The Zamboni effect: Optimizing the ocular surface in premium IOL surgery
A smooth ocular surface is needed before a premium IOL surgery is performed.
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When the NHL returned from its COVID suspension, it was exciting to see my hockey team, the Chicago Blackhawks, pull a surprise upset over the highly favored Edmonton Oilers to make the playoffs.
Unfortunately, their luck ran out with a quick exit by the Vegas Golden Knights. But watching the Hawks play reminded me of what is so important as a refractive cataract premium surgeon: a pristine ocular surface. As I watched the Zamboni between periods and timeouts clean the ice surface, I could only wish my patients undergoing premium IOL surgery would attain such a perfectly smooth ocular surface.
The first ice resurfacer was developed by American inventor and engineer Frank Zamboni in 1949. As such, an ice resurfacer is often referred to as a “Zamboni” regardless of brand or manufacturer. So, as I plan and strategize what is best for our patients undergoing premium IOL surgery, the “Zamboni effect,” as I would like to reference it, will always be a critical part of how we get optimized outcomes. Read on for the critical diagnostics needed for premium surgeons and some of the most current and near-future treatment options for maintaining a Zamboni-like ocular surface.
Diagnostic Zamboni necessities
Published data have shown that up to 80% of patients coming for cataract surgery are asymptomatic for dry eye, but at least 50% of these patients have objective dry eye signs. Without a pristine ocular surface perioperatively, premium IOL outcomes will not be perfect. Preoperative diagnostic testing should include some form of dry eye questionnaire (OSDI, SPEED), slit lamp evaluation of the meibomian glands, fluorescein staining of the cornea, lissamine staining of the conjunctiva, dynamic meibomian gland imaging (LipiView, Johnson & Johnson Vision), MMP-9 (Quidel) and tear osmolarity testing (TearLab).
Based on the diagnostic findings, a variety of treatment options may need to be initiated to optimize the ocular surface to obtain better preoperative IOL calculation data and to reduce postoperative visual fluctuation and blurriness, especially with near vision tasks. As an example, we use thermal pulsation therapy with the TearCare device (Sight Sciences) before surgery with all of our Light Adjustable Lens (RxSight) cases, as an optimized tear film is critical in obtaining precise refractions postoperatively before locking in the end result with this lens.
Mechanical friction component
The mechanical component in the pathophysiology of dry eye disease must be addressed, as the lubrication deficit from induced impaired mechanotransduction of lid pressure of the ocular surfaces may lead to dysregulation of homeostasis in the epithelium, with sensations of pain and secondary inflammation. Ocular pain is possibly the first sign of attrition and may occur in the absence of visible epithelial damage. Attrition typically can result from repeated challenge of the ocular surface tissues by mechanical forces in association with glaucoma surgery or simply from the toxicity of preservatives in many topical medications, including chronic glaucoma therapy. The problem is the dissociation of signs and symptoms with DED, so subjective and objective evaluation perioperatively in premium IOL surgery is critical for obtaining the best and most stable visual outcomes postoperatively. Thanks to Laura Periman, MD, for teaching me about mechanical effects on the ocular surface, allowing me to find the best Zamboni effect possible to prevent such issues with the ocular surface.
Future treatment options
Many novel and innovative pharmaceutical treatments are coming to address the true friction effects of DED, paving the way to a Zamboni treatment. Lubricin (Novartis) is underway in phase 2 clinical trials, Novaliq (perfluorohexyloctane, Bausch + Lomb) has begun phase 3 clinical trials, and many more surface treatments are coming in the near future, so I can be sure my premium patients obtain the true Zamboni effect and feeling on their ocular surface.
- References:
- Gupta PK, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.06.026.
- Trattler WB, et al. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S120159.
- van Setten GB. Int J Mol Sci. 2020;doi:10.3390/ijms21124333.
- van Setten GB. New Front Ophthalmol. 2018;doi:10.15761/NFO.1000199.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
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