Yari has questions for Marjan Farid, MD: Navigating preoperative dry eye disease

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Hi, I'm Yari, and I have questions, and this is Dr. Marjan Farid, and she has answers. Let's see if they match. Marjan, thank you for being here today.

It's a pleasure, thank you for inviting me, Yari.

Oh, I have so many questions, and I'm just so delighted to have you here to help us talk about a term that I heard, and I really want your take on it. So, what is Surgical Temporary Ocular Dryness Syndrome, or STODS?

So STODS is actually a new acronym or term that has been designed to define a space that we already knew was there, and this is dry eye disease that many patients have in the preoperative setting, and some that don't, but we certainly do see a temporary worsening of their signs and symptoms after cataract surgery. And now, we're defining that space, and really shedding light on it.

So then, how impactful is that situation? And in your perspective, how long does it persist? How important is it to have this category focused on for clinicians?

It's essential. If you're a cataract-refractive surgeon, you have to discuss dry eye disease and be able to identify it in your population of patients preoperatively and manage it both preoperatively and postoperatively. It's essential, because if you don't, you're really going to have suboptimal outcomes both from a refractive standpoint, but you'll also have a lot of dissatisfaction from the patient. And you know what, Eric Donnenfeld always said, that sticks in my mind, he said, "If you tell a patient that they have dry eye disease before surgery, and manage it and address it, then it's an expectation after surgery that they're going to have signs and symptoms. If you don't, now, it's a complication, and it's your complication.” And now, you have an unhappy patient, and they don't become advocates for referring their friends and family to you. So it's really essential to running a good practice, having patient satisfaction and growing your practice.

Makes sense. So, what is the process in your practice? How do you work up your patients to understand what their signs and symptoms are beforehand? Let's start there.

This is really important, because in the cataract surgery population, and this has been shown in several papers, Dr. Bill Trattler, Priya Gupta, etc. really have done several pivotal papers showing that patients in this population don't come in telling you they have dry eyes, so they don't come in with a red flag on their heads saying, "I have dry eye disease, treat me." They come in and they say, "I want cataract surgery." [If you ask them] "How do your eyes feel?" Most of them say, "It's fine, I just need cataract surgery. I have fluctuating vision, but that's from my cataract." The onus is on the cataract surgeon and our team to recognize that fluctuating vision is not from cataract, and that's a very strong symptom of dry eye disease, or tear film instability, which might be a better term. And so, in this population of patients, you have to look for signs more than symptoms: signs, signs, signs. So, when my patients come in for their preoperative evaluation, if we pick up that they might have tear film instability early on, I actually won't have my technicians do biometry and topography. I'll say, "Wait, let me see the patient," examine them, do a really nice dry eye workup, and then bring them back. Now, sometimes they come in and they slip through, and the measurements are done, and those measurements, if you look at them, oftentimes they'll show irregularity, incongruence between topography, keratometry measurements and biometry measurements, and those are also red flags, so really look for signs in this population of patients.

Got it, that makes sense. So now, after the fact, say you have a patient that has signs. There is a likelihood they probably could have some exacerbation of that in the healing process post-surgery. What about the patient that doesn't have signs? Is that someone that you still need to be concerned about, or do you think they'd be okay?

Yeah, that's a great question, because you're absolutely right. Some patients will come in, their ocular surface looks good, not bad. They don't have symptoms; they really are just there for simple cataract surgery. Even in those patients, I talk about the fact that after cataract surgery, you'll feel your eyes more. You're going to have these symptoms that we call dry eye symptoms, but you'll feel your eyes more, they may be a little more irritated, you may have a little bit more foreign body sensation, and these are due to a lot of different factors, surgical factors, wound incision, preserve drops that they may be on after surgery, antibiotics, anti-inflammatories, patients don't touch their eyes after cataract surgery, so their lid margin tends to gunk up more, and all of these things sort of lead to this temporary ocular dryness after surgery. And so, you want to warn patients. I say, "Even though your tear film looks good, let's really try to pump it up, because we see these symptoms after surgery, so let's try to optimize your tear film, even though you're dry eye isn't bad." It also helps patients, even if they just get a bottle of preservative-free artificial tears and start using that. It also starts getting them in the habit of putting drops in their eyes before surgery or doing some warm compresses. So even just basic things like that preps them and improves their outcomes after surgery.

That's great. So, look for signs, do pre-work to make sure you're pumped up and ready for surgery, and then use tears and others to supplement that whole process for comfort and healing.

Yes. Now, if they have signs, I'm going to use more than just tears and compresses, right? If they have ocular surface staining, rapid tear break-up time, ugly lid margins, then I'm actually going to put them on a regimen, right? I'm going to maybe put them on an anti-evaporative treatment. We have perfluorohexyloctane, which is a really nice addition because it really helps clean up punctate keratitis from the surface of the cornea rapidly before surgery. I might put them on a little bit of a steroid to clean up inflammation, I may treat their lid margin with a procedure, definitely now have patients look down, look for blepharitis. If they have concerns for Demodex blepharitis, we have a treatment for that now, so we have so many good options now to really help clean the ocular surface and lid margin before surgery.

So that's wonderful to have a number of options, and you're very well-versed in all this as a leader in this space. What about people who are maybe not as comfortable and confident with all the different solutions? Is there any advice you would give to people that is sort of a maybe good step in, or something to always make sure that you're doing, you know, just so that they can move down that path?

Yeah, That's a great question. I don't think you need a lot of fancy point-of-care tests and imaging to diagnose and identify dry eye disease. Just a really good exam goes a long way. Staining the ocular surface, looking for tear break up time, listening to the patient, looking for ocular surface staining, etc. So identifying it, anybody can do, and I don't think you need high tech for that. And then, you know, start with some basics: Lid margin health, inflammation, make sure they're on either preservative-free tears, or an anti-evaporative treatment pre-surgery, and whatever you do, it's going to help, and it'll help educate the patient as well, and get them compliant and ready for surgery, and going in with the proper expectations.

Love it, love it, that's great. Well, thank you for this great education on dry eye. I have one last question for you.

Sure.

Who is your phone-a-friend?

Who is my phone-a-friend? So, my phone-a-friend is one of my dear mentors who has always been there for me and is really a leader in the ocular surface space, and that's Ed Holland. He's sort of been there and guided me through ocular surface health since I was a fellow and immediately after fellowship, and really, he is my phone-a-friend.

I love it. That's great. Well, thank you, Marjan, for being here. I think your answers matched my questions perfectly, so job well done, and thank you so much. And thank you, everyone, for joining us!