November 2019


Managing Irregular Corneas Prior to Cataract Surgery
Algorithm and surgeons address OSD, DED before surgery

by Vanessa Caceres EyeWorld Contributing Writer

Dry eye inducing irregular astigmatism (over 2 D),
topography showing areas of drop out and loss of data (white area) and irregularity of placido rings

After treating DED, more regular topography and regular mires

Dry eye disease with diffuse punctate epithelial erosions (PEE)

Epithelial basement membrane dystrophy (EBMD) and punctate epithelial erosions; both conditions can reduce accuracy of preoperative measurements


Now more than ever, cataract surgery has become a type of refractive surgery, with patients expecting excellent vision postoperatively, especially when they’ve invested in premium IOLs.
Yet the presence of dry eye and/or ocular surface disease (OSD) can make this crisp uncorrected vision hard to achieve.
“Dry eye and ocular surface disease are an epidemic in our current society,” Marjan Farid, MD, said. “[They’re] multifactorial and related to increased screen time, the environment, hormonal impact, and ocular surgery. Being able to diagnose [dry eye and OSD] help to move the needle to treat these patients, especially because we offer premium cataract surgery now. Patients’ expectations are to have sharp vision, and we can’t have that without a pristine ocular surface.”
Although surgeons responding to ASCRS Clinical Surveys have acknowledged the importance of diagnosing and treating dry eye disease (DED), the majority also have said they do not have a uniform way to diagnose and treat DED, Francis Mah, MD, said.
In recent years, although other guidelines for DED have been created by the Tear Film and Ocular Surface Society, the American Academy of Ophthalmology, and the CEDARS/ASPENS group,1-3 none of these have focused specifically on treating OSD and DED before cataract or refractive surgery, Dr. Mah said.
This led the ASCRS Cornea Clinical Committee to create an algorithm for the preop diagnosis and treatment of OSD, published in the May issue of the Journal of Cataract & Refractive Surgery.4 The one-page algorithm guides users through noninvasive objective refractive and OSD assessments, an evaluation of symptoms via a novel questionnaire, the use of additional tests when available, a brief, directed clinical exam called “Look-Lift-Pull-Push” (LLPP), and targeted treatments before scheduling surgery.
“The ASCRS Algorithm is a novel streamlined protocol for integrating OSD identification and management within the context of the standard preoperative refractive surgery patient visit,” Christopher E. Starr, MD, said. “We created it with an emphasis on technician-driven, objective, in-office testing in order to ultimately reduce physician chair time and improve patient outcomes.”
“Whether one uses the algorithm faithfully, partially, or not at all, we recommend that all surgeons attempt to identify and address OSD before surgery,” Dr. Starr said. “Failing to do so could result in a wide variety of complications and patient dissatisfaction.”

Initial dry eye/OSD assessment

When honing in on DED symptoms, Dr. Mah starts out with a questionnaire. The algorithm shares a copy of the ASCRS SPEED II questionnaire, but surgeons can use other questionnaires that suit their needs, Dr. Mah said. Any questionnaire used should ask about dry eye in different ways, as patients may initially say no if you only ask, “Do you have dry eye?” “They won’t say they have dry eye, but they will say they have vision fluctuation or have some other way of commenting on the symptoms,” he said. If a patient has a positive response regarding symptoms, you can bill for some of the diagnostic tests.
At the office of Alice Epitropoulos, MD, technicians are empowered to perform point-of-care testing on symptomatic patients scoring above 6 on the SPEED questionnaire, she said.
The diagnostic tests for DED may vary from surgeon to surgeon, but there are similar themes. The algorithm advises the use of a tear osmolarity test and inflammatory marker (specifically, MMP-9). Those two tests have good data to back up their results, and they can be reimbursed, Dr. Mah said. Patients with abnormal tear osmolarity have been shown to have greater variability in their keratometry readings and IOL power calculations compared to normal osmolar patients.5
“If any one of those is abnormal, then there is a high likelihood of the presence of OSD and potentially visually-significant OSD,” Dr. Starr said.
Refractive tests commonly performed at the preoperative visit (e.g. keratometry, optical biometry, and topography) not only help in selecting the appropriate IOL, they also provide useful information on the status of the ocular surface. “When irregular astigmatism is present on topography, especially when ‘irregularly irregular’ astigmatism is seen or it fluctuates widely from test to test, then DED or another form of visually significant OSD would be highly suspected,” Dr. Starr said.
Some of these diagnostic tools, such as the topography, enable surgeons to see other ocular surface disorders, including pterygium, Salzmann’s nodules, and central corneal anterior basement membrane dystrophy (ABMD), said Brandon Ayres, MD. Topography also can warn surgeons about their prospective lens choice. “If I see irregular astigmatism on topography, then I’m not going to trust the keratometry and lens choice I’m getting on biometry. It’ll often lead me down the wrong path,” Dr. Farid.
Whether OSD is likely or unlikely, the algorithm advises that surgeons conduct a clinical exam using their handy mnemonic, LLPP. The algorithm also recommends at this point that surgeons may want to perform tear break-up time, corneal staining, and a Schirmer’s test.
Although that may seem like a large battery of tests to conduct, they are complementary in the quest to assess for cataract, dry eye, and astigmatism, Dr. Ayres added.
If OSD is ruled out after these tests, surgeons can proceed with their plans. If OSD is present, then treatment should take place preoperatively.

