Jai Parekh, MD, MBA, FAAO, a clinical associate professor of Ophthalmology/The New York Eye & Infirmary of Mount Sinai School of Medicine, and David Hutton, editor-in-chief of Ophthalmology Times discuss the importance of eye health before cataract and refractive surgery, especially with osmolarity testing.
Editor’s note: This transcript has been lightly edited for clarity:
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 fields of surgery, clinical diagnosis, therapeutics, imaging, device technology, gene and cell therapy , practice management and others. last topic. I’m your host, David Hutton. I’m joined today by Dr. Jai Parekh, a clinical associate professor of ophthalmology, [at] Mount Sinai School of Medicine New York Eye and Ear Infirmary. 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, particularly with osmolarity testing. Thank you for joining us today.
Jai Parekh, MD, MBA, FAAO:
Well, thanks for having me.
I am 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 little bit about the potential for this to affect the outcomes of surgery if left untreated?
Absolutely, David. There is no doubt that the ocular surface is incredibly important as a vital sign when we care for patients undergoing any type of surgery, including cataract and refractive surgery. In fact, I would also include MIGs and pterygium surgery if one is undergoing ocular surface reconstruction. There is 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 this. And about 60% of our patients, when tested, actually have an 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 that blurred vision was the reason they came to see us. But often times, when you tease this out, David, you’ll see that patients have fluctuating vision as well. So if they have fluctuating vision as well as blurred vision, I now have several disease states to take care of.
Cataract for sure, if a cataract is commensurate with that blurred vision. Of course, we do a thorough exam to make sure there is no glaucoma, macular degeneration, retinopathy or maculopathy, or any other reason for the blurred vision. But if they have fluctuating vision, of course you know, 99% of the time, there’s probably an ocular surface problem.
And David, you said it very well, it’s not just dry eye – it’s dry eye, it’s some inflammatory condition 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 of the above can lead to some form of fluctuating vision, and therefore ocular surface disease.
So ocular surface disease is certainly a very important part of our patient work. And if the patient has that, guess what, we’ll delay the surgery—we shouldn’t even call it a surgical delay—now we have the patient walk into our rooms or our doors for a trip to refractive cataract surgery and or surface ocular disease rehabilitation. And when they do that, and we take care of the surface of the eye, and you smooth out the fluctuating vision, now you’re going to have better visual outcomes after that surgery.
So you are busy. You are seeing surgical referrals, but you can’t just focus on surgery, you have to deal with diseases of the ocular surface. What does an efficient screening process look like?
It takes a David village. It takes a village of reception. It takes the village of our optometrists who work closely with us. And yes, that cataract surgery, that surgical evaluation now begins preoperatively, intraoperatively, and postoperatively.
After surgery you want to maintain the expectations and vision of these patients. 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 need to make sure we test for ocular surface problems.
We use tear osmolarity as our testing modality in screening these patients for ocular surface problems. If they have numbers that are abnormal, we delay surgery and then start restoring 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 of 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 the front desk. I need my technicians to check for this, to help educate our referring providers that they may not be doing cataract surgery on their patients in the next week or 2 weeks, but they may have the opportunity for me to take care of their eye surface first. , and then undergo surgical intervention. So we need a village, very important [it] get proper testing. We don’t put patients through 20 different tests. We’re going to do a thorough exam, we’re going to use the slit lamp, we’re going to talk to the patient and the family, we’re going to use a tear osmolarity to check for that inflammatory debris, that inflammatory burden. And if it is abnormal, then we will start doing the appropriate medical interventions before we do the cataract surgery.
As you mentioned you are treating patients for 4, 6 or even 8 weeks – How do they feel about the treatment and the delay in their surgery?
You know, that’s a great question. Once we educate them, that we’re going to give them the best outcome in cataract surgery—not just our surgical technique, not just 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’re going to say “no, Dr. And therefore it becomes much easier. If you don’t spend time educating the patient. Now, let’s say that 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 looking after the patient, that’s what the patient wants. They’re paying you, not for surgery, they’re paying for the best possible outcome.But also to make sure they are the right candidates for cataract surgery.
So a patient with an abnormal tear osmolarity or any dysfunctional ocular surface, we’ll delay that and they’ll always, 100% of the time, evaluate us for that.
While you’re treating dry eye, what are you seeing that says, “Okay, the treatment worked, this patient is ready for surgery”?
Well, I tell the patient, if I see them on Monday, I’ll see them again in 4 to 6 weeks. Often, I’ll start them off with a good, name-brand, artificial tear anti-inflammatory. We can do a heating of the lids and the wiping or softening of the obstruction. We can put them on a variety of medications and interventions to help restore the surface of the eye. And as long as they are pointed in the right direction, we soften their wavering vision. We will see them again in 4 weeks, sometimes 5 weeks.
Sometimes we will place a plug then, to make sure the plug closes a good tear layer, not a diseased tear layer. Once, I’m not saying you have to get to 100%, but once we get to 50, 60, 70% then you’ll have a better outcome in surgery. And after the operation they have to maintain it. Surgery maybe 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 floss twice a day, it will come back. again.
So maintaining the health of the patient’s ocular surface and testing them for it is incredibly important.
And finally, do you have any advice for other surgeons who may want to make this an efficient screening and treatment process for dry disease before surgery?
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 is our personality. Our bedside manner extends to the salt lamp in our offices.
So you always enjoy doing surgery, but you want the best results for your patients. In busy surgery, you may have vitreous loss, you may have a patient who may not do well intraoperatively. Sometimes it’s out of our control, isn’t it? Some patients have very rough eyes or traumatic eyes or something, you know, hyper mature cataract. Which can cause them to not perform well, unfortunately. We take care of them after surgery.
In this scenario, we know we don’t want to raise our risk, but manage our risk going forward 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 check them for ocular surface problems – get another doctor in your practice. It’s still under the same umbrella. Have your optometrist do it, have them do tear care to relieve their obstruction, or put you on RESTASIS or Xiidra or CEQUA or a steroid or a plug.
All these are in weaponry. 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? Of your next 1000 patients undergoing cataract surgery, 80% of them will have ocular surface problems, 60% of them may have abnormal tear osmolarity, and many of them may have a measurement deviation that you take around the time of cataract surgery.
Therefore, you will not get a good premium result that all our patients want, regardless of a multifocal lens, regardless of a toric lens, or just a simple straight monofocal, say with a limbal relaxer incision. All of these things will guide their management and truly lead to a happy practice, happy patients and happy doctors.
Excellent. Thank you so much for your great advice today. And thanks for joining us on EyePod.
Thanks for having me, Dave.
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