AAOpt 2026: Optimizing the ocular surface for cataract/refractive surgery: A case study

In an AAOpt poster presentation, Amber Carissa “A.C.” Flynn describes a case illustrating why ocular surface health should be addressed before cataract surgery, especially when a patient also has glaucoma and other eye conditions. The poster, titled “Preservative Toxicity to Biometric Reliability: Ocular Surface Optimization with Cryopreserved Amniotic Membrane Before Cataract and Glaucoma Surgery,” also noted that up to 75% of patients with glaucoma show clinical signs and symptoms of ocular surface disease (OSD).

The patient in the study was a 74-year-old man referred because clinicians could not obtain reliable biometry for cataract surgery. His ocular surface was significantly unhealthy: he had collarettes associated with Demodex blepharitis, punctate corneal staining, reduced tear breakup time, meibomian gland dysfunction, and signs of medication-related toxicity after using four topical medications to lower intraocular pressure (IOP).

Treatment was approached step by step. Flynn first treated the Demodex blepharitis with lotilaner and recommended home care, including warm compresses and artificial tears. The glaucoma regimen was also simplified by moving the patient to combination drops, reducing the number of preserved medications reaching the ocular surface. At follow-up, the lash margin had improved and the collarettes were gone, while tear breakup time had improved somewhat. However, substantial punctate staining remained. This led Flynn to test corneal sensitivity; the patient had no response to stimulation in either eye. The absent sensitivity and persistent staining supported a diagnosis of stage 1 neurotrophic keratitis.

To address the corneal disease, the team used a cryopreserved amniotic membrane over 3 days. Flynn describes it as a biologic scaffold that supports epithelial healing and has anti-inflammatory and anti-angiogenic properties. After treatment, the right cornea was much improved and the left was clear, with only trace staining that could be managed with home care. The improved surface allowed the team to obtain the needed biometry and proceed with surgery.

Cataract surgery was particularly important because the patient also had moderate-to-severe glaucoma with uncontrolled IOP. The procedure included cataract surgery and an Omni glaucoma procedure—canaloplasty with goniotomy. Following treatment and surgery, the patient was doing well, with IOP within the target range. He continued to have meibomian gland dysfunction, so a topical anti-evaporative treatment, perfluorohexyloctane, was used to help keep tears on the ocular surface. His glaucoma treatment had also been reduced from four agents to one combination drop.

Flynn’s central message is that clinicians should not take measurements through an unhealthy cornea or treat cataracts, glaucoma, and ocular-surface disease as unrelated problems. A layered, stepwise approach can address multiple conditions together and support better refractive outcomes and overall eye health. Flynn notes that other options for neurotrophic keratitis, such as recombinant human nerve growth factor or serum/plasma-rich protein tears, can be effective but may require longer treatment. In this case, the amniotic membrane was chosen because the patient needed a timely improvement to move toward surgery. The study findings also emphasizes that patients with several coexisting eye conditions are not unusual, and that coordinated care—including collaboration with the cataract and glaucoma surgeon—can help achieve better outcomes.