When a patient has a cataract diagnosis and dry eye — and let’s face it, that’s a very common scenario — comanaging both conditions needs to be handled with care. Here are four ways to help ensure there are no surprises:
1. Talk to your referring doctors about the importance of making the dry eye diagnosis themselves. When patients learn for the first time that they have dry eye during their cataract consult, it can undermine their confidence in one or both of the comanagement partners. They may wonder why Dr. Smith, who they’ve seen for the past 10 years, never mentioned dry eye. Or they may question whether I have some ulterior motives in making additional diagnoses.
2. Ideally, we want the referring doctor to have started ocular surface treatment prior to sending the patient for a surgical consult. For example, in many cases an immunomodulator like Restasis (cyclosporine, Allergan) or Xiidra (lifitegrast, Shire) is indicated. While symptoms can begin to improve in as little as 2 weeks after starting lifitegrast, I find that improvements in inferior corneal staining still take a minimum of 6 to 8 weeks. I’d rather have that treatment well underway so that the ocular surface is stabilized before attempting my preoperative measurements.
3. We know that up to 86% of patients with dry eye symptoms have an evaporative component, typically caused by meibomian gland dysfunction. Many optometrists refer to our practice because they know we offer thermal pulsation therapy (LipiFlow, Johnson & Johnson Vision) to help unblock the glands and restore healthy lipids to the tear film. But for a patient who is considering premium IOL surgery, we need to be sensitive to the combined cost of both procedures. Ideally, MGD would be handled long before cataract surgery. If it hasn’t been, we will offer a reduced-price package for both thermal pulsation anytime 6 months before or after cataract surgery.
4. Know your ODs. Some of the doctors in our referral network like to manage dry eye disease themselves. They may refer the patient to us for a specific procedure like LipiFlow or self-retaining amniotic membranes, but want to handle medical therapy themselves and give the patient an “all clear” before surgery. Others want to send us the patient with a note about cataract and dry eye and have us deal with all of it. For the sake of preserving the boundaries of patient care and disease management with the primary eye care specialist, be sure you know which end of the spectrum they fall on.
Disclosure: Yeu reports she is a consultant/adviser for Alcon, Allergan, ArcScan, Bausch + Lomb/Valeant, Bio-Tissue, BVI, i-Optics, J&J Vision, Lensar, Kala Pharmaceuticals, Novartis, Ocular Science, Ocular Therapeutix, Ocusoft, Omeros, Science Based Health, Shire, SightLife Surgical, Sun, TearLab, TearScience, Veracity and Zeiss; does research for Alcon, Allergan, Bausch + Lomb, Bio-Tissue, i-Optics, Kala and Topcon; and has an ownership interest in ArcScan, Modernizing Medicine, Ocular Science, SightLife Surgical and Strathspey Crown.