Practice patterns among ophthalmic surgeons in treating concomitant oculoplastic conditions in preoperative period: A questionnaire-based study

Abstract

BACKGROUND

Addressing oculoplastic conditions in the preoperative period ensures both the safety and functional success of any ophthalmic procedure. Some oculoplastic conditions, like nasolacrimal duct obstruction, have been extensively studied, whereas others, like eyelid malposition and thyroid eye disease, have received minimal or no research.

AIM

To investigate the current practice patterns among ophthalmologists while treating concomitant oculoplastic conditions before any subspecialty ophthalmic intervention.

METHODS

A cross-sectional survey was disseminated among ophthalmologists all over India. The survey included questions related to pre-operative evaluation, anaesthetic and surgical techniques preferred, post-operative care, the use of adjunctive therapies, and patient follow-up patterns.

RESULTS

A total of 180 ophthalmologists responded to the survey. Most practitioners (89%) felt that the ROPLAS test was sufficient during pre-operative evaluation before any subspecialty surgery was advised. The most common surgical techniques employed were lacrimal drainage procedures (Dacryocystorhinostomy) (63.3%), eyelid malposition repair (36.9%), and ptosis repair (58.7%). Post-operatively, 47.7 % of respondents emphasized that at least a 4-week gap should be maintained after lacrimal drainage procedures and eyelid surgeries. Sixty-seven percent of ophthalmologists felt that topical anaesthetic procedures should be preferred while performing ocular surgeries in thyroid eye disease patients.

CONCLUSION

Approximately 50% of ophthalmologists handle prevalent oculoplastic issues themselves, seeking the expertise of an oculoplastic surgeon under particular conditions. Many ophthalmologists still favor using ROPLAS as a preliminary screening method before proceeding with cataract surgery. Eyelid conditions and thyroid eye disease are not as commonly addressed before subspecialty procedures compared to issues like nasolacrimal duct obstruction and periocular infections.

Key Words: Oculoplasty; Ophthalmic plastic surgery; Nasolacrimal duct obstruction; Practice patterns; Survey

Core Tip: The study among Indian ophthalmologists reveals reliance on ROPLAS test for preoperative evaluation. Lacrimal drainage procedures dominate surgical interventions, with postoperative care emphasizing a 4-week gap. Topical anaesthesia is preferred for thyroid eye disease surgeries. While many manage oculoplastic issues independently, collaboration with oculoplastic surgeons occurs in complex cases. Nasolacrimal duct obstruction and periocular infections receive more attention compared to eyelid malpositions and thyroid eye disease preoperatively. The findings underscore the importance of comprehensive evaluation and highlight potential areas for practice improvement, including enhancing evaluation methods for less studied conditions and promoting interdisciplinary collaboration for optimal patient care.

INTRODUCTION

The prevalence of patients with oculoplastic diseases in general ophthalmologists’ clinics varies from 1.4% to 7.4% of all new patients presenting for eye care[1,2]. The management of coexisting oculoplastic conditions during the preoperative period varies widely among ophthalmic surgeons and remains an area of diverse practice patterns among surgeons. Routine screening for symptoms and examination of the lacrimal system before cataract surgery is performed worldwide[3-6]. Oculoplastic anomalies, ranging from nasolacrimal duct obstructions, eyelid malposition, periocular infections, thyroid eye disease, etc., can significantly impact surgical planning for any ophthalmic subspecialty practices in addition to cataract surgery[1]. The postoperative outcomes of these surgeries also have an impact on patient satisfaction as well as on the reputation of the ophthalmic surgeon. There is a lacuna in the existing literature regarding the management of common oculoplasty disorders by comprehensive ophthalmologists and exclusive subspecialty surgeons in India. Therefore, this questionnaire-based study explores the prevailing practice patterns among ophthalmic surgeons when confronted with concomitant oculoplastic conditions, particularly before any surgical planning for cataracts or other subspecialty. By analyzing the varied approaches, the study hopes to shed light on the common practices, potential gaps in treatment, and avenues for standardized care.

