We have seen tremendous innovation in the cataract surgery arena. In the era of refractive cataract surgery, with increased patient expectations and out-of-pocket expense related to advanced IOL technology and the use of femtosecond lasers, the stakes are high with respect to patients’ outcomes. To meet these rising expectations, we have to pay attention to the ocular surface. Tear film irregularities can lead to light scatter, increased higher order aberrations and degradation of image quality, which translates to inaccurate biometry, reduced accuracy with respect to refractive targets and decreased patient satisfaction.

Dry eye disease (DED) is extremely common, with studies estimating the prevalence of dry eye globally to range from 5% to 50%.¹ The many dry eye risk factors include advancing age, systemic medications, systemic rheumatologic diseases, contact lens wear and increased screen time. The pandemic has forced many people to spend more time on computers, tablets and phones, and the increased number of calls and visits to the ophthalmologist for dry eye has exploded this year.²

Untreated preoperative dry eye can lead to incorrect biometry and ultimately incorrect IOL selection. Cataract surgery exacerbates DED, so untreated preoperative dry eye can lead to significant postoperative symptoms, including foreign body sensation, burning sensation and fluctuating vision. Untreated lid disease can even increase the risk of postoperative endophthalmitis.³

Here, I will discuss strategies to uncover and treat DED for surgical patients.

THE ASYMPTOMATIC PROBLEM

The reason preoperative dry eye is often missed is that many patients are asymptomatic and unaware that they have dry eye. In the PHACO (Prospective Health Assessment of Cataract Patients’ Ocular Surface) trial, Trattler et al found that, of the 136 patients who were 55 and older scheduled for cataract surgery, only 30 patients (22.1%) had previously been diagnosed with dry eye and only 13% complained half or most of the time of foreign body sensation. However, when tested, the majority of patients had positive findings: 77% of eyes had corneal staining, 50% had central corneal staining, 62.9% had a tear break-up time (TBUT) of ≤5 seconds and 18% of patients even had a Schirmer’s with anesthesia score ≤5 mm.⁴

A study by Gupta et al showed similar findings of prevalent ocular surface disease in cataract surgery patients. In this study of 120 patients, 80% of patients had at least one abnormal test (osmolarity or MMP-9) and 40% had two abnormal tests with 56.7% having abnormal osmolarity and 63.3% having abnormal MMP-9. Based on questionnaire data, 54% (of 100 patients) had positive symptoms. Of the 46 asymptomatic patients examined, 85% still had one abnormal test (osmolarity or MMP-9) and 48% had abnormal results on both tests.⁵ Both of these studies underscore the prevalence of DED and highlight the frequency in asymptomatic patients.

DED AND SURGICAL OUTCOMES

Many studies have shown that cataract surgery exacerbates dry eye. When patients develop symptoms post-operatively, they tend to blame the surgery even if the symptoms stem from exacerbation of an existing problem. We all know the saying: “If a patient is diagnosed prior to surgery, it is the patient’s problem. If a patient is diagnosed after surgery, it is the doctor’s problem.” With such a high prevalence of asymptomatic patients, it is critical to look for dry eye in all pre-operative patients.

A study by Cetinkaya et al examined 192 eyes of 96 patients with chronic dry eye who underwent cataract surgery. In this population, the Ocular Surface Disease Index (OSDI) scores, fluorescein staining patterns, TBUT and Schirmer’s Test 1 values were significantly worse for the first 3 months postoperatively. However, these tests returned to values comparable to preoperative values after three months.⁶

SCREENING AND SLIT LAMP EXAM

Every preoperative patient should be screened for DED given the possible effects on preoperative testing, postoperative symptoms and patient satisfaction. To more effectively identify dry eye, many practices use a dry eye questionnaire such as the OSDI or SPEED questionnaire. These can help pre-identify patients with symptoms indicative of dry eye or other conditions. Every exam should include a thorough slit-lamp examination with the addition of fluorescein or lissamine green staining of the conjunctiva and cornea. Meibum evaluation should also be performed by applying pressure to the meibomian glands and examining the quality of the expressed meibum.

