Shared care of the ocular surface before and after cataract surgery

In all of medicine, particularly in eye care, we have to become more attuned to using a range of providers to deliver the best care to patients. This requires a thoughtfully coordinated effort that also maximizes patients’ and providers’ time.

This is imperative because, while we know the aging population is growing, the pool of providers is not increasing to offset the demand.

When it comes to dry eye, it is preferable that patients preparing for cataract surgery have their ocular surface disease (OSD) issues addressed by their referring optometrist.

Related: Q&A: How to start the dry eye conversation with patients

Ocular surface health plays a key role in patients’ visual quality in the setting of a cataract and is essential for obtaining quality biometry measurements that determine intraocular (IOL) power calculations.

An optimized ocular surface not only allows for more predictable visual results, but it also gives patients the widest range of IOL options from which to choose.

OD-MD relationship:
Know your lane

The relationship between the referring optometrist and the surgeon works best when each concentrates on their role in providing the best opportunity for maximizing visual acuity.

In other words, the optometrist provides primary eye care, whereas the ophthalmologist performs surgery. Ideally, patients previously identified as having dry eye disease (DED) will already be on a treatment regimen.

Preoperatively, there may be a period of more labor-intensive therapy that often includes the short-term use of corticosteroids and interventions, such as LipiFlow (Johnson & Johnson Vision) or TearCare (Sight Sciences, Inc).

The optometrist will explain this to patients, counseling them that they will continue an appropriate and practical routine after surgery to achieve and maintain the best visual results possible.

Related: A narrative guide for cataract postoperative surgical care

Continuing a realistic dry eye therapy regimen postoperatively is a critical issue. This is why it is important patients work with an optometrist to determine a practical treatment plan, narrowing down the options best suited to the patient over a lifetime.

Surgeons might think of cataract surgery as a 1-time event. However, we want patients to continue to be thrilled with their vision over the long term.

The primary eye care provider has an advantage in knowing the patient’s personality and their tolerance for frequent interventions, working with them to keep their ocular surface healthy for consistently high-quality vision.

Remember, the most common reason patients are unhappy with advanced technology lenses postoperatively is overwhelmingly because of ocular surface issues. Effective peri- and postoperative care means a higher likelihood of long-term success.

Choosing long-term treatments

Oftentimes, when it comes to choosing treatments, our patients are not optimally adherent to the recommended interventions—whether it be a drop or a procedure—for a variety of reasons. This is especially true if their dry eye is not always bothersome.

By the time they do feel symptoms, their surface is significantly dry. We know it is best to stay ahead of OSD before the patient becomes symptomatic, but this does not happen often. Patients are more motivated when they are uncomfortable.

Related: Q&A: Common visual habits that lead to dry eye

Nutraceuticals are different from our other treatment options. They are easy for patients to work into their lifestyle and provide a benefit to overall health.

In our experience, many patients are more adherent with a nutraceutical than other therapies. The more disruptive an intervention, the less adherence there will be.

We recommend HydroEye (ScienceBased Health) to our patients with DED. The primary component of HydroEye’s patented formulation is gamma-linolenic acid (GLA), which is derived from black currant seed oil.

GLA is a unique anti-inflammatory omega fatty acid that can play an important role in modulating the inflammatory response.¹

It is also present in breast milk and is naturally produced in the body via conversion from other omegas.

However, GLA is not found in meaningful levels in our diet. It is a precursor to prostaglandin E1, which promotes tear production and fights inflammation, and it has been validated in a variety of clinical trials for improving dry eye symptoms in a range of patient populations.^2-8

The supplement includes a specific balance of other omegas to provide dry eye relief.

Related: Real-world feedback on nasal spray DED treatment

The vast majority of our patients appreciate being able to help their body and their DED with less prescription medication. It provides an underlying foundational treatment they can take, along with any other therapies or interventions they may need—it is a layered approach.

We introduce HydroEye by asking patients whether they take vitamins or supplements to open the conversation.

If they do, then they already understand the benefits of nutraceuticals. We explain the benefit of GLA in modulating the inflammatory response and emphasize that it has been shown in numerous clinical trials to improve dry eye symptoms.

Our patients who use HydroEye feel the difference it makes in managing their dry eye.

Conclusion

According to the US Census Bureau, there are more than 54 million adults 65 years and older in the US, representing 16.5% of the nation’s population. By 2050, that number is projected to rise to an estimated 85.7 million, which is 20% of the overall US population.⁹

People older than 65 years consume 10 times the amount of eye care compared with their younger counterparts.

Related: Why ODs should prepare patients for surgery years before they need it

From 1995 to 2017, the national density of ophthalmologists decreased from 6.3 per 100,000 individuals to 5.68 per 100,000 individuals.¹⁰

Over that time period, the ratio of ophthalmologists older than 55 years to younger ophthalmologists increased from 0.37 to 0.82.¹¹

In 2016, the Health Resources and Services Administration estimated that there will be demand for approximately 22,000 ophthalmic surgeons by 2025.

The number of available ophthalmologists is estimated to fall short of that demand by more than 6000 physicians.^12,13

The need for practices to efficiently integrate optometry and ophthalmology, delegating appropriate care to the proper specialist, is even more pronounced because of staffing shortages exacerbated by the COVID-19 pandemic.

Patients’ total eye care needs are best met and practices are most effective when surgeons do surgery and optometrists provide primary care.

References

1. Kapoor R, Huang YS. Gamma linolenic acid: an antiinflammatory omega-6 fatty acid. Curr Pharm Biotechnol. 2006;7(6):531-534. doi:10.2174/138920106779116874

2. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101. doi:10.1097/00003226-200303000-00002

3. Macrì A, Giuffrida S, Amico V, lester M, Traverso CE. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566. doi:10.1007/s00417-003-0685-x

4. Aragona P, Bucolo C, Spinella R, et al. Systemic omega-6 essential fatty acid treatment and pge1 tear content in Sjögren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005;46(12):4474-4479. doi:10.1167/iovs04-1394

5. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31(3):141-170. doi:10.1016/j.clae.2007.12.001

6. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-264. doi:10.1097/ICO.0b013e318033d79b

7. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011;89(7):e591-e597. doi:10.1111/j.1755-3768.2011.02196.x

8. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304. doi:10.1097/ICO.0b013e318299549c

9. 2021 senior report. United Health Foundation. Accessed March 23, 2022. https://www.americashealthrankings.org/learn/reports/2021-senior-report/introduction

10. Feng PW, Ahluwalia A, Feng H, Adelman RA. National trends in the United States eye care workforce from 1995 to 2017. Am J Ophthalmol. 2020;218:128-135. doi:10.1016/j.ajo.2020.05.018

11. National and regional projections of supply and demand for surgical specialty practitioners: 2013-2025. US Department of Health and Human Services, Health Resources and Services Administration. December 2016. Accessed March 23, 2022. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/surgical-specialty-report.pdf

12. Parke DW. The ophthalmology workforce. EyeNet Magazine. February 2020. Accessed March 23, 2022. https://www.aao.org/eyenet/article/the-ophthalmology-workforce

13. Supply of ophthalmologists. American Academy of Ophthalmology. March 23, 2022. https://www.aao.org/focalpointssnippetdetail.aspx?id=3df1324e-8154-4cd3-b1d5-721e0c941ab9