With all of the recent publications concerning dry eye disease, as well as updates on technology and pharmacologic agents to diagnose and treat it, many practitioners are tuning out of the conversation.
Whether they are overwhelmed by the amount of information to decipher, tired of hearing about it, or think the condition is being overemphasized to create revenue for industry, many optometrists are not eager to hear more about dry eye disease.
With that being said, dry eye disease is still being undertreated by optometrists and ophthalmologists alike. One facet of the patient population that is particularly being underserved is those being referred or evaluated for cataract surgery.
Recent publications have underscored the importance of screening all patients for ocular surface disease prior to cataract surgery. The American Academy of Ophthalmology’s Dry Eye Syndrome Preferred Practice Pattern,1 published in 2018, recommends that “all patients undergoing cataract surgery should be evaluated and managed for dry eye preoperatively.”
In May 2019, the Journal of Cataract and Refractive Surgery published an article proposing new guidelines for how to pre-operatively evaluate and manage ocular surface disease (OSD).2 Christopher Starr, MD, and his colleagues on the American Society of Cataract and Refractive Surgery (ASCRS) Cornea Clinical Committee propose that it is imperative to fully evaluate the health of the ocular surface before considering cataract surgery in all patients, even those who are asymptomatic.
They outlined a clinical assessment algorithm to be sure that “visually significant” OSD is diagnosed and treated prior to surgery until it is well-controlled, or “non-visually significant.” In the article, the ASCRS claims that “by treating OSD preoperatively, postoperative visual outcomes and patient satisfaction can be significantly improved.”
Undiagnosed dry eye
Although experts agree that controlling dry eye pre-operatively is a must, it has previously been reported in literature that dry eye disease is often left undiagnosed prior to cataract surgery.
In a 2018 prospective study, Gupta et al found that 50 percent of asymptomatic patients evaluated for cataract surgery had an abnormal tear osmolarity or matrix metalloproteinase (MMP-9) levels, both positive indicators of OSD.3
The Prospective Health Assessment of Cataract Patients’ Ocular Surface study (PHACO), published in 2017, concluded that 15 to 20 percent of patients evaluated for surgery would have remained undiagnosed if they had not had a full ocular surface evaluation. Furthermore, they determined that it is necessary to perform multiple test in order to identify OSD.4
Cataract surgery and the ocular surface
But what is the harm to patients if they are not diagnosed and treated prior to cataract surgery? Can’t we just manage the side effects afterwards?
One important reason to treat prior to surgical evaluation is that unresolved dry eye disease results in poorer visual outcomes for patients. Precise preoperative measurement of the cornea is critical to minimizing refractive error postoperatively. The cornea is responsible for approximately 70 percent of the total refractive power of the eye, so accurately assessing its’ power is key to selecting the correct intraocular lens (IOL) power.5
1. Akpek EK, Amescua G, Farid M, Garcia-Ferrer FJ, Lin A, Rhee MK, Varu DM, Musch DC, Dunn SP, Mah FS; American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel. Dry Eye Syndrome Preferred Practice Pattern. Ophthalmology. 2019 Jan;126(1):P286-P334.
2. Starr CE, Gupta PK, Farid M, Beckman KA, Chan CC, Yeu E6, Gomes JAP, Ayers BD, Berdahl JP, Holland EJ, Kim T,
Mah FS; ASCRS Cornea Clinical Committee.An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019 May;45(5):669-684.
3. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery. J Cataract Refract Surg. 2018 Sep;44(9):1090-1096.
4. Trattler W, Majmudar P, Donnenfeld D, McDonald MB, Stonecipher KG, Goldberg DF. The Prospective Health
Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017 Aug 7;11:1423-1430.
5. Courville CB, Smolek MK, Klyce SD. Contribution of the ocular surface to visual optics.. Exp Eye Res. 2004 Mar;78(3):417-25.
6. Chuang J, Shih KC, Chan T, Wan KH, Jhanji V, Tong L. Preoperative optimization of ocular surface disease before cataract surgery. J Cataract Refract Surg. 2017 Dec;43(12):1596-1607
7. Gibbons A, Ali TK, Waren DP, Donaldson KE. Causes and correction of dissatisfaction after implantation of presbyopiacorrecting intraocular lenses. Clin Ophthalmol. 2016 Oct 11;10:1965-1970.
8. Cetinkaya S, Mestan E, Acir NO, Cetinkaya YF, Dadaci Z, Yener HI. The course of dry eye after phacoemulsification surgery. BMC Ophthalmol. 30 Jun 2015;15(68):1-5.
9. Han KE, Yoon SC, Ahn JM, Nam SM, Stulting RD, Kim EK, Seo KY. Evaluation of dry eye and meibomian gland dysfunction after cataract surgery. Am J Ophthalmol. 2014 Jun;157(6):1144-1150.e1
10. Caffery B, Devries D, Dunbar M. Improving the Screening, Diagnosis, and Treatment of Dry Eye Disease: Recommendations From The 2014 Dry Eye Summit. Rev Optom. Available at: https://www.reviewofoptometry.com/
publications/improving-the-screening-diagnosis-andtreatment-of-dry-eye-disease. Accesed 1/17/19.