POINT-OF-CARE TESTS

Although we still rely heavily on our clinical slit-lamp examination, we are now able to gather additional pertinent information with point-of-care testing, which has undergone great innovation over the past few years. Point-of-care diagnostics can help zero in on the diagnosis. When a possible dry eye patient is identified on the screening questionnaire or history, this triggers my technicians to perform point-of-care testing before administering any topical drops, as these can skew the results. Tear osmolarity (TearLab) can be a useful test before cataract surgery. High tear osmolarity is observed when the tear film is unstable. We usually consider values greater than 308 mOsm/L or inter-eye variability greater than 8 points as indicating dry eye. Inter-eye variability usually does not occur when the tear film is stable.

Epitropoulos et al demonstrated the importance of tear osmolarity. Average keratometry readings and anterior corneal astigmatism were significantly more variable in hyperosmolar patients. This ultimately influenced power calculations for IOLs.⁷

Elevated levels of MMP-9, another point-of-care diagnostic (InflammaDry, Quidel), have been seen in the tears of patients with dry eye. Positive results for MMP-9, an inflammatory marker, occur when the MMP-9 concentration is >40 ng/mL.

Signs on corneal topography, such as dropout or patchy areas, irregular astigmatism or even inferior steepening, can be another sign of an unstable tear film and should alert the provider to the diagnosis and prompt treatment. A healthy tear film is necessary before preoperative measurements are performed to ensure accuracy.

ALGORITHMS AND TREATMENT OPTIONS

The advancements seen over the past few years, both in terms of our understanding of the pathophysiology of dry eye as well as our diagnostic abilities, have translated to better treatment paradigms. The approach to DED patients should be multipronged and staged. Several great algorithms can help guide diagnosis and treatment.^8-10 Regardless of the algorithm used, the first step is to identify patients through triaging questions, risk factor analysis, examination and diagnostic testing. Once dry eye patients are identified and subtypes are recognized, treatment should begin.

Although my treatment recommendation is tailored to each individual patient, I roughly follow the TFOS DEWS II staged management and treatment recommendations.⁸ In this algorithm, four steps of intervention are described for increasing dry eye severity. Step 1 describes interventions for mild dry eye patients that I think of as the “natural” approach. These interventions include environmental and dietary modifications, topical lubricants, warm compresses and lid hygiene.

When these therapies are ineffective, step 2 therapies should be initiated. Step 2 may include non-preserved ocular lubricants, tear conservation (punctal occlusion, moisture chamber goggles), overnight treatments, meibomian gland dysfunction treatments (LipiFlow, J&J Vision; intense pulsed light therapy, Lumenis) and prescription drugs, including topical cyclosporine (Restasis, Allergan; Cequa, Sun Ophthalmics), lifitegrast (Xiidra, Novartis), corticosteroids (Eysuvis, Kala Pharmaceuticals) and antibiotics and oral antibiotics.⁸

Staged management & treatment recommendations for DED⁸

Step 1.

• Education regarding the condition, its management, treatment and prognosis
• Modification of local environment
• Education regarding potential dietary modifications (including oral essential fatty acid supplementation)
• Identification and potential modification/elimination of offending systemic and topical medications
• Ocular lubricants of various types (if MGD is present, then consider lipid-containing supplements)
• Lid hygiene and warm compresses of various types

Step 2. (If above options are inadequate, consider:)

• Non-preserved ocular lubricants to minimize preservative-induced toxicity
• Tea tree oil treatment for Demodex (if present)
• Tear conservation
• Punctal occlusion
• Moisture chamber spectacles/goggles
• Overnight treatments (such as ointment or moisture chamber devices)
• In-office, physical heating and expression of the meibomian glands (including device-assisted therapies, such as LipiFlow)
• In-office intense pulsed light therapy for MGD
• Prescription drugs to manage DED
• Topical antibiotic or antibiotic/steroid combination applied to the lid margins for anterior blepharitis (if present)
• Topical corticosteroid (limited-duration)
• Topical secretagogues
• Topical non-glucocorticoid immunomodulatory drugs (such as cyclosporine)
• Topical LFA-1 antagonist drugs (such as lifitegrast)
• Oral macrolide or tetracycline antibiotics

Step 3. (If above options are inadequate, consider:)

• Oral secretagogues
• Autologous/allogeneic serum eyedrops
• Therapeutic contact lens options
• Soft bandage lenses
• Rigid scleral lenses

Step 4. (If above options are inadequate, consider:)

• Topical corticosteroid for longer duration
• Amniotic membrane grafts
• Surgical punctal occlusion
• Other surgical approaches (eg, tarsorrhaphy, salivary gland transplantation)

 

 

When step 2 options are inadequate, step 3 options such as oral secretagogues, autologous serum drops and therapeutic contact lenses (soft bandage lenses, rigid scleral lenses) can be considered.

