We have seen collaborative eye care change significantly in the past 30 years. Previously, the optometrist’s role was limited primarily to the post-operative care of the cataract patient. We identified the cataract, referred the patient to the surgeon, and then the surgical practice referred the patient back to us when the patient was stable, to be followed through the remainder of the 90-day post-operative period. Thanks to high-technology lifestyle IOLs, however, the O.D.’s role has evolved to include both pre- and post-op care, with patients and surgeons alike placing a great deal of value on pre-op care, in particular.

Here, I provide the pre-operative steps we should take as these patients’ primary eye care providers:

EDUCATE ON IOL OPTIONS

Typically, we have been providing care for the recently diagnosed cataract patient for years, so we possess a knowledge and understanding of the patient’s vision and visual needs and desires that exceed what the surgeon can extract from the patient during the surgical evaluation. As a result, it makes sense that we be the ones helping educate the pre-surgical cataract patient on the benefits, risks and vision they can expect from specific IOL options, be they torics, multifocals, trifocals or extended depth of focus IOLs:

“Mrs. Jones, we have discussed the astigmatism in your vision correction since I have been taking care of your visual needs. I need to make sure you are aware that, just as I have corrected your astigmatism in your glasses and contact lenses, you will be able to address the correction of your astigmatism with your cataract surgery as well. I will be making sure that the cataract surgeon will give you all of your options for not only correcting your long-standing astigmatism, but also for the ability to simultaneously give you back some of your near vision with a lifestyle, high-technology lens during your cataract surgery.”

PERFORM A PRE-SURGICAL EVALUATION

Our next step is to determine the surgical candidacy of the patient. To accomplish this, we must look at cornea regularity and corneal thickness to see whether the patient requires a fine-tuning with laser vision correction following the cataract surgery. This means the patient must be qualified as a refractive candidate prior to the cataract surgery. Then, an evaluation should include the macula and ensure that the patient is free of AMD or other macular anomalies, such as surface wrinkling retinopathy, as this could reduce the effectiveness of lenses utilizing diffractive technology. Next, is to assess the patient for dry eye disease (DED) — something imperative for the success of a high-technology IOL, in particular, as the light that strikes the lens must not be interrupted by a less-than pristine ocular surface.

Performing DED testing on any patient slated for ocular surgery is high-quality care. According to a study by Trattler, 80.9% of patients referred for cataract surgery have level two, three or four DED, as tested with International Task Force guidelines.¹ If we can identify and treat those patients, we could be helping them to achieve an optimum outcome by potentially improving their pre-operative corneal measurements. This testing and treatment potentially delivers a better post-surgical outcome for our cataract patients; they also lend themselves to an increase in practice revenue: In-office DED treatments are numerous, including microblepharoexfoliation, thermal expression techniques, intense pulse light and amniotic membranes, all geared to help the patient stabilize their DED and corneal measurement.

The identification of mechanical DED (also called conjunctivochalasis) may be paramount as well. Mechanical DED is the conjunctival chalasis that obliterates the tear reservoir in the inferior cul-de-sac, causing inefficient tear storage, retention and spreading of the tear across the ocular surface. The redundant conjunctiva occurs as a result of the deterioration of Tenon’s capsule, which turns into a fibrovascular gel. These patients present with epiphora, and the use of any artificial tear or therapeutic becomes much less effective, as the reservoir is replaced by conjunctival tissue. This tissue can be seen rising above the lower eye lid margin, giving a “Morse Code”-type of appearance of dashes and dots.

In cases of mechanical DED, a referral can be made to a surgeon who has been trained in a conjunctival reservoir restoration procedure utilizing cryopreserved amniotic tissue and surgical glue. This specific procedure restores the normal anatomy of the reservoir.

During the conjunctival reservoir restoration procedure, a small amount of conjunctiva is resected to allow the removal of the deteriorated Tenon’s capsule. A section of cryopreserved amniotic tissue is then glued in place to restore the normal anatomy of the reservoir, and the conjunctival tissue simply grows across the amniotic tissue. The eyes are operated on one at a time and can be monitored post-operatively by the referring O.D. until the fellow eye is ready for surgery. When conventional DED therapy has been attempted, conjunctival chalasis is present, and the patient is symptomatic, a reservoir restoration procedure should be considered. This procedure also will help any therapeutics be more effective and will, once again, lead to an optimized corneal surface and greater assurance of accuracy in corneal measurements. In such cases, O.D.s see the patient through the post-operative period and continue the conventional DED therapy that will now have more efficacy. Seeking out and working with a surgeon who performs this type of procedure can lead to more collaborative care.

THE BENEFITS

The days of diagnosis and immediate referral for pre-cataract surgery patients are over for O.D.s: We educate patients about their IOL options, evaluate their eye health prior to surgery and employ treatments to enable post-surgical success. Patients now present to surgeons knowledgeable of their options and with “prepared” corneas, calming their concerns about the procedure and thwarting surgical delays. All of which enable surgeons to concentrate on their area of expertise. 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; 11: 1423–1430.

DR. DEVRIES is co-founder of Eye Care Associates of Nevada, a medical/surgical co-management referral practice. He has relationships with BioTissue, Bruder and RySurg, among others. Email him at drdevries@nveyelaser.com.