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Subspecialties Cornea / Ocular Surface, Comprehensive, Practice Management

Superior Surface Skills

As ophthalmologists, we strive to meet outcomes that match the increasingly high expectations of our patients. To do this, we invest in the latest diagnostic equipment, commit to staying at the cutting edge of innovation, and continue to learn and adopt new technologies.

Our clinical knowledge of ocular surface disease (OSD) must evolve alongside improvements in technology

But technological advancements are wasted when we don’t factor in the critical role of ocular surface health in the predictability and accuracy of both pre-operative measurements and post-operative outcomes. Our clinical knowledge of ocular surface disease (OSD) must evolve alongside improvements in technology – and we must adapt our protocols for managing dry eye prior to any surgical treatment. Long gone are the days of prescribing artificial tears to all cataract patients – we can now use a much more comprehensive treatment algorithm, factoring in Meibomian gland dysfunction that occurs in up to 86 percent of all OSD cases (1).

For significant OSD, we use aggressive lid hygiene regimens, such as a course of intense-pulse light therapy or thermal lid pulsation, paired with a short course of lower-potency steroids, like fluorometholone acetate ophthalmic suspension (Flarex; Eyevance Pharmaceuticals), or at-home lid hygiene therapy, such as loteprednol (Avenova; NovaBay), in addition to artificial tears. We typically see patients three weeks after treatment – if the ocular surface has improved significantly, we go ahead and proceed with the cataract surgery measurements. We’ve found this regime rapidly improves the ocular surface for the vast majority of patients. And if it doesn’t, we use immunomodulators, like lifitegrast or cyclosporine, and wait a few more weeks before surgery.

With each evolution in our approach, we increase the quality of visual outcomes for all patients, regardless of them opting for a premium lens or not.

Look after the surface

Along with surgical skill, a healthy tear film is one of the most important factors for achieving excellent vision following cataract surgery.

The tear film is the first refractive surface of the eye; when it’s unstable, the quality of corneal reflections is affected. This instability adversely impacts accuracy of keratometry measurements (2, 3), leading to changes in the magnitude and axis of astigmatism – then variable K-readings can affect the accuracy of IOL calculations and result in suboptimal refractive outcomes (2, 3, 4, 5, 6). Moreover, it is common for dry eye disease (DED) symptoms to worsen after surgery (7) – or for the procedure itself induce or exacerbate DED (8, 9).

Beyond the accuracy of astigmatism measurements, DED can cause higher order aberrations – the most clinically significant of which are spherical aberration and coma, but these often improve with treatment.

Increases in tear osmolarity have a central role in the pathophysiology of DED, as described by the Dry Eye Workshop (10). Research supports the use of tear osmolarity as a tool for diagnosis, severity grading, and tracking therapeutic response in DED (11, 12, 13, 14, 15, 16, 17, 18).

In our protocol, patients with osmolarity scores (measured by TearLab Osmolarity testing) above 315 mOsms/L will not proceed to the cataract workup – instead, those patients see me for further ocular surface examination. Time is a valuable commodity to all involved; the cataract workup takes up to 45 minutes, so I waste as little time as possible by not proceeding to this stage unless no further ocular surface optimization is needed.

In short, we have a golden rule: No patient goes to cataract surgery with OSD. Optimizing the ocular surface allows for a more precise outcome and a smoother postoperative course – and it also allows more patients to qualify for a premium IOL.

Conversation is key

Surgeons may worry about telling patients about delays in their progression to cataract surgery, but ensuring the best outcome must be a priority. As always, good communication goes a long way! I carefully explain that that the surface of their eye is too dry for cataract surgery, and I use this analogy: “If your car windshield isn’t clean, you’re never going to see well, so if I rush you through the cataract surgery without taking care of the dry eye ‘windshield’ preoperatively, the outcome will be one that neither of us are proud of.”

It’s also important that patients understand that dry eye is a disease, just like high blood pressure or high cholesterol

In my experience, this sentence engenders patients trust – they are often willing to do whatever it takes because they know that I am looking out for their best interests, and want to deliver a superior outcome. It’s also important that patients understand that dry eye is a disease, just like high blood pressure or high cholesterol. We don’t wait for someone to have a heart attack before we initiate treatment for the latter. And after they’ve had a heart attack, we don’t stop treatment! Dry eye is the same – a lifelong disorder that we can manage, but not eliminate.

An opportunity to upgrade

Through treating the ocular surface, more patients qualify for premium technology. Some surgeons worry that doing any self-pay procedures prior to cataract surgery might discourage patients from paying for advanced IOLs, but I find the reality is the opposite.

