Use ABCDs to capture patients with ocular surface disease for long term
The American Society of Cataract and Refractive Surgery Cornea Clinical Committee has provided us another excellent guideline for the diagnosis and management of dry eye disease.
I use a mnemonic when doing a differential diagnosis of ocular surface disease (OSD) that my fellows have found useful. I call it the ABCD of OSD. A stands for allergy, B for blepharitis/meibomian gland dysfunction (MGD), C for conjunctivitis and D for dry eye disease (DED). Of course, many patients share more than one of these diagnoses and some all four, so the Venn diagram for the four primary causes of OSD have significant overlap.
The ASCRS guideline is focused primarily on the cataract surgical patient and joins those developed by the Dry Eye Workshops 1 and 2, CEDARS/ASPENS and of course the American Academy of Ophthalmology Preferred Practice Pattern. Each of these sources is worth a careful read because OSD is a big part of our practice as ophthalmologists.
As I have said several times in recent commentaries, office-based practice is the core of ophthalmology. Looking at multiple sources of data, I estimate that at least 30% of the population suffer from at least the symptoms of DED and can therefore be classified as having mild DED. If we add in allergy, blepharitis/MGD and conjunctivitis, OSD is clearly second only to refractive error as the most common issue affecting our patients.
According to a Rand study performed about a decade ago, 40% of patients seen by a comprehensive ophthalmologist or optometrist in daily practice have one or more OSD diagnoses. If we see 120 patients in a week at the office, 48 of them will manifest at least one OSD diagnosis if we look for it. In the cataract patient, the focus of the ASCRS guidelines, the number is even larger. I use as a rule of thumb that the percent of patients who will manifest one or another of the ABCD of OSD is equivalent to the patient’s age. So, for the typical 70-year-old patient who presents with a visually significant cataract, there is a 70% likelihood they will have OSD if we take a good history and look carefully during our examination.
In past decades, many of us just ignored the OSD and performed cataract surgery. But today, the data are irrefutable that both short-term and long-term outcomes are significantly improved if OSD in the surgical patient is diagnosed and properly managed before, during and after cataract surgery. I teach that there are four stages of OSD management in the surgery patient. Stage 1 involves making the diagnosis and performing ocular surface preparation before surgery. I find that most patients will respond to a 1- to 2-week course of lid hygiene, artificial tears and a topical antibiotic/steroid drop four times daily. For me, that is the best and quickest way to get the ocular surface prepared for accurate biometry and surgery. Stage 2 is ocular surface protection during surgery. I like to use a dispersive viscoelastic such as OcuCoat (hydroxypropyl methylcellulose 2%, Bausch + Lomb), Viscoat (sodium chondroitin sulfate and sodium hyaluronate, Alcon), EndoCoat (sodium hyaluronate, Johnson & Johnson Vision) or sterile Goniosol (hydroxypropyl methylcellulose) to protect the ocular surface during surgery. This not only reduces intraoperative trauma to the ocular surface but also enhances postoperative comfort and the rate of visual recovery. Stage 3 is ocular surface rehabilitation after surgery, and again, lid hygiene, topical lubricants and topical steroids are a great adjunct here. I believe a punctal plug that releases topical steroid (Dextenza; dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix) is especially attractive in the cataract patient with significant OSD. Stage 4 is long-term ocular surface health maintenance after surgery. This is unfortunately often neglected by the busy cataract surgeon. The patient with significant OSD deserves to be captured in one or another eye doctor’s practice and managed appropriately for life.
For the surgical patient with OSD, I recommend ocular surface preparation before surgery, ocular surface protection during surgery, ocular surface rehabilitation after surgery and lifelong ocular surface health maintenance after surgery. I believe OSD is best managed much like glaucoma. The patient should be under the care of an eye doctor and seen in the office every 3, 6 or 12 months depending on disease severity. Both symptom and sign severity can be monitored today with objective parameters and point-of-service testing such as tear film osmolarity, MMP-9 and meibography. This is not only best for the patient, it is also economically attractive to the practice.
Of the estimated 30 million patients in America with DED, less than 5 million are today captured in an ophthalmology or optometry practice and under appropriate doctor-directed long-term treatment. We can and must do better here. We can start by capturing these patients in our practices, as today we have ever better diagnostics as well as medical and office-based procedural treatments to offer the OSD patient. While the patient is the major beneficiary of the timely and accurate diagnosis and appropriate treatment of OSD, there is also a win here for the eye care provider, their practice and the industry that supports us.
Disclosure: Lindstrom reports relevant financial disclosures for Alcon, Allergan, Allegro, ASCRS Executive Committee, Bausch Health, Bio-Tissue, BlephEx, Bruder, Johnson & Johnson Vision, Minnesota Eye Consultants, NovaBay, Novartis, Ocular Therapeutix, Oyster Point, Surface Inc., Tarsus, TearLab, Unified Vision Partners and Zeiss.