Eyeworld Supplements

continued from previous page OCULAR SURFACE DISEASE IN MY SURGICAL PRACTICE: BEST MANAGEMENT SOLUTIONS He said that with premium vision, there are many ex- cellent machines and diagnostics. We pride ourselves on our ability to hit our outcomes, he said. But refractive misses can occur because of dry eye disease. Dr. Mah went on to highlight the incidence of DED and OSD in cataract surgery candidates, noting literature where 60% of routine cataract patients were asymptomatic, yet 50% had central corneal staining. Eighty percent of patients presenting for cataract surgery had OSD, and in those who were asymptomatic, more than 50% had an abnormal tear osmolarity. DED and OSD increase the risk for surgical infection. Surgery will worsen dry eye. It can also lead to topography, keratometry, refraction, and aberrometry changes. If we do all these tests aiming for a certain outcome, we might get the wrong outcome because of the DED, Dr. Mah said. Patient expectations are higher than ever. If DED is not addressed before surgery, symptoms will worsen and lead to unsatisfactory postoperative vision. DED and OSD can also lead to reduced visual quality and quantity. Dr. Mah went through some of the testing recommend- ed in the ASCRS Preoperative OSD Algorithm, discussing tear osmolarity and MMP-9 more in depth. A lot of issues with tear osmolarity revolved around the fact that people were hoping when it first came out that it would be the test to diagnose dry eyes. If you had a posi- tive osmolarity test, that meant you had dry eyes—but it doesn't exactly work like that, he said. It's more like blood sugar testing or glaucoma IOP testing. You could get some variation, so you need to test these patients, and it's going to guide therapy. The InflammaDry MMP-9 test (Quidel) helps guide ther- apy and helps with education, Dr. Mah said. In general, the osmolarity system is an objective and quantitative test for managing dry eye patients, Dr. Mah said. Hyperosmolarity has been described in the literature as a primary marker of tear film integrity. When the quan- tity or quality of secreted tears is compromised, increased rates of evaporation lead to a more concentrated tear film (increased osmolarity). However, osmolarity numbers can fluctuate, as most clinicians are not following trial proto- col. You need a rigorous protocol where every time you're testing the same way, Dr. Mah said. It's also reimbursed. It's not perfect, but it's a good way to measure and helps with managing and guiding. The ScoutPro (Bausch + Lomb) is used for osmolarity. The system is an excellent and reliable test, Dr. Mah said. It's comparable to cholesterol and blood glucose testing. As far as additional factors that could help in the clinic and with the patient, there's a customer portal, as well as patient support. It's very important for patients to be involved in their own care, he said. InflammaDry is the test for MMP-9. It is a sensitive di- agnostic marker, and anti-inflammatory therapies have been shown to decrease MMP-9 activity. However, MMP-9 is also found in rosacea, blepharitis, ocular allergy, and conjuncti- vochalasis. Lactoferrin is a newer test that Dr. Mah said has been studied in peer-reviewed literature. It helps more with aqueous deficiency. Severe dry eyes can also be determined by lactoferrin. There's a high sensitivity and specificity for further testing. Low levels of lactoferrin indicate suppressed lacrimal function, he said. Changes in lactoferrin levels may show the efficacy of the prescribed treatment. Dr. Mah also mentioned the OcuCheck Biosensor (InnSight Technology), which is not FDA approved. It's a combination of both MMP-9 and osmolarity. It's quantitative, and it can potentially look at other future biomarkers. Then we go into the slit lamp exam, Dr. Mah said, which is the crux of how we diagnose and manage ocular surface disease. There are some other tests that he noted, including meniscometry, looking at lid parallel conjunctival folds, Schirmer's testing, looking at meibomian glands and eyelids margins, looking at meibomian gland expressibility/ duct assessment, and meibography. Most times dry eye testing is reimbursed, Dr. Mah said, but if it's not, many patients are willing to pay for improved outcomes. Failure to address dry eye disease and OSD could lead to unsatisfactory vision, new or worsened OSD symp- toms, and/or postoperative infection. Brandon Ayres, MD Co-Director of the Cornea Fellowship Program Wills Eye Hospital Philadelphia, Pennsylvania Marjan Farid, MD Director of Cornea, Cataract, and Refractive Surgery Gavin Herbert Eye Institute University of California, Irvine Irvine, California Francis Mah, MD Director, Cornea and External Disease Co-Director, Refractive Surgery Scripps Clinic La Jolla, California Christopher Starr, MD Director, Refractive Surgery Director, Ophthalmic Education Co-Director, Cornea, Cataract, Refractive & Ocular Surface Fellowship Weill Cornell Medicine New York Presbyterian Hospital New York, New York About the physicians

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