Address ocular surface disease before surgery to optimize patient satisfaction
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WAIKOLOA, Hawaii — Diagnosing and treating ocular surface disease preoperatively is one of the elements that contribute to elevated patient satisfaction postoperatively, Marjan Farid, MD, said at Hawaiian Eye 2022.
“We know that 50% of patients, at least, who come in for cataract surgery are asymptomatic, but at least 80% of those patients have at least one sign of dry eye disease,” Farid said in a presentation of her five top pearls for her cataract surgery practice. “This will impact our refraction, our topography and postoperative outcomes. We want to treat these patients aggressively.”
Goals for preoperative treatment are to decrease inflammation, improve the tear film and optimize the lipid layer, as well as heal punctate keratitis and epithelial irregularities.
Farid’s second pearl is to match the IOL technology to the patient.
“There is, unfortunately, no lens that fits everybody,” she said. “Everybody has different needs and everybody has different lifestyles, so ask the patient exactly what they are looking for.”
Asking the patient questions about their job, lifestyle and daily activities, and whether they desire spectacle independence can yield answers that inform the decision of which IOLs to offer.
Matching IOL technology to the patient also relies on the preoperative assessment of total eye health, ocular dominance, astigmatism and ocular surface disease.
Pearl No. 3 is to account for posterior corneal astigmatism. The posterior corneal cylinder varies according to the anterior corneal cylinder, she said. In Farid’s practice, she undertreats with-the-rule astigmatism and overtreats against-the-rule astigmatism.
“One of the most profound innovations is the Light Adjustable Lens [RxSight], which allows total correction of optical astigmatism after cataract surgery,” Farid said. “This will hit the anterior and posterior total optical astigmatism and we can really fine-tune it postoperatively.”
Although some corneal abnormalities are potentially treatable, such as pterygia, epithelial basement membrane dystrophy, Salzmann’s nodules and dry eye disease, other corneas cannot be regularized, such as in the case of keratoconus and post-refractive ectasia or RK. Preoperative screening for these abnormalities is Farid’s pearl No. 4 and should be performed with a slit lamp exam, corneal topography and aberrometry.
Pearl No. 5 is to check the macular OCT.
“There are so many subtle macular pathologies that can be easily missed on our regular retinal exams,” Farid said.
If macular pathologies go undiagnosed prior to cataract surgery, then it is easy for the patient to blame poor quality of vision on the surgery itself, she said. Furthermore, with premium IOL technology, patients’ visual expectations are elevated.
“You really can’t miss these things,” she said.
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Farid M. Top 5 pearls in my cataract practice. Presented at: Hawaiian Eye; Jan. 15-21, 2022; Waikoloa, Hawaii.
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