ASCRS algorithm addresses ocular surface disease in five steps
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The American Society of Cataract and Refractive Surgery has a message for its membership and for the global community of ophthalmologists at large: Pay attention to the ocular surface before performing any type of refractive surgery.
ASCRS membership surveys have determined that most cataract and refractive surgeons recognize the importance of ocular surface health on refractive outcomes. The surveys also determined that most surgeons would like to know what to do about it.
In 2017, 83% of survey respondents said they would welcome a clinic-based protocol to address this educational gap, Christopher E. Starr, MD, FACS, said in a presentation at Hawaiian Eye 2020.
Source: Christopher E. Starr, MD, FACS
“We decided to create an algorithm that is consensus-based, evidence-based, can be integrated into the preop visit, specifically with a heavy reliance on technicians and objective testing, in an effort to reduce your chair time and to identify all subtypes of ocular surface disease, not just dry eye,” he said.
The ASCRS Cornea Clinical Committee now provides that guidance as an algorithm for the preoperative diagnosis and treatment of ocular surface disorders, published in the Journal of Cataract and Refractive Surgery.
Reasons to care about OSD
There are good reasons for surgeons to care about the ocular surface preoperatively, said Starr, who was tasked with spearheading the educational effort for the committee.
For one, ocular surface disease (OSD) is present in the majority of cataract patients.
“It’s incredible how common it is, but it’s often asymptomatic,” Starr said.
In the PHACO study, which looked at incidence and severity of dry eye in cataract patients, William B. Trattler, MD, and colleagues found tear breakup time was 5 seconds or less in 62.9% of 272 eyes, corneal staining with fluorescein was positive in 77%, and Schirmer’s test measured 10 mm or less in 18%. In questionnaires completed by all 136 patients, 86% reported feeling no symptoms of dryness and 58.8% reported feeling no foreign body sensation.
OSN Cornea/External Disease Board Member Preeya K. Gupta, MD, and Starr, in a collaborative study between Duke and Weill Cornell, also found a high prevalence of ocular surface dysfunction that was often undiagnosed and asymptomatic. In 120 patients presenting for cataract surgery, osmolarity results were abnormal in 56.7% of patients and MMP-9 results were abnormal in 63.3%. Results were abnormal for at least one of the two tests in 85% of the 46 patients who were asymptomatic.
“Clinicians should be aware of this high prevalence and consider screening with tear testing before surgery,” the authors said.
Whereas tear osmolarity testing is specific for dry eye disease, “MMP-9 speaks to abnormality of the ocular surface, which is equally important for diagnosing epithelial basement membrane dystrophy, recurrent erosion and sometimes allergic disease,” Gupta said.
Furthermore, ocular surface disease reduces accuracy of preoperative and postoperative measurements, Starr said, citing a study by Healio/OSN Board Member Alice T. Epitropoulos, MD, FACS, and colleagues that looked at the effect of tear osmolarity on repeatability of keratometry for cataract surgery planning.
“Measuring tear osmolarity at the time of cataract surgery planning can help identify patients at risk for a refractive surprise due to inaccurate keratometry from dry eye disease,” Epitropoulos said.
In the observational, prospective, nonrandomized study involving three clinical sites, cataract surgery patients were prospectively recruited into two groups based on tear osmolarity: a hyperosmolar group (>316 mOsm/L in at least one eye) and a normal group (<308 mOsm/L in both eyes).
“Hyperosmolar patients had significantly greater variability in K readings and IOL power calculations compared to the normal osmolar group. The hyperosmolar group also had a higher percentage of eyes with a 1 D or greater difference in measured corneal astigmatism,” Epitropoulos said.
Failure to address problems with the tear film and ocular surface before surgery can have a significant impact on surgical outcomes and patient satisfaction, she said.
Cataract surgery has become a refractive procedure, Cynthia A. Matossian, MD, FACS, an OSN Cataract Surgery Board Member and co-author of the tear osmolarity study, said.
“While we are removing a cloudy lens that has aged, we are at the same time correcting that patient’s astigmatism, that patient’s refractive error, and giving them a wide range of vision,” she said.
Having reliable measurements to input into IOL calculation formulas is the only way to achieve that refractive goal, Matossian said.
“If the tear film is unstable and if the patient has ocular surface disease, then the data we’re collecting is not going to be reliable. This will lead to a less than ideal postsurgical refractive outcome,” she said.
