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The EnVision Summit, co-founded by Bonnie An Henderson, MD, is a unique family-friendly, multispecialty CME ophthalmology conference, along with a newly introduced optometry track. Henderson sits down with 

' Sheryl Stevenson, group editorial director - eye care, to talk about the 2025 conference that will take place February 14 to 17 at the Caribe Hilton San Juan, in Puerto Rico.

Henderson describes the meeting as “a place where not only are physicians and optometrists learning, but their families are part of the experience too,” emphasizing the opportunity for personal and professional growth in a supportive, community-oriented environment.

The 2025 agenda will include symposia, surgical videos, panel discussions, and leadership seminars that highlight rapid advancements across ophthalmology specialties, including cataract, refractive, retina, glaucoma, pediatrics, and oculoplastics. “It’s incredible how quickly things change in ophthalmology—if you miss a year or two, you’ll be amazed by the innovations that have emerged,” Henderson shared. Updates on new intraocular lenses, surgical tools, and diagnostic techniques will showcase the field’s forward momentum. Additionally, a leadership seminar led by Malvina Eydelman, MD, Director of the Office of Ophthalmic, Anesthesia, Respiratory, ENT, and Dental Devices at FDA, Silver Spring, Maryland, will feature discussions on career pathways and diversity, empowering attendees with insights from industry leaders.

The optometry track, introduced last year, continues to expand, emphasizing collaboration between ophthalmologists and optometrists in critical areas like preoperative and postoperative care, medications, and diagnostic tools. As Henderson explained, “It's important for both fields to come together and discuss how we can work together to improve patient care.” This cross-disciplinary dialogue reflects the summit's dedication to advancing care through shared expertise.

The youth program offers age-appropriate activities that allow children to engage in fun learning while also witnessing their parents' professional contributions. "It’s amazing to watch these kids grow up at EnVision Summit and form lasting friendships,” said Henderson. The trainee program, which offers free registration for residents, fellows, and medical students, has also seen growth. Henderson highlighted the program’s value, noting that it “gives young professionals the chance to network with leaders in the field and gain invaluable mentorship.”



To learn more about or to register for EnVision Summit 2025,

EnVision Summit

The EnVision Summit, co-founded by Bonnie An Henderson, MD, is a unique family-oriented, multispecialty ophthalmology CME conference, along with a newly introduced optometry track. Henderson sits down with Ophthalmology Times to talk about the 2025 conference that will take place February 14 to 17 at the Caribe Hilton San Juan, in Puerto Rico.

Connect, learn, and innovate in a family-friendly atmosphere:  What to expect at EnVision Summit 2025

Neda Shamie, MD, and Peter J. McDonnell, MD, discuss the evolving role of femtosecond laser-assisted cataract surgery (FLACS) in ophthalmology, highlighting its benefits in addressing corneal astigmatism, capsulotomy precision, and aiding complex cases, while acknowledging regional variations in patient interest and emphasizing the need for ongoing evaluation in the context of advancing premium lens technology.

The views and perspectives expressed are those of Dr. Shamie and Dr. McDonnell.

This transcript has been edited for clarity.

Hi, everyone, and welcome to this episode of the 

This is Sheryl Stevenson, group editorial director with the Eye Care Group here at MJH Life Sciences, and we are joined today by our co-chief medical editors from the West Coast to the East Coast.

Dr. Peter J. McDonnell is the director of the Wilmer Eye Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland, and Dr. Neda Shamie is a cataract, LASIK, and corneal surgeon and partner of the Maloney-Shamie Vision Institute in Los Angeles, California, as well as an adjunct clinical professor of ophthalmology at the USC Keck School of Medicine.

In this episode, Dr. Neda Shamie and Dr. Peter McDonnell explore the current landscape of femtosecond laser-assisted cataract surgery, sharing insights on its integration into their practices, emphasizing its benefits in addressing corneal astigmatism, enhancing capsulotomy precision, and aiding in complex cases, while acknowledging regional variations in patient interest and the need for ongoing evaluation of its impact on outcomes and advancements in premium lens technology.