When the patient has an optimized ocular surface, they’re told they are now a good candidate for an advanced refractive lens, and you can feel the buzz of excitement generated from them. Their willingness and enthusiasm to invest in advanced IOL technologies and OSD treatments increases, once they realize the impact that good vision has on their quality of life – especially when they’ve already made a good step in the right direction. It’s like rewarding yourself with better running shoes after you’ve completed a couch-to-5k program – this prior investment in the process often leads to patients opting for the most advanced technologies available to them, thereby increasing the financial return for my practice. I continually reinforce the idea that living with OSD is a process that requires life-long treatments to both preserve the health of patients’ eyes, and achieve their best vision.

In other words, devoting time to optimization of the ocular surface benefits both the patients and our practice – a true win-win!

Ivan Mac reports the following financial disclosures: Consultant to Alcon, Tarsus Inc., Eyevance/Santeen Pharmaceuticals, Sun Pharmaceuticals, Ellex Inc., NovaBay, Visionary Ventures Group, TearLab.

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  1. MA Lemp et al., “Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study,” Cornea, 31, 472 (2012). PMID: 22378109.
  2. AT Epitropoulos et al., “Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning,” J Cataract Refract Surg, 41, 1672 (2015). PMID: 26432124.
  3. P Kim P, S Plugfelder, AR Slomovic, “Top 5 pearls to consider when implanting advanced-technology IOLs in patients with ocular surface disease,” Int Ophthalmol Clin, 52, 51 (2012).
  4. DF Goldberg, “Preoperative evaluation of patients before cataract and refractive surgery,” Int Ophthalmol Clin, 51, 97 (2011). PMID: 21383583.
  5. JBA Magar, “Comparison of the corneal curvatures obtained from three different keratometers,” Nepal J Ophthalmol, 5, 9 (2013). PMID: 23584640.
  6. CA Manning, PM Kloess. “Comparison of portable automated keratometry and manual keratometry for IOL calculation,” J Cataract Refract Surg, 23, 1213 (1997). PMID: 9368167.
  7. T Oh et al, “Changes in the tear film and ocular surface after cataract surgery,” Jpn. J Ophthalmol, 56, 113 (2012). PMID: 22298313.
  8. XM Li, L Hu, J Hu, W Wang, “Investigation of Dry Eye Disease and Analysis of the Pathogenic Factors in Patients after Cataract Surgery,” Cornea, 26, S16 (2007). PMID: 17881910.
  9. Y Yu et al., “Evaluation of dry eye after femtosecond laser–assisted cataract surgery,” J Cataract Refract, Surg, 41, 2614 (2015). PMID: 26796442.
  10. JP Craig et al., “TFOS DEWS II Report Executive Summary,” Ocul Surf, 15, 802 (2017). PMID: 28797892.
  11. BD Sullivan et al., “An objective approach to dry eye disease severity,” Invest Ophthalmol Vis Sci, 51, 6125 (2010). PMID: 20631232.
  12. BD Sullivan et al., “Clinical utility of objective tests for dry eye disease: variability over time and implications for clinical trials and disease management,” Cornea, 31, 1000 (2012). PMID: 22475641.
  13. JS Nelson, RL Farris, “Sodium hyaluronate and polyvinyl alcohol artificial tear preparations. A comparison in patients with keratoconjunctivitis sicca,” Arch Ophthalmol, 106, 484 (1988). PMID: 2451494.
  14. MA Lemp et al., “Tear osmolarity in the diagnosis and management of dry eye disease,” American Journal of Ophthalmology, 151, 792 (2011). PMID: 21310379.
  15. R Potvin, S Makari, CJ Rapuano, “Tear film osmolarity and dry eye disease: a review of the literature,” Clin Ophthalmol, 9, 2039 (2015). PMID: 26586933.
  16. EK Akpek et al., “Dry Eye Syndrome Preferred Practice Pattern®,” Ophthalmology, 126, 286 (2019). PMID: 30366798.
  17. A Tomlinson et al., “Tear film osmolarity: determination of a referent for dry eye diagnosis. Meta-Analysis,” Invest Ophthalmol Vis Sci, 47, 4309 (2006). PMID: 17003420.
  18. FDA K083184 (2021). Available at:​​​​​​​
About the Author
Ivan Mac

Founder of Metrolina Eye Associates in North and South Carolina. He is based in Charlotte, North Carolina, USA.

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