Managing dry eye crucial for cataract surgery success
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Comanagement has become an intrinsic part of every optometric practice, but it is not always seamless.
When patients who need cataract surgery also need perioperative therapy for dry eye disease to optimize the ocular surface, the process has the potential to get a bit bumpy.
In my clinic, a multispecialty practice with 11 optometrists and 11 ophthalmologists, we see not only our own primary care patients, but also many patients referred for a range of surgical procedures, the most common being cataract surgery.
Data show that about 80% of patients presenting for cataract surgery have at least one abnormal test for dry eye disease (DED) (Gupta et al.), so we often need to treat DED to ensure we get accurate measurements and IOP calculations, as well as improve patient comfort and satisfaction. Based on my experience following a well-established comanagement pattern, here are some tips that I hope can help any primary care optometrist with an interest in comanaging DED perioperatively.
Know who is treating your patients. Any surgeon to whom you are referring patients should welcome questions about the practice and internal procedures—even a tour, if you like. In my clinic, optometrists work in conjunction with surgeons to do the initial evaluation, performing most of the significant data collection. These pre-op optometrists are in tune with the ocular surface and treat mild DED as needed. If a patient has more significant DED, they send the patient to me for more extensive therapy and education.
Consider treating mild DED before referral. If you like, you can treat mild DED in your own practice and refer only more moderate/severe cases to a specialist for advanced care. Many optometrists who choose to treat DED in their office based on investments made in diagnostic tools call us for advice preoperatively, and we are happy to help.
Partner in patient education. You can prepare patients in advance for the possibility that their surgeon will need to prepare the ocular surface for surgery. I educate them about the need to treat DED before surgery, as well as its chronic nature, which means management will be a part of their lives postoperatively and beyond. Throughout ongoing DED management, they will need continued education and encouragement from their own optometrist.
Get a complete report of your patient’s treatment. The detailed report you receive after surgery should include details from the doctor who provided preoperative DED therapy. I list all of the diagnostic tests and their results, all treatments the patient has received and all chronic therapy the patient has started.
For example, my patients complete a verified Standard Patient Evaluation of Eye Dryness Questionnaire (SPEED) questionnaire, a tear breakup time (TBUT) test and staining. In more severe cases, I may also measure tear osmolarity (TearLab Osmolarity System, Tearlab), test for inflammatory markers (InflammaDry, Quidel) or perform other advanced tests.
Common therapies include nonpreserved, artificial tears, punctal occlusion, moisture goggles, warm compresses (Bruder mask), topical immunomodulator drops (Cequa [cyclosporine ophthalmic solution 0.09%, Sun Pharma]; Klarity-C [cyclosporine 0.1%, Imprimis]; Xiidra [lifitegrast, Novartis]), omega-3 supplements, autologous tears, amniotic membrane, in-office thermal expression of the meibomian glands (iLux, Alcon; LipiFlow, Johnson & Johnson Vision; TearCare, Sight Sciences), topical antibiotics (Klarity-A [azithromycin, ImprimisRx]), steroids (Eysuvis [loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals]) or antibiotic/steroid combinations.
Your patients might still have questions about their DED care after they return to your practice. You do not have to be a DED specialist to answer, just well versed in current therapies.
Continue DED care and refer to a dry eye specialist if needed. Most referring optometrists I work with continue to manage DED after surgery. Other optometrists prefer to follow their patients on annual visits while those patients continue to see me about DED. Both are good approaches. If you want to manage DED, I recommend seeing patients at 6-month intervals to intercept any seasonal exacerbations. The SPEED questionnaire and a TBUT are usually adequate metrics to follow the condition.
If a patient’s DED worsens and you need help or perhaps an in-office procedure, a dry eye specialist is always available. I am pleased that many primary care optometrists feel comfortable comanaging DED with me on an ongoing basis, which gives patients the benefits of seeing their trusted doctor while accessing advanced diagnostics and therapies when needed.
Reference:
- Gupta PK, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.06.026.
Thomas Chester, OD, FAAO, is clinical director at the Cleveland Eye Clinic, Brecksville, Ohio. He can be reached at drchester@clevelandeyeclinic.com.
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