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65 65 Diagnosing DED starts with categoriz- ing patients into asymptomatic or symp- tomatic categories and performing testing based on their symptom presentation, then further categorizing them and developing a treatment plan based on their place in the spectrum of symptoms. DEWS II makes slight changes to the classic definition of tear film. Previously it was described as a three-layer system en- compassing the lipid layer, aqueous layer, and mucin layer. In DEWS II it is described as a two-layer system comprising the lipid layer and a muco-aqueous layer, which contains biomarkers potentially useful in the diagnostic process. Conclusion DED is a multifactorial disease, and there is no single one size fits all treatment. It must be diagnosed and treated early in an effort to break the cycle of inflammation and restore tear homeostasis. References 1. Bron AJ, et al. TFOS DEWS II pathophysiology report. Ocul Surf. 2017;15:438–510. 2. Craig JP, et al. TFOS DEWS II definition and classifi- cation report. Ocul Surf. 2017;15:276–283. Editors' note: Dr. Farid is director of cornea, cataract, and refractive surgery; vice-chair of ophthalmic faculty; director of the cornea fellowship program; and associate professor of ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine. She has financial interests with Allergan, BioTissue, Johnson & Johnson Vision, Kala, Shire Phar- maceuticals, and SightLife Surgical. She can be contacted at mfarid@uci.edu. ASCRS Cornea Clinical Committee algorithm focuses on OSD in preoperative cataract and refractive surgery patients by Christopher Starr, MD A chieving a pre- mium surgical outcome is impossible in the absence of a premium ocular surface. The mission of the ASCRS Cornea Clinical Committee's Preoperative OSD Cataract and Refractive Surgery Algorithm is to aid busy surgeons in identifying and reversing potentially visually significant OSD preoperatively. Proactive screening While the TFOS DEWS II diagnostic algorithm and treatment rubric are appropriate for the general dry eye disease (DED) and/or ocular surface disease (OSD) patient, there are special considerations required for preoperative refractive surgery patients with OSD. Symptoms are a primary component of most general DED algorithms and are a key driver in obtaining further diagnostic testing. It's known that a high percentage of preoperative cataract surgery patients are asymptomatic and yet often have fairly advanced visually significant DED and/or OSD. Thus, the ASCRS Cornea Clinical Committee algorithm emphasizes point-of-care testing (osmolarity and MMP-9) and other objective testing in addition to a novel surgery-specific symptom questionnaire in all patients during their pre-surgical office visit. If visually significant OSD is detected by the algorithm, refractive measurements and surgery are delayed until it is fully treated. Aggressive treatment An important commonality between TFOS DEWS II and the ASCRS Cornea Clinical Committee algorithm is that both recommend identifying the DED subtype, evaporative dry eye (EDE) or aqueous deficient dry eye (ADDE) disease, in addition to any other DED masqueraders (e.g., floppy eyelid syndrome, epithelial basement membrane dystrophy, allergy, conjunctivochalasis) to best tailor effective treatment. In TFOS DEWS II, the first step for most patients with DED is low level palliative treatment. Conversely, the ASCRS Cornea Clinical Committee stresses that patients who are having refractive surgical interventions do not have the luxury of time to start slow and increase treatment incrementally as this will lead to unacceptably long surgical delays. When managing preoperative patients with visually significant OSD, the ASCRS Cornea Clinical Committee recommends starting treatment at the TFOS DEWS II Step 2 level with more advanced interventions and to use a multifaceted approach to achieve a more rapid response. A combination of prescription medications (e.g., topical immunomodulators, steroids, antibiot- ics, etc.) as well as procedural interven- tions (e.g., blepharoexfoliation, thermal pulsation, intense pulsed light, punctal plugs, therapeutic contact lenses, etc.) are typically required for rapid reversal of OSD preoperatively. Manage expectations The ASCRS Cornea Clinical Committee stresses that surgical patients should know in advance that their vision may fluctuate postoperatively and their OSD may worsen, and thus should expect to continue OSD treatment for at least 3–6 months after surgery. The take-home message is: Diagnose early, educate the patient about their OSD, treat aggressive- ly, and maintain appropriate postopera- tive surveillance and treatment. Editors' note: Dr. Starr is associate professor of ophthalmology, director of refractive surgery, director of ophthalmic education, and director of the cornea, cataract, and refractive surgery fellowship, Weill Cornell Medicine, New York Presbyterian Hospital, New York. He has financial interests with Allergan, Alcon, Bausch + Long, Sun, Shire, Kala, Bruder, BlephEx, TearLab, and RPS. He can be contacted at cestarr@ med.cornell.edu. Six steps to establishing a Dry Eye Center of Excellence by Marguerite McDonald, MD Given these circumstances, cataract surgeons should treat every patient as a dry eye patient. We have two choices: Create a Dry Eye Center of Excellence to ensure optimal outcomes in your surgical patients, or refer your pre-surgical patients to col- leagues who will optimize their ocular sur- face and send them back to you. If you opt to create a Dry Eye Center of Excellence, I recommend the following steps. Stepwise strategy 1. Have a team meeting to let your staff know that focusing on dry eye is im- portant to you and that it will benefit the practice and the patients. Encourage buy-in by explaining that it can be a lucrative endeavor, and the healthier the practice, O cular surface disease (OSD) is per- vasive, with at least one study showing that 87% of patients scheduled for cataract surgery are diagnosed with dry eye disease (DED). 1 Even mild OSD can lead to suboptimal refractive outcomes after cataract surgery, and the signs and symp- toms of OSD are often poorly correlated; therefore, patients with OSD may be missed if clinicians rely heavily on symptomatolo- gy for diagnosis. 2 continued from page 64 continued on page 66 Meibomian gland imaging • Look for duct dilation, gland constipation, curling and shortening (atrophy), hazy appearance, dropout • Powerful tool to motivate patients to accept/perform preventive care EARLY STAGE MGD/NON-OBVIOUS LATER STAGE MGD/DRY EYE GLAND LOSS Figure 1. Meibomian gland imaging in the first frame shows early stage MGD with a small amount of duct dilation. The second frame shows curling, shortening, and gland atrophy. The third frame shows end stage truncated glands. EARLY STAGE MGD/ NON-OBVIOUS LATER STAGE MGD/DRY EYE GLAND LOSS the greater the likelihood of staff bonuses and pay raises. 2. Visit another Dry Eye Center of Excellence. Bring your office manager and lead technician along, and take notes. Make sure the practice is an hour or more away, so they won't consider you as com- petition. Be gracious; buy the staff lunch. You may want to visit again in a year to observe with fresh eyes.

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