and you should decide to accept it, Dr. Bond, is to make a diagnosis of DED.
Asymptomatic patients will not improve
Now that you have made a supportable diagnosis of DED, you must treat every single patient who is going to have a surgical procedure. (Specific treatment plans for specific procedures to come in my blog on Healio.com/OSN.) Remember, though, that some of your patients were totally unaware that they had DED before your testing, and they still do not have any symptoms as far as they are concerned. I have shared this next harsh truth before: You cannot make an asymptomatic patient feel better.
It is entirely possible that you will find it harder to get your patient on board with treating his or her DED than it is to help them come to the realization that it is worth $1,200 per eye to treat 0.125 D of incision-induced cylinder they do not have yet with a golden scal–, er, femtosecond laser. Once you have committed to treating your patient’s DED, you really need to be serious about doing so, and that means using a real, live, honest-to-goodness medication for which you will write a prescription. We all know that this is going to generate countless pharmacy calls, preauthorization requests and clutter on that patient portal you were required to put in your EMR (and admit it, planned to ignore) so that you could get MU credit.
They feel great, no symptoms whatsoever, and you are making them pay for something they do not realize they really do need because ...
Surgery makes DED worse
... all of your surgical magic really is going to make them worse. Your cutting-edge Symfony toric (Abbott Medical Optics)? Drier than preop. That patient who got all excited about having a perfectly round capsulorrhexis to go with that prophylactic limbal relaxing incision? You bet; that one, too. Even your plain Jane, no-frills basic IOL case will likely have more DED than they did preop, whether or not they complain about it. Making the diagnosis preop allows you to begin every conversation about DED in the postop arena with something that goes along the lines of, “When we talked about your dry eye before the surgery I said ... .”
This is also much easier if, after making the diagnosis of DED, you really did go ahead and start some sort of treatment. My view has always been that the higher the stakes in the surgery (presbyopia-correcting IOL, FLACS conversion of any type, LASIK), the more important it is to begin aggressive treatment of DED before you operate. There are now countless studies that show an improvement in visual acuity and visual quality with a healthy pre-corneal tear film. While there is a dearth of hard science to back this up, it is axiomatic that neuroadaptation to complex optics occurs more rapidly if all other elements of the ocular system have been optimized.
DED treatment treats the surgeon
The ultimate bad diagnosis in surgery of all types is a case of mis-met expectations. This is especially true in surgeries that are non-urgent in basic nature, and painfully so when there is an element of optional, noncovered care involved. No conversations are quite as uncomfortable than ones in which you, the surgeon, are called to account for something that “went wrong.” Diagnosis and treatment of DED in the preop setting tends to take one very troublesome topic off of your postop table.
Most of what is written about DED care in anterior segment surgery is about so-called “advanced” or “upgraded” services. This is all well and good, but because we know that treated DED leads to better outcomes, I am starting to wonder why I do not do this for all of my surgical patients. Perhaps I should just face the truth: I do not do it for everyone because it is hard to do, and somehow it feels easier if I am being paid to provide that extra service. The harsh truth may be that if I am going to ask patients with limited funds to pay extra for care around the time of surgery, especially cataract surgery, perhaps they would be better off choosing to pay for their Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Xiidra (lifitegrast ophthalmic solution 5%, Shire).
“The truth hurts.” – Anonymous
- 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.