Whitney Hauser: Hi, I’m Dr. Whitney Hauser with Dry Eye Coach podcast and we welcome today Dr. Tal Raviv, Founder and Medical Director of the Eye Center of New York. Welcome, doctor.
Tal Raviv: Thanks for having me. I’m a fan of your podcast.
Whitney Hauser: Oh, very good. Very good. Thanks so much. We really enjoy doing them and we rely on experts like yourself to provide us some content and clarity on a lot of interesting issues in dry eye disease. Today we’re going to be talking about dry eye treatment pre and post cataract surgery. And this, I know, is impactful for our patients and for our practices both in optometry and ophthalmology. So we’re just gonna kind of get the ball rolling here in a few minutes with some questions, but is there anything just sort of off the top of your head that comes to mind about pre and postop for eye disease that listeners need to consider?
Tal Raviv: I think we’ll get into the conversation, but certainly the fact that we have a whole podcast on this just highlights the importance of it and we’ll get into why that is, and it’s an issue that I talk about every day. In fact, my last patient today was someone who was post op with dry eye, and we got into this conversation. The more we speak with them before, the better prepared we are to speak with them after.
Whitney Hauser: Right, right. I think we’ve all heard that before. You know, it’s your fault if it happens afterwards. Otherwise, if you’ve diagnosed on the front end, you know, it’s really something that the doctor and patient really try to conquer together.
Tal Raviv: Exactly.
Whitney Hauser: To kind of set the foundation, in the Trattler’s Landmark PHACO study that was published a few years ago, we found that about three quarters of patients presenting for cataract surgery had ocular surface disease and at least half have ocular surface problems that alter the results of biometry or could otherwise negatively affect surgical outcomes. So, like you said, there’s such an impact to the patient in terms of the numbers and in terms of their ultimate outcome with the surgery. I guess the first question really to kind of get things going is, those numbers are very large. So let’s talk about what they mean. What is the impact or what could dry eye have on the outcomes of cataract surgery if it went untreated?
Tal Raviv: Well, I think that study, the PHACO study, was really a great paper in documenting what many of us already know, but actually documenting even worse than what we thought. He found up to 78 percent, and, you know, I think Dr. Gupta had a study that found up to 80 percent of patients coming in for cataract surgery, had some signs and symptoms of dry eye disease. Now, how does it affect us? It impacts cataract surgeons in three ways. Not the surgeons, but patients and then their conversations with their surgeons, that is. Number one, as you mentioned, is getting poor biometry or keratometry which is a key part of our calculations. Keratometry is exquisitely sensitive to dryness and if we don’t pay attention to that, the studies have shown – Alice Epitropoulus has great study showing as well – that with high osmolarity, we’re likely to have an error in our biometry. So that’s a very specific, long lasting effect on those patients — they end up with a refractive error that we don’t desire. Number two is that dry eye signs, such as punctate kerotopathy and corneal staining also have a negative effect on the visual quality, so if we place an advanced technology lens, such as a presbyopic IOL in the patient and they revert back to their worn out cornea that’s dry, they’re going to have poor visual outcome. They won’t see far or near and be unsatisfied in that way.
So, that’s a second way, where even if we hit our biometry, we can still get burned by our patients with dry eye. And number three, and these are sometimes the most challenging, the ones that I screen for a lot; these are the patients that never thought they had dry eye, never felt anything preoperatively, their surgery comes out well vision-wise; however, they have a dry eye, foreign body sensation that they think they’ve never had before and they’re frequently right, and this persists and this makes them lose confidence in the surgeon because now their eye is dry and they never had “dry eye” before. So all three of those situations, they’re all a little different. Dry eye is an umbrella term that encompasses different things. The PHACO study showed that, I think, eight out of 10 patients that had dry eye signs had no dry eye symptoms. This was just something found on the exam. So, we’ve got to think a little bit differently treating dry eye in this population than just our average dry eye patients.
Whitney Hauser: So do you think that surgeons still rely heavily on symptoms or do you think there’s a shift toward both signs and symptoms? I mean, are they waiting for patients to say I have dry eyes before they do any type of investigation pre operatively?
