Cataract surgery is one of the most commonly performed surgeries in the world. And, as the US population ages, this surgical volume is predicted to continue to increase.¹

With new innovations such as the femtosecond laser and presbyopia-correcting IOL technology, ophthalmologists are increasingly able to address patients’ refractive needs with cataract surgery. That said, dry eye disease (DED) is a common impediment to achieving optimal refractive outcomes. Roughly 50% of patients with cataracts are estimated to also have comorbid DED.²

Treating DED is important due to its widespread impact on quality of life. It is even more important to treat DED prior to cataract surgery because DED can influence refractive outcomes, increase in severity after surgery if not adequately addressed preoperatively and have a significant impact on postoperative patient satisfaction. DED diagnosed after cataract surgery is challenging to explain to patients, hence the need for proper identification and preoperative counseling.

In this article, we’ll discuss the importance of treating DED prior to cataract surgery, pearls for preoperative evaluation, perioperative treatment options, intraoperative considerations and postoperative treatment.

PATHOPHYSIOLOGY OF DED

Dry eye is one of the most cited patient complaints following cataract surgery.^3,4 The etiology of DED is multifaceted and is frequently categorized into aqueous deficient and evaporative subtypes. The former describes failure to produce enough of the water component of tears while the latter describes a deficiency in the lipid layer of the tear film. Most cases of DED likely have components of both.⁵

PREOPERATIVE EVALUATION

DED is likely being under detected by ophthalmologists prior to cataract surgery. The PHACO study found that more than 60% of patients scheduled to undergo routine cataract surgery had an abnormal tear film breakup-up time of less than 5 seconds and 77% had positive corneal staining at their preoperative visit, many of whom were asymptomatic.⁶ This underscores the importance of careful preoperative evaluation to intervene early and manage patient expectations, which we will discuss below.

History

Strategies for uncovering DED while taking patient history include:

• Assess for symptoms such as fluctuating blurry vision, redness, watering, burning, itching and eye fatigue.
• Inquire about other common risk factors for DED including: 1) systemic conditions such as Sjogren’s, rheumatoid arthritis, systemic lupus erythematosus, rosacea, diabetes mellitus and thyroid disease, 2) medications such as antihistamines, tricyclic antidepressants, selective serotonin reuptake inhibitors, diuretics, beta blockers, isotretinoin, gliptins, anticancer agents and preservative-containing eyedrops, 3) hormonal changes, 4) contact lens use, or 5) prior corneal refractive surgery.^7-9
• Use DED questionnaires such as the Ocular Surface Disease Index, Standard Patient Evaluation of Eye Dryness Questionnaire and the Symptom Assessment in Dry Eye to screen for at-risk patients¹⁰

Physical exam

At the slit lamp, evaluate for:

• Corneal and conjunctival integrity (aided with fluorescein or lissamine green stain)
• Tear film break-up time
• Tear film debris
• Tear lake/meniscus height
• Meibomian gland dysfunction
• Lid margin health (eg, frothiness, telangiectasias, chalazia)
• Lid laxity
• Blepharitis
• Conjunctivochalasis

Additional testing

Other tests to uncover DED include:

• Schirmer test — utilized for suspicious aqueous deficiency
• Tear osmolarity — in the setting of quick tear break of time or changing vision
• Matrix metalloproteinase-9, or MMP-9 — when inflammatory dry eye is suspected
• Corneal esthesiometry — if patient has cornea staining with minimal symptoms (stain without pain)
• Infrared meibography — if available for quick tear break of time or changing vision

Irregular tear film can influence estimates of corneal power and affect IOL calculations, toric axis and magnitude estimates, as well as topography. Inadequate treatment of DED can lead to residual myopia, hyperopia or astigmatism after surgery. Authors have previously shown that IOL power calculations can vary by as much as 0.5 diopters between visits in patients with an unstable tear film.¹¹

This is particularly undesirable in an environment where patients are increasingly paying out of pocket for premium IOLs and expectations are high. If the patient is noted to have untreated DED at preoperative evaluation, it is better to postpone surgery, stabilize the ocular surface first and then bring them back for repeat measurements.

PREOPERATIVE TREATMENT ALGORITHM

Educating the patient about the basics of DED and its impacts on eye health and surgical outcomes is paramount. In our practice, we commonly start by recommending the following measures to all patients prior to cataract surgery:

• Optimization of environmental factors. Reduce screen time, minimize exposure to cigarette smoke/allergens, hydrate frequently, avoid desiccating ambient conditions
• Eyelid cleansing (eg, with the use of tea tree oil or hypochlorous acid 0.01% cleansers). This not only improves dry eye symptoms, but also decreases risk of endophthalmitis after surgery in patients with blepharitis.
• Warm compresses and eyelid massage to facilitate meibomian glands expression
• Preservative-free artificial tears for ocular lubrication
• Contact lens holiday. Allow corneas to resume their normal shape (soft contact lenses should be stopped at least 3 days before IOL measurements and rigid contact lenses should be stopped for at least 2 weeks).

