Ocular surface optimization has become essential to achieving reliable surgical outcomes, particularly in the aging population, where ocular surface disease (OSD) and the need for ophthalmic surgery frequently overlap.1
Pre-existing OSD contributes to inflammation, tear film instability, structural changes, and reduced corneal clarity—all factors that complicate surgical planning and healing.1 Studies consistently show how widespread OSD is in pre-operative patients, with high rates of abnormal tear breakup time (TBUT), osmolarity, MMP-9, and corneal staining.1
As demonstrated by the PHACO study, close to 80% of patients presenting for cataract evaluation have visually significant OSD, and most of these patients do not have the traditional symptoms of dry eye.2 Patients often have visual symptoms, such as fluctuating vision, difficulty seeing at night, and eye fatigue.2
These findings highlight the importance of identifying and treating OSD early, even when symptoms are non-existent, subtle or atypical. By adopting a practical, multimodal approach, ophthalmologists and optometrists can stabilize the ocular surface, improve biometric accuracy, and deliver more predictable surgical results.1,3
We spoke to ophthalmologist Ranjan Malhotra, MD, and optometrist Cecelia Koetting, OD, FAAO, to gain further insight into this topic.
The nature of dry eye disease
The TFOS DEWS III defines dry eye as “a multifactorial, symptomatic disease involving loss of tear film/ocular surface homeostasis, characterized by instability, hyperosmolarity, inflammation, damage, and neurosensory issues.”
It is also characterized as chronic and progressive.4 One of the most complicated aspects of dry eye in pre-surgical patients, and in general, is that sometimes the symptoms don’t correlate with our clinical signs.
According to Dr. Koetting, “We know that OSD/DED is multifactorial, so oftentimes there are multiple underlying issues that may need to be addressed simultaneously.” Dr. Malhotra added, “I think dry eye is kind of a misnomer, because dry eye has a connotation of having to be felt. I feel like a better name for the disease could be dysfunctional tear or dirty tear disease.”
Impact of ocular surface optimization on ocular surgery
Streamlined, proactive ocular surface assessment offers one of the most effective ways to enhance visual outcomes and reduce post-operative complications, especially as patient expectations rise with premium IOL technologies.5
Dr. Malhotra points out that in patients with significant DED, approximately 70% of their vision loss is due to cataracts, while the remaining 30% is related to their dry eye. Therefore, even if he performs a perfect surgery, it will be only 70% successful if the dry eye is not identified and managed.
A study assessing how dry eye influences the reproducibility of keratometry (K) measurements in patients undergoing cataract surgery found that dry eye can reduce the reliability of these measurements, ultimately impacting the accuracy of intraocular lens power calculations.6
This underscores the need to identify both subjective and objective signs of dry eye and to implement effective treatment in order to prevent refractive errors resulting from inaccurate keratometry measurements. “If their eyes aren't dry and chapped, it makes the measurements for astigmatism and decision on the type of lens we're going to put in their eye much more accurate,” Dr. Malhotra said.
Dr. Koetting seconded this, noting, “If the ocular surface is inflamed and there is epithelial cell desiccation or the TBUT is low, this may lead to the incorrect lens being selected. These are crucial to being able to obtain a stable biometry reading.”
Assessing pre-operative patients for dry eye
Dr. Malhotra suggests a four-step approach to assessing patients for dry eye disease:
- Listen to the patient’s complaints and note:
- Fluctuating vision
- Worsening vision throughout the day
- Visual improvement through blinking
- Assess the quality of the surface, specifically:
- Tear film quality
- Is it clear or does it have an “Italian dressing” appearance?
- TBUT
- Is there evidence of superficial punctate keratitis (SPK)?
- Perform a tear osmolarity test to assess the tear film for:
- Electrolytes
- Minerals
- Salt
- Utilize topography to detect irregularities in the surface
Both clinicians also pointed out the importance of staining to provide visible evidence of corneal damage. Each also uses tear film osmolarity, as it has been shown in studies to increase variation of light scatter post-cataract surgery, which is also likely prior to surgery.7
They also suggest utilizing MMP-9 testing to understand whether there is an active inflammatory component so that an immunomodulator and/or topical corticosteroid may be indicated. In addition, Dr. Malhotra and Dr. Koetting employ topography to map the surface and reveal any irregularity in the surface, as well as meibography to assess the meibomian gland structure.
According to Dr. Koetting, “A slit lamp exam with vital dyes is invaluable. Evaluating the tear film stability (TBUT), tear meniscus height, corneal integrity, and meibomian gland function is the very minimum."
Addressing DED pre-operatively
Optimizing the ocular surface often requires a multitiered approach, including hygiene, over-the-counter eye drops, and prescription medications. Dr. Koetting begins with the basics: “In line with DEWS II and III, it is important to start with good daily habits and hygiene and build from there depending on the findings for each individual patient.”
To treat dry eye in her practice prior to patients moving on to surgery, she initiates baseline treatments with warm compresses to help improve meibum flow, lid hygiene with eyesafe and specific foam/wipes (i.e., Myze Daily wipe or The Foam, Zocufoam, Optase TTO wipe), and/or hypochlorous acid spray (i.e., Optase or Myze) to control bacteria and pH of the skin, as well as nutraceuticals.
