Optometry’s Critical Role in Surgical Management

By: Paul M. Karpecki, OD, FAAO Clinical Director – PECAA

What has always stunned me is how ophthalmic companies with a surgical product have focused solely on the surgeon. Certainly that is a top priority, however, to avoid educating the doctor who manages these patients, namely the optometrist, has cost these companies millions. 88% of all comprehensive eye exams are conducted by optometry. I work in a surgical practice and if the primary care optometrist doesn’t mention a premium IOL option, it rarely gets implanted.

Although optics in IOL’s continue to advance and have much improved results, such as extended depth of focus IOLs (e.g. Symfony by J&J), the facts are that you may be the most valuable doctor when it comes to ocular surgery. I’m certainly not diminishing the surgeon as they require decades of training to hone their surgical expertise, but the surgeon (or the optometrist) in that surgical practice can’t ensure a successful outcome without your proactive involvement. I am a big fan of toric IOLs as they seem to correct astigmatic cataract patients eyes better than what we could do with glasses or contact lenses because they are placed internally near the nodal point, they don’t move or rotate, there is no distortion when looking peripherally and they are often less expensive than other premium IOL offerings. But I received a call from a colleague about a year ago referring a cataract patients to Kentucky Eye Institutes surgeons but stating emphatically not to put a toric IOL in this patient. When I examined the patient I noted 1.00 D of with-the-rule astigmatism, and in this circumstance I would normally discuss the benefits of a toric IOL to the patient. But I’ll always rely on my colleagues recommendation because I may spend 10 minutes with a cataract surgery candidate and I’ll never have the  knowledge or trust the primary eye care provider has established in 3 or 20+ years of knowing and treating that patient. In this case, my colleague had previously tried toric contact lenses and although not typical, this patient far preferred a spherical contact lens. Of course that was the same case after cataract surgery and a testament to the value of knowing your patients and conveying that valuable information to the surgeon.  This could include mono vision success (or not) and the dioptric power the patient preferred, it could include personality traits such as extreme meticulousness or perfectionism.  This combined with clinical knowledge from ocular surface disease and blepharitis to a history of HSV, allow you to play the most important role in the success of the patient’s post surgical outcome.

Another area to involve yourself in is micro-incisional glaucoma surgery or MIGS.  There are numerous technologies available ranging from the originally approved iStent to the resent approval of the Hydrus (Ivantis Inc). There are also MIGS procedures like the Xen (Allergan) that have replaced more invasive trabeculectomy procedures in many cases.  The Hydrus pivotal trial shows the capabilities of these technologies in managing glaucoma patients. The trial involved 369 patients having cataract surgery with the Hydrus microstent and 187 who had phacoemulsification alone. At 24 months 77.2% of the Hydrus group had at least a 20-percent drop in IOP (compared to 57.8% with cataract surgery alone). Keep in mind that cataract surgery alone has been shown to lower IOP, but this delta between the two is the highest observed to date in any FDA clinical trial involving a canal-based surgery. The mean change in IOP was -7.6mmHg, which again is the highest IOP lowering effect achieved to date in a pivotal clinical trial.

Perhaps it’s because of the 3 openings in the microstent, the lumen to the collector channels is significantly larger, it is easy to identify if it’s in the proper location and that an 8mm microstent covers the entire inferior nasal quadrant that allows for these superior results. From my perspective the most important finding from the trial may be that ~80% of the patients didn’t require any glaucoma medications at 2 years post procedure.

Finally with all these great advances and technologies like light-adjustable IOL’s (RxSight) in the near future, will allow for UV light laser dioptric power modification AFTER cataract surgery, we still must be diligent about evaluating the ocular surface. This means looking for early signs of blepharitis when the lash follicles show edema or biofilm at the base of the lash as opposed to when quorum sensing has occurred and the lashes are covered in discharge. These patients can benefit prior to surgery from procedures you can do such as Blephex. It’s also important to expressing meibomian glands for diagnostic purposes to determine meibomian gland dysfunction and administering treatment with devices such as LipiFlow/iLux/TearCare and hydrating compresses (Bruder). And it certainly means treating dry eye and the inflammation associated with it prior to surgery. A recent study showed that 17% of patients who measured hyperosmolarity with the TearLab osmometer missed their IOP target by a diopter or as much as 5.5 diopters simply because the compromised tearfilm affected biometry measurements.  Ironically in those patients with normal osmolarity and hence no dry eye, 100% achieved a post cataract outcome within 0.50D of the intended refractive error.

Optometry plays the key role in orchestrating the success of patients about to undergo ocular surgical procedures such as LASIK, cataract surgery and even cataract surgery with MIGS (which is the only time you can currently perform these MIGS procedures). Understanding this critical role and enhancing your knowledge may do more to the success of these patients than anything anyone else can provide.

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