Jai Parekh, MD, MBA, FAAO, clinical associate professor of ophthalmology/New York Eye and Mount Sinai School of Medicine, and David Hutton, managing editor of Cataract Times, discuss the importance of eye health before cataracts develop and disappear. Surgery, especially with osmolarity testing.
Editor’s Note: This transcript has been slightly edited for clarity.
Welcome to EyePod, a podcast series from Ophthalmology Times featuring interviews with key opinion leaders in surgery, clinical diagnostics, therapeutics, imaging, device technology, gene and cell therapy, practice management and other innovations. Cutting topics. I’m your host, David Hutton. Today I’m joined by Dr. Jai Parekh, Clinical Associate Professor of Ophthalmology; [at] New York Eye and Ear Clinic at Mount Sinai School of Medicine. His practice in Woodland Park, New Jersey specializes in cataract, corneal and macular surgeries. We will discuss the importance of eye health before cataract surgery and especially osmolarity testing. Thanks for joining us today.
Jai Parekh, MD, MBA, FAAO:
Well, thanks for having me.
I am seeing in the literature that over half of patients referred for cataract surgery have dry eye disease or meibomian disorder and/or blepharitis. Can you talk a little bit about the potential conditions that can affect surgical outcomes if left untreated?
Absolutely David. There is no doubt that the ocular surface is incredibly important as a vital sign when caring for patients undergoing any type of surgery, including cataract and refractive surgery. In fact, I would add MIGs and pterygium surgery to anyone undergoing ocular surface reconstruction. There is no doubt that up to 80% of our patients in our waiting rooms awaiting evaluation for cataract surgery have some form of macular disease. And the literature supports it. And 60% of our patients have some abnormal tear osmolarity when tested.
So these signs are very important. When a patient comes to me, traditionally, over the past few decades, we’ve had cataract surgery, and we’ve assumed that it’s blurry vision that’s why they’re coming to see us. But the more often you tease David, you’ll see that patients’ vision changes as well. So if they have fluctuating vision and blurred vision, now I have two diseases to take care of.
Definitely a cataract, if the cataracts equate to this blurry vision. Of course, we do a full exam to make sure there is no glaucoma, macular degeneration, or retinopathy or maculopathy, or any other cause for the blurred vision. But if they have fluctuating vision, you know 99% of the time, there’s probably an ocular surface problem.
And David, you said it well, it’s not just dry eye – it’s dry eye, it’s any inflammatory condition of the corneal surface, it’s lid disease, it’s a meibomian gland problem. It can be Demodex, it can be a blocking lid disease, any and all of the above can lead to some kind of variable vision, and therefore, eye disease.
Therefore, eye disease, of course, is the most important part of our work of the patient. And if the patient has, guess what, we delay the surgery – we don’t even have to call it delaying surgery – now we have the patient walk into our room or our doors for cataract surgery and or rehab to travel on the surface of the eye. And when you do that, and we take care of the ocular surface, and you reduce the shifting vision, you’ll now have better visual outcomes after surgery.
So you are busy. You are seeing surgical referrals, but you can’t just focus on surgery, you have to deal with macular disease. What does an effective screening process look like?
David takes a village. The front desk takes the village. It takes the village of our eyes that works closely with us. And yes, that cataract surgery, surgical evaluation now begins preoperatively, intraoperatively, and intraoperatively.
They want to maintain the hope and vision of these patients after surgery. And nowadays, all the companies have come out with some great multifocal IOLs and some great toric IOLs. But guess what, even if the patient doesn’t pay for the upgrade, or can’t afford the upgrade, they still want good vision. These patients need very, very good vision. To do this, we must make sure to check the eye surface issues.
We use our diagnostic method to screen these patients for issues related to the surface of the eye. If they have abnormal numbers, then we will delay the operation, and after that we will identify the cause and start restoring the eyelid. It could be inflammation, it could be an obstruction, it could be an infection, or it could be all of the above. And sometimes we wait 4, 6 and even 8 weeks.
