Dry eye and the surgical patient: This is still a thing
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You know, I really thought that significant gains had been made in raising the awareness of both the prevalence of and the need to treat dry eye disease in the perioperative period for cataract and refractive surgeries.
I mean, it has been nearly a decade since this topic began to show up on the schedules in meetings of all sizes. The American Society of Cataract and Refractive Surgery and the American Academy of Ophthalmology have had agendas with dry eye disease (DED) in the surgical patient as the headline topic, for goodness’ sake.
Why now? What pushed this to the center of my radar screen, making me feel the need to devote a full column to the topic of the diagnosis and treatment of DED in the surgical setting? Like so many other things in life, this one is personal. Someone in my closest circle called me to discuss their cataracts and an upcoming visit with a surgeon. We discussed the options they had, and because I had been able to examine them on a visit to Cleveland, I had all the data available that I would have used had they decided to have surgery here with me. It turns out that this person close to me was a good candidate for nearly any of the advanced/premium presbyopia-correcting IOLs with one notable cautionary issue:
They had symptomatic DED of long-standing.
And here, dear friends, is why I am once more going to the cataract surgery and DED well: I told the surgeon about the dry eye history. The DED was bad enough that the patient was unable to wear contact lenses for decades. Bad enough that I counseled them that laser vision correction of any type was too much of a risk to consider. Like so many DED patients in mid-life, this person just assumed that the way they felt was normal and did not seek ongoing care. Just like the huge percentage of cataract preop patients who have multiple signs of DED during their preop exam but who have no discernible symptoms.
You know where this is going, of course. Despite the presence of DED signs, despite the preop phone call “alert,” there was no proactive intervention instituted before surgery. This is not a tiny niche position, something only DED obsessives think about and act upon. No, this is something significant enough that ASCRS sponsored a position paper on the topic of treating DED in the perioperative setting for cataract and refractive surgery. Headed by Christopher Starr of Weill Cornell Medicine, the “Starr Chamber” outlined a preferred practice of preop evaluation and treatment of what was described as “visually significant” DED.
As much as I love the “Starr Chamber” moniker, the publication is more widely known as the “ASCRS algorithm.” It is an attempt to help surgeons avoid running afoul of Donnenfeld’s law of surgical dry eye: If you diagnose DED preop, it is the patient’s problem; if you diagnose it postoperatively, it is the surgeon’s problem. The algorithm is our most important surgical society’s effort to make diagnosing and treating perioperative DED the default process for cataract and refractive surgery, especially if we think that the “pain” of not doing so is in some way shared by doctor and patient.
There’s the rub. Every patient who has postop symptoms from DED suffers. Maybe it is discomfort. Lots of folks with postop dryness complain of grittiness and burning. As often as not, especially in the upgraded IOL space, it is a question of suboptimal vision. Constant blur occurs, and in the case of evaporative DED, patients complain of fluctuating vision as well. “Is my lens moving? Sometimes I see great, but other times I can hardly see anything at all.”
Anyone who has seen one of these patients, the corneal staining, the rapid tear breakup time and the subsequent improvement of their vision by treating their DED needs no convincing about the need to treat DED. Like those famous cases presented at numerous meetings by luminaries such as Bill Trattler and Alice Epitropoulos showing 2 D or more of preoperative cylinder that disappears when dryness is treated, we see the same thing happen when we treat visually significant DED for the first time postop.
My “close person” had a persistent foreign body sensation in both eyes, and they were kind of disappointed with their postop vision. Because they happened to be in Cleveland visiting, I invited them to drop by the office for a visit. Their symptom complex triggered our standard initial DED evaluation. To no one’s surprise, we found elevated, asymmetric tear osmolarity (which itself can cause light scatter and blur), a rapid tear breakup time and punctate corneal staining. Topography showed irregular astigmatism that improved after instilling hypotonic artificial tears containing hyaluronic acid. Because they had just been to a postop visit with their surgeon the prior week, I asked what the surgeon had to say about whether DED was the problem:
“I’m a cataract factory. I have never written a prescription to treat dry eye.”
Not gonna lie, that one left me speechless. According to the patient, there was little else offered other than a suggestion that perhaps the referring OD might take a look. Is this still a thing? Do cataract surgeons, especially those who charge thousands of dollars for laser-assisted surgery and advanced IOLs, not treat DED when doing so might improve an outcome and create a fan? In 2024? Still? The treatment of perioperative DED, especially in the “premium” category, is perhaps the lowest hanging fruit in the orchard. Patients are already scheduled for a visit, and after ponying up for an advanced IOL, they are highly motivated to resolve their problem. As long as “my person” was in my office, we went ahead and started treatment.
I have purposefully blurred all possible identifiers of either patient or surgeon, partly because I do not wish to sour their professional relationship but also to avoid any embarrassment for the professionals involved. But more than that, if you see even a little bit of yourself in this surgeon, I want you to think that I am talking about you. This is neither rocket science nor an issue on the fringes of eye care. The time it takes to make the diagnosis is trivial; you are already doing almost all the tests. Your “chair time” engagement is trivial; after choosing the treatment, you can delegate the rest of the process including education, just like we all do with standard pre- and postop instructions. It is not hard.
Diagnosing and treating DED in cataract and refractive surgery is a “thing.” Still. Has been for a while, actually. It should be normal. Common. What is it going to take to make that the story?
- References:
- 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:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
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