Tal Raviv: I would say that 10 years ago, five years ago, I had all my cataract patients fill out a whole OSDI or speed test. I want to unburden my cataract surgery patients, they already have a lot to fill out, so I’d rather not do it. What I found was it wasn’t very correlative. Patients who said they were completely fine, they would come in, and they would have the worst dry eye. In fact, those are the ones that I feared the most because of the biometric errors we can have with them. Now, what I’ve done is I’ve created a new pre-cataract survey. I’ve taken a few questions on lifestyle which are like a lifestyle questionnaire for cataracts. I’ve just taken two dry eye questions and put on there and then I have a few questions from the Dell questionnaire to try to sort out what their visual outcome desires are. I put that into a new questionnaire that we have. So, six, seven questions, I get just an idea, a glimpse, but really, your question was very pertinent, is that we look for those signs. Those signs are something we can pick up on our average workup. We can’t miss those signs, because those signs are the ones that are going to throw us off.
Whitney Hauser: And so… no go ahead!
Tal Raviv: And the question of course becomes, maybe how do we work up our average cataract equation, or what do we do?
Whitney Hauser: Right.
Tal Raviv: And there’s two schools of thought. We are a dry eye center and by the way, my practice is primarily a refractive cataract practice in Manhattan. So, the setting is also important. I primarily see cataract and refractive surgery patients , which is what led me over the last 10 years to develop this dry eye practice. To be best-in-class in those two specialties you have to optimize dry eye in every way and so we became a dry eye clinic necessarily for our surgical patients. Now we have optometrists that practiced the full scope dry eye. For those patients that come in for a dry eye evaluation, we do questionnaires, we do OSDI, right up front. But for cataract surgery patients we don’t. We actually abbreviate a little bit. I don’t do all the dry eye tests.
Maybe in a perfect world I could do all those tests on everyone and there are some surgeons that do. I try to be a little more efficient with their time, and so when they come in, they fill out that mini questionnaire with one or two questions about dry eye. In their history, I know also whether or not they use artificial tears, which is a red flag and then we do our screening tests, which includes topography – we use an LED based topography that uses corneal reflection. That’s the most sensitive way of picking up surface abnormalities. Similar to placido topography we can see small irregularities in the tear film and of course we then see them on slit lamp examination. I see them before any drops are placed in the eye and that’s when we look for staining, tear breakup time, those classic findings that are really critical for diagnosing dry eye. Now if we find those things then we on a future visit we’ll perform point of care testing, but we don’t screen them all with those off the bat – at least not at this point.
Whitney Hauser: Right. Well, and to that point, sometimes you cast a really wide net on an asymptomatic patient population and you get back a lot of confounding diagnostic data and it’s not only inefficient running the test, it’s interpreting data that may not be really terribly relevant. So I think you’re right
Tal Raviv: I agree with you. Now I will say something that’s on one end of the opinion spectrum in the dry eye world. While some may argue to screen everyone for dry eye and treat everyone, I feel we can get lots of false positives in any widely applied screening, so I want to be selective and specific. I look at the ones that are symptomatic or have slit lamp signs when they’re coming in for cataracts. I think that’s a great point.
Whitney Hauser: Right, right. So, what is your protocol for optimizing the ocular surface before surgery and how would you maybe treat a mild dry eye patient if they came in?
Tal Raviv: I think I would preface by saying, you know, the I see two types of patients, I see the ones that come in from our practice and our in-house doctors. In those, of course, we have an opportunity to diagnose both dry eye and cataracts, or maybe they have decreased vision, and they’re going to get full dry eye workup and treatment protocol – that we can take our time to optimize. What I want to talk to you today, of course, are all the patients that are just coming to me for cataract surgery — they may be coming in from one of my co-managing optometrists or many times they’re just coming in from an internet research or just word of mouth. They come with different levels of knowledge and prior diagnoses of dry eye – I make sure to uncover it and if it exists discuss it with the patient.
Normally dry eye is broken up into mild, moderate and severe, but in a cataract surgery evaluation patient I categorize it into two buckets. I put them into the bucket of, are they mild enough that I can safely use the biometric information I have today and proceed with scheduling, or will I need to provide treatment and have them return for repeat measurements. So those are the two buckets I have. Of course, in the second bucket, it can be moderate or severe if you want to call it that way. The mild patient is someone that has some minor symptoms of dry eye for which they may be using an artificial tear that keeps their symptoms under control. They have a normal topography, and have very minimal to no staining. I look at my three different keratometry measurements for concordance. I compare the auto-keratometer, topographer and biometer which performs multifocal keratometry measurements several times and provides a standard deviation.
