Dry eyes are a common complication following refractive cataract surgery. While normally temporary, the condition can have a negative effect on visual recovery, patient satisfaction and overall quality of life.¹ One of my favorite quotes on this subject is from Dr. Eric Donnenfeld: “If you diagnose dry eye prior to cataract surgery, it’s an expectation; if you don’t diagnose it until after surgery, it is a complication.”

Many of our colleagues, both optometrists and ophthalmologists, may not recognize the value of actively looking for dry eye disease (DED) in our preoperative patients or are unsure of how to do so. Others may feel it may have a negative effect on the flow and efficiency in the office.

Given the prevalence of post-surgical dry eye, it is essential to detect it before surgery — in order to manage the patient’s expectations, prevent DED from compromising surgical outcomes and devise a treatment plan for the aggravated condition that is likely to present after surgery.

IF YOU’RE STILL DOUBTFUL …

Trattler et al reported that the percentage of patients scheduled for cataract surgery who have signs or symptoms of dry eye is higher than anticipated; the majority of patients screened for cataract surgery do not have symptoms, but up to 80% had conjunctival or corneal staining.¹ Gupta et al similarly found that objective findings of DED were common among patients presenting for cataract surgery, yet many were undiagnosed.²

Ocular surface disease (OSD) can reduce quality of vision and adversely affect accuracy of IOL power calculations prior to cataract and refractive surgery. My colleagues and I reported patients with hyperosmolarity had greater variability in keratometry readings resulting in variability in IOL power calculations.³

Furthermore, ocular surgery can induce or exacerbate DED, which can compromise quality of vision, worsen dry eye symptoms and lead to dissatisfied patients. In fact, dry eye is one of the most frequent complaints in the postoperative period.^4,5 Dry eye after cataract surgery was categorized as a surgically induced iatrogenic DED by the Tear Film and Ocular Surface Society International Dry Eye Workshop (TFOS DEWS) II iatrogenic report.⁶

The exacerbation of dry eye signs and symptoms after cataract surgery is multifactorial: a combination of damage to the corneal nerves from the corneal incision, heat and light from the microscope,⁷ postop inflammation and drops containing preservatives can contribute. Although NSAIDs are effective in decreasing the prevalence and severity of postoperative CME, they can cause adverse side effects, including ocular surface abnormalities.^8,9

According to Oh et al, the duration of surgery was associated with a decrease in goblet cell density in the conjunctiva. They discovered that more severe inflammatory responses and longer surgery times can damage the ocular surface and reduce goblet cell density.¹⁰

Park et al evaluated the ocular surface after cataract surgery, noting that lid margin abnormalities and quality of meibum decreased in patients with dry eye after cataract surgery.¹¹

An increased awareness of the high prevalence of OSD in this population, including asymptomatic patients, should lead to careful evaluation, counseling and treatment of the ocular surface both before and after surgery.¹ I typically follow a combination of the three major dry eye algorithms — the DEWS II, ASCRS or the more disease-based CEDARS algorithm (Table) — to develop my treatment plans.^12-14

DETECTION TOOLS

DED is a multifactorial condition that can be challenging to diagnose and treat. Nonetheless, taking a systematic approach will help with evaluation, treatment decisions and management strategies. The use of a patient-reported symptom questionnaire, such as the Ocular Surface Disease Index (OSDI) or the Standardized Patient Evaluation of Eye Dryness (SPEED), as a first step in screening is suggested to assess the patient’s awareness of their ocular surface issues.

Point-of-care diagnostic tests, such as tear osmolarity (TearLab; I-Pen, I-Med Pharm), MMP-9 (InflammaDry, Quidel) or meibography (LipiScan, Johnson & Johnson Vision; Keratograph 5M, Oculus; HD Analyzer, Visiometrics) may be triggered by symptomatic patients.

Topography can be used to assess subtle signs of OSD. We want to see whether the visual symptoms of patients are related to the degree of cataract and not to other comorbidities. Not only may topography help diagnose DED, but it can also help detect other pathologies, including epithelial basement membrane dystrophy, irregular astigmatism and keratoconus — all of which may not be visible at the slit lamp.

Using a combination of these diagnostic instruments, as well as a thorough history and clinical examination, is important to determine if OSD is present.

EDUCATION STARTS EARLY

Because it is more challenging to treat asymptomatic dry eye patients, I believe that educating patients about their pre-existing dry eye condition and discussing the consequences of proceeding with cataract surgery without treatment helps to improve patient understanding and compliance. I show patients their photos if they have keratitis, unstable tear film (reduced tear breakup time) and abnormal meibomian glands.

These objective findings provide a platform for explaining the cause of their problems, their therapeutic options and the likelihood that therapy must be continued after surgery.

THE POSTOP PLAN

Currently no prophylactic treatments or drops approved for use in preventing the development of postoperative dry eye are on-label. Your best chance to combat it remains actively screening and evaluating for DED, patient education and optimizing the health of the ocular surface preoperatively. Therapy for perioperative dry eye should be determined based on type and severity of dry eye.

Preservative-free lipid-containing artificial tears are a first-line treatment for meibomian gland disease (MGD) and may be adequate for mild dry eye symptoms after cataract surgery. However, with more severe or persistent complaints, adjunctive therapy should be added based on the underlying condition. Reducing inflammation on the ocular surface is the primary goal in treating moderate to advanced DED.

