Because ocular surface conditions such as dry eye can affect patients’ outcomes after cataract or refractive surgery, it’s important to establish a healthy ocular surface preoperatively. Notably, the recent PHACO study found that the incidence of dry eye in patients scheduled to undergo cataract surgery was higher than anticipated.1

This prospective, multicenter, observational study included 136 patients who were at least 55 years old and were scheduled to undergo cataract surgery. Patients’ mean age was 70.7 years. Most were Caucasian (73.5 percent), and half were women. Almost 60 percent had never complained of foreign body sensation. Most patients (62.9 percent) had a tear breakup time of five seconds or less, and 77 percent had positive corneal staining. Half of the eyes had positive central corneal staining, and 18 percent had a Schirmer’s score with anesthesia of 5 mm or less. These findings were definitely not what was anticipated in the standard cataract patient population that presents routinely to the office.

According to Robert Latkany, MD, who is in practice in New York City, preparing the ocular surface for cataract or refractive surgery requires a customized approach for each patient. “If you neglect the ocular surface in patients undergoing cataract or refractive surgery, outcomes will be compromised, and you will have fewer happy patients,” he says. “However, the drying effects of cataract surgery are not nearly as devastating or detrimental to the ocular surface as refractive surgery. So, I’d probably be a lot more aggressive in the refractive surgery patient than in the cataract patient. Unfortunately, there is no cookbook answer. I look at the eye and the anatomy and listen to patients’ complaints, and then I determine what I can do to ensure the best possible outcome.”

According to John Sheppard, MD, who is in practice in Norfolk, Virginia, the main difference between cataract and refractive patients is age. “Many refractive patients are disgruntled or unsuccessful with contact lens usage, so they have much more environmental, iatrogenic dry eye than elderly cataract surgery patients. Lifestyle changes, as well as managing contact lenses or eliminating them preoperatively, are an important component of the treatment plan,” he says.

Edward Manche, MD, who is in practice at Stanford University, agrees. “Cataract patients are often significantly older than refractive patients, often by several decades,” he says. “From that standpoint, treatment may be a bit different, but you still approach them with the same philosophy. However, older patients often have issues that a younger person might not have.”

Preoperative Management

According to Karl Stonecipher, MD, who is in practice in Greensboro, North Carolina, the ocular surface disease index is still a great screening tool for dry eye. “We put it out in our waiting area, and it’s part of our intake form,” he says. “If a patient scores in the normal range, we move on. If he or she scores mild, moderate or severe, it behooves us, whether it’s a cataract or refractive patient, to move to the next level. I’ve empowered my staff to do two simple things: tear breakup time and corneal staining. They’re trained to read and put into my EMR a staining pattern with fluorescein, a tear breakup time or a lissamine green stain.”

Dr. Stonecipher says that diagnosis is key, because he doesn’t want to measure patients until their dry eye has been treated. “I typically see patterns of dryness,” he notes. “Younger patients tend to have evaporative dry eye because they still have pretty healthy tear-film levels. At the same time, we’re definitely seeing meibomian gland disease present at a much earlier age. Perimenopausal women between the ages of 40 and 60 with dysfunctional lens syndrome are more likely to have aqueous deficiency. My older patients are all over the board. They can have an evaporative component, an aqueous component or a mixed-mechanism dry eye, and most of them do.”

According to Dr. Stonecipher, if a refractive surgery patient is severely dry, you may want to consider only operating on him or her during the summer, when there are higher humidity levels. Alternatively, patients can try cyclosporine or lifitegrast for four to six weeks to see if they improve. “I often use Restasis (cyclosporine ophthalmic emulsion, 0.05%; Allergan) or Xiidra (lifitegrast ophthalmic solution, 5%; Shire) for a month prior to testing and treatment to improve the ocular surface,” he says.

For younger refractive surgery patients, Dr. Stonecipher also is investigating the use of Epic Treatment (Espansione, Italy), which is a combination of intense pulsed light and low-level light therapy. It simultaneously treats the lower and upper eyelids with direct and indirect applications. The company claims it improves dry-eye symptoms after a few hours, as a result of the synergy of the two technologies helping meibomian glands resume production of the necessary lipids. “Although the mechanism of action is still debated, IPL primarily opens, heats and stretches the glands,” says Dr. Stonecipher. “The nice thing about the Epic System is that it’s a nogel IPL, so you don’t have to put gel around the eyes. You can do one quick treatment of IPL and then follow that with low-level light therapy, which is a photobiomodulation,” he says.

Dr. Stonecipher also expresses patients’ meibomian glands. “I have also just started to use TempSure (Hologic), which uses radiofrequency to heat the glands, [which is a treatment] for the more resistant patients who are not responding to the Epic system,” he explains.

Patients who continue to be resistant then undergo LipiFlow (TearScience) treatments. “We have a tier system because it’s all out-of-pocket. The cost is a little less for Epic versus TempSure versus LipiFlow. I think all of these systems have their pluses and minuses, but insurance doesn’t pay for any of this, which is an issue. LipiFlow costs, on average, $1,000 to $1,500 per treatment of both eyes, while the others are between $350 and $550 per bilateral treatment,” he notes.

IPL combined with meibomian gland expression has been found to safely and effectively treat meibomian gland dysfunction, according to a study that was published this summer.2 The prospective, randomized, doublemasked, controlled study involved 44 patients. One eye was randomly selected for IPL treatment, and the fellow eye was a control. Study eyes received three IPL treatments four weeks apart. IPL was applied directly on the eyelids, while the eye was protected with a Jaeger lid plate. Control eyes received sham IPL treatments, and both eyes received meibomian gland expression. Meibomian-glandyielding-secretion score, tear breakup time, standard patient evaluation of eye dryness (SPEED) and cornea fluorescein staining (CFS) scores all improved in the study eyes, while only SPEED and CFS scores improved in the control eyes. Changes in meibomian-gland-yielding-secretion score and tear breakup time were higher in the study eyes compared to the control eyes. Changes in SPEED and CFS scores were similar.

