Again, to the surface
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Can someone take a look at the archives and figure out the first time I spouted off about the importance of treating the ocular surface preop and postop?
It feels like I must have started talking about this around the time that Kareem was setting the all-time NBA scoring record. And how many times have I gone to this well, either here in The Dry Eye column or over on my cheekier, snarkier blog? I am betting that I have trod this turf at least as many times as the Lakers gave out press credentials to cover LeBron breaking Kareem’s record in February (roughly 200 by game time). But judging by the second (and third and 12th) opinions I am seeing in my practice and what I am hearing from various courtrooms around the country, you are still not listening to me and my erstwhile dry eye colleagues.
And so, once again, to the surface!
Listen, I get it. Really, I do. Diagnosing and treating dry eye disease (DED) has a bad rep. There can be so much to unpack, it can be hard to know which is the bigger pain in the tuchus. You have your asymptomatic patients with corneas as dry as a potato chip who simply have no idea what you are talking about when you tell them that you need to treat their DED before they have surgery. They remind you of White’s Rule: You cannot make an asymptomatic patient feel better. Everything you do, everything you ask them to do, is considered a burden because — wait for it — they do not have a problem. But treat them you must, especially if you are going to let them write you a check for an upgraded IOL or any type of refractive laser whatsoever.
On the other hand, there would be the truly symptomatic DED patients. Again, I get it. You have made yourself into a big deal refractive cataract and laser surgeon in part so that you never have to treat dry eye. Admit it. You know that is true. These poor folks are miserable. Their eyes are really and truly uncomfortable, and in a super inconvenient way (you are hoping to operate on them to make them see better), they have poor vision due to DED. Sometimes, if you try very hard, you do such a good job at treating the dryness that they no longer need surgery. Inconvenient, that.
The only thing worse than not doing surgery on someone who looks like a candidate for surgery if only they did not have that pesky dry eye thing is to go ahead and do the surgery without addressing the dry eye. Trust me. I see your patients every single day so that they can learn why it is that they cannot see after their surgery, despite all indications that the surgery was successful. And it was! You did a beautiful job, one that I would have been proud to have done myself. But they do not see well, and more often than not, they do not feel well either. If you are lucky, they are only disappointed and maybe a bit frustrated.
A whole lot of them are outright pis–, er, angry. Angry enough that I am now seeing legal cases typically involving unhappy multifocal IOL patients in which the culprit is actually either undiagnosed or incompletely treated DED.
Telling you this is not meant to let you off the hook. Oh, no. Not in the least. This is just your buddy, the Dry Eye Guy, being the canary in the coal mine, letting you know that there is stuff out there you can avoid. Remember the other saying you hear from me all the time, the Eric Donnenfeld Rule? If you diagnose DED preop, it is the patient’s problem; if you diagnose it postop, it is yours. It is so much better to find the problem before you operate, start the treatment and then follow through with continued therapy after you pull off yet another perfect surgery.
Here, then, is how to return to the surface: Someone needs to look at the ocular surface, preferably with a slit lamp and a dollop of fluorescein dye. That is literally the biggest deal. It does not need to be you, the surgeon. An optometrist, either on your team and in your office or an outside referral source, can do it. A well-trained, highly experienced technician, likely the same one who you trust to tell you which patients not to do a multifocal IOL for, can probably be the one who looks. A low tear volume, tear breakup time less than 8 seconds, any staining on the cornea or conjunctiva whatsoever, and you have diagnosed DED preop.
If I were you and offering any upgraded IOL, toric, multifocal or extended depth of focus, I would go at least one step further and incorporate tear osmolarity (tear osmolarity greater than 310 mOsm/L or inter-eye asymmetry greater than 8 µm) and topography into the preop evaluation. You need to actually look at the ring images on the topo. Blank areas or ring segments that look like Salvador Dali was doodling on your screen means that your patient has treatable DED. I do this for all cataract and laser preop patients.
Now you have to get to work treating everyone who has DED. It still does not need to be you, but this time the person treating the patient needs to be an MD or an OD. This is not a free lunch. Whoever does the treating gets paid to do so. There are all kinds of protocols and algorithms that you can follow. Heck, our archivist can likely find a few in my past columns or on the blog. Remember that no matter what kind of surgery you are doing, you will make the ocular surface drier for at least 3 to 6 months postop. Tell the patient just that preop. Err on the side of more rather than less during this phase.
Early visual success in refractive cataract or laser surgery goes a long way in building long-term goodwill, whether or not you personally do the DED care or, for that matter, if you even see the patient after surgery. This is low-hanging fruit. Find and treat these people. Keep them from being disappointed, and that will keep them out of my, and your local shark lawyer’s, office. It is good medicine. It is good for your peace of mind. And trust me, my editor Christine has seen this particular column so many times now she has a kind of literary PTSD.
If nothing else, do it for Christine.
- For more information:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
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