The importance of ocular health prior to cataract and refractive surgery

Jai Parekh, MD, MBA, FAAO, a clinical associate professor of Ophthalmology/The New York Eye & Infirmary of the Mount Sinai School of Medicine, and David Hutton, Managing Editor of Ophthalmology Times discuss the importance of ocular health prior to cataract and refractive surgery, specifically with osmolarity testing.

Editor's note: This transcript has been lightly edited for clarity:

David Hutton:

Welcome to EyePod, a podcast series from Ophthalmology Times in which we engage with key opinion leaders in interviews about the latest innovations in the areas of surgery, clinical diagnosis, therapeutics, imaging, device technology, gene and cell therapy, practice management, and other cutting edge topics. I'm your host, David Hutton. I'm joined today by Dr. Jai Parekh, a clinical associate professor of ophthalmology, [at] the New York Eye and Ear Infirmary of the Mount Sinai School of Medicine. He specializes in cataract, corneal, and refractive surgery at his practice in Woodland Park, New Jersey. We will discuss the importance of ocular health prior to cataract and refractive surgery, specifically with osmolarity testing. Thank you for joining us today.

Jai Parekh, MD, MBA, FAAO:

Well, thank you for having me.

David Hutton:

I'm seeing in the literature that more than half of patients referred for cataract surgery have dry eye disease, or meibomian dysfunction and/or blepharitis. Can you talk a bit about the potential for that to affect the outcomes of surgery if left untreated?

Jai Parekh:

Absolutely, David. There's no doubt that the ocular surface is incredibly important, as a vital sign when we're taking care of patients undergoing any kind of surgery, including cataract and refractive surgery. In fact, I would also include MIGs and pterygium surgery, are anyone undergoing ocular surface reconstruction. There's no doubt that up to 80% of our patients who are in our waiting rooms awaiting a cataract surgery evaluation, have some form of ocular surface disease. The literature supports that. And around 60% of our patients, when tested, actually have some abnormal tear osmolarity.

So these vital signs are very important. When a patient comes to me, traditionally, over the last few decades, with cataract surgery, we always assumed blurry vision was why they came to see us. But often times when you tease that out, David, you'll see that patients also have fluctuating vision. So if they have fluctuating vision as well as blurry vision, I now have a couple of disease states to take care of.

For sure the cataract, if a cataract is commensurate with that blurry vision. Of course, we do a complete examination to make sure there's no glaucoma, no macular degeneration, or no retinopathy or maculopathy, or any other reason for the blurry vision. But if they have fluctuating vision, you sure as well know, 99% of the time, there's probably an ocular surface issue.

And David, you said it so well, it's not just dry eye — it's dry eye, it's any inflammatory state of the corneal surface, it's lid disease, it's been meibomian gland dysfunction. It could be Demodex, it could be obstructive lid disease, any and all the above can lead to some form of fluctuating vision, and therefore, ocular surface disease.

So ocular surface disease, for sure, is a very important part of our workup of the patient. And if the patient has it, guess what, we will delay the surgery—we don't even have to call it delaying surgery—we now have the patient enter our rooms or our doors for a journey in cataract refractive surgery and or ocular surface disease rehabilitation. And when they do that, and we take care of the ocular surface, and you mitigate the fluctuating vision, you'll now have better visual outcomes after that surgery.

David Hutton:

So you're busy. You're seeing surgical referrals, but you can't just focus on surgery, you have to deal with ocular surface disease. What does an efficient screening process look like?

Jai Parekh:

It takes a village David. It takes a village of the front desk. It takes the village of our optometrists that work closely with us. And yes, that cataract surgery, that surgical evaluation now begins preoperatively, intraoperatively, and postoperatively.

Postoperatively you want to maintain these patients' expectations and vision. And nowadays, all the companies have come out with some great multifocal IOLs and some great toric IOLs. But guess what, even though the patient doesn't pay for the upgrade, or can't afford the upgrade, they still want good vision. These patients want very, very good vision. And to do that, we have to make sure we test for the ocular surface issues.

We use tear osmolarity as our go-to testing modality in screening these patients for ocular surface issues. If they have numbers that are abnormal, we then delay the surgery, and we then start to restore their ocular surface by addressing the underlying cause. It could be inflammation, it could be obstruction, it could be infection, or it could be all the above. And sometimes we wait 4, 6 and even 8 weeks.