 Hi, it's Peter McDonnell, and we're here with the podcast on Ophthalmology Times where we're talking about the exciting new developments in our field of ophthalmology. I'm excited to be here with my co-chief medical editor, Dr. Neda Shamie.

Neda, femtosecond laser-assisted cataract surgery [FLACS]...That took the world by storm a few years ago and there been new developments in the last year or two in terms of pipeline of approved products. So, share with me where currently...where does femtosecond laser-assisted surgery fit in your practice?

 Well, thank you, Peter. It's great to be here with you again and having these kind of casual conversations about topics that are front and center in our practice.

I've been doing femtosecond laser cataract surgery for 12 years now. I initially started with LenSx and then had experience with the Catalys and then more recently have had experience with the Ally or the LENSAR laser.

In my practice, possibly because I'm in Los Angeles, West LA, the type of practice that I have where patients seek me out because of the premium offerings that we have, we have a large percentage of our patients who choose to have femtosecond laser surgery...more than the majority; it's close to 90-plus percent. As we know, laser cataract surgery has been approved for treatment of astigmatism. And so I make sure that if I am offering laser cataract surgery, it is in cases where the patient has corneal astigmatism that can be treated with the limbal-relaxing incisions that the laser can make.

Although I love the other steps of the surgery that the laser really has fine tuned and adds a level of precision that I say that, even as great of a surgeon as I am because I had the best mentor in Peter McDonnell, I still am not as good as a laser is. I love...I think femtosecond laser-enabled cataract surgery is a very elegant way of doing cataract surgery.

And there's controversy as to whether or not there are benefits. Most definitely, I think the benefit of addressing the corneal astigmatism in my hands...if it's less than one diopter I use the laser, .5 to about 1.25 or 1.5. I use a laser to create limbal-relaxing incisions that are very, very reliable and now with image guidance, perfectly positioned based on prior measurements preop.

But I also like the centration of the capsulotomy. I like the perfect sizing of the capsulotomy so that there is overlay of the lens implant. I like that it helps me in complex cases, or very dense cataracts. It softens the nucleus of the cataract such that, at least in my hands, I feel that it's a more reliable way of doing cataract surgery with the least amount of energy used. So it's great. I mean...currently with the Ally, I'm really enjoying the image guidance. The image guidance with the Ally laser, it's streamlined and it really allows me to feel comfortable with toric lens implantation and toric alignment because the Ally, based on image guidance using the Pentacam, creates these nubs in the capsulotomy so that I know exactly where the axis of the toric alignment should be. So that's my thought...my two cents on it.

 Yeah, well, I have no financial interest in any of the companies that make this technology but I really like the technology. It's very impressive to me. We looked rigorously in our institution at things like endothelial cell counts and postoperative visual acuities, etc. between the femtosecond laser and 'traditional' phaco and could not find demonstrable advantages in most of these areas. Certainly, the centration and the circularity of the capsulorhexis is advantaged with the femtosecond laser, I think.

But it is interesting, you mentioned how, in certain markets, it's really valued by the population if you can offer this. And in our area, Baltimore and Washington, DC, are very interestingly very different markets in that regard. There's much greater interest in the national capital region in the laser-assisted surgery than there is in Baltimore. So, you know, it is a matter of being sensitive and responsive to the desires of the population in the area in which you live. And since you're in the Los Angeles area, it doesn't surprise me that that's probably something that a high percentage of the population values. So I think having that comfort with it and being able to offer it to the appropriate patients makes total sense.

 Yeah, absolutely. Obviously, one of the biggest hurdles is if you operate at a surgery center that does not have access to the laser it wouldn't be possible. I'm grateful and feel really privileged that in our surgery center we have one of each of the three lasers currently available to us. Our experience has been really positive with it.

But, as you said, the data doesn't speak as to anything that is of a significant difference as far as a benefit to the laser. And that's where the challenge is, is to really...how we decide to fit it into our practice really comes down to patient choice. I don't press it on our patients at all. This is a choice that the patients make. Our practice draws patients who are interested in advanced technology.