If all those K’s are very similar with a low standard deviation, I’m pretty comfortable labeling it mild dry eyes, discussing it with them, and then proceeding without having to repeat biometry on those patients. One of the most important things I discuss with them, is that their mild dry eye may flare up a little bit postoperatively. With any ocular procedure, a lot of inflammatory markers are released, and in some dry eye patients like yourself, Mrs. Smith, you are likely to have a flare up of your dry eye. It’s going to get a little worse before it gets better. You’re going to feel more stinging, you’re going to feel more irritation, and foreign body sensation. That’s okay, we’re going to work with you to minimize that. In those patients
Whitney Hauser: In what percentage … Go ahead. Actually, go ahead and finish what you’re saying, but I’m interested now what percentage of your patients you do repeat biometry on? Just anecdotally.
Tal Raviv: That’s another thing that I’m a little bit different. If you ask 50 cataract surgeons, I think more than half of practices, most of the ones that do general and cataract surgery, will see a patient on the initial visit to evaluate and diagnose the cataract, and have them return again for biometry. There’s a benefit to that workflow, because you have to ability to optimize everyone’s ocular surface. My workflow is different. My patients are referred in from optometrists and many of them are already optimized and have been treated for dry eye. They just want to have the surgery. Maybe it’s a Manhattan thing too, but I’m sure it’s universal. It’s part of our dilemma as dry eye specialists, is how much can we put the brakes on some of these patients that need further ocular surface optimization? We’ll get into that in the more severe category.
Whitney Hauser: Some people are never … you can optimize as much as you want
Tal Raviv: Many of our patients have poor vision and can’t do their work, their emails, or drive. How long should we force them to delay, we’ll get into that a little bit. We’ll have that discussion. I would say maybe 20% to 25% of my initial cataract evaluation patients come back for repeat biometry, which is a pretty low number, so I’m not treating everyone. There are some practices that everyone gets the whole dry eye protocol and again, I’m a little more efficient with it. Because we’re so busy and we want to not over treat, I just try to be selective and treat the ones that need to.
Whitney Hauser: Well I think usually things, the truth lies in the middle. You know, if you do nothing, that’s not a great idea and if you do everything, that’s probably not the best idea either because they can be exhausting to the patient, can be confusing to a lot of cataract patients. What are you doing? Why are you doing it? And then really the doctor may not garner a lot of additional information. So I think you’re spot on to kind of live in the middle.
Tal Raviv: So, that first conversation, before we can get to the cataract, we talk about this mild dry eye. We may just reinforce they may have some new symptoms afterwards. We think nowadays that pain is of neuropathic origin. We stimulate something during surgery, and in susceptible patients an afferent nerve may start firing abnormally and produce dry eye symptoms. I want to put that flame out as quickly as possible in those patients, usually with steroids. I’ll pretreat them with steroids on their second eye as well.
Tal Raviv: The question may be, should we treat them with immunomodulators? These mild dry eye patients are coming in, they use eye drops occasionally, they have minimal staining and their topography is close to perfect. If the meds were cheap and we had unlimited resources, potentially, but that’s not the case and so typically I’m not putting those patients on pre-op immunomodulators. At least not in the beginning, but you never know, they may flare up and you may have to use other tools later. Most of these mild cases have no problem afterwards, so I’ve just discussed it with them. I may recommend hot compresses and fish oil to be used and if needed we can discuss other options after surgery.
Whitney Hauser: Right. What about the more severe?
Tal Raviv: With the more severe dry eye, this is where biometry and other, visual quality issues are going to start playing a role. If someone’s coming in with a very, very dry eye, and my most of my practice is a premium IOL practice, I’m going to advise against a presbyopic IOL solution. Because even if I treat the dry eye to the best of my ability and they clear up, there’s a good chance they’re going to drift back to where they started. That’s what the severe case is, and despite being on immunomodulators and being the perfect patient, which no one is, they’re potentially not going to get the benefit of that lens. Presbyopic IOLs have some sacrifice in contrast sensitivity, less so with the latest generation EDOF IOLs, but coupled with poor ocular surface those patients may end up with poor quality of vision. I recommend a monofocal solution, I can still treat their astigmatism and utilize monovision. So that’s just the lens choice.
