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4 | SUPPLEMENT TO EYEWORLD | OCTOBER 2020 Step 5. Visually significant OSD aggressively treated based on subtypes and severity In the last several years, a number of new algorithms, suggestions, and guidelines have come out, said Fran- cis Mah, MD. Is the ASCRS Preoperative OSD Algorithm different? "There have been a lot of initiatives in terms of dry eye guidelines over the past sev- eral years. … I think the main difference with our algorithm is that it's a very practical, evidence-based approach in addressing dry eye in the presurgical patient," said Terry Kim, MD. "All the other initiatives have focused on dry eye in the general population; this focuses on the preoper- ative cataract and refractive patient." Dr. Kim noted the unique features of the algorithm, such as the customized patient questionnaire, its pearls for the clinical exam, and its multifaceted treatment recom- mendations to optimize the ocular surface quickly to pro- ceed to the surgical procedure. If ophthalmologists use this algorithm in their preop- erative practice, Dr. Kim said he thinks "we'll see a better and more improved identifica- tion of these patients so that we can get better IOL calcula- tions and surgical results." It's been more than a year since the algorithm was intro- duced and Dr. Starr said its reception has been amazing. "It thrills me to see it referenced by others and hear other speakers lecture about it," Dr. Starr said, adding that he's heard it called among the most influential and widely cited ophthalmic manuscripts in recent history. "For all those reasons I'm extremely proud of what we did, and I'm glad we spent the extra time to get it just right and break new ground." Dr. Mah said the ASCRS Cornea Clinical Committee's ultimate goal was to make more ophthalmologists aware of the impact of OSD and en- courage them to use some sort of screening and treatment algorithm. "I think people think OSD is an important issue sur- rounding cataract surgery, and the next steps are how do we diagnose it and treat it. The algorithm is a great way to do that," Dr. Mah said, adding, however, that the committee was not trying to be dog- matic. "For people who look at the algorithm or read the paper and say, 'I don't have all these different tests and/or machines, this is worthless to me,' that wasn't the goal. "The goal was to think about OSD as a critical com- ponent of the perioperative patient to improve outcomes and create more happy pa- tients. … [The algorithm is] meant to highlight that OSD is important; start with whatever testing and treatment options you've got." A point that Dr. Starr clar- ified is what to do (or not do) when the algorithm diagno- ses neuropathic corneal pain (i.e., pain without stain). This contraindicates elective inci- sional surgery like laser vision correction or astigmatic limbal or corneal incisions, Dr. Starr said. "While it is technically non-visually significant OSD (NVS-OSD) due to an absence of corneal staining, when cataract surgery is needed, it is safe to proceed without delay. But patients should be counseled in advance and told that it might worsen or become visually significant after surgery and may require more advanced treatment afterward," Dr. Starr said. "As new diagnostic tools and treatments get approved, they will all have a place in the algorithm, and hopefully we will update it periodically as new things enter the mar- ket," Dr. Starr added. continued from page 1 OSD diagnostic tools Osmolarity • TearLab Osmolarity System (TearLab) MMP-9 • InflammaDry (Quidel) Stains • Fluorescein • Lissamine green • Rose bengal Meibography • HD Analyzer (Visiometrics) • ICP MGD (MiBo Medical) • Keratograph 5M (Oculus) • LipiScan (Johnson & Johnson Vision) Corneal topography • ATLAS 9000 Corneal Topographer (Carl Zeiss Meditec) • Easygraph (Oculus) • EyeSys Vista (EyeSys) • GALILEI (Ziemer Ophthalmic Systems) • OPD-Scan II (Nidek) • Orbscan II (Bausch + Lomb) • TMS-4N and RT-7000 Multifunctional Auto Ref/K/Topo (Tomey) Other tools • Aberrometry • LLT • OCT tear meniscus height • Rho antibodies (SSA, SSB) • Schirmer's test strips • Immco Sjögren's Diagnostic Test Panel (Trinity Biotech) • Tear breakup time *This list may not include all OSD diagnostic tools. Incorporating the ASCRS Preoperative OSD Algorithm into practice "I think people think OSD is an important issue surrounding cataract surgery, and the next steps are how do we diagnose it and treat it. The algorithm is a great way to do that." —Francis Mah, MD

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