Finally, when patients are still not controlled with treatments, step 4 therapies can be used. These include longer duration topical corticosteroids, amniotic membrane grafts, surgical punctal occlusion and other surgical approaches such as tarsorrhaphy.⁸

My typical regimen for surgical patients with preoperative dry eye, regardless of symptoms, consists of non-preserved artificial tears, a pulsed topical corticosteroid, topical cyclosporine or lifitegrast and the addition of punctal plugs several weeks later if necessary. The time a patient needs to be pretreated prior to surgery varies based on the patient, the surgery planned and the severity of disease. For patients with mild disease, 4 to 6 weeks of treatment may be adequate. For moderate to severe disease, at least a few months of treatment is often needed.

I typically bring patients back after 4 weeks to reevaluate. I only proceed once I see improved image quality, refractive and topographic stability and agreement in my keratometry readings. I like to see stability and agreement on multiple testing modalities on visits at least 2 weeks apart before proceeding. Waiting for measurement stability ensures more accurate measurements and ultimately more accurate IOL selection.

CONCLUSION

DED is extremely common. Due to its effect on surgical outcomes and patient satisfaction, it is critical to diagnose and treat preoperatively. All patients should be screened for DED. Consider following an algorithm to standardize the process for all patients. This will ensure identification of asymptomatic patients and allow for a deeper understanding of each patient’s DED.

Pretreat patients for as long as it takes to achieve consistent measurements and only proceed when patients are stable. You may worry that you will lose surgical patients due to the delays incurred with pretreatment, but I have found that most patients are thankful for your careful assessment and expertise. Ultimately, your results will speak for themselves. OM

REFERENCES

1. Stapleton F, Alves M, Bunya V, et al. TFOS DEWS II Epidemiology Report. The Ocular Surface. 2017;15:334-365.
2. Giannaccare G, Vaccaro S, Mancini A, Scorcia V. Dry eye in the COVID-19 era: how the measures for controlling pandemic might harm ocular surface. Graefe’s Arch Clin Exp Ophthal. 2020;258:2567-2568.
3. Mino De Kasper H, Ta CN, Froehlich SJ, et al. Prospective study of risk factors for conjunctival bacterial contamination in patients undergoing intraocular surgery. Eur J Ophthalmol. 2009;19:717-722.
4. Trattler WB, Reilly CD, Goldberg DF, et al. Cataract and dry eye: prospective health assessment of cataract patients’ ocular surface study. San Diego, ASCRS-ASOA Symposium & Congress, March 2011.
5. Gupta PK, Drinkwater OJ, VanDusen KW, et al. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018;44:1090-1096.
6. Cetinkaya S, Mestan E, Oncel Acir N, et al. The course of dry eye after phacoemulsification surgery. BMC Ophthalmol. 2015;15:68.
7. Epitropoulos AT, Matossian C, Berdy G, Malhorta R, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672-1677.
8. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15:575-628.
9. Starr CE, Gupta PK, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669-684.
10. Milner MS, Beckman KA, Luchs JI, et al. Dysfunctional tear syndrome: dry eye disease and associated tear film disorders – new strategies for diagnosis and treatment. Curr Opin Ophthalmol. 2017;27(Suppl1):3-47.

About the Author

Jessica Ciralsky is an associate professor of ophthalmology at Weill Cornell Medicine in New York City. Her practice interests include corneal diseases and corneal surgery, cataract surgery and refractive surgery.

Disclosures: Dr. Ciralsky revealed relationships with Bruder Healthcare, J&J Vision and Novartis.