And then also, it's important to note that again it's not approved for anything other than correcting astigmatism.

So with that, there's a lot of information out there. I would love for the next generation of ophthalmologists to have at least some introduction to laser because my expectation is that there will be opportunities, especially in the premium lens sector, that there may be some benefits to using laser, if you're implanting a toric lens, if you're implanting premium lenses like presbyopia correcting lenses, as far as centration and tilt of the lens and maybe with data that can those kinds of differences can be elucidated.

 Yeah, I agree with you. Once I think we have an accommodating lens that works really well that it may be necessary to pair that with a device like the femtosecond laser. So it's a fun field and I'm sure there'll be exciting progress and developments in the coming years. It'll be really fun to follow this along as we get more and more experienced with it.

Wilmer Eye Institute

In this podcast, Neda Shamie, MD, and Peter J. McDonnell, MD, discuss real-world experiences, patient choices, and the nuances of integrating femtosecond laser-assisted cataract surgery into practice, offering insights into the latest developments in ophthalmology.

EyePod: Integrating cutting-edge pipeline devices for enhanced cataract surgery

In this episode, Neda Shamie, MD, and Peter J. McDonnell, MD, discuss the benefits and challenges of implementing the many options from the premium lens pipeline into practice, emphasizing the importance of customization based on patients' lifestyles and expectations, while also addressing concerns and sharing their positive experiences with the evolving technology in the field.

 Hi, everyone, and welcome to this episode of the 

In this episode, Dr Shamie and Dr McDonnell discuss the benefits and challenges of implementing the many options from the premium lens pipeline into practice, emphasizing the importance of customization based on patients' lifestyles and expectations, while also addressing concerns and sharing their positive experiences with the evolving technology in the field.

 Hi, everyone! This is Neda Shamie, and welcome to another episode of 

 EyePod, where I have the pleasure of sitting here with Dr. Peter McDonnell, who's a colleague, a dear friend, and my mentor—all-time mentor—talking about different subjects that hopefully are of interest to you. They are most definitely of interest to us and very applicable and relevant to our day-to-day practice.

Today, we're going to be talking about premium lenses and how we can implement them in our practice, where the value is to our patients, and what our experience has been between Peter and I [me]. I'm hoping you'll take some pearls from this conversation.

Welcome, Peter. So nice to be here with you again.

 Great to be with you, Neda. It's a great time to be an ophthalmologist, isn't it? With all the technology that we can bring to help our patients lead better lives including, so often, spectacle independence. The premium IOLs have done a great service to our profession and our patients, don't you think?

 I absolutely agree. I think, especially with the further advances and the most recent generation of these premium lenses, I forge ahead in my practice with real enthusiasm and offering my patients the lenses. 

It's brought a lot of fun into what we do as cataract surgeons in that we are not only clarifying the vision, improving their vision, but also potentially impacting their quality of life by, like you said, offering options that could potentially get them out of glasses. 

And a lot of our patients now are empowered with that information ahead of time. They come in expecting a premium offering. But it's also fun when a patient had no such expectation to be able to make that offer, and what a gift that could be to them.

So when I was training with you and I was your fellow...we were all excited because toric lenses became available. The challenge now with the premium lenses is that, unlike how it was 20 years ago where we really had only one option and it was pretty straightforward discussion, the chair time has increased. 

And I think we still sadly don't see enough surgeons offer premium lens options, presbyopia-correcting lens options, to their patients partly because I think the feedback we're getting from our colleagues is that the chair time is more challenging for them; the discussion potentially is more confusing; and they're afraid of unhappy patients. Because when patients invest in premium lenses their expectations are higher and the chances of them being potentially unhappy is higher.

But I think you and I can maybe share our experience how it's added a lot of value to our practice. It's added a lot of value to how I interact with my patients. And it's kind of...it has put me on the map, in a sense. This is something I take great pride in is that when a patient comes to me, I spent a lot of time customizing the treatment plan to them. And that customization really comes down to trying to find what the best lens option would be for them.