In addition to these measures, one or more additional treatments (see “Perioperative treatment options,” below) may need to be initiated to manage moderate or severe cases of dry eye preoperatively or to preempt decompensation in high-risk patients.¹² 

INTRAOPERATIVE CONSIDERATIONS

The following intraoperative factors have been shown to decrease tear film break-up time and mean goblet cell density: larger incisions, increased operation time, prolonged irrigation and greater duration of microscopic light exposure.¹³

In patients at high risk for postoperative DED, care should be given to mitigate the above risk factors as much as possible during surgery such as frequent intraoperative lubrication and care with placement and removal of lid speculum.

Lastly, intraoperative procedures such as cauterization of conjunctivochalasis, use of punctal plugs, or placement of intracanalicular stents with or without eluting drugs can assist with patients who have aqueous deficiency.

POSTOPERATIVE TREATMENT

In addition to continuing preoperative DED treatments on an as-needed basis, give care to tapering postoperative drops (topical antibiotics, steroids and nonsteroidal anti-inflammatory drugs) once they are no longer needed due to the detrimental impact of eyedrop use on goblet cell density.¹⁴ Newer treatment options such as intracameral medications, drug eluding stents or implants at the time of surgery can help ease the drop burden.

Also, continue to assess for ocular surface complications and recurrence of DED symptoms at routine postoperative follow-ups. Treatment options for postoperative ocular surface disease are similar to preoperative prevention.

CONCLUSION

Treating DED is important due to its widespread impact on quality of life, but it is even more critical to treat prior to cataract surgery. Educating the patient about the basics of DED and its impacts on eye health and surgical outcomes is also key.

A good place to start is by recommending the measures outlined in this article to your patients prior to cataract surgery. You can also refer to the perioperative treatment options (above) that are available to manage moderate or severe cases of dry eye preoperatively or to preempt decompensation in high-risk patients. OM

REFERENCES

1. Liu YC, Wilkins M, Kim T, Malyugin B, Mehta JS. Cataracts. Lancet. 2017;390(10094):600-612.

2. Chuang J, Shih KC, Chan TC, Wan KH, Jhanji V, Tong L. Preoperative optimization of ocular surface disease before cataract surgery. J Cataract Refract Surg. 2017;43:1596-1607.

3. Kasetsuwan N, Satitpitakul V, Changul T, Jariyakosol S. Incidence and pattern of dry eye after cataract surgery. PLoS One. 2013;8(11):e78657. Published 2013 Nov 12.

4. Gibbons A, Ali TK, Waren DP, Donaldson KE. Causes and correction of dissatisfaction after implantation of presbyopia-correcting intraocular lenses. Clin Ophthalmol. 2016;10:1965-1970. Published Oct 11, 2016.

5. Craig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo CK, Liu Z, Nelson JD, Nichols JJ, Tsubota K, Stapleton F. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15:276-283.

6. 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. 2017;11:1423-1430. Published Aug 7,2017.

7. Bron AJ, de Paiva CS, Chauhan SK, Bonini S, Gabison EE, Jain S, Knop E, Markoulli M, Ogawa Y, Perez V, Uchino Y, Yokoi N, Zoukhri D, Sullivan DA. TFOS DEWS II pathophysiology report [published correction appears in Ocul Surf. 2019 Oct;17(4):842]. Ocul Surf. 2017;15(3):438-510.

8. Kam KW, Di Zazzo A, De Gregorio C, Narang P, Jhanji V, Basu S. A review on drug-induced dry eye disease. Indian J Ophthalmol. 2023;71:1263-1269.

9. Sutu C, Fukuoka H, Afshari NA. Mechanisms and management of dry eye in cataract surgery patients. Curr Opin Ophthalmol. 2016;27:24-30.

10. Rapoport, Y. Essential dry eye diagnostics. Ophthalmology Management. digital.ophthalmologymanagement.com/articles/essential-dry-eye-diagnostics. Accessed Feb. 28, 2024.

11. 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.

12. Schechter B, Mah F. Optimization of the ocular surface through treatment of ocular surface disease before ophthalmic surgery: A narrative review. Ophthalmol Ther. 2022;11:1001-1015.

13. Oh T, Jung Y, Chang D, Kim J, Kim H. Changes in the tear film and ocular surface after cataract surgery. Jpn J Ophthalmol. 2012;56:113-118.

14. Li XM, Hu L, Hu J, Wang W. Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. Cornea. 2007 Oct;26(9 Suppl 1):S16-20.

Sumitra S. Khandelwal, MD, is a professor of ophthalmology at Baylor College of Medicine and medical director of the Lions Eye Bank of Texas. Disclosures: Dr. Khandelwal is a consultant to AbbVie, Bausch + Lomb and Viatris.

Sanchay Gupta, MD, MBA, is an ophthalmology resident at Baylor College of Medicine. He completed his MD/MBA at Harvard Medical School and Harvard Business School. Dr. Gupta reports no relevant disclosures.