Tremendous emphasis is placed on optimizing postoperative outcomes. From the precision techniques we perform to the advanced technologies we use, every detail is carefully considered to ensure the best visual results for our patients. Achieving these outcomes, however, starts well before the procedure itself. A healthy ocular surface has been shown to promote both tear film stability and vision.¹  

Addressing ocular surface issues before surgery improves the accuracy of our preoperative measurements. It also enhances intraoperative performance and sets the stage for long-term vision and patient satisfaction. Just as important, however, is how the ocular surface is managed in the postoperative period. A proactive approach to ocular surface health after surgery supports faster healing, reduces the rate of complications, and enhances overall visual quality,^2-4 ensuring that patients fully benefit from their surgical procedure.  

Transient But Disruptive

Surgical temporary ocular discomfort syndrome (STODS) is a transient but potentially disruptive disturbance to the ocular surface that occurs after cataract and refractive surgery. It is part of the normal healing process and affects patients to varying degrees.⁵ STODS typically lasts a few days to weeks. Rarely, it can extend beyond a year.

Characterized by temporary discomfort, visual disturbances (such as blurred vision and fluctuating acuity), and patient dissatisfaction with their surgical outcome, STODS is distinct from dry eye disease (DED). Unlike DED, a chronic condition that develops over years, STODS is typically an acute response to surgical trauma with symptoms that eventually resolve. Researchers postulate that STODS is caused by the transection of the corneal nerve plexus and attenuated by the upregulation of inflammatory mediators, as well as other factors.⁶ Corneal nerve fiber bundles that are transected after procedures like cataract surgery and LASIK have been shown to return within 1 year postoperatively.

Certain patients are at risk for developing STODS. In particular, those with pre-existing dry eye are at increased risk. The literature shows that up to 80% of patients have clinically significant ocular surface disease before surgery and that only 22% of these are diagnosed cases.³

Additional risk factors include:

• Age-related changes to the tear film
• Collagen vascular disease
• Systemic conditions requiring medications that affect tear production
• Hormonal changes, such as those in menopausal and perimenopausal individuals
• A history of ocular surgery that disrupted corneal nerve function.

Given that a stable tear film is essential for both preoperative diagnostics and postoperative vision⁷ (see box below), addressing these risk factors before surgery is critical and may help to reduce the severity of STODS.

Minimizing STODS

A thorough ocular surface assessment should be a standard component of preoperative planning for any ocular surgery procedure. I like to include tear breakup time, tear film osmolarity testing, meibography, and ocular staining with fluorescein and lissamine green dye as mainstays in the preoperative assessment. Additionally, a thorough examination of the base of the eyelashes to look for signs of blepharitis, including Demodex, is important. The patient should be asked to look both downward and straight ahead. Demodex blepharitis is often seen in conjunction with DED and can increase symptoms.⁸

I also evaluate patients for punctate epithelial erosions and low tear lakes with desiccation; excessive, frequent, or incomplete blinking; skin manifestations of rosacea; and blepharitis, lagophthalmos, and eye rubbing. I ask patients about contact lens use, typical ocular comfort, and symptoms of dry eye to help guide the examination.

When tear film abnormalities are detected, proactive treatment with one or more of the following is initiated before proceeding with surgery:

• Artificial and lipid-based tears
• Punctal occlusion in cases of aqueous deficiency
• Anti-inflammatory therapies such as cyclosporine, lifitegrast, and short-term corticosteroids
• Warm compresses and lid hygiene in the presence of meibomian gland dysfunction
• In-office treatments like intense pulsed-light and thermal pulsation therapy for more severe cases.

Such tactics can help minimize the risk for STODS, but patients should also be cautioned that it may still occur depending on the type of surgery they undergo, their postoperative healing response, and environmental factors. For patients undergoing cataract surgery, I explain that multifocal and extended depth of focus lenses are extremely sensitive to ocular surface disease, and they are more likely to experience variability and dissatisfaction with their vision if their disease is not under control.

Intraoperative Considerations

Even with a comprehensive approach to managing the ocular surface pre-
operatively, some patients may still experience STODS. Surgical technique has been shown to contribute to ocular surface health. The following intraoperative considerations can help minimize disruption to the ocular surface:

• Incision size. A smaller corneal incision in both cataract and refractive surgery procedures has been shown to disrupt the corneal nerves to a lesser extent compared to larger incisions.^7,9
  
  
• Duration of surgery and surgical setting. A longer operating time, the bright light and heat from microscope illumination, and use of a lid speculum can impact the ocular surface after surgery and potentially exacerbate symptoms.¹⁰ A precise and efficient workflow is therefore critical.

