Dr. Gupta’s blog is designed to cover the latest innovations in ocular surface and MGD diagnosis and treatment from a practical, clinical perspective. Topics will range from dry eye demographics to treatment pearls and workflow tips and tricks, all focusing on real-world implementation of techniques and technologies.

BLOG: OSD algorithm targets surgery patients

Great work has gone into helping ophthalmologists become better at understanding dry eye disease. None of the recent treatment algorithms, however, have focused specifically on cataract and refractive surgery patients. As Chris Starr, MD, and I recently found, 80% of patients reporting for cataract surgery have ocular surface disease. The impact of this is enormous in terms of accurate keratometry and biometry measurements, as well as comfort and overall patient satisfaction around cataract and refractive surgery.

Unmet need: focused approach

In light of this large unmet need, we on the ASCRS Cornea Clinical Committee undertook a project to create an algorithm to help streamline the process of diagnosing OSD, honing in on the cataract and refractive presurgical population. It was important we capture the 50% of patients presenting for cataract surgery who have OSD yet are asymptomatic. We sought to integrate a protocol using objective point-of-care tests proven to identify OSD, often even before patients have symptoms; this new approach was published in the May issue of the Journal of Cataract and Refractive Surgery.

Questions f irst

Our formal OSD assessment for signs and the symptoms begins with the ASCRS SPEED II preop questionnaire. This combines the traditional SPEED questionnaire, which has been validated to identify DED and meibomian gland disease, and additional questions to help the surgeon identify the patient’s expectations and visual needs.

Key point-of-care t ests

We recommend testing tear osmolarity (eg, TearLab) and the inflammatory marker MMP-9 (Quidel). With no symptoms or no signs, a patient is considered a “negative screen,” and the clinician would move on to the clinical exam and surgery can proceed. If, however, the patient has symptoms, an abnormal osmolarity or an abnormal MMP-9, that’s a “positive screen,” suggesting that OSD is likely. Other tests can be used as well. I rely on meibography in my clinic as well, and I routinely perform topography for surgical planning and for DED screening information.

Clinical exam : LLPP

The mnemonic LLPP — look, lift, pull and push — guides the presurgical slit lamp exam, highlighting the areas where disease is found.

Looking at blinks, lids and lashes, and corneal surface. In my practice, I also use fluorescein from a strip to help identify any punctate epithelial erosions.

Lifting underneath the superior eyelid for signs of OSD.

Pulling to identify lid laxity and to see into the fornices.

Pushing the meibomian glands to assess quality and flow of the meibum.

Red flag: time out

Visually significant OSD is a red flag, telling the clinician to hit the pause button and address the ocular surface before proceeding. Subsequent treatment should be tailored to the subtype of disease found. For an inflammatory component, steroids may be the right choice with or without a long-term anti-inflammatory agent. Someone with MGD might benefit from an in-office procedure like thermal pulsation with LipiFlow (Johnson & Johnson Vision) or other gland-based treatment.


Simply put, we recommend screening presurgical patients using two main tools: questionnaires and point-of-care tests. These measures are easy to implement in practice as the technician can perform them, and the physician interprets the data. The information obtained allows for a more efficient diagnosis of OSD, so we can deliver premium outcomes to our patients.


Gupta PK, et al. J Cataract Refract Surg. 2018;doi:10.1016/j.jcrs.2018.06.026.

Starr CE, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2019.03.023.

Disclosure: Gupta reports she is a consultant to Allergan, Alcon, Bio-Tissue, Johnson & Johnson Vision, Kala, NovaBay, Oyster Point Pharmaceuticals, Ocular Science, Shire, TearLab and Zeiss.