Why DOs should prepare patients for surgery years before they need it
The time to start thinking about preparing patients for surgery is not when they want or need it, but rather during pre-visits. Another way to phrase this obvious yet seemingly unrealized mode of healing is to prepare for the worst and hope for the best.
The ocular surface is the refractive epicenter of the eye and therefore requires full attention at every encounter with the patient. Research has shown that there is a cumulative effect of inflammation and dryness that can not only prevent healing, but also impair surgical stones.1.2 Further research shows that the meibomian glands are negatively affected at increasingly early ages.
So how can ODs fight this? It’s all about anticipation. The simplest answer to the question “When do we start planning to prepare the ocular surface for possible surgery?” Is: “On your last visit”.
Take the edict that every patient is a dry eye patient until proven guilty. Each meibomian gland begins to atrophy or the meibum is altered until eyecare professionals do not see these changes. All lids have an overabundance of Demodex, especially cylindrical films, unless you can’t see them, because you watched.
Eye care clinicians are responsible for protecting eyesight, but we don’t use our sight or insight when we need to prevent surface damage.
As an ideological posture, assuming everyone has ocular surface disease (OSD) until proven guilty works if we live and work in a vacuum. However, the eyes of this generation are taxed more than others. It is naive to think that the OSD won’t show its ugly head if we indulge in some pesky OSD modification habits uncontrollably. In other words, we can’t expect that continued use of our sights won’t erode the OSD faster and faster without doing something to slow it down. I tried with my teeth, and let me say I should have flossed for decades.
The good news is that ophthalmologists have many unobtrusive and intuitive options to help patients prepare early for a post-OSD era. For example, a universal battle cry of all ophthalmologists is now: “Stop, collaborate and look away from your monitor!” This is the old 20/20/20 rule modified to sound cooler like a one-hit 1980s wonder.
Equip patients wearing contact lenses with daily disposable lenses, integrate eyelid hygiene, use anti-inflammatory immunomodulatory drops to increase tear production (and increase wearing time) are efforts to prevent the brain drain. drop out of contact lenses around 40 or 50 years old.
Regular use of a moist heat mask on the eyelids, at a younger age, will prevent meibomian gland obstruction? Most likely. At best, it can be like brushing your teeth every day while consuming an oral cornucopia of sugary treats. To break this down, anything we do now will only help in the future.
Now, without the ability to go through with Doc Brown and go back to the future, ODs have to become myopic while preparing a patient for surgery. Fortunately, ODs have some treatment tips.
This year, eye care practitioners saw the first approval of a topical corticosteroid (Eysuvis, 0.25% Loteprednol Etabonate Ophthalmic Suspension; Kala Pharmaceuticals) indicated for short-term treatment (up to 2 weeks). ) signs and symptoms of dry eye (DED).
Another option available is the use of an amniotic membrane to improve overt dryness or help smooth irregular corneas with corneal dystrophy. Although the latter may require corneal debridement in coordination with a cryopreserved amniotic membrane, the former can be treated with a cryopreserved membrane alone.
Another quick and important part is to clean the eyelid margin of the offending inflammatory debris. Microblepharoexfoliation treatments can accomplish this before any surgical treatment. Using hypochlorous acid to clean the lids has also been very effective in eradicating pesky insects quickly.
Focusing on the eyelids is easier with meibography. Similar to using tomography to help with refractive surgery, meibography gives a landscape of the glands. Not only does this visual assess the current and future potential of the glands, but it is a clear picture from which patients can understand the consequences of their actions. Meibography, in my opinion, should be performed at all examinations regardless of the patient’s age. By using the symptoms and the glands as a road map, we can prepare patients for other treatments.
Thermal pulsation may be required prior to the presurgical evaluation. However, when more time is available, an Intense Pulsed Light (IPL) procedure could and should be implemented.
ODs feature countless examples of proactive preparation without thinking twice. We owe it to our patients to start a preoperative dialogue and a course of treatment well before any actual procedure. When is the right time to implement this mindset? I would put the year in the DeLorean at 1985, or at least now.
1. Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for planning cataract surgery. Cataract refraction surgery J. 2015 ; 41 (8): 1672-1677. doi: 10.1016 / j.jcrs.2015.01.016
2. Tichenor AA, Ziemanski JF, Ngo W, Nichols JJ, Nichols KK. Tear film and features of the meibomian glands in adolescents. Cornea. 2019; 38 (12): 1475-1482. doi: 10.1097 / ICO.0000000000002154