June-July 2020


Ocular Surface Considerations For Surgery
Addressing dry eye prior to cataract surgery

by Ellen Stodola Editorial Co-Director

Surface qualifier images from the Cassini (Cassini Technologies) showing missing and irregular lines consistent with an unstable tear film

Placido disc images from OPD-Scan III (Nidek) showing irregular and warped mires consistent with an unstable
tear film
Source (all): Cynthia Matossian, MD

Visually significant corneal staining is common prior to cataract surgery, but patients are often asymptomatic.
Source: Christopher Starr, MD

When performing cataract surgery, it’s important to ensure the patient’s ocular surface is optimized prior to surgery, and this often means addressing the problem of dry eye.
“Dry eye disease is extremely commonplace, and most of the patients who are in the age group for cataract surgery have a component of dry eye disease,” said Cynthia Matossian, MD.
As such, she continued, it’s incumbent on the cataract surgeon to look for and diagnose dry eye disease when evaluating a patient for cataract surgery. Dr. Matossian stressed that it’s important to educate these patients that they’re dealing with more than one disease: One is the cataract, which can be cured by taking the lens out and replacing it with an implant, and the other is dry eye, which is ongoing and progressive.

Prevalence of dry eye

Dry eye disease is underdiagnosed and undertreated, said Alice Epitropoulos, MD. It is estimated that 30 million adults in the U.S. report symptoms without a formal diagnosis, and an estimated 16 million adults in the U.S. have been diagnosed, she said. 
Many patients who come in for a cataract surgery consult have poor vision and think it’s 100% caused by the cataract, said William Trattler, MD, but in reality, many have dry eyes that’s contributing to their complaints of blurred vision.
The scope of this problem is huge, said Christopher Starr, MD. “One could argue that when you combine dry eye and ocular surface disease, it’s ubiquitous,” he said. “If you look for it, you’ll find it in almost everyone, especially in the cataract age group.” However, he noted that it doesn’t necessarily mean that it’s visually significant in everyone.
Based on a paper Dr. Starr co-wrote in 2018, he said the overall prevalence of dry eye and ocular surface disease in cataract patients is about 80%.1
Another factor is that many patients are asymptomatic, so symptoms may not be the best tool to diagnose dry eye. Dr. Starr noted that his study also found a tremendously high prevalence in patients who are completely asymptomatic on questionnaires; in the asymptomatic group, 85% had at least one abnormality in either tear osmolarity or MMP-9, and almost 50% of those patients had abnormalities on both osmolarity and MMP-9. The signs can be there despite symptoms, and it’s the signs, like corneal staining, that can be visually significant, he said.
Dr. Epitropoulos mentioned the PHACO study by Trattler et al., which found that 77% of patients being evaluated for cataract surgery had corneal staining, and 63% of patients had an unstable tear film (rapid tear breakup time).2


There are a number of diagnostics available when it comes to identifying dry eye.
Dr. Starr citied a paper published in the Journal of Cataract & Refractive Surgery by the ASCRS Cornea Clinical Committee, which presented consensus guidelines on how to approach ocular surface disease in pre-cataract patients.3 It included a recommended ocular surface disease screening battery utilizing both a novel symptom questionnaire and objective point-of-care testing for signs (tear osmolarity and MMP-9). The questionnaire incorporates elements from the SPEED and Dell IOL questionnaires and adds other scoreable elements for identifying non-dry eye disease ocular surface disease subtypes and their visual significance.
Dr. Starr said the combination of using tear osmolarity and MMP-9 and the questionnaire can tell the physician a lot about whether ocular surface disease is present, how severe it is, and how visually significant it is. He thinks osmolarity is a good dry eye test, and the magnitude of the abnormal osmolarity test is linearly related to severity of dry eye. He thinks MMP-9 is a great adjunct as well, not just for dry eye disease but also for other subtypes of ocular surface disease that lead to inflammation.
Dr. Matossian said that even if the doctor does not have diagnostic tests readily available, a basic slit lamp and two vital dyes that every practice can easily obtain, lissamine green and fluorescein, can tell a lot about the surface. She added that looking at the glands, eyelid margins, meibomian gland orifices, and staining the conjunctiva and cornea will tell a lot of the story.
Dr. Trattler said he uses a slit lamp exam to diagnose dry eye. He examines the tear volume and degree of corneal staining. He will perform a subjective tear breakup time to evaluate the quality of the tear film. He also reviews the topography of patients scheduled for surgery, noting that irregular topography can potentially be a sign of dry eye. Dr. Trattler also evaluates the eyelids for MGD and blepharitis.
Dr. Starr recommends the quick and directed yet thorough “look, lift, pull, push,” or LLPP, ocular surface exam for all patients undergoing surgery.


