Eyeworld Supplements

6 | SUPPLEMENT TO EYEWORLD | OCTOBER 2020 Customizing the dry eye screening battery for your practice T he dry eye screening battery in the ASCRS Preoperative OSD Algo- rithm guides physicians in assessing signs and symp- toms of dry eye. For signs, it starts with osmolarity testing (TearLab Osmolarity System, TearLab) and looking for inflammato- ry biomarkers, like MMP-9 (InflammaDry, Quidel). For symptoms, the ASCRS Cornea Clinical Committee developed the ASCRS SPEED II Preop Questionnaire, which includes elements of other validated dry eye questionnaires as well as additional questions specif- ic to the preoperative patient. In the 2018 ASCRS Clini- cal Survey, more than 50% of respondents said osmolarity, MMP-9, and a dry eye ques- tionnaire were not included in their practice. These three elements are an integral part of starting the ASCRS Preop- erative OSD Algorithm, said Francis Mah, MD. So what if a practice doesn't have osmolar- ity or MMP-9 testing? What if a practice has its own dry eye questionnaire or OSD patient feedback process already in place? "I think screening is very important, and point-of-care testing, while it's new, it's not that new, and we've had time to realize that it adds so much value to diagnosing our patients who are at risk for ocular surface disease or who have ocular surface disease and are asymptomatic," said Preeya Gupta, MD. "I would say if you're not using point- of-care testing, now is the time. … We have a lot of data showing that if you're utilizing point-of-care testing, you're going to be able to identify dry eye and ocular surface disease in the asymptomatic state, and I would even say earlier in the disease state. If we take that out to how we manage and treat these patients, the earlier we catch this, the easier it is to treat, the happier the patients are in terms of their comfort. That would be my one request to everyone who isn't using point-of-care testing." Dr. Gupta said that if you don't have point-of-care testing, that doesn't mean you can't use the algorithm. Integrating vital dyes like lissamine green or fluoresce- in and topography can help identify ocular surface disease, she said. "There is a lot of informa- tion that can be gleaned from a topographer," she continued. "Missing data, irregular astig- matism, those can be used as a clue that there is underlying ocular surface disease, wheth- er it's anterior basement mem- brane dystrophy, Salzmann's nodules, pterygia, or even dry eye with corneal staining." Another helpful test is meibography as it gives struc- tural insight into the meibo- mian gland architecture and disease level. "Everyone can partici- pate, there are a lot of tests and tools, and if you have access to any of the tools in the algorithm, even starting with one of them is better than not participating at all. This algorithm highlights an opportunity for us to become better diagnosticians, better clinicians, and get to that next Changing cylinder and sphere D r. Mah gets a topog- raphy on everyone. "Topography clues me in on the fact that there is something wrong with the ocular surface and that will throw up the yellow flag to look at keratometry and I look at biometry," he said. "It gets me to talk to the patient about the ocular surface and the fact that we need to get this normal." The topographic picture helps in this patient discussion. Dr. Mah described a patient with irregular topography who was originally indicated to receive a toric IOL. He spoke with the patient preoperatively about needing to get her ocular surface managed (it turned out she had meibomian gland disease). Eight weeks of warm compresses, lid scrubs, TearCare (Sight Sciences), steroids, and lifitegrast (Xiidra, Novartis) changed her repeat measurements dramatically. "Not only did she not need a toric IOL, but it changed the amount of sphere correction 18 D to 19 D, from a T4 to a spherical IOL," Dr. Mah said. "I think people are motivated to get the right lens to get their vision improved." Visually significant corneal staining is common prior to cataract surgery, but patients are often asymptomatic. Source: Christopher Starr, MD Incorporating the ASCRS Preoperative OSD Algorithm into practice

• Cover