Postoperative Management

The proactive use of a high-quality, over-the-counter tear after ocular surgery should help mitigate the onset of STODS. The tear should be designed to relieve the dryness and discomfort associated with mild to moderate DED, and should be formulated with the following characteristics:

• A physiologic pH
• The capability to reduce cellular oxidative stress and edema
• Enhanced viscosity for good surface lubrication and prolonged contact time

The diagnosis of STODS relies on a combination of patient-reported symptoms, clinical examination, and diagnostic testing. I tend to focus on uncorrected and best-corrected image quality in addition to visual acuity. If clarity of vision improves with frequent blinking and if a patient perceives their vision to be dull despite good visual acuity, tear film instability is suspected. Objective tests such as tear film osmolarity, meibography, corneal and conjunctival staining, and expression of the meibomian glands help confirm the diagnosis.

For patients who develop STODS, a combination of treatments can help restore ocular surface health. I typically start with preservative-free artificial tears, ocular lubricants, and night-time ointments. While these agents provide relief, they do not restore ocular surface perturbations. A combination with other treatments—including short-term use of topical steroids and immunomodulators, punctal plugs, and neurostimulation devices—may be useful. 

Lifestyle changes are also helpful. I encourage patients to use a humidifier and reduce the use of overhead fans, at least until symptoms clear. As with DED, prolonged reading and screentime can also exacerbate STODS symptoms. The use of a blue-light filter on screens, warm compresses, and eyelid scrubs may also provide some symptomatic relief.

Conclusion

STODS, typically transient, can negatively impact patient satisfaction and surgical outcomes. Surgeons can reduce patient burden by identifying at-risk patients; optimizing the ocular surface before surgery; adopting surgical techniques that minimize disruption to the ocular surface; and managing postoperative symptoms proactively. OM

References 

1. D’Souza S, Annavajjhala S, Thakur P, Mullick R, Tejal SJ, Shetty N. Study of tear film optics and its impact on quality of vision. Indian J Ophthalmol. 2020;68(12):2899-2902. doi:10.4103/ijo.IJO_2629_20

2. Barabino S, Labetoulle M, Rolando M, Messmer EM. Understanding symptoms and quality of life in patients with dry eye syndrome. Ocul Surf. 2016;14(3):365-376. doi:10.1016/j.jtos.2016.04.005

3. 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 2017 Aug 7. doi:10.2147/OPTH.S120159

4. Donthineni PR, Das AV, Shanbhag SS, Basu S. Cataract surgery in dry eye disease: visual outcomes and complications. Front Med (Lausanne). 2020;7:575834. Published 2020 Oct 7. doi:10.3389/fmed.2020.575834

5. Hirabayashi MT, Barnett BP. Solving STODS-surgical temporary ocular discomfort syndrome. Diagnostics (Basel). 2023;13(5):837. Published 2023 Feb 22. doi:10.3390/diagnostics13050837

6. Lee BH, McLaren JW, Erie JC, Hodge DO, Bourne WM. Reinnervation in the cornea after LASIK. Invest Ophthalmol Vis Sci. 2002;43(12):3660-3664.

7. Mohamed-Noriega K, Riau AK, Lwin NC, Chaurasia SS, Tan DT, Mehta JS. Early corneal nerve damage and recovery following small incision lenticule extraction (SMILE) and laser in situ keratomileusis (LASIK). Invest Ophthalmol Vis Sci. 2014;55(3):1823-1834. Published 2014 Mar 25. doi:10.1167/iovs.13-13324

8. Recchioni A, Sisó-Fuertes I, Hartwig A, et al. Short-term impact of FS-LASIK and SMILE on dry eye metrics and corneal nerve morphology. Cornea. 2020;39(7):851-857. doi:10.1097/ICO.0000000000002312

9. Ishrat S, Nema N, Chandravanshi SCL. Incidence and pattern of dry eye after cataract surgery. Saudi J Ophthalmol. 2019;33(1):34-40. doi:10.1016/j.sjopt.2018.10.009

10. Kato K, Miyake K, Hirano K, Kondo M. Management of postoperative inflammation and dry eye after cataract surgery. Cornea. 2019;38:S25-S33. doi:10.1097/ICO.0000000000002125 

Vance Thompson, MD, is founder of Vance Thompson Vision, which has locations in Minnesota, Montana, Nebraska, North Dakota, and South Dakota. Dr. Thompson is a consultant/advisor to AdOM, Alcon, Bausch + Lomb, eyeBrain Medical Inc., Eyedetec, Eyesafe, Johnson & Johnson Vision, Nordic Pharma, Rayner, Singular Strategies, Stuart Therapeutics, Surface Pharmaceuticals Inc., Tarsus, and Zhaoke. He is a researcher for Alcon, Bausch + Lomb, Johnson & Johnson Vision, and Rayner. Dr. Thompson has stock options in AdOM, eyeBrain Medical Inc., Eyedetec, Eyesafe, Fontana Biosciences, Rayner, Stuart Therapeutics, Surface Pharmaceuticals, and Tarsus. He is an equity owner in Bausch + Lomb, Johnson & Johnson Vision, and Singular Strategies.