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continued on next page since many cataract-aged patients have significant signs of OSD but are asymptomatic. He mentioned that none of the commonly used DED questionnaires were particularly well-suited for surgical patients, and therefore the ASCRS SPEED II Preop OSD Questionnaire was created for this algorithm. Dr. Starr went on to discuss the signs of OSD. He noted the usefulness of both osmolarity and MMP-9 testing in the original algorithm, as well as ancillary testing such as meibography, topography, OCT, light scatter, lactoferrin, and other point-of-care tests. No algorithm would be complete without an exam, he said, noting the importance of a quick, directed slit lamp exam to assess for VS-OSD. For this exam, Dr. Starr stressed the LLPP technique—look, lift, pull, push. Look at the face for things like rosacea; look at the lids for things like en/ ectropion and symmetry; look at the blink quality, tear me- niscus, lashes, meibomian glands, cornea/conjunctiva, and for anterior blepharitis/keratin/biofilms/scurf, and have the patient look down for collarettes and Demodex. Lift the up- per lid to examine the superior cornea for things like EBMD or SLK. Pull out the upper lid to assess for lid laxity. Push on the lower lid margin to check meibomian gland expres- sion for quality and quantity. Testing for corneal sensation before eye drops is important to detect nerve abnormalities like neuropathic corneal pain and neurotrophic keratitis. You can use contact methods tissue, Cochet-Bonnet etc., but these may disrupt the corneal epithelium. The non-contact Corneal Esthesiometer Brill (Brill Engines) is useful be- cause it does not disrupt the ocular surface and can be done earlier in the algorithm by the technicians who do the other tests, he said. The last step is vital dye instillation to detect corneal epithelial staining, which often qualifies as VS-OSD. At this point, you've probably ruled OSD in, but you have to decide if it's visually significant and if it will impact your planned surgery, Dr. Starr said. For non-visually signif- icant OSD, surgery can proceed, and the refractive plan can be finalized, but surgeons should counsel the patient that they have OSD and it may worsen after surgery. A proac- tive treatment plan should be instituted preoperatively and monitored closely postoperatively. For VS-OSD, the surgery, if imminent, and the final refractive plan should be delayed, patients should be counseled about OSD and its impact on surgery, and an aggressive treatment should be started to minimize the surgical delay. VS-OSD should be treated based on OSD subtypes, often several, and their severity. Dr. Starr said to start at the TFOS DEWS II Step 2 or 3 for these patients, rather than Step 1. Treatment could include a combination of prescrip- tion medications and procedural treatments, with follow-up typically in 2–4 weeks when the algorithm is repeated from the beginning. Only proceed with the surgery when the VS-OSD has converted to non-visually significant OSD. Whether one adopts this algorithm faithfully, partially, or not at all, ASCRS encourages all refractive and cataract surgeons to pay close attention to the visually important ocular surface prior to surgery, Dr. Starr concluded. Diagnostics Dr. Mah highlighted diagnostics and how to incorporate them into your surgical practice. "It's not limited to the presurgical patient, but I'm going to present it in the light of the presurgical patient," he said. "These tests can also be done in a non-surgical patient in your dry eye clinic." A lot of the tests and the entire algorithm can be done before the surgeon comes in; technicians can complete these tests. Dr. Mah shared a case to highlight the importance of identifying and treating ocular surface disease in presurgi- cal patients. This case involved a 75-year-old woman with worsening vision, particularly when reading and watching television. Her BCVA was 20/50 in the right eye and 20/40 in the left eye. She was using artificial tears and lifitegrast and had some rosacea and ocular staining. Dr. Mah said the tear osmolarity was 305 and 317, but the inter-eye difference was more than 10. MMP-9 was pos- itive, she had cataracts, shortened glands on meibography, and thickened meibum. With preop testing, Dr. Mah said you would expect to use a T4 because she had 2 D cylinder, and it's an 18 D lens (based on the IOLMaster, Zeiss). Because we identified visually significant dry eye prior, we decided to treat her accordingly, Dr. Mah said. He started the patient on MIEBO (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) 4 times a day and started steroids to get the surface more rapidly turned over. He also considered mechanical thermal pulsation. After 8 weeks, the IOLMaster had changed, and the topography became more normal. The patient didn't need a toric lens anymore. She would have been hyperopic and had induced astigmatism if the original plan was used. Initial refractive testing showed inconsistent keratometry, astigmatism axis, and an irregular topography; despite not having symptoms of DED, the patient had VS-OSD and significant corneal staining. Source: Christopher Starr, MD

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