After surgery, ocular surface disease, which reduces “visual quality, quantity and performance,” can be further complicated with implantation of a multifocal IOL, Starr said.
There are also risks that accompany the presence of bacteria, which is associated with anterior blepharitis and bacterial conjunctivitis.
“If that isn’t treated prior to surgery, that could increase the risk of endophthalmitis,” Starr said. “And certainly we know that any eye surgery can worsen dry eye disease, usually temporarily but sometimes chronically.”
Step 1: Getting started
After undertaking the quest to develop an algorithm that addresses concerns for all types of ocular surface disease in a preoperative refractive surgery population, and after multiple iterations over multiple years, “We finally got it right,” Starr said.
At the preoperative visit, which is also the last chance to identify ocular surface disease before surgery, the noninvasive refractive measurements, such as keratometry, topography, optical biometry and aberrometry, are obtained first, before ocular surface testing potentially disrupts the ocular surface.
“Then comes what we call the OSD screening battery that involves assessing symptoms and signs,” Starr said. “Again, it’s OSD, not just dry eye. Yes, dry eye is a big component of OSD, but there are a lot of other subtypes that can be visually significant in the context of surgery.”
Step 2: Screen for signs and symptoms
The first part of the screen is to assess for symptoms.
“We looked at all of the validated dry eye questionnaires, and they’re all good for dry eye, but they weren’t geared toward surgery. So, we basically had to create a new questionnaire,” Starr said.
The novel ASCRS SPEED II Preoperative OSD Questionnaire incorporates modifications of the SPEED questionnaire (Johnson & Johnson), which is validated and scoreable, then adds other targeted questions for identifying other potentially significant OSD subtypes. “A little chunk of Steven Dell, MD’s, Cataract and Refractive Lens Exchange questionnaire, which asks about personality type, is incorporated as well,” Starr said.
“Are you easygoing? Are you a perfectionist? Do you want to be spectacle-independent after surgery? Are you willing to pay out-of-pocket costs? These things are all very informative when you’re evaluating a patient prior to surgery,” he said.
The questionnaire is tallied and scored by the technician and recorded at the bottom. These overall numbers are quickly reviewed by the physician before seeing the patient. The higher the SPEED score and the higher number of “red boxes” increase the suspicion for the presence of OSD.
The second part of the screen is to rapidly and objectively assess for signs of OSD.
“We selected a combination of osmolarity and MMP-9 because both tests give different information,” Gupta, who is also a co-author of the published algorithm, said. “Osmolarity is a great screening test because it has a high specificity for dry eye, while MMP-9 is a measure of the amount of inflammation on the surface, which is a validated tool to assess dry eye but is also a marker of elevated inflammation in other ocular surface disease.”
When put together, the two tests have a high positive predictive value for ocular surface disease, according to Starr.
The tests are quick, easy and available in many offices. Furthermore, testing is done by technicians and is often reimbursable or, if not, can be bundled into a premium package, he said.
Screening determines whether ocular surface disease is likely, whether it is severe and whether there is inflammation. What it does not determine is the subtype of OSD or DED. Further objective testing, such as for lipid layer thickness, meibography, noninvasive tear breakup time, quantification of tear meniscus height, tear lactoferrin levels, topography/tomography, aberrometry and ocular scatter index, can help distinguish evaporative dry eye, meibomian gland dysfunction, aqueous deficient dry eye or other visually significant ocular surface disease.
“Use them if you’ve got them,” Starr said. “That will help identify the subtypes and how visually significant the OSD is.”
Step 3: Look, lift, pull, push
The next step is the clinical examination, which “does not need to be irksome or onerous,” Starr said. “Just a quick 20-second LLPP: look, lift, pull, push.”
What that means is first look at the blink, the lids, the meniscus, the lashes, the meibomian glands and the interpalpebral cornea/conjunctiva, noting any scurf and signs of bacteria. Then lift the upper lid.
“There’s a lot of stuff up there, epithelial basement membrane dystrophy being the big one,” Starr said.
Next, pull the upper lid, looking for laxity and floppy eyelid syndrome, which is often missed but is a frequent source of significant OSD. Lastly, push on the lower eyelid margin, expressing the meibomian glands.
“All of us as cataract surgeons should be aware of the prevalence of dry eye disease and diagnose it before surgery. This can be accomplished with a minimal set of diagnostic tools to include fluorescein and lissamine green vital dyes, and tear breakup time. It can be as simple as looking, lifting, pulling and pressing on the eyelid at the slit lamp,” Matossian said.
