Patients who present for cataract or refractive surgery are often not tested for ocular surface disease (OSD), as many are asymptomatic—especially those with dry-eye disease. However, a new consensus-based practical diagnostic OSD algorithm has been developed to specifically address this population, aiding surgeons in diagnosing and treating visually significant OSD before any form of refractive surgery is performed.
The algorithm, presented in a study by the American Society of Cataract and Refractive Surgery (ASCRS) Cornea Clinical Committee, emphasizes the use of efficient point-of-care testing for assessing OSD preoperatively. While a number of tests are available, it may not always be clear how clinicians should incorporate these tests into practice.
In this Q&A, Preeya K. Gupta, MD, a corneal specialist at the Duke Eye Center and co-author of the study, describes the impact of this algorithm on presurgical cataract and refractive patient outcomes and recommends specific point-of-care tests.
How does this new algorithm improve upon the traditional methods for screening for OSD preoperatively?
Gupta: We are trying to create a new standard of care for the presurgical patient because we recognize through our previous work that 80% of patients who report for cataract surgery evaluation suffer from dry-eye disease and are not being diagnosed when they could be. Point-of-care testing is an effective tool for screening for dry-eye disease, but it is not typically a routine occurrence for preoperative cataract patients and is significantly underutilized in the ophthalmic community. If we rely on traditional tests such as only using questionnaires or screening for corneal staining, that will often result in a late diagnosis. It’s also a potential missed opportunity to diagnose and treat a disease before it becomes more of a problem postoperatively.
What implications does an early diagnosis of OSD have for presurgical cataract and refractive patients?
Gupta: It helps set patient expectations because they understand that they have two diseases. Often what happens is that patients present for a second or third opinion postoperatively because they feel that something went wrong with their surgery, when in fact, the surgery decompensated their ocular surface and their dry-eye disease became worse. By making that diagnosis ahead of time, the patient is going to have a better understanding of their clinical situation.
Which questionnaire and point-of-care tests are recommended for this patient population?
Gupta: We chose the tear osmolarity and the inflammatory marker MMP-9 tests because they are readily available and streamlined. They are easy and efficient and take less than a minute for a technician to do. I also find value in conducting some more advanced testing in patients. For example, meibography shows through an infrared image what percentage of the meibomian glands are atrophied or lost. We also recommend giving the ASCRS SPEED II Pre-Op Questionnaire that screens for dry-eye disease and helps identify the patient’s visual needs as it relates to cataract surgery planning.
What difference does this preoperative algorithm make with regard to patient outcomes?
Gupta: With cataract surgery, there are many different intraocular lens implant options, and to be successful with the premium category of technology, you really need a pristine ocular surface. By diagnosing and treating dry-eye disease properly and in a more timely fashion, there is an inherent improvement in the refractive outcomes of the cataract surgery, and the patient’s satisfaction and visual quality will be higher as a result.