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8 | SUPPLEMENT TO EYEWORLD | OCTOBER 2020 Incorporating the ASCRS Preoperative OSD Algorithm into practice How the protocol impacts surgical decisions I t can be hard to convince busy ophthalmologists to treat OSD, often a chronic condition, said Kenneth Beckman, MD. But with unhappy patients postop, the PHACO study finding under- reporting of dry eye signs and symptoms among cataract patients, 1 and the release of the ASCRS Preoperative OSD Algorithm, more and more ophthalmologists are coming on board with preoperative identification and treatment of OSD. While the algorithm itself can seem overwhelming, it's a critical part of the cataract evaluation. "It's easy to use if someone wants to pay atten- tion to it," Dr. Beckman said. "I think the confusion people get with all these algo- rithms is it's not that these are competitive algorithms—they build on each other," he said. Christopher Starr, MD, said the ASCRS Preopera- tive OSD Algorithm was not created in a vacuum, and all the seminal papers—CEDARS DTS, TFOS DEWS II, TFOS MGDW, and others—were all highly influential. The value of the ASCRS Preoperative OSD Algorithm is it tells the surgeon 1) don't forget to look for OSD, 2) how to look for it, 3) how to deal with it after you've discovered it, Dr. Beckman said. While some might talk about treating visually significant OSD as delaying surgery, Dr. Beckman said that's not usually the case in his practice. He said patients often come in for their annual exam and at that time say they're ready to have their worsening cataracts ad- dressed. Dr. Beckman con- ducts screening for OSD at that time, ahead of the initial cataract consult. If dry eye is mild, patients are started on an artificial tear and asked to come back in a week for cata- ract preop testing. If their dry eye is more severe, he'll start them on a more aggressive treatment, such as a steroid, and have them come back 2 weeks later. Sometimes he'll test and find that the patient needs further intervention, but it's rare to do it more than twice. Patients are usually on board with the regimen and repeat testing because he ex- plains the value to them. "If you give them the proper message, they know how vulnerable they are," he said. Dr. Beckman's message is that surgery is being "delayed" to 1) prevent infection, 2) en- sure accurate measurements for correct lens calculations, and 3) to prevent postop aberrations. To the point of patient conversations, Francis Mah, MD, said non-visually sig- nificant, asymptomatic OSD should still be discussed with the patient preoperatively because it could become symptomatic after surgery. Dr. Starr shared similar advice, saying that he thinks the algorithm is "most useful in those mild, non-obvious cases that could easily be missed in a busy clinic during a lengthy preop exam. Sim- ilarly, in those patients with mild or non-visually signifi- cant OSD, if you don't inform the patient of its presence and the possibility of postoperative worsening it could be per- ceived later as a complication rather than a pre-existing condition." "For the obvious visually significant OSD cases, like central corneal staining, you don't necessarily need an algo- rithm to arrive at the diagno- sis, but having our guidelines and recommendations, as well as objective data, makes the conversation with the patient easier and clearer. … It is great for facilitating patient education and buy-in to our treatment plans." Dr. Beckman thinks more ophthalmologists are aware of testing for OSD preoperatively now. "I used to get a lot of patients from doctors who put in premium lenses that ended up being unhappy, and I was cleaning them up afterward," Dr. Beckman said. "Now those same doctors are sending patients to me before cataract surgery. … A lot of times I'll tell them not to put in a premium lens but at least get them cleaned up for regular cataract surgery. That's a change I've seen, so they're paying attention to it." Reference 1. Trattler W, et al. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423–1430. "I think the confusion people get with all these algorithms is it's not that these are competitive algorithms—they build on each other." —Kenneth Beckman, MD

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