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Developing an OSD treatment plan based on subtype and severity T here are a range of OSD subtypes and se- verity levels for which the ASCRS Preoper- ative OSD Algorithm helps identify and guide a treatment plan. When it comes to this plan, Marjan Farid, MD, said physicians want to take a more aggressive multifaceted treatment approach. "Where do we start? Where do we go from here? There is not as much time in the preoperative setting to take the stepwise approach that we sometimes do with non-surgical patients. With these patients, we want to clear up the ocular surface as quickly as possible so that we can get them in for their surgery. "What we want to do in this setting is take a multi- faceted, aggressive approach, optimize the tear film, really clear up the surface of the eye, and get these patients back in for biometry measurement and get them into surgery," Dr. Farid said. So where should you start? Dr. Farid has three big areas to work on. The first is to treat ocular surface in- flammation. The second is to improve the lipid layer of the tear film by lid disease man- agement. The third is to clean up ocular surface staining. With inflammation specifically, Dr. Farid said she'll reach for a fast-acting, prescription, topical medication, such as low side effect steroids like loteprednol (Lotemax, Bausch + Lomb) or a fast-acting anti- inflammatory like lifitegrast (Xiidra, Novartis). For MGD, which Dr. Farid said is underdiagnosed, home therapies are often encour- aged by doctors, then not actually done by the patient. "We're now incorporating procedural meibomian gland treatments in the office. Ther- mal pulsation [iLux, Alcon; LipiFlow, Johnson & Johnson Vision] is my favorite," Dr. Far- id said, noting that she'll do this procedure about a month before bringing the patient back for biometry. She also mentioned other procedural meibomian gland treatments. "This is where I would encour- age everyone to look at incor- porating a procedural therapy in their practice for treating meibomian gland disease." Addressing bacterial dry eye disease is important as well. For this Dr. Farid turns to microblepharoexfolia- tion (BlephEx, RySurg). She couples this with thermal pulsation because the mi- croblepharoexfoliation can clear debris, epithelial hyper- proliferation, and anything that might be plugging the meibomian gland. "It debrides the bacteria, which also decreases your risk of endophthalmitis," she said. Oral macrolides are a "great adjunct" to when there is concurrent rosacea. Physi- cians may want to do a low- dose doxycycline for a month to 6 weeks before biometry and surgical planning to clean up the lid margin inflamma- tion, Dr. Farid said. Oral ome- ga-3 supplementation is also a great addition for treatment of inflammation and lipid layer normalization. When there is central cor- neal staining, which is agreed to be visually significant OSD, Dr. Farid said she'll adjust her approach depending on sever- ity. There are a lot of therapies that can be used in this subset of patients, including autol- ogous serum, self-retaining amniotic membrane, and ban- dage contact lenses. Dr. Farid said "steroids are fantastic," and she reaches for them early on with these patients to also help clear significant punctate keratitis. Francis Mah, MD, said he thinks the range of pro- cedural, in-office treatments can be attractive to patients to address OSD every 3–6 months, rather than more regular, patient-directed home therapies. Overall, he thinks there has been a shift in that devices are being used first with medications and at-home warm compresses, for exam- ple, being used as the adjunct. "I'm surprised when I offer [procedural therapies] to patients in that we'd ex- pect because it's a cash-pay procedure that they would be turned off, but more patients would rather pay a small amount up front to get their lids taken care of than have to be regimented to do a warm compress every day," Dr. Farid said. Preeya Gupta, MD, said OSD is also being diagnosed more frequently at younger ages, and these younger pa- tients seem more receptive to the out-of-pocket procedures that get the situation taken care of and are easier than having to do something every day at home. "One caveat I have with that, though, is as we keep the bar lower with the expectation for our implants, we have to do that with these treatments because most of these treat- ments are lifetime treatments; while it's nice to think you can still get it fixed, I don't encour- age them to think 'Get this and you're done and you don't have to take drops anymore,'" said Kenneth Beckman, MD. "They have to understand this is a chronic condition," Dr. Gupta said. OSD tools in the pipeline • EYSUVIS (Kala Pharmaceuticals) • Lacripep (Tear Solutions) • OC-1 (Oyster Point Pharmaceuticals) • Reproxalap (Aldeyra Therapeutics) • TOP1630 (TopiVert) • TP-03 (Tarsus Pharmaceuticals) • Voclosporin ophthalmic solution (Aurinia Pharmaceuticals) *This list may not include all OSD tools in the pipeline. Incorporating the ASCRS Preoperative OSD Algorithm into practice Copyright 2020 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed in this publication do not necessarily reflect those of the staff and leadership of EyeWorld and ASCRS, and in no way imply endorsement by EyeWorld and ASCRS.

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