Now in that moderate, severe category, my main goal after maybe ruling out presbyopic lens is to optimize their ocular surface. How do we do that most efficiently? I think that these bad dry eye patients presenting for cataract surgery need a rapid onset treatment and also, what I refer to as a disease modifying treatment going forward or else they will completely regress to their current state. The fastest acting way of getting their eyes to spruce up, I find is to give them a topical steroid. We usually give them a pulse of steroids and artificial tears. And that’s just to get the ocular surface refined and see if their vision improves. Some improved to the point of not needing cataract surgery at the time. Then they need some kind of long-term disease modifying therapy. What is that?
That’s usually going to be an anti-inflammatory therapy and there I decide what type of dry eye they have – typically its either aqueous deficient or evaporative dry eye and most have an evaporative MGD component. And if they have telangiectasia, or any signs of ocular rosacea, I’m going to recommend a solution such as IPL (Optima IPL, Lumenis) to treat and actually eliminate the abnormal feeder vessels. And this is where we can make a big impact. we can produce cytokine modifying effects – and IPL has been shown to decrease MMP9 activity. So we’re doing a disease modifying treatment and usually I want to treat them with that. I’ll get in as many as treatments I can before cataract surgery, if they’re on board with it. A lot of these patients may know they have dry eye that’s never been controlled. So they’ll be happy to hear about something we can do. So we will give them the steroid and initiate IPL treatment.
Whitney Hauser: Do you typically do a series of say four treatments of IPL?
Tal Raviv: Yes. I usually do four or five.
Whitney Hauser: Okay. At what point in the series do you usually say, okay, let’s go ahead and do cataract surgery? I would assume you don’t wait until the fourth or fifth one, correct?
Tal Raviv: That’s correct. So these patients get topical steroid as well. The steroids are going to help and maybe even an immunomodulator, but if it’s mostly MGD with telangiectasias, I’m going to go with the IPL. I’d like to get at least two treatments in knowing that they’ve already started. They understand that the benefits of IPL usually seen after the third and definitely after the fourth treatment is when patients really feel a difference and by starting it, at least they’re going to be on that third one right after cataract surgery. Right when the dry eye sort of can flare up and they get to fourth one as well. That sort of gets them primed./p>
Now, like I said, for my own patients if they’re coming into my practice, they’ve already had IPL before cataract surgery, but someone just coming in, we probably end up getting in a treatment or two while using the steroid drop. We come back for follow up. I see that there is a regularization of all their numbers and then we can proceed with surgery at some point there. And those patients, I may not have started on an immunomodulator yet on those specific patients. The other half of the patients who may not have as much MGD or are not candidates for IPL for other reasons, we’re going to start them most likely on either topical cyclosporin or lifitegrast to give them something long term, that will immunomodulate and prevent this from bouncing back once we’re finished with the surgery.
Whitney Hauser: And obviously there’s the concern about the initiation of it, that the surgery itself will trigger the dryness or make an asymptomatic patient symptomatic. There’s the concern of the biometry, but then there’s the longterm concern about the patient having the progressive and chronic condition of dry eye. And I think a lot of doctors, I think a lot of doctors, and I’ve been there because I worked in a surgical practice for 10 years. I think we get very good at siloing the patient as this is a cataract patient and we don’t look at them in totality and we don’t look at them and in respect to their ocular surface outside of that moment, perhaps, where we’re looking at how it affects things, but after they’re finished, I don’t think we’re necessarily always are aggressive with the chronic nature of the disease.