So I can’t do this myself. I need an optician, I need my front desk. In order to check my technicians for this issue, I would like to teach our referring providers that in the next week or 2 weeks they have not performed cataract surgery on their patients, but they may have the opportunity to preserve their vision first, and then do surgical intervention. So it takes a village, very important [it] It takes the right test. We don’t put patients through 20 different tests. We do a full examination, we use the slit lamp, we talk to the patient and the family, we use tear osmolarity to check for that inflammatory debris, that inflammatory burden. And if it is abnormal, we will start doing the right medical intervention before doing the cataract surgery.
As you mentioned, you’re treating patients for 4, 6, or 8 weeks — how do they feel about delaying treatment and surgery?
You know, that’s a really good question. Once we teach them that we can offer them the best results in cataract surgery – not only with our surgical technique, with the right IOL or the right combination of antibiotics and steroidal and non-steroidal cataract surgery, but also their ocular surface.
And when they heard that and I changed my mind, they would say, “No Dr. J, you mentioned delaying the surgery, we believe you, we sent you through other doctors or other family members.” And so it will be very easy. If you don’t take the time to educate the patient. Now, suppose a surgeon has to do this. Sometimes it is a surgeon and an ophthalmologist, or a surgeon and another doctor, which is good. That battery of specialists takes care of the patient, what the patient needs. They are paying you, not for surgery, for better results. But also to make sure they are the right candidates for cataract surgery.
So we delay a patient with abnormal tear osmolarity or some dysfunctional eyelid and they always 100% appreciate us for that.
When treating dry eye, what do you look for that says, “Well, treatment worked, this patient is ready for surgery”?
Well, I tell the patient, I’ll get back to them in 4 to 6 weeks after I see them on Monday. Usually, I start them with a good, brand name, artificial tear anti-inflammatory. We can heat the coating, and clean it, or reduce the barrier. We may prescribe medications and interventions to help restore vision. And unless they’re moving in the right direction, we’re going to slow down their changing vision. We see them in 4 weeks, sometimes 5 weeks.
Sometimes we put the plug in, to make sure the plug is plugging in a good tear film and not a sick film. Once, I’m not saying you have to get to 100%, but once we get to 50, 60, 70%, you’re going to get better results with surgery. And they have to maintain that after the surgery. The surgery is probably whitening the teeth, if I can use an example, but if they don’t stop drinking coffee, or drink soda through a straw, or eat that apple, or brush their teeth twice a day, it will come back. one more time.
Therefore, it is incredibly important to maintain the health of the patient’s ocular surface and test them.
And finally, do you have any tips for other surgeons looking to diagnose and treat preoperative dry skin disease who want to make this an efficient process?
Listen, I’ve been doing surgery for the last 2 and a half decades now. We love being in the operating room. But the best thing about our specialties is that our personalities come out. Our practice in bed comes out on the salt lamp in our offices.
So you always like to do surgery but you want good results for your patients. In a busy operation, you may have a virulence loss, you may have a patient who does not do well in the operation. Sometimes it’s out of our control, isn’t it? Some patients have very hard eyes or painful eyes or something, you know, hyper mature cataract. Unfortunately, it can make them not work well. We take care of them after surgery.
In this case, we know we don’t want to float our risk, but we manage our risk up front and make sure to take care of the surface of the eye. So if you don’t have enough time as a surgeon, to listen to your patients or diagnose eye problems – let another doctor do it. It is still under the same umbrella. Get your ophthalmologist to work on it, get them on tear care to reduce their blockage, or put on RESTASIS or Xiidra or CEQUA or steroids or plugs.
All these things are in the weapon. So it takes a village of technicians, surgeons, ophthalmologists, all eye care providers to get the best results for the patient. Because guess what? Of your next 1000 patients undergoing cataract surgery, 80% will have cataracts, 60% will have abnormal tear osmolarity, and many will have problems with the measurements they take during the cataract surgery.
And so, you won’t get the good premium results that all of our patients want, say a multifocal lens, even a toric lens, or a straight good monofocal, with a limb relaxing slit. All of these things guide their management and lead to happy practices, happy patients and happy doctors.
great. Thank you so much for your great advice today. And thanks for joining us on EyePod.
Thanks for having me, Dave.
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