Immunomodulators including cyclosporine (Restasis, Allergan; Cequa, Sun Ophthalmics) or lifitegrast (Xiidra, Novartis) target the inflammatory pathway and are an effective treatment option for patients with postoperative DED. In addition, using a mild short-term topical steroid such as loteprednol etabonate 0.25% (Eysuvis, Kala Pharmaceuticals) or fluorometholone acetate (Flarex, Eyevance) provides a tool to rapidly reduce inflammation. A high-quality omega-3 supplement has also been shown to improve both signs and symptoms of DED^15,16 and is recommended in most of the DED algorithms.^{5, 6, 17}

After cataract surgery, corticosteroid and NSAID drops are often included in the regimen to reduce the inflammatory response; these are usually tapered over the first month. Most topical NSAIDs are weakly acidic, which can be more irritating. They may also contain preservatives such as benzalkonium chloride, which increase ocular surface irritation. Punctate epitheliopathy,¹⁸ subepithelial infiltrates/immune rings,¹⁹ stromal infiltrates²⁰ and epithelial defects²¹ have all been linked to topical NSAIDs.

With persistent dry eye symptoms, I continue their omega-3 supplements and immunomodulator indefinitely; an additional short-term course (2 to 4 weeks) of a mild topical corticosteroid that is friendly to the ocular surface (such as loteprednol etabonate ophthalmic suspension 0.25% or fluorometholone acetate ophthalmic suspension) can be very effective in relieving dry-eye exacerbations.

If the source is MGD, in-office thermal treatments, such as thermal pulsation with expression (LipiFlow, Johnson & Johnson Vision; iLux, Alcon; TearCare, Sight Sciences), have been shown to be very effective in restoring meibomian gland function, stabilizing the tear film and reducing dry-eye symptoms.^22-24

Symptomatic patients with aqueous tear deficiency may benefit from punctal occlusion, however, ensure that the integrity of the tear film has been optimized. If this is done prematurely, patients tend to become more symptomatic due to the inflammatory mediators that remain in the tear film. If patients show significant punctate epitheliopathy, cryopreserved amniotic membrane (AM) (BioTissue) or dehydrated AM (IOP Ophthalmics, BioDOptix, Seed Biotech) can be implemented.

THE BEST DEFENSE IS A GOOD OFFENSE

Development or exacerbation of dry-eye symptoms is extremely common after cataract surgery. Because this can adversely affect patient outcomes and satisfaction, providers should recognize the condition before surgery, be aware of the impact it can have and treat it appropriately. Optimizing the health of the ocular surface perioperatively results in happier, more satisfied patients and improved surgical outcomes. OM

REFERENCES

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. 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 Sep;44:1090-1096.
3. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017. 15:575-628.
4. 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.
5. Milner MS, Beckman KA, Luchs J, et al. Dysfunctional tear syndrome: dry eye disease and associated tear film disorders — new strategies for diagnosis and treatment. Curr Opin Ophthalmol. 2017. 27 Suppl 1(Suppl 1):3-47.
6. Epitropoulos AT, Matossian C, Berdy GJ, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015. 41:1672-1677.
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8. Jones RR, Maguire LJ. Corneal complications after cataract surgery in patients with rheumatoid arthritis. Cornea. 1992. 11:148-150.
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14. Park Y, Hwang HB, Kim HS. Observation of influence of cataract surgery on the ocular surface. PLoS One. 2016. 11: p. e0152460.
15. Epitropoulos AT, Donnenfeld ED, Shah ZA, et al. Effect of oral re-esterified omega-3 nutritional supplementation on dry eyes. Cornea. 2016. 35:1185-1191.
16. Giannaccare G, Pellegrini M, Sebastiani et al. Efficacy of omega-3 fatty acid supplementation for treatment of dry eye disease: A meta-analysis of clinical trials. Cornea. 2019. 38: 565-573.
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18. Gills JP. Voltaren associated with medication keratitis. J Cataract Refract Surg. 1994. 20:110.
19. Probst LE,Machat JJ. Corneal subepithelial infiltrates following photorefractive keratectomy. J Cataract Refract Surg. 1996. 22:281.
20. Sher NA, Krueger RR, Teal P, et al. Role of topical corticosteroids and nonsteroidal antiinflammatory drugs in the etiology of stromal infiltrates after excimer photorefractive keratectomy. J Refract Corneal Surg. 1994. 10:587-588.
21. Shimazaki J, Saito J, Yang HY, et al. Persistent epithelial defect following penetrating keratoplasty: an adverse effect of diclofenac eyedrops. Cornea. 1995. 14:623-627.
22. Greiner JV. A single LipiFlow Thermal Pulsation System treatment improves meibomian gland function and reduces dry eye symptoms for 9 months. Curr Eye Res. 2012. 37:272-278.
23. Matossian C. Impact of thermal pulsation treatment on astigmatism management and outcomes in meibomian gland dysfunction patients undergoing cataract surgery. Clin Ophthalmol. 2020. 14:2283-2289.
24. Finis D, Hayajneh J, Konig C, et al. Evaluation of an automated thermodynamic treatment (LipiFlow) system for meibomian gland dysfunction: a prospective, randomized, observer-masked trial. Ocul Surf. 2014. 12:146-154.

About the Author

Alice T. Epitropoulos, MD, FACS, is in practice at Ophthalmic Surgeons & Consultants of Ohio and The Eye Center of Columbus and serves as clinical assistant professor at The Ohio State University. Email her at eyesmd33@gmail.com.

Disclosures: Dr. Epitropoulos is a consultant for Allergan, Johnson & Johnson Vision, Novartis, Physician Recommended Nutriceuticals, SUN and TearLab, as well as other companies not relevant to this article.