According to Dr. Sheppard, surgeons need to consider the ocular surface unit as a whole and look for more than just dry eye. Other things to consider are lid or lash abnormalities. “That’s very important. If there’s a lid abnormality, I’m not really interested in doing cataract surgery quite yet. If the seventh cranial nerve doesn’t function, then obviously there’s poor protection of the eye, and intelligent intervention is required. The fifth cranial nerve, of course, is the sensory nerve, and eyes with poor sensation heal very slowly, blink infrequently and develop a host of related problems. Obviously, if the tear production is low or the oil glands don’t produce well or are deficient— which we can now image—the ocular surface will be dysfunctional as well. Many of these conditions contribute to punctate keratopathy, which is desiccation of corneal epithelial cells that can render a patient uncomfortable, blur the vision and, more importantly, create bad measurements prior to cataract surgery. Bad measurements result in bad outcomes and unhappy patients,” he says.

Dr. Sheppard also assesses the patient for blepharitis and allergy. “Those tend to be either confused with dry eye or ignored in the presence of dry eye as a contributory condition,” he adds.

He notes that 75 percent of his patients presenting for cataract surgery have dry eye or a combination of ocular surface conditions that manifest as dry eye. “We create an intervention, and then we look to see that the critical central corneal epithelium is optically acceptable, clear and regular. We do that by confirming topographies, biometries, and even aberrometries of the visual system, looking for repeatability between methodologies. We’ll obtain three different measurements of the cornea in our cataract evaluation. If the astigmatic powers and cylinder axis are reproducible by different devices, we’re generally fairly satisfied that the patient indeed has accurate measurements and that he or she will produce an accurate calculation for intraocular lenses. So, we’re looking for consistency and repeatability of measurements before proceeding with cataract surgery,” he explains.

Postoperative Management

Some patients continue to experience or develop dry-eye symptoms after surgery. Dr. Stonecipher says that he sees five or six patients a month who have undiagnosed dry-eye disease post premium IOL or refractive surgery and who are extremely unhappy with their surgical outcome. “Most of the patients who come to see me for refractive surgery are young patients who have meibomian gland disease because they’re staring at their computers and phones all day,” he says. “I’m seeing increasing numbers of patients with severe evaporative dry eye, which is leading to their contact lens wear being compromised. Of my LASIK volume each month, approximately 20 to 30 percent of my patients fall into that category. That’s a significant number, and if I operate on those patients and make their problem worse, even if it’s temporary, it’s my problem and not their problem anymore. However, if you tune them up before surgery, you will have fewer unhappy patients.”

Training staff to read staining patterns can help the surgeon quickly identify ocular surface problems preop, experts say. Photo by Christopher Rapuano, MD

Dr. Sheppard adds that it’s important to remember that any surgical procedure worsens existing ocular surface disease or can create new ocular surface disease. “When patients have no idea that there were abnormalities present prior to cataract surgery and then suddenly they arise, a very difficult discussion ensues,” he says. “Therefore, warn patients about their pre-existing ocular surface conditions. Postoperatively, we definitely trigger more ocular surface disease and dry eyes because of the incisions, the lights and the microscope, the speculum holding the eye wide open, and all the medicines that patients are using.”

According to Dr. Manche, many cases of dry eye resolve on their own after refractive surgery. “Dry eye generally tends to get better on its own over time following keratorefractive surgery,” he says. “However, I try to think in terms of patient satisfaction as well as the speed of recovery, so I think it’s important to treat these patients. Depending on the severity of the dry eye and the external disease, you may have patients with chronic problems. It’s really important to treat patients, both preoperatively and postoperatively, to help minimize patient dissatisfaction and speed recovery. I’m pretty aggressive about treating patients both preand postoperatively.”

These surgeons agree that managing patient expectations is the key to a successful surgical outcome. According to Dr. Latkany, patients need to be wellinformed about what they’re getting into. “The unhappiest LASIK patients are those you’ve told that LASIK is just like a haircut, that they will see great, and nothing will happen,” he says. “Then, they have surgery, they experience dry eye and they panic. They never had this annoying feeling before, and no one told them about this. Then, they fixate on it and life becomes miserable. If we tell patients that the procedure can make them a little drier, they’re not as unhappy as the ones who seem blindsided and shocked by this new finding they never even knew could happen.”

The Future

Dr. Sheppard notes that we live in an interesting time for treating dry eye. “It’s a truly exciting field that we’re experiencing,” he says. “Twenty years ago, dry eye was neglected and, if considered at all, treated only with tear supplements. Now, we understand that a variety of factors contribute to ocular surface disease and dryness, and we can treat our patients with genuinely targeted intent,” he says.

Drs. Latkany, Sheppard and Manche have no financial interest in the products they mentioned. Dr. Stonecipher has consulted for Allergan, Espansione and Shire.

1. Trattler WB, Majmudar PA, Donnenfeld ED, et al. The prospective health assessment of cataract patients’ ocular surface (PHACO): The effect of dry eye. Clin Ophthalmol 2017;11:1423-1430.
2. Rong B, Tang Y, Tu P, et al. Intense pulsed light applied directly on eyelids combined with meibomian gland expression to treat meibomian gland dysfunction. Photomed Laser Surg 2018;36:6:326-332.