The power of the handoff: Comanaging cataract surgery in a patient with severe OSD

Cataract comanagement is often framed around efficiency for both the clinic and the patient; who does what, when referrals happen, and how postoperative visits are divided. But in real-world practice, successful comanagement is not only logistics; rather, it is understanding the patient history, continuity, trust, and knowing which provider the patient needs at each stage of care.

This is especially true for patients with significant ocular surface disease (OSD). For these patients, cataract surgery is not a single event; it is a process. Although preoperative ocular surface optimization is critical, the postoperative period is often where patients need the most support, reassurance, and flexibility.

The following case highlights how intentional postoperative handoff and close optometric monitoring played a central role in both the clinical outcome and the patient’s overall experience.

The patient

The patient was in her late 60s and had been under my care for severe OSD. After a long road, her ocular surface and symptoms were finally controlled to a level she found tolerable. She was functional again. Comfortable enough. Stable.

At the same time, her cataracts were progressing. She reported increasing glare, light sensitivity returning, fluctuating vision, and significant difficulty with night driving. Her vision changes were beginning to impact her independence and quality of life. Cataract surgery was the logical next step, yet both she and I were understandably hesitant.

Our fear was not unfounded. I knew cataract surgery could worsen dry eye symptoms, and we were both worried that surgery would undo all the progress we had worked so hard to achieve. Significant time was spent discussing the risks and benefits. In her words, she didn’t want to “fix one problem just to create another.” But I had a plan, and she trusted me. We had navigated her ocular surface disease together, adjusted medications over time, and had built a strong therapeutic relationship. That trust would ultimately shape how her postoperative care was managed.

She was referred to one of my most capable surgeons, someone I trust not only for surgical skill but for bedside manner. I knew this patient needed more than technical excellence; she needed patience, reassurance, and a surgeon who would take the time to meet her where she was emotionally. From the start, I assured her that the surgeon and I would be in close communication throughout her care, and that she would not be navigating this process alone.

The surgeon and I discussed her case in detail and agreed that minimizing ocular surface disruption during the perioperative period would be critical. Together, we decided to utilize compounded postoperative drops to reduce preservative exposure, recognizing the role preservatives can play in exacerbating ocular surface disease. In addition, we made a decision that I would see the patient for her 1-week postoperative visit, allowing for close monitoring of her corneal surface, symptom burden, and tolerance of the postoperative regimen.

This visit was less about checking boxes and more about holding her hand through a vulnerable phase of recovery. It allowed time to listen, reassure, and make real-time adjustments to her postoperative drops as needed, something that was particularly important given her history.

After surgery on the first eye, the outcome exceeded our expectations. She was ecstatic about her vision, but what surprised her most was that her eye actually felt better. Her ocular comfort improved enough that she was able to function without the therapeutic soft contact lens she had previously relied on to manage her corneal hyperesthesia, a milestone that neither of us had anticipated and one that significantly reinforced her confidence moving forward with surgery on the fellow eye.

An intentional handoff

Early postoperative visits are protocol-driven and focused on surgical healing milestones: wound integrity, inflammation, IOP, and visual acuity.

For most patients, that is appropriate. For this patient, it was not enough.

Because of her history of severe OSD, and anxiety surrounding possible changes, the decision was made for her to return to me early in the postoperative period. This was not about replacing the surgeon’s care, but complementing it.

She needed:

1. Close monitoring of her ocular surface
2. The ability to adjust medications quickly
3. Reassurance when symptoms fluctuated
4. A provider she already trusted to help interpret what she was feeling

This is where comanagement moves beyond task sharing and becomes true collaborative care.

Communication

Comanagement works best when communication is intentional and ongoing. Before surgery, the surgeon and I aligned on roles, postoperative responsibilities, and medication plans, ensuring the patient’s ocular surface was closely monitored. At the same time, the patient knew both of us were in contact, which reduced anxiety and built trust. When symptoms fluctuated after surgery, she knew exactly whom to turn to. Clear communication transformed the handoff into a continuous, coordinated care experience, keeping the patient and team on the same page.

Medication flexibility

Standard postoperative regimens are not always ideal for patients with compromised ocular surfaces. Topical ocular drop protocols used after surgery often contain preservatives, include nonsteroidal anti-inflammatory drugs, and employ dosing schedules that can destabilize the tear film or worsen surface inflammation.¹ For this patient, it was decided prior to surgery that compounded medication was the best starting point. Many clinics already use these drops as part of their standard protocol for all patients. Another approach could have been to start with a conventional regimen and switch if needed.

By closely monitoring at-risk patients, we are able to^2-5:

• Restart topical therapies earlier if needed
• Adjust usage of over-the-counter therapies like ocular lubricants
• Modify anti-inflammatory therapy
• Change or pause medications that worsened ocular surface discomfort
• Tailor treatment to patient response, not just what the protocol dictates

This flexibility can help maintain surface stability without interrupting postoperative healing.

Surgical outcomes beyond VA

Clinically, the outcome was excellent. Visual acuity improved as expected, glare was reduced, and she returned to driving with confidence. Her ocular surface disease remained controlled throughout, with the added benefit of no longer needing her bandage contact lens during the day.

But the most meaningful outcome was the patient’s experience. She felt supported rather than rushed. Heard rather than dismissed. Guided rather than handed off. For a patient who entered surgery with fear, this mattered just as much as the visual result.

This case reinforced several important principles that extend beyond cataract surgery:

• Comanagement is not about equal division of time; it’s about appropriate care.
• Patients with complex OSD often benefit from individualized postoperative management.
• Trust is a clinical asset. When patients feel safe, adherence improves and anxiety decreases.
• Optometrists are uniquely positioned to manage postoperative ocular surface fluctuations because we have flexibility and longitudinal relationships to do so.
• Strong OD/MD relationships allow care to be customized. Communication is key.

This case demonstrates that successful comanagement is not only about preoperative optimization or postoperative checklists. It is about intentional handoffs, continuity of care, and recognizing when a patient needs familiarity more than formality. When done well, comanagement improves the entire patient experience.

References

1. Jones L, Downie LE, Korb D, et al. TFOS DEWS II management and therapy report. Ocul Surf. 2017;15(3):575-628. doi:10.1016/j.jtos.2017.05.006

2. Starr CE, Gupta PK, Farid M, et al; ASCRS Cornea Clinical Committee. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684. doi:10.1016/j.jcrs.2019.03.023

3. Coco G, Messmer EM, Starr CE, et al. A practical approach for optimizing ocular surface status before cataract surgery to improve visual outcomes and reduce the risk of postoperative dry eye. Ophthalmology and therapy. 2025;14(11):2697-2733. doi:10.1007/s40123-025-01251-7

4. Nuzzi R, Tibaldi D, Nuzzi A. The impact of cataract surgery on tear film physiology: signs and symptoms, progression and treatment. Frontiers in medicine. 2025;12(1559323). doi:10.3389/fmed.2025.1559323

5. Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: The effect of dry eye. Clin Ophthalmol (Auckland, NZ). 2017;11:1423-1430. doi:10.2147/OPTH.S120159