Tal Raviv: You couldn’t have said it better. They’re coming in with, you know, at least two diseases at that point, dry eye and cataract. The cataract has the surgical solution, the dry eye requires a more chronic solution. We thankfully have these in office procedures that are disease modifying. They’re really not just palliative like some of the tears are. So I think it’s critical to do that because otherwise they’ll revert to another visually threatening condition, which is what dry eye can be, essentially. Besides its symptoms. It can also actually just frankly decrease their vision. So we always want to do something like that. I think omega-3 is helpful also, despite the recent negative NEJM study, a recent meta analysis in the Jan 2019 issue of Cornea shows that there is benefit to omega-3. And I do recommend the triglyceride form of omega-3 in all these patients
In some of our dry eye patients, we actually confirm it with blood tests – that they’re getting enough omega-3 absorbed and we find that also has anti-inflammatory effect and some disease modifying effect. I should add to be complete, in these IPL patients, frequently we’ll also do a thermal pulsation, which right now we’re using the LipiFlow. There’s a few new lid heating devices that are now commercially available, handheld versions, etc. But we use LipiFlow to augment the IPL. We either do LipiFlow first and then IPL or we’ll do IPL first and then a LipiFlow. The patient should understand that they’ll need to have more follow-up treatments with those two. But usually by doing IPL, we can extend out our need for repeat LipiFlow significantly, because the inflammation and occlusion comes back less significantly.
Whitney Hauser: If I’m hearing you correctly. And I definitely think that I am. It really sounds like you have a layered sort of perspective on treatment. It’s not just any one treatment, you know, you’re using the ophthalmic medications, you’re using lid hygiene. But then thermal pulsation, IPL. I think that probably too many practices rely on one thing to carry the burden of dry eye disease for their practice and when it fails, we think gosh, well that didn’t live up to my expectation and I think it’s not a one size fits all disease. And I think that approach that you have, that sort of layered approach to things is really very appropriate.
Tal Raviv: I think of the TFOS DEWS2 report and it’s hundreds of pages. But you know, they have a quote in there about the heterogeneity of dry eye disease… it’s almost part of the definition of the condition. Everyone is so different and I think in 10, 15 years, hopefully sooner we’ll know this is really 17 different diseases. We’ll be able to just take a tear sample and measure dozens of cytokines. So until that point, we have to use all our efforts and tailor it, I hate to use tailor, because that means, do we really know what we’re doing if we tailor? I’m more of a proponent of using in office treatments such as IPL and LipiFlow and even Blephex in certain patients early on, especially because they have a lasting effect and I may use those before I use the topical anti-inflammatory.
On the other hand, some patients come in and we may feel that based on their hyperosmolarity or their elevated MMP9, and healthy meibomian secretions, we may just start the immunomodulator right away, but we do tailor it. The key is to identify it and not just based on patient questionnaire but also what we see and ideally showing it to a patient is also effective. I think one of the innovations that the LipiView system allows is to actually illustrate on a big screen, that we have in our lanes, to show them what their diseased glands looks like. Ideally, i would show them also their topography, and this looks irregular, but they can’t appreciate that as much. And if you take a photo of their fluorescein staining, that’s an effective technique also, explaining what it looks like. So those tools are good. I also use the technology to explain the patients different things.
Whitney Hauser: Right. I agree with you though, using meibography, I mean a picture’s worth a thousand words as we all know. And when you have a grading scale on a laminated sheet or print out that they can take with them and you say this is you, this is what “ideal” looks like. You can see here how you fall short of the ideal. I mean it really resonates and it sounds like you’ve probably experienced what I have, which is my patients oftentimes tell me, you just told me something no one has ever told me before. And I think understanding the disease for these patients is half the battle.
Tal Raviv: Yes. I’m a big proponent off images, we’re in the digital age right now, we should be able to show patients a digital version of what’s in their eye. I have one room with a modern big screen monitor, I’m going to get this in all my future lanes, by the way, that shows them what their cataract looks like … Just so you know, here’s what your cataract is. Wow. They had no idea. Just showing them that and a picture of a normal one right next to it on the screen. So they have a comparison. That’s where we’re heading, and I think we’re starting to get that for dry eye. Meibography was the first major move to really shine a light on the anatomy here and I hope other imaging will come.
Whitney Hauser: Dry eye disease … I was going to say dry eye disease and cataract surgery is so ubiquitous that just, we all say it, and talk about it, patients, I mean, they know the terms, but they know so little that what really even a cataract is. They interchange it with glaucoma regularly. So being able to show that image, you know, lets the lay person really embrace it and understand what you’re doing. And it’s huge, huge for your … really informed consent of knowing what you’re doing for them.
Tal Raviv: It’s true. When the patients come in and you know, some of the most grateful patients, of course, are the ones that never knew had dry eye. We diagnose it, we treat them, they come back in for their follow-up visit. Their vision is so much better and, boy, they’re just so grateful.
