Strategies for Identifying and Treating OSD
ESCRS and EuCornea delegates reveal their diagnostic and therapeutic preferences and protocols in 2017 survey data results
Continued advances in cataract surgery technology, such as the use of the femtosecond laser and premium IOLs, enable surgeons to achieve excellent refractive outcomes for patients, and patients in turn expect truly outstanding results.
The success of today’s cataract interventions, however, is largely dependent on the health of the ocular surface. Ocular surface disease (OSD) is prevalent in the cataract-age population, and its presence can affect the accuracy of preoperative measurements and IOL calculations, as well as postoperative visual quality. (1)
The 2017 ESCRS Clinical Survey of OSD was administered onsite at the annual meeting in Lisbon, Portugal, and available to be taken online. Of the almost 1,900 respondents, close to 60% have been in practice for more than a decade.
LOOKING FOR OSD
Of the respondents, 42% said they systematically perform a check of the ocular surface as part of the preoperative cataract surgery assessment in all patients. Thirty percent systematically check for OSD in most cases, 23% said they only check if the patient presents with dry eye disease (DED) and 5% rarely or never check the ocular surface (Figure 1).
When asked about the percentage of patients who were asymptomatic to OSD prior to surgery but developed symptoms afterward, 60% of the delegates noted that this was the case in up to 10% of their patients, and 59% said somewhere between 11% and 25% of their patients. There were 18% of delegates who said that 26-to-50% of their patients develop symptoms of OSD postoperatively.
TREATMENT CHOICES – DED
There is an ever-increasing number of treatments for OSD, from over-the-counter drops to prescription therapy, plugs or thermal expression, for example. By far, artificial tears and lubricants are the most widely used therapy by ESCRS and EuCornea delegates, with 93% of surgeons using these drops as a primary therapy in moderate and severe aqueous-deficient or unspecified DED (Figure 2). For severe disease, 52% of the respondents use cyclosporine, 44% punctal occlusion, 43% oral omega-3s and 42% a topical corticosteroid. The use of cyclosporine as a preferred therapy in patients with moderate disease dropped to 23%. More than 40% of the delegates recommend patients with moderate disease take omega-3s.
Other therapies ESCRS and EuCornea delegates employ for moderate and severe aqueous-deficient or unspecified disease include thermal expression (manual or heated), topical azithromycin and oral cyclines such as doxycycline or minocycline.
TREATMENT CHOICES – MGD
Meibomian gland dysfunction (MGD) and Sjögren and non-Sjögren lacrimal disease remain the leading causes of evaporative and aqueous-deficient DED, according to the recent update from the TFOS International Dry Eye WorkShop (DEWS II). (2) Many hybrid forms of DED exist, and they often overlap.
Warm compresses are the primary therapy for MGD among the ESCRS and EuCornea delegates, with 74% using conventional methods and 34% recommending commercial products.
For 17% of the respondents, meibomian gland probing is a favoured technique, 7% use thermal pulsation and 5% employ intense pulsed light.
Like the rising amount of treatment choices, the number of point-of-care tests used to evaluate the health of the ocular surface has dramatically increased in recent years, as evidenced by the survey’s results (Figure 3). To varying degrees, delegates employ the following diagnostics:
• corneal and conjunctival staining;
• tear break-up time;
• Schirmer testing;
• dry eye questionnaires;
• lipid layer interferometry;
• meibomian gland expression.
In most patients, at the initial point of care, corneal and conjunctival staining (44%) and tear break-up time (38%) are the most commonly incorporated diagnostics. Fourteen percent of respondents use Schirmer testing and 14% administer a questionnaire.
On a case-by-case basis, during the consultation ESCRS and EuCornea delegates’ use of testing increased: Schirmer testing rose to 72%, tear break-up time to 55%, corneal and conjunctival staining to 44% and dry eye questionnaires to 41%. Meibography is employed by 18% of respondents and osmolarity in 16%.
Some respondents indicated that they do not see the value of various diagnostic tests. Specifically, 15% do not use osmolarity, 14% do not use questionnaires and 12% replied that they do not see the value of either meibography or Schirmer testing. This question on the survey also captured delegates access to the various technology (Figure 3).
BARRIERS TO ADDING NEW TESTS
When asked about the barriers to incorporating advanced tear film diagnostics in their practice, 8% of the delegates said they had no objections and are currently using these tests. Delegates not using advanced methods, however, said the main reasons are a lack of access to the technologies, the tests not being covered by the health system (38% for each) and the cost to the surgeon (36%). The other objections include:
• do not see the value (no difference in safety and efficacy) = 17%;
• increases chair time = 17%;
• disrupts practice flow = 10%.
It is more common than surgeons may think for asymptomatic patients to develop symptoms of OSD after surgery, particularly in the elderly population, noted Béatrice Cochener, MD, PhD, head of the Department of Ophthalmology at Brest University Hospital and President of the ESCRS. She and colleagues recently reported a study conducted at her centre that found 52% of patients (342 eyes of 180 patients) presenting for cataract surgery had MGD identified on meibography – 49% of them were asymptomatic. (3)
Although only 42% of ESCRS and EuCornea delegates said they check the ocular surface as part of the preoperative cataract surgery assessment in all patients, Dr Cochener believes that surgeons should screen for OSD in most of their patients. “We know that it is always better to prevent than to treat, meaning the discovery of an OSD does not necessarily contraindicate the surgery, but it justifies preparing the ocular surface for surgery and informing the patient,” she said.
Dr Cochener noted the importance of a careful slit-lamp exam and the utility of fluorescein to gather information about tear break-up time, disease severity, and chronicity, as well as meibum expression to evaluate the quality of the lipid layer. She noted that questionnaires yield subjective information, however, and emphasised the importance of using objective diagnostic tools to complete the picture. “We hope that refined diagnosis allowed by new platforms of diagnosis will allow more targeted treatment,” she said.
1. TFOS International Dry Eye WorkShop (DEWS II). Ocular Surf. 2017;15:269-650.
2. Trattler WB, Majmudar PA, Donnenfeld ED, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.
3. Cochener B, Cassan A, Omiel L. Prevalence of meibomian gland dysfunction at the time of cataract surgery. J Cataract Refract Surg. 2018;44(2):144-148.
For more information on the ESCRS Education Forum, including video presentations, supplements and articles see forum.escrs.org