 Well, thank you for alluding to my age, how long I've been practicing, and that I antedate all this great modern technology. 

But you're right on. To me, it's so fun to talk to people and say, Hey, what do you do for a living? What do you do for fun? Find out are they the avid golfers? Are they people who drive at night? Are they the Type A perfectionists? Are they the easygoing, fun people? What, what's their definition of 'wonderful' in terms of vision and then using our best knowledge and experience to match their hopes and goals and expectations with the technology available to us. 

And so it really gets away from the one size fits all, all patients are the same sort of thing and lets us use all that judgment and experience. That's why we went to medical school.

I'll just say there are some docs who had negative experiences maybe early on and that's caused them to wonder do they want to continue offering these to patients. I think of some of the warning signs of maybe patients to avoid; people with some pretty advanced dry eye; maybe people with epithelial basement membrane dystrophy in the cornea that's going to cause corneal irregularity; maybe macular degeneration, looking and make sure there's not some macular pathology that would decrease contrast sensitivity. 

So we definitely want to avoid particularly early on in our experience offering this technology to patients who are potentially borderline or bad candidates. But you're exactly right, matching the right lens to the right patient with the right expectations. It's just so rewarding both for surgeons and for patients.

And I think there are so many different options that could match your comfort level as a surgeon. And again, as we both alluded to, the quality of the technology has improved and the type of vision our patients are getting from the trifocal lenses that are available to us now is so superior to what the previous generations were that I really urge any surgeon who may have had suboptimal outcomes with the previous generation lenses to really consider the fact that these newer lenses are game changers. 

They really are changing the way we approach cataract surgery patients and there's now small-aperture lens options. There are light adjustable lenses, nondiffractive, presbyopia-correcting lenses, extended-range lenses, trifocal lenses—a lot of different options, a lot of opportunity for education through 

 and other sources to really pick what fits comfortably in your hands as a surgeon. 

I would really urge you to enter this field because honestly, as a cataract surgeon, you're going to fall behind. Patients will come to your practice expecting such offerings and you may lose that patient if you don't offer them a customized approach to treatment.

So with that, I am going to end our session here. 

Hopefully, this was some enticement to really pursue more resources to engage in the premium cataract surgery field. And we're always here for help if you'd like more information.

EyePod: Navigating the premium lens landscape from pipeline to practice

In this EyePod® episode, Peter J. McDonnell, MD, and Neda Shamie, MD, discuss the transformative impact of minimally invasive glaucoma surgery (MIGS) on glaucoma care and its integration with cataract surgery, sharing insights and practical tips for ophthalmologists.

The views and perspectives expressed are those of Dr. McDonnell and Dr. Shamie.

Hi, everyone! Welcome to this episode of the 

This is Sheryl Stevenson, group editorial director with 

, and we are joined today by our co-chief medical editors.

In today’s episode, they discuss how embracing MIGS procedures can significantly enhance glaucoma management during cataract surgeries, offering patients the opportunity to reduce their reliance on eye drops and improve overall treatment outcomes. They share how integrating MIGS into clinical practice can be a rewarding endeavor that empowers ophthalmologists to provide more effective care for patients with glaucoma.

 Welcome, everyone! This is Neda Shamie and you are listening to EyePod, which is sponsored by 

, where we talk about topics at hand in ophthalmology and really kind of bring it to the forefront of your thoughts so that you can explore further.

It's going to be a short conversation that I will be having with Dr. Peter McDonnell, who is my mentor, a dear friend, and someone who is truly an expert in the field of ophthalmology and I turn to for advice all the time. Hi, Peter!

 Hi, Neda! It's great to be here with my co-chief medical editor of 

 and talk about a really exciting thing that, I think, taking the world of glaucoma by storm, which are these great new MIGS devices. It's really caused in evolution in glaucoma care in the United States. And you've had very positive experience yourself with these devices, right?

