On this episode of Interventional Mindset, Preeya K. Gupta, MD, and Heather Weissman, MD, discuss ocular surface optimization prior to cataract surgery. Dr. Weissman is an ophthalmologist at Atlanta Ophthalmology Associates and specializes in cataract surgery, LASIK, PRK, advanced corneal transplantation, and corneal collagen cross-linking.
The importance of pre-surgical diagnosis
Diagnosing ocular surface disease (OSD) before surgery is critical. Many patients are asymptomatic or confuse dry eye symptoms—such as blurred or fluctuating vision—with cataract symptoms, and because of the poor association between signs and symptoms, it can be hard to diagnose.1
Drs. Gupta and Weissman discuss how undiagnosed dry eye symptoms and/or signs post-operatively can lead to dissatisfaction among patients,1 who in turn blame their surgeon. Identifying OSD beforehand helps them understand it as a chronic condition requiring long-term management rather than a temporary surgical complication.
“I think an ounce of prevention is even just highlighting to the patient that there are two concurrent disease processes," explained Dr. Gupta. "Cataracts are curable. We fix it, and they go away, but that's not how dry eye and MGD work. They're chronic conditions that are going to be a part of the patients' lives, whether they realize it now or later.”
Diagnostic tools and methods
Pre-operative workup for cataract surgery patients, even in the absence of significant symptoms, is key and includes:1
- Patient history: Asking specific questions about whether vision fluctuates throughout the day can help differentiate between cataract-related and ocular surface-related blur.
- Point-of-care testing: Tools such as osmolarity and MMP-9 testing are useful for screening, particularly for identifying disease in asymptomatic patients.
- Topography: Assess regular astigmatism and identify signs of dry eye in the Placido disc image or in the mires.
- Slit lamp exam: This is considered the most important yet underrated diagnostic tool for assessing the lids for meibomian gland dysfunction (MGD) and for using fluorescein stain to evaluate tear breakup time and corneal staining.
- Refraction: Inconsistent refraction can indicate dry eye, especially after cataract surgery.
Strategies for pre-operatively optimizing the ocular surface
While many patients can be managed with non-prescription, preservative-free artificial tears to ensure a lubricated surface before measurements, Dr. Weissmann prescribes medications such as XIIDRA (lifitegrast ophthalmic solution, Bausch+Lomb) or MIEBO (perfluorohexyloctane ophthalmic solution, Bausch+Lomb) for some patients with inflammation or evaporative dry eye, often starting treatment at least 2 to 4 weeks before taking surgical measurements.2
For patients seeking premium lenses, such as trifocal or toric IOLs, more aggressive OSD management is required because their visual expectations are higher.
“Those are the patients you really do want to be aggressive with, just because they will have the highest expectations going into cataract surgery," noted Dr. Weissman. "I always mention prior to doing the surgery, ‘I see dry eye on your exam. We're going to do our very best to rehabilitate your ocular surface prior to surgery, but this is likely going to be something you are managing after surgery.’”
Additionally, set expectations and inform patients that surgery may be delayed to obtain the most accurate measurements and achieve the best possible visual outcome.
Final thoughts
Cataract surgeons should consider screening patients for ocular surface dysfunction before surgery to ensure optimal post-operative visual outcomes and enhance patient satisfaction. The ASCRS Preoperative OSD Algorithm offers a useful downloadable guide and questionnaire that Drs. Gupta and Weissman utilize in their practices.