MATERIALS AND METHODS

A cross-sectional questionnaire-based study was designed. A total of 180 ophthalmic surgeons, encompassing a mix of early, mid, and late-career professionals, were selected randomly from various institutions and private practices across the country. The 22-question survey questionnaire was meticulously crafted, containing both closed and open-ended questions, to glean insights into their diagnostic, therapeutic, and decision-making strategies. It covered topics such as common oculoplastic conditions encountered, preferred management techniques, and factors influencing treatment choices in treating these conditions. The entire questionnaire was validated by an in-house pilot study in the tertiary eye care institute. The data was collected during the period of three months, from 1^st April to 30^th June 2023. Communication was primarily via WhatsApp, supplemented by email, with three reminders sent at one-week intervals. The ethical approval of the institute was obtained, and all participants provided informed consent before participating in the study. Data from Google sheets was analysed using Excel and STATA 14.0. Participation was voluntary and anonymous. Statistics showcased the preferred surgical methods, with responses presented as frequencies, percentages, and means with standard deviations. The responses were anonymized and statistically analysed using SPSS.

RESULTS

Of the 180 ophthalmologists who responded, 94 (52.2%) were female and 86 (47.8 %) were male. Most of the participants, 98 (54.4%), were in the age group of 30-40 years. Of these, 24 (13.3%) had ophthalmologists with practicing experience of less than 5 years, 73 (40.6%) were practicing ophthalmology for 5-10 years, 53 (29.4%) had 10-20 years, and 30 (16.7%) had more than 20 years of practical experience. Notably, 106 (58.9%) practiced in urban areas, while only 8 (4.4%) practiced in rural areas, 35 (19.4) in Semi-urban and 31 (17.2) in Metropolitan areas. Majority of ophthalmologists 69 (38.3%) were private practitioners, followed by ophthalmologists who practiced in institutes 43 (23.9%), trust hospitals with large volume of surgeries 35 (19.4%), and 33 (18.3%) worked in medical colleges. There were 109 comprehensive ophthalmologists (60.6%) and 71 fellowship-trained specialists (39.4%). Of these, 78(43.8%) expressed their view that they didn’t treat oculoplasty disorders and refer them to a specialist, 52 (29.2%) had an interest in oculoplasty and treat simple conditions, 19 (10.7%) treated all common Oculoplastic conditions but more interested in their own sub-specialty and 29 (16.3%) practiced their sub-specialty exclusively.

Practice pattern in treating concomitant lacrimal conditions

Respondents were asked to give opinions regarding preoperative lacrimal syringing, done routinely in their practice. Majority of them 89 (49.7%) thought ROPLAS testing was sufficient to confirm nasolacrimal duct (NLD) patency before subspecialty surgery. However, 79 (44.1%) were doing lacrimal passage irrigation in all cases, while only 11 (6.2%) were of the opinion that nasolacrimal duct patency testing was not required before performing their subspecialty surgeries. When asked about their preferred surgical approach for nasolacrimal duct obstruction, 63.3% (114 individuals) favored dacryocystorhinostomy, while 10% (18 individuals) chose dacryocystectomy. Of the remaining participants, 13.3% (24 individuals) opted for punctal cautery in cases where there was partial regurgitation of clear fluid. Another 13.3% (24 individuals) continued with their subspecialty surgery in cases of asymptomatic nasolacrimal duct obstruction (NLDO). Meanwhile, 2.2% (4 individuals) were uncertain about the best approach to the situation. Managing patients with partial nasolacrimal duct obstruction is also a dilemma among ophthalmologists regarding whether to treat or not. While 90 (50.8%) preferred to proceed with ocular surgery in asymptomatic partial NLDO, 48 (27.1%) of them preferred punctal cautery, and the rest of them opted for definitive lacrimal surgeries. Most ophthalmologists preferred a minimum gap of 4 weeks before allowing a sub-specialty surgery after lacrimal surgeries.

Practice pattern while treating concomitant eyelid malposition

Eyelid malposition such as entropion, ectropion, and ptosis can be problematic, acting as potential triggers for infection in the pre-operative phase. When participants were questioned about treating these conditions, 43% (77 individuals) favored surgical treatment before the subspecialty surgery. In contrast, 36.9% (66 individuals) chose surgical treatment only in specific cases. The remaining participants did not opt for surgical treatment, either due to concerns about delaying their scheduled surgery or because they did not perceive any increased risk of infection.