 Yes, most definitely. I agree with you. I think in glaucoma, there's been a real significant paradigm shift since the advent of different MIGS devices that have allowed for a minimally invasive approach to treating glaucoma. When I was in my training, it was either [eye] drops or maybe some laser treatments, but ultimately, trabeculectomies and trabeculotomies and tubes and shunts and such, which have a lot of comorbidity associated with them. 

These minimally invasive glaucoma shunts and procedures that are done often at the same time as cataract surgery can really have very little added risks to the surgery, but have significant impact on glaucoma management of patients, lessen the load of the eye drops and the toxicity that go along with them. And really a wonderful addition to the armamentarium of not just glaucoma surgeons, but also cataract surgeons. And I think that's where we should really emphasize our discussion on. 

There's no question that glaucoma surgeons, at least the ones I speak to, are huge advocates of the advanced technology in the MIGS procedures. I think the challenge is that the gatekeepers are often the general eye doctors and cataract surgeons. And a lot of the time when these patients who have glaucoma and comorbidities associated with glaucoma, when they're ready to have cataract surgery and they have the opportunity to be a candidate for the MIGS, the MIGS procedures are not necessarily offered to them. 

I think the hurdle is to get past that because there's not enough glaucoma surgeons out there to really take care of all of the glaucoma patients out there. And often the feedback I'm getting from glaucoma surgeons is they really want us cataract surgeons to consider MIGS procedures at the time of our cataract surgery to lessen the burden of glaucoma for these patients and, hopefully, prevent progressive disease for them. 

 You know, I think you hit on a lot of really key points there. When I look at the data from the Academy's IRIS Registry [Intelligent Research in Sight] and also the Medicare database, 75% or more of glaucoma surgical procedures now are MIGS. And in this recent report only 13% were trabs. In my day, that was pretty much the glaucoma operation. 

And from my perspective, it was sort of for a refractive surgeon to do this 'loosey-goosey' tighten the sutures enough but not too much, etc. It was sort of imprecise. To me, there's lots of appeal of these MIGS and to see it go from very little to such a high percentage, almost 80% now of glaucoma surgical procedures are MIGS. That's really impressive. I'm wondering, in terms of getting people who are not glaucoma specialists and don't have much experience yet, and maybe there's a little trepidation about how to get started. 

What pearls would you offer? How did you make that transition to get going?

 Often, what happens with new additions to our surgical armamentarium, it's a patient that encourages us to forge ahead. 

I had a patient who had glaucoma who came to me [and] really wanted to have her cataract surgery done by me and was on 3 [eye] drops for glaucoma management. She's the one who said — this is a while ago, this is probably nearly 8 years ago — why aren't you offering me MIGS. Truthfully, she put me to shame because there was enough evidence for the benefits that iStent at the time was offering that I should have offered it together with a cataract surgery. And so I was very honest and transparent with her. And I said, I have not done one. And she says, why don't you have my case be your first. It really just takes that motivation. 

It takes that incentive to really want to do the best for your patients to bring on new technology. There is no question that the technology has now been proven to be effective. And the truth of the matter is, what do you have to lose and that's my attitude to my colleagues who push back on MIGS. You have really nothing to lose and everything to gain for your patients. 

To bring on the MIGS procedures it's a very simple addition to your surgery. The learning curve is very, very quick. For those of us who do a lot of anterior segment surgeries, having the ability to do that gonio visualization of the angle, and being able to maneuver in the anterior chamber is not very different than what we do in our preop exams. And we all know how to use a gonio lens. And it doesn't take much to learn how to do it in intraoperatively. And we all know how to maneuver in the eye without collateral damage to structures inside the eye. 

So I would say if there's trepidation, look at the data. Like anything, I do my research. I look at the data. I ask colleagues who have experience. And now with YouTube, 

, all the different resources available to really get as much information ahead of time as possible it again shouldn't take much to forge ahead.

I would suggest starting with one device first, getting familiar with probably the simplest device, which for me, at least, it was the iStent, but for others, it may be different approaches. And then from there moving forward. I think probably the biggest challenge is how to use the gonio intraoperatively. And then kind of understanding what the postoperative management of these patients are. 