So I can't do this myself. I need my optometrist, I need my front desk. I need my technicians to screen for this, to help educate our providers that refer to us that they may not have cataract surgery their patients the next week or 2 weeks, but they could have the opportunity for me to take care of their ocular surface first, and then undergo the surgical intervention. So it takes a village, very important [it] takes the right testing. We don't put patients through 20 different tests. We'll do a full examination, use the slit lamp, speak to the patient and family, use a tear osmolarity to check for that inflammatory debris, that inflammatory burden. And if abnormal, we will then start making the right medical interventions before we undergo the cataract surgery.

David Hutton:

As you mentioned you're treating patients for 4, 6 or even 8 weeks — How do they feel about treatment and about delaying their surgery?

Jai Parekh:

You know, that's a great question. Once we educate them, that we are going to provide them the best outcome in cataract surgery — not only in our surgical technique, not only what we do intraoperatively with the right IOL or the right combination of antibiotics and steroids and nonsteroidals after cataract surgery, but also their ocular surface.

So when they hear that, and if I change my mind, they'd be like "no, Dr. J, you mentioned delaying the surgery, we trust you. We were refered to you by other doctors or other family members." And therefore it becomes much easier. If you don't spend the time to educate the patient. Now, let's say a surgeon has to do that. Sometimes it's the surgeon and the optometrist, or the surgeon and the other doctor in the practice, that's fine. That battery of specialists take care of the patient, is what the patient wants. They're paying you, not for surgery, they're paying for the best outcome possible. But also to make sure that they're the right candidates for cataract surgery.

So a patient with an abnormal tear osmolarity or some dysfunctional ocular surface, we're going to delay it and they'll always, 100% of the time, appreciate us for that.

David Hutton:

While you're treating dry eye, what are you looking at that says "Okay, treatment has worked, this patient is ready for surgery"?

Jai Parekh:

Well, I tell the patient, if I see them on Monday, I'll see them back in 4 to 6 weeks. Oftentimes, I will start them with a good, brand name, artificial tear anti-inflammatories. We may do a warming of the lids, and wiping away, or mitigating the obstruction. We may put them on a bunch of medications and interventions to help restore the ocular surface. And as long as they're headed in the right direction, we mitigate their fluctuating vision. We'll see them back in 4 weeks, sometimes 5 weeks.

We'll sometimes put in a plug then, to make sure that the plug is plugging up a good tear film, not a disease tear film. Once, I'm not saying you got to get to 100%, but once we get to 50, 60, 70% you then will have a better outcome in surgery. And after surgery they have to maintain that. The surgery maybe the teeth whitening, if I can use an analogy, but if they don't stop drinking coffee, or drink soda with a straw, or eat that apple or brush their teeth twice a day with flossing, it's going to come back again.

So maintaining the patient's ocular surface health and testing them for it is incredibly important.

David Hutton:

And lastly, do you have any tips for other surgeons who may want to make this an efficient process screening and treatment for dry disease before surgery?

Jai Parekh:

Listen, I've been doing surgery now for the last 2 and a half decades. We love being in the operating room. But the best thing about our specialties our personality comes out. Our bedside manner comes out at the salt lamp in our offices.

So always love to do surgery but you want the best outcomes for your patients. In busy surgery, you may have vitreous loss, you may have a patient that may not do well intraoperatively. Sometimes it's out of our control, right? Some patients have very tough eyes or traumatic eyes or something, you know, hyper mature cataract. Which may lead them to not do well, unfortunately. We take care of them postoperatively.

In this scenario, we know we want to not float our risk, but manage our risk up front and make sure we take care of the ocular surface. So if you don't have enough time as a surgeon, to listen to your patient, or to screen them for ocular surface issues — have another doctor in your practice do it. It's still under the same umbrella. Have your optometrist do it, have them do the tear care to mitigate their obstruction, or put them on RESTASIS or Xiidra or CEQUA or a steroid or a plug.

All these things are in armamentarium. So it takes a village from the technicians, the surgeons, the optometrists, all the eye care providers in your practice, to really afford the patient the best outcome. Because guess what? Your next 1000 patients undergoing cataract surgery, 80% of them will have ocular surface issues, 60% of them may have abnormal tear osmolarity, and a lot of them may have an aberration in the measurements you take around the time of cataract surgery.

And therefore, you're not going to achieve a good premium outcome that all of our patients want, despite a multifocal lens, despite a toric lens, or just a straight plain good monofocal, say with a limbal relaxing incision. All these things will guide their management and really lead to a happy practice, happy patients and happy doctors.

David Hutton:

Excellent. Thank you so much for your great advice today. And thank you for joining us on EyePod.

Jai Parekh:

Thanks for having me, Dave.

David Hutton:

Thanks for listening to this episode of EyePod by Ophthalmology Times. If there are topics you would like to hear about, let us know. You can also stay connected with us on Twitter, LinkedIn or Instagram. We'll see you next time.