Adam S. Friend, MD

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	By Adam S. Friend, MD; Special to Ophthalmology Times

Ophthalmologists are fortunate to be practicing at a time when we can offer cataract surgery patients highly advanced lens implants that provide-at a minimum-excellent uncorrected vision at a distance, with the option for vision at multiple distances with a multifocal or extended depth-of-focus (EDOF) IOLs. The performance of these IOLs is better than ever, yet if not addressed proactively, the eye’s first refractive surface-the tear film-has the potential to limit the IOL’s performance.

	Ocular surface disease (OSD) reduces the accuracy of keratometry and distorts topography. It also can result in unsatisfactory visual quality and discomfort after surgery. A careful assessment of the ocular surface and initiation of treatment, if warranted, should be an important part of every cataract surgery consultation.

	In my practice, all patients complete a short questionnaire that asks about OSD symptoms, such as dryness, burning, tearing, and foreign body sensation. One of the most important questions we ask is whether they experience fluctuating vision. Cataracts do not fluctuate. So, if a patient is complaining of fluctuating vision something else must be going on.

	We cannot rely on symptoms alone to guide the screening process. Many patients do not notice their symptoms, or they have a “stoic” personality that is not given to ready articulation of their symptoms. So, every cataract surgery candidate in our practice also is given a quantitative tear test (Schirmer’s) and a qualitative tear test (TearLab Osmolarity Test, Tearlab). We perform these tests empirically, because for optimal results, they must be performed before the patient receives any drops or dilation.

	This screening process allows me to address OSD proactively, rather than try to fix problems or soothe unhappy patients after surgery. With these and other elements of my exam, I want to answer four essential questions before proceeding with cataract surgery.

		Is the patient producing enough tears? Schirmer’s testing and tear break-up time help me to identify cases of pure aqueous-deficient dry eye. If the patient’s tear production is insufficient, I start the patient on artificial tears and I consider placing punctal plugs.

		How is the health of ocular surface cells? Vital dye staining, preferably with lissamine green, is critical to my determination of whether to postpone surgery. If there is any staining, that tells me that keratometry will likely not be accurate. I start the patient on topical cyclosporine or lifitegrast and re-evaluate after one month. If the cornea still stains, I will delay surgery, especially in the case of a toric or presbyopia-correcting IOL.

		Are the meibomian glands healthy? I perform diagnostic expression of the glands on every patient so that I can characterize the quality of the meibum secretions. Although we know that thickened secretions adversely affect the tear film quality, meibomian gland dysfunction (MGD) is probably widely underdiagnosed and undertreated. At present, I instruct patients to use a Bruder heat mask at home, and I treat the glands with topical azithromycin ophthalmic solution (AzaSite, Akorn) and/or oral doxycycline. I look forward to evaluating the glands with dynamic meibomian imaging and performing thermal pulsation therapy in the future, once I add the technologies (LipiScan and LipiFlow; TearScience/Johnson & Johnson Vision) to my practice.

		Is there any pathology that affects the shape of the cornea? During the slit lamp exam and in reviewing the topography, I look for other mild pathology that may be masquerading as dry eye, such as pterygium, Salzmann’s nodule, or map-dot fingerprint dystrophy. All of these can cause inaccurate preoperative measurements and poor postoperative quality of vision.

	Incorporating these screening processes into a preoperative workup is good medical practice and takes little of the physician’s time, as the questionnaire, osmolarity, and some of the other tests can be performed by technicians. Things become a bit more complicated when treatment delays affect the work flow and surgical schedule.

	At my practice, we end up delaying about 10% of cataract surgery cases for further OSD treatment beyond the initial month of topical anti-inflammatories or lid hygiene therapy. These delays are well worth their while-an IOL exchange and multiple visits with an unhappy patient can be far more disruptive in the long run.

	It is important to counsel patients appropriately. I find that patients who come to see me already consider themselves to be candidates for cataract surgery and may be surprised to suddenly be discussing a separate condition they did not even know they had.

	It is helpful if referring physicians are educated about the emphasis on ocular surface health and fully on board with it. If an optometrist can identify and treat dry eye before referring the patient for surgery, that certainly helps to streamline the process.

	OSD has become less of a reason to disqualify a patient for a premium IOL, thanks to the introduction of extended depth-of-focus (EDOF) lenses. I find a new EDOF lens (Tecnis Symfony EDOF, Johnson & Johnson Vision) to be more forgiving than multifocal IOLs, so I will now consider it for patients with mild pathology.

	Addressing ocular surface problems proactively helps ensure a clear visual pathway and allows the patient to enjoy the full benefit of their new lenses, whether those lenses are EDOF, multifocal, toric, or monofocal.

	Dr. Friend is a cornea and cataract specialist at Eye Care Associates of New Jersey in Elmwood Park, NJ. He also serves as medical director of the Bergen Passaic Cataract Surgery & Laser Center. Dr. Friend has no financial interest in Johnson & Johnson Vision.

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A thorough investigation of ocular surface health and initiation of any necessary treatment is the first step toward successful cataract surgery.

Adam S. Friend, MD

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