Whitney Hauser: I’ve got just a couple of quick questions as we wrap up. One is, we’ve talked a lot about the induction of dry eye postsurgical, but you know, how do you detect and treat the problem at … Pardon me, postoperatively, we talked about identifying preoperatively. What do you do postoperatively to identify those patients? Is there anything you’d do differently than you would otherwise do?
Tal Raviv: I would say this, I’m very sensitive to their complaints, so if after a week or so, if they start feeling a really bad foreign body or burning sensation, or they’ll say, I really feel like an eyelash is in there. A lot of times they’ll come in, we’ll stain them, they eye is quiet and there’s not much stain. So, these are patients that we have optimized already, so there’s not much staining, but they still feel horrible and this is where I think that a neuropathic component may be developing. What I do with those patients, I quickly bump up their steroid. I’m happy to put them on q2 hour steroids for a week or two just to get them comfortable to really try to prevent a long-lasting neuropathic firing of those nerves and it seems to work. I give them a pulse much more than I normally would ever after cataract surgery because we know steroids in most other parts of surgery, neurosurgery, trauma, they’re given in pulses. they’re not given as slow tapers. So, I find that works.
Tal Raviv: As far as dry eye signs, they may have some punctate keratopathy or some other corneal staining and a lot of times they have no accompanying dry eye complaints. Now, these patients are on the neurotrophic spectrum. They don’t feel bad, but their corneas look terrible, and those are the ones that I’m going to quickly discontinue the NSAID. Even with brand NSAIDS, we can quickly exacerbate these signs and develop an erosion, dellen, other thinning or worse. So stopping the NSAID, maintaining the steroid, and adding a frequent preservative free lubricant seems to do the trick.
Whitney Hauser: Okay, excellent. So final question then, what’s the ongoing dry eye treatment for these patients? You know, we’ve talked about the chronic progressive nature of it. How do you, when you sort of start developing a plan, if you’re sending that patient back to their referring ophthalmologists, referring optometrists, what do you do to kind of discuss that plan and pass that along to the doctors?
Tal Raviv: And I think this is one of the most critical foundations of our care is this handoff. I work with, let’s say co-managing optometrist, my relationships, I try to have a very close relationship with all my co-managing optometrists, we text each other and I know what their scope of practice is like. We’ve talked before about dry eye and what our protocols are and there are a few that strongly embrace the treatment of dry eye. I would perhaps treat their patients in one way and I’ll tell them postoperatively to follow up with their doctor for LipiFlow or other treatment. You know, Dr. Smith is going to take continue your dry eye care when you get back. I’ll communicate that back to Dr. Smith so he knows we’ve done this much and we need to continue this much more. And so they’ll continue the care.
Those are great, when the referring doctor and my practice are all aligned. I have other cases where some referring doctors, ophthalmologists, optometrists, where advanced dry eye is not part of their practice. They’ll want me to optimize the patient, maybe I’ll do an IPL or other treatments and then I’ll recommended perhaps they have maintenance with either omega-3 and an immunomodulator and they’ll follow them. My practice will still be a resource and our other doctors will be available should further IPL be required a year later or something like that.
Whitney Hauser: Right. So I think you’re probably exactly right there. You have to know who’s on the team and you know, some doctors want to dive in deep into LipiFlow and IPL and are writing scripts for dry eye medications. Like you said, it’s just not their area of interest or perhaps their practice is heavier than in some other sub specialty of eye care and they leave that all up to you to kind of lead the way and maybe retain that patient, but it’s really an open dialogue and making sure everyone’s on the same page so you’re not stepping on toes, which always goes along way with everyone. I’m certain.
Tal Raviv: And we try never to retain these patients. We really want simply do their surgery, but for their dry eye, some will come in just once a year for an IPL touch up, as we call it, and they’ll be managed the rest of the time at their primary eye doctor and that’ll be a good combination just to keep them happy.
Whitney Hauser: Yep. Well then everyone’s winning if you’ve got the dry eye patient happy.
Tal Raviv: That’s true.
Whitney Hauser: Yeah, Dr. Raviv, thank you so much for joining us today for our Dry Eye Coach podcast. We really appreciate your time.
Tal Raviv: Well thanks so much for having me. It’s been a pleasure and I look forward to learning more, as I always do from you and your guests.
Whitney Hauser: All right, thanks so much.