Not every complaint about a premium intraocular lens (IOL) traces back to the lens itself. A gentleman who’d undergone cataract surgery at another clinic came to our facility after researching his IOL’s FDA study data, performed by our center.
This patient equated his dissatisfaction with surgical failure and requested explantation of his trifocal lens. Though his refraction was accurate, his capsules were clouded and his tear film compromised. This individual's frustration stemmed not from lens selection but an unmanaged ocular surface.
His experience illustrates a diagnostic principle too often overlooked in premium IOL practices: the tear film accounts for roughly 80% of the eye's total refractive power, meaning a compromised ocular surface can undermine even a perfectly executed multifocal implant.1
Case: Diagnosing dissatisfaction after trifocal IOL
Background: A 72-year-old male requested explant of his trifocals.
- VA (UCVA): 20/30 OU
- Manifest Refraction:
- OD: +0.50-1.00 X 134 20/25
- OS: +0.50-1.25 X 172 20/25
- Tear Osmolarity
- OD: 320
- OS: 322
- Examination: Slight redness with no staining and 1-2+ PCO OU
Reframing the conversation chairside
Before recommending a course of action, I needed to show him—not just tell him—what explantation would actually mean for his vision. I explained that I did not recommend removing the trifocal IOLs and used a −3.00D lens over his eyes to demonstrate what his near vision would look like without them.
I asked him, “If you end up like this but using glasses for near or doing monofocal monovision for near, which blurs distance, will you be okay?” I confused him, and he responded, “Doctor, I started this because I don’t want to wear glasses for reading and I don’t want a blurry distance and I am frustrated…what do you suggest I do?”
His response made clear that the trifocal had been the right choice for his goals—he simply needed help getting there. I told him I was confident his treatment plan would deliver that, but that the outcome would depend on his risk tolerance and patience while we optimized his optical system.
The cost of skipping the pre-operative OSD discussion
This case underscores how much a different conversation before surgery could have changed his experience. Had we discussed, pre-operatively, the importance of a healthy tear film working in concert with the IOL—and that we would proactively manage his tear film after surgery, something no prior provider had done—he would have understood the plan from the outset.
This would have increased his comprehension of why capsular clarity, residual astigmatism, and neural adaptation all mattered, and that the original trifocal studies showed higher satisfaction when tear film health, refractive error, and capsular clarity were optimized, compared to monofocal outcomes. He would also have understood that converting from trifocal to monofocal is not a simple swap.
“It was my job to optimize his eyes first, so his brain could adapt second—framed that way, he would have seen the plan as complete rather than incomplete.”
My recommendation: Treat his dry eye and perform bilateral YAG capsulotomy.
Follow-up post-YAG
At his follow-up:
- UCVA: OU 20/25
- Manifest Refraction:
- OD +0.50-1.00 X 131 20/20 “crisp”
- OS +0.50-1.25 X 172 20/20 “crisp”
- Tear Osmolarity:
- OD: 302
- OS: 300
- Examination: No staining and capsules clear
With both eyes now near plano on spherical equivalent, I performed bilateral astigmatic keratotomy. I encouraged him to follow up with his original surgeon so that the surgeon could see the improved outcome, but he declined. Instead, he followed up with a new provider, whose report indicated that he was satisfied with his vision.
Why the tear film outweighs the implant
TFOS DEWS III defines dry eye as “a multifactorial, symptomatic disease characterized by a loss of homeostasis of the tear film and/or ocular surface, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities are etiological factors.”2 So how does dry eye affect optics?
The tear film and the anterior surface of the eye contribute ~80% of the eye's refractive power, making them the most significant focusing elements.1 Because of the index of refraction and Snell's Law, it is the most powerful focusing element of the eye, mainly because of this difference in refractive index going from the air to the tear. As clinicians, we need to understand the physiology of tears and how to assist patients therapeutically to maximize their optical benefits.
An irregular tear film induces high-order aberrations and fluctuating vision.1,3 Those high-order aberrations, image distortion, and fluctuating vision are all happening in that three-micron layer,4 and we can show this on our exams with topography. From experience, treating the tear film pre-operatively can significantly reduce these corneal aberrations.
Tear anemia: The overlooked pre-operative workup
Although tears lack red blood cells and platelets, they carry over 1,500 proteins, 150 lipid species, glucose, nutrients, and oxygen, while providing anti-inflammatory, antifungal, antiviral, and antibacterial protection,5 making them "blood of the cornea.” This is why serum tears work so well. Supplementation provides external support, but treatment provides biological correction.
In general surgery, blood tests are performed to assess for anemia, and, if necessary, treatment is administered before surgery. A similar approach should be taken for patients with ocular surface disease (OSD). I refer to a low tear film as "tear anemia," and it is important to address this condition prior to surgery.
Identifying the source before treating the symptom
One question that I have pondered throughout my career is which appeared first: inflammation or OSD? I think dry eyes developed first, since tears act as mild steroids due to their anti-inflammatory properties.
All cataract patients should be screened using diagnostic tests such as tear osmolarity testing, staining, and meibography.6 The tear film is guilty until proven innocent, and that's because so many people are asymptomatic, and that's why we need to test everybody to not wait for symptoms.
Dry eye can result from multiple causes. For example, modern activities such as "near work" and screen time significantly reduce blink rates, leading to dehydration of the corneal surface.7 Furthermore, lid margin infestations, such as Demodex, can cause meibomian gland dysfunction, leading to tear film breakdown and blurred vision.8
Artificial tears are an artificial treatment, and it’s imperative to address the root cause of dry eye and help them produce more tears. Treatments such as punctal plugs6 and Demodex therapies, such as lotilaner ophthalmic solution 0.25% (XDEMVY, Tarsus Pharmaceuticals), help the body restore its natural tear film.8
The importance of explaining STODS
Cataract surgery involves cutting through corneal nerves, and nearly all patients experience temporary dryness afterward, a condition known as surgical temporary ocular discomfort syndrome (STOD).9 If patients are not informed about this beforehand, they may unintentionally blame the surgery for their dry eyes.
When patients believe that their symptoms are a direct result of the surgery, they often overlook pre-existing conditions such as dry eyes or floaters. It is crucial to ensure that patients understand these issues before the procedure.
I now make it a point to inform every patient about their dry eyes and floaters, highlighting the importance of addressing these conditions. During our meetings, I focus not only on listening to their concerns but also on observing their blink rate. It is essential to frame the improvement of the tear film as a collaborative effort that combines the surgeon's physical interventions with the brain's neural adaptation.
The takeaway
The tear film is not a footnote to premium IOL surgery—it is the lens patients see through first. My patient didn't need a different lens; he needed a healthier ocular surface and a conversation that came before his frustration, not after.
Screening for ocular surface disease, treating "tear anemia" pre-operatively, and setting expectations about post-operative dryness turn a preventable complaint into a satisfied outcome.