It just simply took me communicating with colleagues and friends who've done a lot of these and getting their protocols in place. I feel great about offering it to my patients. I think as a cataract surgeon you're doing your patient disservice if they come in with glaucoma and they’re on at least 1 if not 2 drops and not offer them MIGS you have taken away an opportunity for them to be able to lessen their dependency on glaucoma drops.

I think those are all great pearls. The risk:benefit, I agree, is very much in favor of the benefit. We don't see the really feared complications of hypotony with the MIGS devices, so that's really nice. Now, it is true that a few years ago, Alcon did voluntarily recall the CyPass MIGS device because of concerns regarding endothelial cell loss...progressive endothelial cell loss. As two cornea specialists, you and I both love endothelial cells and we know they're important. But beyond that, I think the track record over the years has really been pretty darn positive in terms of relatively few adverse events and I think that's really helped support the increasing use over time.

And I think all the points you made are excellent. I guess if I was still concerned about getting started, I might ask a colleague who is available that day...maybe is also operating at the ASC...to sit there next to me while I do my first one or two cases or any tricks. Someone who has experience with using the MIGS. I can't agree with you more that starting with one and then getting comfortable and then moving on makes sense.

 In my practice, I don't have necessarily a go-to but I offer the iStent infinite, the Hydrus, and Omni canaloplasty and I kind of mix and match based on the degree of the patient's glaucoma, their dependence on drops, and I would say probably the biggest challenge and the steepest or the hardest learning curve really is how to fit the different options in your practice, how to present it to the patients, where does it land in your discussion and counseling of patients, and most importantly, how do you manage the postop. 

Again, there's very different kind of varied ways of doing all of that. In our practice, we have trained our technicians to be familiar with all the different technologies available and to present the options to our patients as they come in right at the same time as they discuss cataract surgery with our patients and educate them and then flag the chart so that I know to talk about the different MIGS procedures when I go in. 

And then postop, we have the patients continue to go through glaucoma eye drops until they're off of their steroid eye drops after which then we remove, we have 1 drop removed at a time of the glaucoma drops with a 1-month time to really kind of gauge what the pressure response would be. If a patient is comanaged, which many of my patients are, our comanaging doctors are well trained on how to do that. 

I feel great about really being at the forefront of this technology and I have had great results being able to lessen the burden of glaucoma drops for my patients. And that's key I think to create just like anything else have the expectations be realistic that this is not going to cure them of glaucoma, it's only going to help with management and potentially lessen their burden of the drops, maybe 1 possibly more than 1 drops.

So with that, I think, hopefully, for those listeners out there, you're convinced to at least explore the option of MIGS and adding that to your practice. Because after all, we're here to offer our patients the best treatment options out there and this treatment has been shown to be proven effective and safe. A patient who has glaucoma together with their cataract deserve to be offered this. By the way, I should also state that their Omni can also be offered without cataract surgery. So that's one treatment option...one of the MIGS procedures that can be done standalone, which, in itself, is an excellent opportunity to lessen the burden of glaucoma on our patients.

Thank you so much, Peter, for a wonderful discussion. I look forward to our next one.

 Always a pleasure, Neda. I love these stories of innovation in ophthalmology. It's a great field. 

You'll remember, you and I in our younger days, we were colleagues with George Baerveldt. He was, of course, the author of the Baerveldt Implant and he was a great innovator and he was careful and scientific in his approach, but it's great to see what I think is this dramatic, exciting development in terms of improving our management for glaucoma patients. I'm very positive about it. Very happy to see it.

Peter J. McDonnell, MD, and Neda Shamie, MD, discuss the transformative impact of minimally invasive glaucoma surgery (MIGS) on glaucoma care and its integration with cataract surgery, sharing insights and practical tips for ophthalmologists.