Treatment before surgery

If you see a patient with DED who is not having surgery, you may add treatments methodically. However, if it’s a preop patient who is eager to have a cataract removed, trying several treatments at once is often the way to go, according to the surgeons.
The ASCRS algorithm divides patients with OSD as having non-visually significant or visually significant OSD. The ones with visually significant OSD require more pre-treatment and may need to postpone their surgery.
“Never hesitate to delay surgery until the ocular surface is healthy enough,” Dr. Epitropoulos advised. Although the algorithm recommends waiting 2–4 weeks before starting treatment and repeating measurements, she will typically wait 4–6 weeks. Dr. Mah usually schedules surgery 6 weeks out.
The algorithm suggests reworking your way through the beginning of the algorithm when a patient returns after treatment. The goal prior to surgery is to either eradicate OSD completely or convert it from visually-significant to non-visually significant OSD via an aggressive treatment regimen targeting each OSD subtype.
Some ocular surface problems such as EBMD, floppy eyelid syndrome, or Salzmann’s nodules may require surgical interventions preoperatively when deemed visually-signifcant. However, if the patient has DED or MGD, more treatments are needed.
For aqueous-deficient dry eye, preservative-free artificial tears, over-the-counter gels and ointments, and an immunomodulator such as lifitegrast (Xiidra, Shire) or cyclosporine A (Restasis, Allergan) are often used, Dr. Mah said. Cequa (cyclosporine ophthalmic solution 0.09%, Sun Pharma), approved in the U.S. but not yet commercially available, may become a third possible option, he added. Some patients may require the immunomodulator chronically, even after surgery. A topical corticosteroid also may be used for a short time before surgery.
For patients with MGD and blepharitis, treatments such as warm compresses, lid scrubs, thermal pulsation, blepharoexfoliation, oral doxycycline or minocycline, topical antibiotics, intense pulsed light therapy, and tea tree oil may be used, according to sources. In addition to those treatments, Dr. Epitropoulos will recommend omega-3 supplements, particularly higher-quality ones that have been re-esterified and provide users with the full omega-3 dose available in the supplement, she said.
In severe dry eye, Dr. Farid will use serum eye drops or a PROKERA (Bio-Tissue), the latter of which provides a microenvironment for healing, she explained. Dr. Mah prefers to use serum or amniotic eye drops before using PROKERA.
Ocular allergies sometimes are also a problem to be addressed before surgery, Dr. Mah said.

Patient education

Patient education is a crucial part of any preop surgery prep, but it’s especially important when explaining to asymptomatic patients with DED why the condition may become symptomatic after surgery. This could involve the continuous use of agents like cyclosporine or lifitegrast or working toward better lid management.
“As a referral doctor, I see patients on a routine basis who complain about their quality of vision after surgery. They have good vision, but they are unhappy patients,” Dr. Ayres said. “They don’t understand how they went in feeling fine and then come out not feeling fine. Warning patients about the symptoms of dry eye will help them understand the problem.”

At a glance

• Dry eye and OSD are common problems before cataract and refractive surgery. Addressing these problems can help patients obtain better vision through surgery.
• A new algorithm developed by the ASCRS Cornea Clinical Committee addresses the diagnosis and treatment of DED and OSD preoperatively.
• The goal of treatment is to have non-visually significant OSD or no OSD present at all preop.
• Some patients may require treatment for DED even after surgery.

Relevant financial interests

: None
Epitropoulos: AbbVie, Alcon, Allergan, AMO, Biotissue, Johnson & Johnson Vision, PRN, Shire, SUN, Takeda, TearCare, TearLab, TearScience
Farid: Allergan, Bio-Tissue, CorneaGen, Dompe, Eyepoint, Eyevance, Johnson & Johnson Vision, KALA, Shire
Mah: Avedro
Starr: Alcon, Allergan, Blephex, Bruder, Dompe, Eyevance, Johnson & Johnson Vision,
Kala, Shire, Sun, TearLab, Quidel

About the doctors

Brandon Ayres, MD
Cornea specialist
Wills Eye Hospital

Alice T. Epitropoulos, MD
Ophthalmic Surgeons & Consultants of Ohio
The Eye Center of Columbus
Clinical assistant professor,
The Ohio State University
Columbus, Ohio

Marjan Farid, MD
Director, cornea, cataract,
and refractive surgery
Vice-chair of ophthalmic faculty
Professor of ophthalmology
Gavin Herbert Eye Institute, University of California, Irvine
Irvine, California

Francis Mah, MD
Scripps Health
La Jolla, California

Christopher E. Starr, MD
Associate professor of ophthalmology
Director, Cornea Fellowship, Refractive Surgery Service,
and Ophthalmic Education,
Weill Cornell Medicine, New York Presbyterian Hospital
New York


1. Jones L, et al. TFOS DEWS II management and therapy report. The Ocular Surface. 2017;15;3;575–628.
2. Milner MS, 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 1:3–47.
3. American Academy of Ophthalmology Cornea/External Disease Committee. Dry Eye Syndrome PPO. 2018. Available at:
4. Starr CE, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45:669–684.
5. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672–1677.

Contact information



Here are some highlights of what is recommended in the LLPP mnemonic described in the paper by the ASCRS Cornea Clinical Committee. Find more details in the algorithm paper.4
•Look at the blink quality and quantity, examine the eyelids, and look for signs of anterior and posterior blepharitis.
•Lift and pull up the eyelid to rule out superior EBMD and identify floppy eyelid syndrome and eyelid laxity, because these are often missed in exams.
•Push on the lower lid margin to express the meibum.

Algorithm and surgeons address OSD, DED before surgery Algorithm and surgeons address OSD, DED before surgery
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