Practice patterns while treating concomitant thyroid eye disease

We also tried to evaluate the practice pattern in managing thyroid eye disease before ocular surgery, which is crucial for ensuring the best surgical outcomes. Eighty-five (47.5%) of them wanted to treat thyroid eye disease in selective cases, and 53 (29.6%) of them wanted to treat thyroid disease first before proceeding with subspecialty surgery. Twenty-seven (15.1) of them did not want to get treated as they didn’t pose any intra-operative problem or because the treatment would delay their planned surgery. Regarding the type of anesthesia they would prefer in the presence of thyroid eye disease, the majority of ophthalmologists 67 (38.3%) prefer topical anesthesia followed by the peribulbar route in 52 (29.7%), few of them, 42 (24%) preferred Sub-tenon route while 11 (6.3%) of them were not sure about the route of anesthesia during ocular surgery.

Practice patterns while treating concomitant periocular infections

Adnexal infections, such as stye, chalazion, and canaliculitis, can increase the risk of endophthalmitis after intraocular surgery. As a result, it is essential to address these infections in the preoperative phase. Of the participants, 84.7% (150 individuals) chose to treat any coexisting infectious conditions in all instances. In contrast, 13.6% (24 individuals) opted to treat only in specific cases. A small group, 1.7% (3 individuals), did not see the need for treatment, either because they didn't believe these conditions increased the risk of infection or because treatment might postpone their scheduled surgery. Table 1 shows the number of ophthalmologists grouped according to their experience and opinion regarding managing concomitant periocular infections.

Table 1 The demographic characteristics of the participants and responses to the survey questions, n (%).

Parameters	n = 180
Age of the ophthalmologist (in years)
< 30	4 (2.2)
30-40	98 (54.4)
40-50	49 (27.2)
> 50	29 (16.1)
Gender
Male	86 (47.8)
Female	94 (52.2)
Years of practice
< 5	24 (13.3)
5-10	73 (40.6)
10-20	53 (29.4)
> 20	30 (16.7)
Area of practice
Rural	8 (4.4)
Urban	106 (58.9)
Semi-urban	35 (19.4)
Metropolitan	31 (17.2)
Type of hospital
Govt. hospital	33 (18.3)
Private practice	69 (38.3)
Single institution practice with teaching	43 (23.9)
Trust hospital with large volume of surgeries	35 (19.4)
Which part of the India do you practice in clinically
North zone	30 (16.7)
East zone	75 (41.7)
South zone	60 (33.3)
West zone	15 (8.3)
Comprehensive ophthalmologist
Yes	109 (60.6)
No	71 (39.4)
Exposure into common oculoplastic disorders
I don’t treat and refer them to a specialist	78 (43.8)
I have an interest in oculoplasty and treat simple conditions	52 (29.2)
I treat all common oculoplastic but more interested in sub-specialty	19 (10.7)
My practice is exclusively sub-specialty based	29 (16.3)
NLD patency testing prior to sub-specialty surgery
Yes, irrigation in all cases	79 (44.1)
Yes, checking for ROPLAS is sufficient	89 (49.7)
No, NLD patency testing is not required	11 (6.2)
NLD obstruction detected during preoperative evaluation
Dacryocystectomy	18 (10)
Dacryocystorhinostomy	114 (63.3)
Punctal cautery in cases of partial regurgitation of clear fluid	24 (13.3)
Planned ocular surgery in asymptomatic NLDO	24 (13.3)
Not sure	4 (2.2)
Partial NLD detected during pre-op evaluation
Dacryocystectomy	6 (3.4)
Dacryocystorhinostomy	18 (10.2)
Punctal cautery in cases of partial regurgitation of clear fluid	48 (27.1)
Planned ocular surgery in asymptomatic NLDO	90 (50.8)
Not sure	15 (8.5)
Minimum gap that you prefer prior to allowing a sub-specialty surgery after dacryocystorhinostomy
< 1 week	1 (0.6)
2 weeks	49 (27.5)
4 weeks	85 (47.7)
6 weeks	40 (22.5)
Not sure	3 (1.7)
Minimum gap that you prefer prior to allowing a sub-specialty surgery after dacryocystectomy
< 1 week	10 (5.6)
2 weeks	69 (38.8)
4 weeks	70 (39.3)
6 weeks	19 (10.7)
Not sure	10 (5.6)
Treat any stye/chalazion/canaliculitis before performing your subspecialty ophthalmic procedure
Yes, in all cases	150 (84.7)
Yes, in selective cases	24 (13.6)
No, because they do not pose any risk of infection	1 (0.6)
No, because procedure may delay planed surgery	2 (1.1)
Waiting time after treating stye/chalazion/canaliculitis before performing
< 1 week	47 (26.3)
2 weeks	81 (45.3)
4 weeks	13 (7.3)
6 weeks	33 (18.4)
Not sure	5 (2.8)
Treat co-existing entropion and ectropion before procedure
Yes, in all cases	77 (43)
Yes, in selective cases	66 (36.9)
No, because they do not pose any risk of infection	14 (7.8)
No, because procedure may delay planed surgery	17 (9.5)
Not sure	5 (2.8)
Waiting time after ocular surgery
< 1 week	7 (3.9)
2 weeks	56 (31.3)
4 weeks	69 (38.6)
6 weeks	20 (11.2)
Not sure	27 (15.1)
Treat coexisting thyroid eye disease before performing your ocular surgeries
Yes, in all cases	53 (29.6)
Yes, in selective cases	85 (47.5)
No, because they don’t pose any intra-operative problem	27 (15.1)
No, because procedure may delay planed surgery	7 (3.9)
Not sure	7 (3.9)
Treat coexisting ptosis before performing your ocular surgeries
Yes, in all cases	16 (8.9)
Yes, in selective cases	105 (58.7)
No, because they don’t pose any intra-operative problem	41 (22.9)
No, because procedure may delay planned surgery	12 (6.7)
Not sure	5 (2.3)
Waiting time after ptosis repair
< 1 week	3 (1.7)
2 weeks	34 (19.2)
4 weeks	75 (42.4)
6 weeks	34 (19.2)
Not sure	31 (17.5)
Anesthesia preferred prior to any surgery in thyroid eye disease patients
Topical	67 (38.3)
Peri-bulbar	52 (29.7)
Sub-tenon	42 (24)
Don’t know	11 (6.3)
Topical + sub-tenon	1 (0.6)
Retro-bulbar	2 (1.1)