EyePod: Transforming the MIGS pipeline into clinical reality

Jai Parekh, MD, MBA, FAAO, a clinical associate professor of Ophthalmology/The New York Eye & Infirmary of the Mount Sinai School of Medicine, and David Hutton, Managing Editor of Ophthalmology Times discuss the importance of ocular health prior to cataract and refractive surgery, specifically with osmolarity testing.

Editor's note: This transcript has been lightly edited for clarity:

Welcome to EyePod, a podcast series from Ophthalmology Times in which we engage with key opinion leaders in interviews about the latest innovations in the areas of surgery, clinical diagnosis, therapeutics, imaging, device technology, gene and cell therapy, practice management, and other cutting edge topics. I'm your host, David Hutton. I'm joined today by Dr. Jai Parekh, a clinical associate professor of ophthalmology, [at] the New York Eye and Ear Infirmary of the Mount Sinai School of Medicine. He specializes in cataract, corneal, and refractive surgery at his practice in Woodland Park, New Jersey. We will discuss the importance of ocular health prior to cataract and refractive surgery, specifically with osmolarity testing. Thank you for joining us today.

I'm seeing in the literature that more than half of patients referred for cataract surgery have dry eye disease, or meibomian dysfunction and/or blepharitis. Can you talk a bit about the potential for that to affect the outcomes of surgery if left untreated?

Absolutely, David. There's no doubt that the ocular surface is incredibly important, as a vital sign when we're taking care of patients undergoing any kind of surgery, including cataract and refractive surgery. In fact, I would also include MIGs and pterygium surgery, are anyone undergoing ocular surface reconstruction. There's no doubt that up to 80% of our patients who are in our waiting rooms awaiting a cataract surgery evaluation, have some form of ocular surface disease. The literature supports that. And around 60% of our patients, when tested, actually have some abnormal tear osmolarity. 

So these vital signs are very important. When a patient comes to me, traditionally, over the last few decades, with cataract surgery, we always assumed blurry vision was why they came to see us. But often times when you tease that out, David, you'll see that patients also have fluctuating vision. So if they have fluctuating vision as well as blurry vision, I now have a couple of disease states to take care of. 

For sure the cataract, if a cataract is commensurate with that blurry vision. Of course, we do a complete examination to make sure there's no glaucoma, no macular degeneration, or no retinopathy or maculopathy, or any other reason for the blurry vision. But if they have fluctuating vision, you sure as well know, 99% of the time, there's probably an ocular surface issue. 

And David, you said it so well, it's not just dry eye — it's dry eye, it's any inflammatory state of the corneal surface, it's lid disease, it's been meibomian gland dysfunction. It could be Demodex, it could be obstructive lid disease, any and all the above can lead to some form of fluctuating vision, and therefore, ocular surface disease. 

So ocular surface disease, for sure, is a very important part of our workup of the patient. And if the patient has it, guess what, we will delay the surgery—we don't even have to call it delaying surgery—we now have the patient enter our rooms or our doors for a journey in cataract refractive surgery and or ocular surface disease rehabilitation. And when they do that, and we take care of the ocular surface, and you mitigate the fluctuating vision, you'll now have better visual outcomes after that surgery.

So you're busy. You're seeing surgical referrals, but you can't just focus on surgery, you have to deal with ocular surface disease. What does an efficient screening process look like?

It takes a village David. It takes a village of the front desk. It takes the village of our optometrists that work closely with us. And yes, that cataract surgery, that surgical evaluation now begins preoperatively, intraoperatively, and postoperatively. 

Postoperatively you want to maintain these patients' expectations and vision. And nowadays, all the companies have come out with some great multifocal IOLs and some great toric IOLs. But guess what, even though the patient doesn't pay for the upgrade, or can't afford the upgrade, they still want good vision. These patients want very, very good vision. And to do that, we have to make sure we test for the ocular surface issues.

Dr. Jai Parekh, a clinical associate professor of Ophthalmology/The New York Eye & Infirmary of the Mount Sinai School of Medicine and David Hutton, Managing Editor of Opthalmology Times discuss the importance of ocular health prior to cataract and refractive surgery, specifically with osmolarity testing.

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