Cataract surgery success for dry eye patients

Patients with ocular surface disease can still achieve premium results.

Ophthalmologists have three main reasons to identify — and aggressively treat — dry eye disease (DED) before cataract surgery:

  • To address symptoms
  • To prevent infection
  • To obtain accurate measurements

Achieving these goals requires some work but results in accurate IOL selection and a happy patient. Read on for my guidance in nailing these imperatives.


  • Symptoms. To properly set expectations for the postoperative period, surgeons should educate patients that they have a precondition. Make sure they understand that DED symptoms will likely be exacerbated by the surgery but that the reason is their disease, not the cataract surgery.
  • Infection. Treating blepharitis and eradicating the bacterial load around the eye pays dividends postoperatively for patients. Surgeons often do not discuss the important role of infection prophylaxis when it comes to caring for and normalizing the ocular surface before cataract surgery.
  • Measurements. To ensure accurate surgical measurements and to nail the IOL power calculations, the ocular tear film must be healthy. The quality of the tear film affects the accuracy of the sphere power and astigmatic measurements.


In patients with known ocular surface issues, it is even more critical to be diligent in the preoperative examination and diagnostic assessment. During the past few years, new DED diagnostic and treatment algorithms have been introduced, such as the CEDARS (Figure 1) and TFOS DEWS II recommendations (Figure 2).


Figure 2: TFOS DEWS II Report Executive Summary. Recommended diagnostic approach for DED.

I am a member of the ASCRS cornea committee that formed recommendations for another treatment approach scheme. The ASCRS algorithm, soon to be published in the Journal of Cataract & Refractive Surgery, focuses on getting patients ready for cataract surgery. The goal was to make a clinically useful tool. We aimed to create a recipe based on findings and include allergic conjunctivitis, infectious, viral or bacterial conjunctivitis and anterior basement membrane dystrophy — conditions that can masquerade as ocular surface disease.

The ASCRS algorithm also includes step-by-step recommendations for diagnosis and incorporates guidance on all the available tests. It includes a questionnaire, testing for osmolarity and/or inflammation and tear-film interferometry. Eventually, we hope to create an online algorithm that will allow ophthalmologists to input the testing information and return a tentative list of diagnoses.


Prior to cataract surgery, I assess the patient’s tear film by staining either with lissamine green or fluorescein and measure tear breakup time to evaluate stability of the lipid layer. I look at and under the lids, push on the oil glands and perform tear film analysis and InflammaDry (Quidel).

On topography, I look for irregularities, which can have an impact on the cylinder measurements and my ability to obtain an optimal reading.

If I can sufficiently clear the ocular surface and feel comfortable with patients’ topography, then I can offer premium IOLs to the patient and be confident in the results. If patients have measurements that are suboptimal, I will not be able to nail my measurements. In that case, I may recommend a monofocal implant, as they will not enjoy the full benefits of the multifocal or extended-depth-of-focus technology.

Patients who are not candidates for premium technology typically include those with chronic and refractory punctate keratitis — usually a result of severe autoimmune disease. Additionally, a short course of steroids (ie, loteprednol) to quickly resolve tear film inflammation and prepare the ocular surface for surgery can be used in severe patients.


If DED patients are compliant with treatment, however, most have success with premium implants. Patients must be motivated to stay on top of managing their tear film inflammation and lid margin disease while maximizing the lipid layer. With proper treatment, the ocular surface will be smooth enough to yield accurate calculations.

I recommend LipiFlow (Johnson & Johnson Vision) to all my cataract patients with DED and MGD; I estimate about 20-30% opt for the treatment. For DED patients who are motivated to receive a premium implant, LipiFlow treatment makes a big difference. I perform the procedure about one month before surgery — it takes about that long for the new oils to come in and establish a balanced tear film. I combine LipiFlow with warm compresses.

I explain to patients that because they cannot use warm compresses for a time after surgery, I want to maximize them preoperatively. Although procedural options optimize the lipid layer, thermal pulsation is FDA approved. The use of intense pulse laser may also be beneficial but is not approved for use in MGD at this time.

Again, managing and setting patients’ expectations are paramount. I emphasize that they will not receive the full benefits from a premium IOL without a healthy ocular surface, and I put the responsibility for complying with treatment on the patient. If we cannot optimize the ocular surface and obtain reproducible topography, then I steer the patient away from that option.

The number one reason for unhappy multifocal IOL patients is DED and tear film instability.


During the perioperative period when patients receive their presurgery drops, they tend to keep their eyes open because they are numb. I remind patients to close their eyes between drops because I want to minimize their exposure, particularly in those with ocular surface disease. During surgery, I take extra care to keep the cornea hydrated and minimize evaporation by not over opening the lid speculum.

Because generic nonsteroidal anti-inflammatories are usually not friendly to the ocular surface, I use branded daily or twice-daily alternatives or avoid them altogether in standard, nondiabetic patients with a routine surgery. For patients taking non-preserved artificial tears, I instruct them to increase the frequency and to not use warm compresses because of pressure to the eye (as mentioned previously, I maximize the use of compresses before surgery).

I continue autologous serum drops in patients already taking them and insist on their continuing anti-inflammatory prescription drops as usual.


Most patients with DED can enjoy the benefits of premium IOL technology with meticulous presurgical care and a lot of patience. To minimize postoperative symptoms, prevent infections and nail preoperative measurements, we must use a combination of tools. This starts with a detailed workup that must feature staining and assessing the components and break-up time of the tear film. In the preoperative period, it is critical to maximize the available treatments appropriate for the individual patient. In-office treatments combined with at-home compresses help set the stage for premium outcomes that our patients demand from cataract surgery. OM

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