Guest Editorial

A holistic approach to eye care

In his landmark Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study, William Trattler, MD, demonstrated the near-ubiquitous prevalence of dry eye among cataract patients.1 A dry, unstable ocular surface can have an adverse effect on biometry and topography (with consequences for surgical decision making),2 and dry eye affects light scatter, quality of vision and visual performance.3

With these understandings, along with the advent of new modalities for diagnosing and treating dry eye, my treatment paradigm has evolved in a number of ways.


First, we have embraced a holistic approach to refractive cataract surgery and vision correction. We attempt to take into account everything that could affect the visual outcome — from the devices we use to surgical technique to ocular surface optimization.

Think about it: Does it make sense to deploy increasingly sophisticated lasers, phaco machines and IOLs that are capable of producing highly precise outcomes but then leave the patient with poor quality or fluctuating vision due to problems with the ocular surface? Of course not. That’s why we now incorporate advanced diagnostics to screen for dry eye, including dynamic meibomian imaging. Meibography, along with diagnostic expression, helps us determine whether meibomian gland dysfunction (MGD) plays a significant role. We know this is not uncommon, with 86% of dry eye cases having MGD as at least one component.4


The second major change in our protocols is that, rather than just doing the minimum to get through surgery successfully, we now take a more proactive and preventative approach to ocular health and wellness. I realized that if we could optimize patients’ visual quality prior to a refractive procedure, we could really push the limits of their vision performance.

By removing their cataract, improving focusing ability with a presbyopia-correcting IOL and getting to the tear film to a more pristine state, we could achieve better outcomes and higher patient satisfaction than ever before. We are in the process of formally evaluating this, and our anecdotal impression is that our outcomes are better. I also feel that a healthy ocular surface contributes to better healing after surgery.

Ideally, all of this should take place much earlier — long before patients need surgery at all. That requires partnering with one’s in-house or referring optometrists to make ocular surface care a higher priority in primary eye care.


In setting the stage for treating MGD and dry eye, we use client-centric terms like “health,” “wellness” and “lid cleaning.” We talk to clients about helping them achieve their goals and that it might mean a long-term ocular surface regimen.

A couple of great analogies can help patients understand the ocular surface disease process and their role in their ocular health. One of these is weight loss. If my goal is to lose 20 pounds, I probably can’t achieve that in just one step. I might need to change my diet, my exercise routine and even my environment or habits to be successful and to maintain a healthy weight loss over time.

I explain to patients that dealing with dry eye is very similar. We will do several different things simultaneously to treat their lids and tear film. And — very importantly — they will need to be good stewards of their ocular health to get better.

Dental hygiene is another analogy I like to use. Most of our patients see their dentist twice a year for regular cleanings. Patients understand that it’s better to do this proactively and not just wait until they have a cavity or gum disease. They also understand that building better habits at home (i.e., brushing and flossing) can stave off dental problems.

Again, there are a lot of parallels with dry eye. We might treat a patient with thermal pulsation therapy, punctal occlusion and a steroid-sparing immunomodulatory agent (lifitegrast [Xiidra, Shire] or cyclosporine [Restasis, Allergan]), but they will also need to take their medical-grade omega supplements daily and use a thermal mask at home. Just like dental cleanings, thermal pulsation therapy might need to be repeated every year or two to maintain meibomian gland structure and healthy tear function, hopefully preventing the irreversible, end-stage sequelae of MGD.

I am very optimistic about the impact these changes will have on our practice and excited about all the new resources available for understanding and treating the ocular surface. OM


  1. Trattler WB, Majmudar PA, Donnenfeld ED, et al. The Prospective Health Assessment of Cataract Patients’ Ocular surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.
  2. Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672-1677.
  3. Brundrett A, Crouse M, Waring IV GO, Rocha KM. Dynamic optical quality assessment using a double-pass wavefront system as compared to objective and subjective clinical measures in dry eye disease. Presented at ASCRS 2016.
  4. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31:472-478.