When the LLPP exam is complete, instill fluorescein or lissamine green for corneal staining.
“At that point, you’re not going to get any more refractive measurements because there is dye in the eye,” Starr said.
Step 4: Determine visual significance
Ocular surface disease is ruled out when the exam is normal: no corneal staining, no signs and no symptoms. Ocular surface disease is ruled in when any combination of signs and/or symptoms is demonstrated, making it a likely diagnosis.
“OSD is prevalent, but it’s not always visually significant, and that’s the next determination. Is it visually significant or not?” Starr asked.
Patients with non-visually significant ocular surface disease may proceed to surgery using the refractive measurements obtained at the start of the protocol. The patient still needs to know that they have ocular surface disease, however.
“You have to mention it to the patient before surgery and prophylactically treat it so that if it worsens after surgery it’s not viewed as a complication and you told them about it before surgery,” Starr said.
Step 5: Planning treatment
When ocular surface disease is visually significant, it can affect refractive outcomes and patient satisfaction and needs to be reversed before surgery, even if that requires delaying surgery, Starr said.
A multifaceted treatment regimen that combines prescription medication, high-quality omega-3 supplements and procedural therapies would likely be recommended until the visually significant ocular surface disease is resolved, according to Epitropoulos.
“When that visually significant OSD is converted to non-visually significant OSD, then final refractive measurements and surgery can proceed,” Starr said.
Symbiotic protocols
There are other published protocols that address identification and treatment of ocular surface disease, notably the recommendations of the Tear Film & Ocular Surface Society Dry Eye Workshop II (TFOS DEWS II) and of the Cornea, External Disease, and Refractive Society (CEDARS) Dysfunctional Tear Syndrome (DTS) panel, both published in 2017.
Healio/OSN Board Member Kenneth A. Beckman, MD, FACS, who was on the DTS panel as well as a co-author on the ASCRS algorithm, does not believe the three guidelines are competitive but are rather symbiotic.
“Each builds upon the others to formulate a more clear approach to management of these patients. The DEWS II report provides an all-encompassing summary of dry eyes and ocular surface disease and is a wonderful reference for understanding all aspects of this complex disease,” Beckman said. “In contrast, the CEDARS algorithm attempts to create an ‘at your fingertips’ manual of how to manage these patients.”
The CEDARS report distinguishes categories of the complex disease, describes the mechanisms to test for and identify each category, and lists a treatment tree for each category. Flow charts for diagnosing and for treating each subtype of disease can be referenced “on the fly to quickly aid in decision-making,” he said.
The ASCRS algorithm combines information from both to aid in management of ocular surface disease in surgical patients specifically.
“We know that ocular surface disease is very common in surgical patients and may have a significant impact on the success of the procedures. This report outlines a very clear and concise protocol as to how to look for these conditions in this population and then how to treat them to get them ready for surgery,” Beckman said.
All the dry eye algorithms have benefits, but they should not be seen as a rigid, stepwise approach, but as an organizational tool to aid in treatment decisions. Treatment should be individualized based on patient signs, symptoms and situation, Epitropoulos said.
Even though Epitropoulos routinely evaluates for and treats ocular surface disease before cataract or refractive surgery with a protocol that closely follows the recommendations of the ASCRS algorithm, these algorithms should be looked at as a guide with a list of suggested options, she said.
“While the algorithm and protocol is easy and inexpensive to institute faithfully as we designed it, the methodology is flexible and adaptable enough to allow diagnostic and treatment substitutions based on the technology, experience and workflow of individual practices,” Starr said in an interview. “On a fundamental level, if we have raised the widespread awareness of the importance of addressing visually significant OSD and dry eye disease preoperatively, then we have succeeded in our original mission.”
Beckman hopes the repeated reference to the algorithms will lead clinicians to reevaluate how they manage patients with ocular surface disease.
“The most important thing is the raising of awareness of this condition,” he said. “These reports have been referenced repeatedly in the literature and at major meetings. The repeated references emphasize to the clinicians that this condition is incredibly common and critical to manage.”
“Not working up the patient for dry eye disease, not doing diagnostic tests, not making the proper presurgical diagnosis of dry eye disease and therefore not addressing the chronic and progressive issue at hand is only going to come back to bite us as surgeons and create unhappy patients,” Matossian said.
