Success in cataract and refractive surgery depends on more than surgical technique  and technology alone. Increasingly, attention is turning to the ocular surface, particularly the impact of dry eye disease on preoperative measurements, postoperative recovery, and patient satisfaction.^1-5

During Nordic Pharma’s recent webinar, Ocular Surface Control: A Modern Approach to Peri-operative Dry Eye Management, corneal specialists Sajjad Ahmad (UK) and Eric Donnenfeld (US) discussed why proactive dry eye management is becoming a central part of modern surgical care.

Their message was clear: identifying and managing ocular surface disease before surgery can help support more accurate diagnostics, smoother recovery, and better patient experience.

Why dry eye matters before surgery

Dry eye is one of the most common ocular surface diseases seen in patients presenting for cataract and refractive surgery.⁶ Yet many patients remain undiagnosed or undertreated prior to surgery.

Ocular surface disease (OSD) can significantly affect:^7-10

• Keratometry

• corneal topography

• biometry measurements

• intraocular lens (IOL) calculations

This becomes particularly important when patients are receiving premium IOLs or have high visual expectations.

Studies highlighted during the webinar showed that:

• up to 80% of cataract surgery candidates may have some degree of dry eye disease^11-13

• almost half of LASIK patients report transient dry eye symptoms prior to surgery¹⁴

Even patients with minimal symptoms may have clinically significant ocular surface disease that affects surgical planning and postoperative satisfaction.¹⁵

Prof Donnenfeld highlighted that surgery can often push these patients “over the edge,” transforming a borderline ocular surface into clinically significant postoperative dry eye that can ultimately affect patient satisfaction despite good visual outcomes.  These asymptomatic dry eye patients that become symptomatic following surgery view this as a complication of the procedure.

Surgery itself can worsen dry eye

Ocular surgery can further destabilize the ocular surface through:^3,16,17

• corneal nerve disruption

• exposure during surgery

• preserved medications

• topical anaesthetics

• postoperative drops

As a result, many patients who were previously asymptomatic may develop postoperative dry eye symptoms.¹⁸

This can lead to the so-called “unhappy 20/20” patient, individuals with excellent visual acuity who remain dissatisfied because of fluctuating vision, irritation, or ocular discomfort.¹⁹

The speakers emphasized that preoperative OSD screening is therefore essential, particularly for patients undergoing refractive procedures or considering premium implants.

Common assessments include:

• tear breakup time

• fluorescein staining

• meibomian gland evaluation

• corneal topography

• tear osmolarity testing where available

Ocular surface optimization strategies

Both speakers highlighted the importance of treating dry eye before surgery rather than reacting to symptoms afterwards.

Prof. Ahmad explained, dry eye management should be aligned to the recently published TFOS DEWS III guidelines¹, focusing on addressing the underlying disease process, including meibomian gland dysfunction, inflammation, tear film instability, and eyelid disease, rather than simply treating symptoms alone. This process often requires a multimodal treatment approach to effectively manage the disease.

Conventional management strategies may include:

• lubricants

• lid hygiene

• warm compresses

• nutritional support

• tear secretagogues

• treatment of Demodex blepharitis

• tear conservation / lacrimal occlusion

• topical anti-inflammatory therapy

• oral tetracyclines in selected patients

Patient education also plays an important role. Setting expectations around recovery, compliance, and ocular surface health can help improve the overall surgical experience.

Prof. Ahmad noted that surgeons may sometimes need to delay surgery temporarily in order to stabilize the tear film and obtain more reliable measurements, an investment that can ultimately support better refractive accuracy and patient satisfaction.

Where Lacrifill® Canalicular Gel may provide perioperative ocular surface control

The speakers suggested that sustained tear retention strategies may be especially relevant in perioperative patients, where maintaining a stable tear film is critical for accurate biometry and postoperative recovery. In this context, the webinar highlighted the role of Lacrifill® in ocular surface optimization. 

Lacrifill® is a cross-linked hyaluronic acid canalicular gel designed to temporarily occlude tear drainage for six months and retain the patient’s natural tears on the ocular surface.²⁰

Unlike traditional punctal plugs, the gel conforms to the canalicular anatomy and is designed to avoid issues such as extrusion, irritation, or biofilm formation associated with some plug-based approaches.

Prof. Donnenfeld discussed findings from the HaLF-DOME study, a prospective multicentre trial comparing Lacrifill® with a hydrogel plug in patients with dry eye disease.

According to the data presented, Lacrifill® demonstrated improvements in:²¹

• tear quantity

• tear film stability

• ocular surface health

• symptoms

Benefits were reported for up to six months following a single administration.

Expert perspectives

During the Q&A discussion, both clinicians described how ocular surface optimization has become increasingly integrated into their surgical workflow, particularly as patient expectations around refractive accuracy and postoperative comfort continue to rise.

Prof. Donnenfeld explained that, in his own practice, Lacrifill® has become “the cornerstone” of ocular surface management for surgical patients, reflecting a broader shift toward earlier intervention and proactive tear film stabilization before cataract and refractive procedures. He emphasized that achieving optimal surgical outcomes depends not only on the procedure itself, but also on the quality and stability of the ocular surface before measurements are even taken.

Both speakers highlighted the importance of identifying dry eye disease preoperatively, particularly in patients with subtle or borderline disease that may otherwise go unnoticed. Prof. Donnenfeld noted that, while Lacrifill® plays a broader role in perioperative ocular surface optimization across a range of dry eye severity in his practice, some of the greatest benefit may be seen in patients with a mildly compromised ocular surface, Individuals who may have minimal symptoms before surgery, but who are at risk of becoming significantly symptomatic afterwards if the tear film is not addressed proactively.

The discussion also reinforced the importance of expectation management. Prof. Donnenfeld remarked that “anything you diagnose preoperatively becomes an expectation; when you diagnose it postoperatively, it becomes your complication,” underlining why comprehensive ocular surface assessment is increasingly viewed as an essential part of surgical planning rather than an optional extra.

Prof. Ahmad similarly described how his own approach has evolved with greater experience using Lacrifill,® noting that he would now consider using it earlier in selected patients, particularly those experiencing postoperative dry eye following refractive surgery or those requiring prolonged postoperative topical therapy.

Both clinicians agreed that earlier ocular surface optimization may help surgeons achieve more reliable diagnostics, greater control over perioperative ocular surface management, smoother recovery, and a better overall surgical experience for patients.

 For more information on Lacrifill® – visit Lacrifill.info