NLD: Nasolacrimal duct; NLDO: Nasolacrimal duct obstruction.

The demographic characteristics of the participants and the responses to the survey questions have been summarized in Table 1.

DISCUSSION

Managing oculoplastic conditions during the preoperative period presents unique challenges and opportunities for ophthalmic surgeons. Therefore, this survey was conducted with the intent to understand the prevailing practices in managing concomitant oculoplastic conditions during the preoperative period among Indian ophthalmologists. In the present study, 102/180 participants were comprehensive ophthalmologists. This could explain the varied responses, as the primary focus of the questions pertained to coexisting oculoplastic conditions. The data reveals 107/180 participants referred cases to an oculoplasty specialist. This indicates that comprehensive and non-oculoplastic subspecialty surgeons do not have considerable knowledge acquired during their training regarding managing basic oculoplastic conditions. Given this, the present study becomes even more pertinent, aiming to establish a consensus on managing co-existing oculoplastic conditions alongside other subspecialty eye conditions. This definitely needs a revision in the subspecialty curriculum in India, where ophthalmologists opting for fellowships must be trained in comprehensive ophthalmology before pursuing their subspecialty. However, there are few institutes that provide comprehensive ophthalmic knowledge before entering into their subspecialty practice.

In the present study, the majority favor ROPLAS over syringing as a screening test before any subspecialty surgery. The results are similar to a study by Thomas et al[7], who assessed the effectiveness of the ROPLAS test as a screening tool for coexisting dacryocystitis and compared it to syringing. In their study, out of 621 outpatients examined, the sensitivity and specificity of ROPLAS were 93.2% and 99.3%, respectively, and this high specificity suggested that if ROPLAS was negative, preoperative syringing may be redundant unless suspicion for the condition is high. In the present study, 10% of those surveyed reported performing dacryocystectomy, while 13.3% cited using punctal cautery. These figures suggest that, besides the more extensive dacryocystectomy for nasolacrimal duct obstruction, less invasive procedures also play a role in managing the condition, especially when patients undergo surgery for other ophthalmic issues. The specific circumstances where these less invasive options may be chosen include advanced age and ambiguous cases of nasolacrimal duct obstruction, where there is regurgitation of clear fluid without the presence of obvious pus, which might lead to dacryocystectomy. Punctal cauterization is commonly used to treat a range of ocular surface conditions linked to a deficiency in tear production, such as primary dry eye syndrome, Sjögren syndrome, ocular graft-versus-host disease, mucous membrane pemphigoid, and Stevens-Johnson syndrome[8-11]. Although there are no documented instances in the literature of using punctal cautery for the temporary occlusion of the lacrimal passage before cataract surgery, our study indicates that the practice persists. This area warrants further investigation.