Global outreach
Since publication of the ASCRS algorithm, Starr has taken a lead role in disseminating the protocol in the U.S. and abroad.
“Our algorithm paper has been overwhelmingly well received, not only in the U.S. but around the world. I have traveled the world in the last year lecturing on this topic, and I’m always impressed by the genuine interest in the algorithm and its widespread adoption. One of my proudest moments in my academic career was being in attendance at the Korean Ophthalmologic Society meeting in Seoul and seeing our algorithm and questionnaire translated into Korean and presented to an eager audience of thousands. A few months later I witnessed the same thing in China at their annual Ocular Surface Disease Congress,” he said. “We’re not saying you have to follow these exact guidelines. It is a protocol that you can use faithfully or adapt to your office setting. The take-home message is this: Pay more attention to the ocular surface before surgery, and your patients — and you — will be a lot happier.” – by Patricia Nale, ELS
- References:
- Epitropoulos AT, et al. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2015.01.016.
- Gupta PK, et al. J Cataract Refract Surg. 2018;doi:10.1016/jcrs.2018.06.026.
- McDonnell PJ, et al. BMC Ophthalmol. 2017;doi:10.1186/s12886-017-0646-5.
- Starr CE. Managing OSD in cataract and refractive surgery: The ASCRS algorithm. Presented at: Hawaiian Eye 2020; Jan. 18-24, 2020; Koloa, Hawaii.
- Starr CE, et al. J Cataract Refract Surg. 2019;doi:10.1016/J.JCRS.2019.03.023.
- Trattler WB, et al. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S120159.
- For more information:
- Kenneth A. Beckman, MD, FACS, can be reached at Comprehensive Eye Care of Central Ohio, 450 Alkyre Run Drive, No. 100, Westerville, OH 43209; email: kenbeckman22@aol.com.
- Alice T. Epitropoulos, MD, FACS, can be reached at Ophthalmic Surgeons & Consultants of Ohio at The Eye Center, 262 Neil Ave., Suite 410, Columbus, OH 43215; email: eyesmd33@gmail.com.
- Preeya K. Gupta, MD, can be reached at Duke University, Department of Ophthalmology, Box 3802, Durham, NC 27710; email: preeya.gupta@duke.edu.
- Cynthia A. Matossian, MD, FACS, can be reached at Matossian Eye Associates; email: cmatossian@matossianeye.com.
- Christopher E. Starr, MD, FACS, can be reached at Weill Cornell Medicine, New York-Presbyterian Hospital Department of Ophthalmology, 1305 York Ave, New York, NY 10021; email: cestarr@med.cornell.edu.
Disclosures: Beckman reports no relevant financial disclosures. Epitropoulos reports she is a consultant to TearLab. Gupta reports she is a consultant to TearLab and Quidel. Matossian reports no relevant financial disclosures. Starr reports he is a consultant to TearLab, Quidel, Johnson & Johnson, Allergan, Novartis, Eyevance, Bruder, Kala and BlephEx.
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Perspective
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John A. Hovanesian, MD, FACS
A few years ago, TearScience did a market research study that showed the average eye care provider spends 10% of his time but makes only 2% of his income taking care of ocular surface disease (OSD). This is one reason so many of our colleagues regard OSD as a low-value condition to treat. It takes so much time to communicate with patients, and this perception may be the biggest barrier to implementation of an otherwise valuable dry eye protocol. Traditionally, cataract surgery has been our highest-value activity, and it can remain so despite declining reimbursement if more patients adopt refractive options. Studies have shown that 80% of patients are willing to pay extra for a lifetime of better vision when undergoing cataract surgery, but we simply cannot increase adoption of refractive cataract options unless we meet three goals. Two of them are optimizing our patients visual potential and delivering accurate refractive results. Both are achieved when we manage OSD, as shown in studies by our group and others. Curiously, the third and biggest barrier to succeeding with refractive cataract surgery is often the same barrier to succeeding in managing OSD a willingness to spend time communicating with the patient about their treatment.
In the days of healthy cataract reimbursement, we could afford to have short conversations about dry eye and a cavalier approach to treatment. Now, subordinating dry eye is a disservice to both the patient and the practice. In other words, we have the technical tools to achieve better results with both OSD and refractive cataract surgery. Patients want those results, and we are fairly reimbursed to deliver them. The challenge is whether we clinicians will give enough importance to a condition we once considered to be a bother.
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