Co-management of patients is important for the future of eye care. It not only helps to increase patient satisfaction and decrease chair time for eye care professionals, it also helps to build practice revenue. When it comes to co-managing cataract or refractive surgery patients, it’s imperative ODs look for and treat dry eye disease (DED) and ocular surface disease (OSD), regardless of whether symptoms are present, before referring patients for the consult.
Consider this: Over 80% of pre-cataract surgery patients had DED, yet only 20% were diagnosed and treated prior to presentation, according to one study.1 Another study reveals that 45% of patients planning to undergo corneal refractive surgery had DED.2
Given that many of these patients are referred by their optometrists, it makes sense to discuss the reasons ODs should look for and treat DED prior to these referrals, as part of their co-management.
Corneal measurement reliability
Precise and consistent corneal-based measurements help to ensure good surgical outcomes, and happy patients. One study evaluated pre-cataract surgery patients and the effects of hyperosmolarity on the repeatability of keratometry (K) measurements used to calculate the IOL power.3 Patients with tear osmolarity >316 had higher variability in their average K readings, with 17% having corneal measurement differences of >1.00 D cylinder between two visits, and a higher percentage of IOL power calculations with errors of >0.50D.3 These errors, especially in patients paying for premium IOLs, can lead to some costly and time-consuming mistakes.
DED exacerbation
After corneal refractive and cataract surgeries, there is an increased risk for new onset of DED signs and symptoms, as well as the worsening of existing DED. This occurs because:
(1) Nerve damage from these procedures results in a slower tear response time.4
(2) Corneal irritation and toxicity results from preservatives in commonly used post-operative topical medications.
Worsening of patients’ DED and OSD symptoms affects all involved in post-operative care. This can lead to an increased number of appointments, longer discussions surrounding unstable vision, refraction checks, and glasses remakes.
Losing patients
When a patient presents for their cataract or refractive surgery referral and their surgeon diagnoses DED and explains the importance of doing so prior to the procedure, the patient will question their referring OD’s judgement: “Why didn’t Dr. Smith find and tell me about this?” This can result in a loss of trust and, as a result, the end of the OD-patient relationship.
Showing value
When it comes to co-management in any area of eye care, both the OD and the MD have their individual responsibilities and opportunities. In this case, the optometrist should prepare the patient’s ocular surface for surgical success: assessing lid and ocular surface health, initiating treatment, and educating the patient. In doing so, the OD becomes the hero. OM
References:
1. Trattler, WB, Majmudar PA. Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017; 7:11:1423-1430. doi: 10.2147/OPTH.S120159.
2. Zhao PF, Zhou YH, Hu YB, et al. Evaluation of preoperative dry eye in people undergoing corneal refractive surgery to correct myopia. Int J Ophthalmol. 2021;14(7): 1047–1051. doi: 10.18240/ijo.2021.07.13.
3. Epitropoulos, AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41(8):1672-7. doi: 10.1016/j.jcrs.2015.01.016.
4. Shtein RM. Post-LASIK dry eye. Expert Rev Ophthalmol. 2011; 6(5): 575-582. doi: 10.1586/eop.11.56
