July 2019


Research Highlight
ASCRS Cornea Clinical Committee develops preop OSD guidance tool

by Liz Hillman EyeWorld Senior Staff Writer

“A vast majority of respondents [to the ASCRS Clinical Surveys] thought a novel diagnostic and treatment algorithm, tailored to the needs of busy cataract and refractive surgeons, would be useful, so we created one.”
—Christopher Starr, MD

Ophthalmologists, in general, are aware of the impact the ocular surface can have on refractive outcomes, but ASCRS Clinical Surveys have revealed a disconnect between that knowledge and putting it into action to improve outcomes.
New information and guidelines, a slew of diagnostic options, and a plethora of treatment modalities have made addressing the ocular surface to improve outcomes overwhelming, so the ASCRS Cornea Clinical Committee stepped up to the task. The ASCRS Preoperative OSD Algorithm was published with the May 2019 issue of
the Journal of Cataract & Refractive Surgery1 and was widely discussed at the 2019 ASCRS ASOA Annual Meeting.
“A vast majority of respondents [to the ASCRS Clinical Surveys] thought a novel diagnostic and treatment algorithm, tailored to the needs of busy cataract and refractive surgeons, would be useful, so we created one,” said Christopher Starr, MD, who took the lead on this project with the ASCRS Cornea Clinical Committee.
The ASCRS Preoperative OSD Algorithm functions as a flow chart to guide ophthalmologists through the testing, diagnostics, and treatment of visually significant OSD preoperatively.
Dr. Starr said that when he and the clinical committee set out to create the tool, it “seemed like an easy job at first.” He quickly learned it was “more complicated than I ever imagined.”
“But that actually speaks to the educational gaps we aimed to address,” Dr. Starr said. “Managing DED and OSD in the modern era is complicated because the field has exploded with new publications (CEDARS DTS paper, TFOS DEWS II, among others), new diagnostic tools, and new FDA-approved medications and procedural treatments. This, along with the rise in patient expectations with cataract and refractive surgery, new surgical technologies, and new IOLs and refractive procedures, has made it increasingly difficult for busy surgical practices to manage both simultaneously.”
Dr. Starr said the ASCRS Preoperative OSD Algorithm aims for seamless integration into the preoperative refractive and cataract surgical patient visit and relies heavily on technician performed objective testing to reduce chair time. The algorithm and protocol guides the workflow and assists the surgeon in establishing signs and symptoms of OSD, determining visual significance, and treating all OSD subtypes appropriately.
Dr. Starr pointed out that the protocol as published is not the only way, nor is it a new universal standard of care that every practice must meet. As such, it was created to be adaptable based on practice resources, equipment, and established preoperative visit flow. If a practice doesn’t have tear osmolarity, MMP-9, or other newer point-of-care OSD testing, the ASCRS SPEED II preoperative OSD questionnaire developed to go with the algorithm along with the “look, lift, pull, push” exam cost nothing and can lead to increased awareness and diagnosis of visually significant OSD, Dr. Starr said. Though, he noted, the ASCRS Corneal Clinical Committee’s consensus is that osmolarity and MMP-9 testing are essential components of the OSD screening battery.
“Any abnormality on any portion of the essential screening battery makes a diagnosis of OSD highly likely, even if subtle, subclinical, or non-visually significant,” Dr. Starr explained. “These are important to identify and treat preoperatively as they often worsen after surgery and could become visually significant afterward.”
Dr. Starr said he finds the tool easy to use. By making it a standard part of his preoperative protocol, the ocular surface is never ignored, and visually significant OSD is identified and treated prior to surgery, he said.
“It is also important to stress the fact that this is an OSD, not just a DED, algorithm as we think that any ocular surface disease, including but not limited to DED, can potentially be visually significant and lead to suboptimal visual outcomes if neglected,” he said.
The new ASCRS Preoperative OSD Algorithm and SPEED II preoperative OSD questionnaire are available to Journal of Cataract & Refractive Surgery subscribers and to ASCRS members.

About the doctor

Christopher Starr, MD
Associate professor of ophthalmology
Director of the Refractive
Surgery Service
Director of ophthalmic education
Weill Cornell Medicine
New York


1. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669–684.

Financial interests

Starr: Allergan, Novartis, Alcon, Shire, Bruder, TearLab, Quidel, Kala Pharmaceuticals, Novaliq, Sun Pharmaceutical, BlephEx, Eyevance Pharmaceuticals,
EyePoint Pharmaceuticals, Dompé

Contact information

Starr: cestarr@med.cornell.edu

Why the ASCRS Preoperative OSD Algorithm was created

Previous ASCRS Clinical Surveys identified educational gaps and underutilization of widely available diagnostic testing, despite 91% of respondents saying that mild to moderate dry eye disease impacts patient satisfaction in cataract and
refractive surgery.
•75% of respondents were unfamiliar with the TFOS DEWS II and the Delphi Panel International Task Force recommendations for dry eye and ocular surface disease.
•9% were using osmolarity.
•5% were performing MMP-9 testing.
•83% said an algorithm for ocular surface diagnosis would be helpful (2017).

ASCRS Cornea Clinical Committee develops preop OSD guidance tool ASCRS Cornea Clinical Committee develops preop OSD guidance tool
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