Prepping the Ocular Surface for Cataract and Refractive Surgery

Failure to diagnose dry eye disease (DED) prior to a patient undergoing cataract or refractive surgery can result in incorrect biometry readings, unintended visual results, and worse DED postsurgery. This translates to a negative patient experience and can have a detrimental impact on our relationship with the patient. Since we are the gatekeepers of eye care, we need to be hypervigilant in diagnosing and managing DED prior to cataract and refractive surgery.

Here, I provide the action steps I follow to do so.

1. I DEDUCE EVERY PATIENT HAS DED

I realized early on in my 25-year career working alongside high-volume cataract and refractive surgeons that practically every patient I encounter has DED. What’s more, a recent study supports this, revealing that about one in 11 people worldwide has this chronic and visually impactful condition.¹ Therefore, every one of my precataract surgery and prerefractive surgery patients undergo a diagnostic assessment for DED.

2. I INQUIRE ABOUT DED SIGNS/SYMPTOMS

At the beginning of my time with these patients, I ask them some basic questions about how their eyes feel and the stability of their vision. I keep it simple and start by asking, “Do you feel any stinging, burning, itching, or discomfort, or do you notice any fluctuations in your vision?” I think we underestimate the presence of fluctuating vision as an early sign of DED. A standardized questionnaire, such as the Ocular Surface Disease Index-6, can also be beneficial.

3. I EMPLOY CORNEAL STAINING

I use staining to assess tear film stability and tear meniscus height and to watch for my nemesis, corneal staining. Tear osmolarity and ocular surface interferometer devices are also available to aid in tear assessment. The former reveals the loss of homeostasis on the ocular surface, while the latter indicates aqueous layer evaporation. Additionally, matrix metalloproteinase-9 testing can indicate tear film homeostasis loss, as the tears of patients who have severe DED have increased levels. Finally, it’s worth noting that several DED diagnostic combination devices are available that can offer objective data on blink dynamics, corneal topography, fluorescein imaging, ocular interferometry, meibography, tear meniscus height, and more.

4. I EVALUATE THE LIDS

I use a penlight and retroillumination of the meibomian glands to assess the lids for signs of meibomian gland dysfunction (MGD), such as gland tortuosity and dropout. Several meibographers are also available that enable us to spot the clinical signs of MGD. In addition to gland tortuosity, these clinical devices can also reveal gland dropout, dilation, gland density irregularity, obstructed gland orifices, and fibrotic or scarred areas of the glands.

5. I PRESCRIBE APPROPRIATE TREATMENT

Several DED treatments are available and evolving to manage the condition effectively, enabling our cataract and refractive surgery patients to have successful postoperative outcomes. These options can be directed at the specific cause of the patient’s DED (ie, lifestyle, tear insufficiency, eyelid abnormalities, inflammation, microorganisms, anatomic surface abnormalities, poor diet, or a combination thereof). The Tear Film & Ocular Surface Society’s Dry Eye Workshop III: Management and Therapy Report provides an in-depth look at all the interventions, along with a Prescribing Algorithm. (See www.ajo.com/article/S0002-9394(25)00274-0/fulltext.)

• Pro Tip. If the cataract or refractive surgery evaluation is scheduled sooner versus later, we should prescribe a fast-acting treatment, such as those that can provide significant improvements in signs and symptoms as soon as 2 weeks.

VIGILANCE IS CRUCIAL

In recognizing that ocular surface health is essential for patients to achieve a desired postop outcome, and considering that we are the eyecare gatekeepers, we must diagnose and treat DED before cataract and refractive surgeries. Thoughtful ocular surface optimization is paramount to successful outcomes. Failing to identify DED is not in the best interest of our patients.