The ocular surface is the first refracting surface of the eye; therefore, the tear film provides the basis for good vision. An unhealthy tear film can cause an almost 1.00 D fluctuation in visual acuity.1,2
In the case of patients undergoing cataract or refractive surgery, optometrists ensure a stable ocular surface before the surgeon performs preoperative calculations. In my practice, I evaluate patients using a tear break-up test and vital dye staining of the cornea and conjunctiva, and then if necessary, schedule them back for a presurgical dry eye disease (DED) examination.
My full DED evaluation includes meibomian gland evaluation using the Korb gland evaluator as well as LipiView II Ocular Surface Interferometer with Dynamic Meibomian Imaging (DMI; Johnson & Johnson Vision), which measures lipid layer thickness, captures blink dynamics, and images the meibomian gland structure). I also conduct osmolarity reading with TearLab Osmolarity System (TearLab Corp.), look for MMP-9 inflammatory marker with InflammaDry (Quidel), and stain the cornea and conjunctiva using both fluorescein and lissamine green vital dyes.
Once I determine the cause of the physiologic imbalance, I can initiate treatment before the patient sees the surgeon. Restoring tear film homeostasis in DED patients leads to improved surgical outcomes.3,4
Previously from Dr. O'Dell: Why meibography can be a game-changer in treating dry eye
Patient education helps
Education is paramount for patients to commit to their DED treatment plan. Asymptomatic individuals who develop postoperative ocular surface disease (OSD) concerns are prone to unfairly blame the surgeon for their discomfort. With meibography, for example, I can show patients what their glands look like (and what healthy ones should look like), which helps them understand why they need treatment and makes them more receptive to the required follow-up regimen.
For patients who are symptomatic, education provides more evidence on why we need to be aggressive in their treatment. They already understand they have a condition, and I explain that surgery will increase their inflammatory response and possibly worsen their symptoms.
By aggressively treating OSD in presurgical patients, I build better relationships with my referring surgeons. Although rare, the most feared complication of surgery is
endophthalmitis.5-7 For patients with signs of blepharitis, I perform BlephEx (RySurg) to exfoliate the lids and remove the bacterial load. I also recommend a lid hygiene regimen and a lid wipe containing hypochlorous acid, further ensuring optimal outcomes.