If the focus is stabilizing the tear film as quickly as possible prior to cataract surgery, Dr. Matossian’s treatment is intentionally more aggressive to get the patient to that level quickly as opposed to treatment for the chronic, long-term period post-cataract surgery.
To get the surface tuned up, first educate the patient or they won’t be compliant, she said. Next, start the patient on oral omega-3 supplements, a heated, microwaveable mask, and preservative-free artificial tears. They will continue with all of these post-surgery.
She uses a short-term steroid BID for 2 weeks to get the surface optimized, but this is discontinued after cataract surgery.
Dr. Matossian recommends a treatment like LipiFlow (Johnson & Johnson Vision) or a combination of LipiFlow and BlephEx to evacuate the meibomian glands and exfoliate the biofilm on the lid margin to achieve a more stable tear film as quickly as possible in preparation for surgical measurements.
Dr. Trattler said it’s important to determine if you’re dealing with evaporative or aqueous deficient dry eye. For aqueous deficient dry eye, he typically treats with topical steroids short term and often starts long-term therapy with Restasis (cyclosporine, Allergan), Xiidra (lifitegrast, Novartis), or Cequa (cyclosporine, Sun Pharma). He also considers whether a punctal plug might be helpful to raise the tear film.
Dr. Trattler said that if the patient has blepharitis, he would treat with topical steroids to help quiet inflammation, along with hypochlorous acid spray and warm compresses. If patients aren’t responding well, he discusses additional therapies with them including LipiFlow or TearCare (Sight Sciences).
While there is no rigid standard of care for treatment, Dr. Starr said there are a lot of treatment recommendations based on severity and subtype. Treatment recommendations put forth by the ASCRS Cornea Clinical Committee largely follow the TFOS DEWS II treatment recommendations, with the difference being that you may have to act a bit more aggressively in a pre-surgical patient.
Dr. Starr noted the identification of both visually significant ocular surface disease and non-visually significant ocular surface disease. Many will have non-visually significant ocular surface disease, he said, which doesn’t necessarily require you to cancel surgery and do aggressive treatment. However, it’s important for the patient to be aware of this prior to surgery. If you don’t tell them prior to surgery and it gets worse afterward, it’s considered a complication, he said.
Meanwhile, visually significant ocular surface disease needs to be treated and reversed prior to surgery, Dr. Starr said, which can delay the surgery.
Dr. Epitropoulos said she’s had excellent results reducing inflammation with immunomodulators, often in conjunction with a short course of a steroid and high-quality omega-3 supplements. It’s important to unblock the glands, especially prior to cataract or refractive surgery, and this can be done by heating and evacuating the glands with thermal pulsation treatment or using a handheld instrument that delivers light energy to soften blockages of the meibomian glands. Results are maximized when combined with microblepharoexfoliation, she said.

Dry eye and premium lenses

Dr. Trattler said that premium lenses, especially presbyopia-correcting lenses, can be sensitive to residual astigmatism. Physicians have to be sure that they are getting accurate measurements so that the optimal lens power is selected, he said. This typically requires aggressive treatment of MGD and dry eye first to obtain good measurements. Dr. Trattler also mentioned the Light Adjustable Lens (RxSight), where the measurements and in-lens refractive treatments are done 3–4 weeks after surgery. For patients that receive these lenses, it’s important to pretreat and optimize their ocular surface and continue this treatment until the lens power is locked in.
“Especially for patients who are paying out of pocket for a premium lens, we need to nail that refractive outcome, otherwise we’re going to have an unhappy patient,” Dr. Matossian said. Their expectation is beyond perfect because they’re paying thousands of dollars, she added, so tuning up the surface to get more reliable information is important, especially in a subset of patients seeking less dependence on spectacles. If they have very severe dry eye disease with an underlying chronic medical condition, they may not be a candidate for a presbyopia-correcting implant, and they would have to be educated as to why they’re not a good candidate, Dr. Matossian said.

At a glance

• Millions of people in the U.S. have some form of dry eye. Not all dry eye is visually significant or symptomatic.
• It’s important to diagnose dry eye and determine its potential impact prior to surgery. Patient questionnaires can be used, as can osmolarity and MMP-9 testing and slit lamp examination and staining.
• Treatment options vary for dry eye but could include oral omega-3 steroids, a heated mask, preservative-free artificial tears, steroids, mechanical treatments, and punctal plugs. Some of these treatments may need to be continued postop as well.

About the doctors

Alice Epitropoulos, MD

Clinical assistant professor
of ophthalmology
The Ohio State University
Columbus, Ohio

Cynthia Matossian, MD
Matossian Eye Associates
Doylestown, Pennsylvania

Christopher Starr, MD
Associate professor
of ophthalmology
Weill Cornell Medicine 
New York, New York

William Trattler, MD
Director of Cornea
Center for Excellence
in Eye Care
Miami, Florida


1. Gupta PK, et al. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018;44:1090–1096.
2. Trattler WB, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423–1430.
3. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669–684.

Relevant disclosures

: Novartis, Allergan, Sun, Johnson & Johnson Vision, PRN, BlephEx
Matossian: Johnson & Johnson Vision, Quidel, TearLab, Bruder, PRN, BlephEx
Starr: Allergan, Novartis, Alcon, Johnson & Johnson Vision, Dompe, BlephEx, Bruder, TearLab, Quidel, Sun, Kala, Eyevance
Trattler: Allergan, Novartis, Sun, Sight Sciences, Johnson & Johnson Vision, Bausch + Lomb, NovaBay, Alcon


Epitropoulos: eyesmd33@gmail.com
Matossian: cmatossian@matossianeye.com
Starr: cestarr@med.cornell.edu
Trattler: wtrattler@gmail.com

Addressing dry eye prior to cataract surgery Addressing dry eye prior to cataract surgery
Ophthalmology News - EyeWorld Magazine
283 110
220 165
True, 6