In a study by Zucoloto et al[12], 78% of surgeons performed lacrimal surgery before the intraocular surgery, waiting 4 to 6 weeks to proceed with the cataract surgery. The procedure of choice for treating nasolacrimal duct obstruction before cataract surgery was dacryocystorhinostomy (88.4%). Similarly, in the present study, the consensus among respondents was to wait four weeks between lacrimal surgery and subsequent major eye procedures such as cataract, corneal, glaucoma, or vitreoretinal surgery. However, a few suggested a shorter interval of approximately one week. This shortened timeframe is particularly relevant in camp settings, where there is a risk that patients, once released after duct surgery, may not return for their subsequent cataract operation. Therefore, surgeons prefer to retain patients in the camp hospital for a week, performing cataract surgery within that period before discharge to ensure the promised treatment is fulfilled. Discharging patients before their cataract surgery could necessitate uncomfortable explanations, as patients are often unsatisfied if the promised treatment is not delivered. Additionally, there is the matter of increased costs for the patient’s extended stay and meals at the hospital, which is also a consideration.

There is still debate regarding the time sequence of surgical correction of eyelid malposition in relation to cataract surgery. Previously there was a consensus as to treat eyelid malposition before cataract surgery since it could lead to postoperative ocular irritation and endophthalmitis, but a remarkable study published by Yarmak et al[13] in 2022 supports the fact that out of 129 instances across 90 patients, which included 86 cases of involutional entropion and 43 of involutional ectropion, not a single case of endophthalmitis was reported. In the present study, the consensus among ophthalmologists varied for ptosis and ectropion, as well as entropion. While 67% opted to treat ptosis before subspecialty procedures, 80% wanted to treat ectropion and entropion at first, most likely due to the reason that it could lead to irritation and pose a risk for endophthalmitis. However, there is another school of thought that supports the idea that patients undergoing phacoemulsification have an increased chance of getting lower eyelid laxity, probably due to intraoperative eyelid stretch by speculum[14].

In the present study, 77% of participants opted to treat thyroid eye diseases before subspecialty surgeries, with most of them indicating that they would address these conditions under 'special circumstances.' This indicates that, nowadays, ophthalmologists are aware of the nuances involved while performing surgeries in patients with coexisting thyroid eye disease. According to a study by Strong Caldwell et al., patients with thyroid eye disease are at increased risk for refractive prediction error following cataract surgery, which needs discussion with patients regarding their risk and possible need for glasses following surgery[15]. There are reports of flare-ups of activity in orbit after receiving retrobulbar anesthesia for cataract surgeries, which is probably the reason why few participants in the present study prefer subtenon and topical anesthesia[16-18].

Apart from nasolacrimal duct obstruction, certain conditions like blepharitis, conjunctivitis, canaliculitis, the use of contact lenses, presence of an artificial prosthesis elevate the risk for acquiring endophthalmitis[19]. Therefore, it is imperative to treat coexisting stye, chalazion and canaliculitis prior to any intraocular procedure more so in large outreach camps where patients have doubtful lid hygiene. In a study by Gangwe et al[20], they diagnosed 98 patients with concomitant oculoplasty diseases such as NLDO, stye, chalazion, and ectropion, which needed surgical correction in 73 patients prior to cataract surgery and therefore emphasized the need for comprehensive ophthalmic evaluation in camps. In the present study, 97% participants opted for treating periocular infections probably because more than half of them were involved in private practices or single institution practice or trust hospitals with large volume surgeries.

There are certain limitations of this study. One is that it solely included Indian ophthalmologists as participants. Incorporating international ophthalmologists would have provided a more comprehensive understanding of global practice patterns. Another limitation of this study is the small sample size, which may reduce the generalizability of the findings to a broader population. The questionnaire was not framed about the activity of thyroid eye disease and the degree of entropion and ectropion; therefore, some answers might have ambiguity. There are still some areas like kerato-refractive surgeries which were not covered in the questionnaire.

CONCLUSION

There is a need to provide comprehensive ophthalmic knowledge, specifically in the management of common oculoplastic conditions, to the Ophthalmic residents and to the young Ophthalmologists opting for various subspecialties. Future collaborative efforts between different subspecialties of ophthalmology could focus on creating comprehensive guidelines that balance individualized patient care with standardized best practices.