She then recommends adding on a good preservative-free artificial tear to be used as needed by the patient, while considering lipid-based tears for patients who have MGD or poor meibum quality. She offers this advice: “Be specific in what brand you want your patient to use; otherwise, at the store, they will run into a wall of options and analysis paralysis.”
Along the same lines, Dr. Malhotra said, “I use a sodium hyaluronate-based tear (i.e., OPTASE, OASIS PLUS, BLINK, iVIZIA), which helps decrease evaporation and lower the osmolarity. In addition, I add MIEBO to treat evaporation.”
Both doctors and patients want to get OSD under control so that they can move forward with surgery, so time is a key factor. If there is an obvious issue, such as corneal staining, a prescription is likely needed. The same applies to a positive MMP, hyperosmolarity, and simply to decreasing the time between treatment and surgery.
The role of anti-inflammatory drops in dry eye management
Dr. Malhotra emphasized that all the dry eye algorithms—DEWS, CEDARS, ASPEN—recommend that if the patient has visually significant dry eye, they should be prescribed an anti-inflammatory (i.e., VEVYE 0.1%, XIIDRA, CEQUA 0.09%, RESTASIS 0.05%).8 Moreover, “To get patients out of the inflammatory cascade that they have entered, it is crucial to enlist a pharmaceutical therapy.”
He noted that though eyecare professionals have had commercially available cyclosporine for 23 years, in the past, burning from the prescribed drops was a major complaint, with up to 20% of patients reporting significant discomfort. In some cases, they complained that the treatment was more painful than the dry eye itself, making adherence to the treatment challenging.
Dr. Malhotra explained, “My anti-inflammatory of choice is VEVYE. It’s a cyclosporine-based inflammatory with the highest concentration of cyclosporine A (CsA) and the best tolerability because of its vehicle. The vehicle is a semifluorinated alkane (perfluorobutylpentane), which provides greater bioavailability with superior tolerability for the patient. I’ve found it has the least amount of burning and stinging of all the cyclosporine products available.”
However, both doctors revealed that, despite personal preferences, the patient’s insurance acceptance ultimately plays a role in the medication they prescribe.
Increasing compliance with patient education
One of the most daunting challenges is facing resistance from patients when they don’t feel any symptoms related to dry eye, such as redness, grittiness, tiredness, or itchiness.
For Dr. Malhotra, this is when quantifiable testing, imaging, and education come into play to increase compliance. First, he reveals the results of their testing and presents imaging of their slip lamp exam and tear film stability. He said, “I'm in Missouri, so I’ll say, ‘Since we're in the Show Me state, I want to show you how chapped and dry your eyes are.’”
He also points out to them how excessive salt in the tears, which can be seen in the imaging as having the appearance of “Italian dressing,” causes light to scatter, which can cause blurred vision, halo, and glare; these are often the symptoms that have led them to cataract surgery in the first place.
To further simplify the explanation, he uses the analogy of a car windshield that has become covered in salt in the winter, making it impossible to see. The only solution is to thoroughly clean the glass. Similarly, the ocular surface must be cleaned by using drops and medication.
Co-management considerations for pre-surgical dry eye patients
As the majority of cataract patients are co-managed both pre- and post-operatively, it is vital to have a seamless referral and aligned messaging. Dr. Koetting stated, “Communication and continued contact throughout the process and setting expectations with both the surgeon and the patient for how long it will take to stabilize is key.”
In Dr. Koetting’s pre-operative patient conversation, prior to handing off her patients to their surgeon, she emphasizes the importance of first addressing the ocular surface. “I make sure that they understand that dry eye could impact whether or not the correct lens is chosen. The other thing I let them know is that if we get them stable on the front end, they will do much better post-operatively, since we know that OSD/DED can worsen after cataract surgery.”
When asked what advice he would offer his optometry counterparts, Dr. Malhotra stated, “Before you're actually referring a patient to an ophthalmologist for the cataract, start looking for signs of dry eye—even if the patients don't have traditional symptoms of dry eye—and address it by both treating the signs and explaining to the patient how important it is to achieving optimal surgical results.
The post-operative paradigm
As mentioned in the section above, the most effective way to ensure that the ocular surface does not have to endure severe post-operative dryness and damage is to educate and treat in the pre-operative stage.
According to Dr. Malhotra, “Cataract surgery will get patients out of their spectacles and contacts (as their old prescription will no longer be accurate), which means their eyes will actually get drier after surgery. It’s literally from evaporation; their eyes hit the air more because they don't have glasses in front of them—they've lost their windshield. So, it's really going to make their post-operative vision and comfort significantly better, if dry eye is addressed ahead of time.”
Dr. Koetting added, “Stabilize on the front end and continue as much of the OSD treatments as you can post-operatively. Consider utilizing compounded post-operative drops to decrease the patient's exposure to significant amounts of preservatives.”
Conclusion
Ocular surface optimization is no longer optional—it is foundational to delivering the visual outcomes today’s cataract patients expect.
As the evidence and expert insights make clear, undiagnosed or undertreated OSD can compromise biometry, limit post-operative satisfaction, and reduce the overall success of an otherwise flawless surgery.
In closing, Dr. Malhotra stated concisely, “Addressing dry eye on their initial consultation before surgery improves refractive accuracy, healing time, and overall patient satisfaction.”
