Rapid ocular surface optimization in pre-op patients with cataract

Modern cataract surgery depends on precise preoperative measurements to determine the correct intraocular lens (IOL). However, large observational studies have shown that a majority of patients with cataract present with ocular surface dysfunction, often without significant symptoms.^1,2 Any condition that disrupts the health of the tear film or the corneal surface, such as dry eye disease, meibomian gland dysfunction, blepharitis, epithelial basement membrane dystrophy, or Salzmann nodular degeneration, can undermine measurement reliability.^1,2 Although advanced imaging technologies, such as aberrometry, allow precise measurements in healthy eyes, their accuracy depends on the quality of the surface being measured. An irregular or compromised ocular surface can distort these readings and ultimately jeopardize surgical outcomes.

Managing cataract surgery timelines and patient expectations

When I see patients before cataract surgery, it’s usually because their visual dysfunction is affecting their ability to perform daily activities. As such, these patients typically want to undergo surgery as soon as possible, especially if they have already had to navigate scheduling delays and multiple medical evaluations. That is why it is important to keep in mind that the preoperative end point for patients with cataract is not total resolution of all ocular surface symptoms, but the reliability of the measurements and the visible improvement of the ocular surface. Although symptom relief matters in dry eye management, if the tear film stabilizes and corneal staining resolves enough to produce consistent topography and biometry, we may be able to proceed with cataract surgery even if patient-reported symptoms improve more slowly than the clinical measures. While this can be a bit confusing for patients, I always walk them through this process before surgery, setting the proper expectations and helping them understand how we work toward providing them with the relief they need as quickly as possible.

Approaches to rapid ocular surface improvement

In my experience, a layered therapeutic strategy gives patients the fastest path to a stable ocular surface. When significant corneal staining is present, I typically start a topical corticosteroid course and may consider simultaneously initiating a topical immunomodulator such as cyclosporine or lifitegrast, both of which have shown the ability to begin improving the ocular surface within weeks.^3,4 Newer pharmacologic options, including varenicline nasal spray, acoltremon, and perfluorohexyloctane, offer additional mechanisms for managing dry eye disease.^5-7 Although their onset of action in the preoperative setting is less well established, they serve as valuable adjuncts when used with more established therapies. Punctal or lacrimal occlusion may further support ocular surface stability during the preoperative period.

Inflammatory eyelid margin disease is another possible disruptor of the ocular surface and may require the use of targeted in-office therapies such as intense pulsed light therapy, low-level light therapy (LLLT), and blepharoexfoliation to resolve.^8,9 Data from a recent study showed that LLLT may also support the postoperative healing process in patients who undergo cataract surgery.⁸ Demodex blepharitis is another significant factor that can complicate preoperative measurements, and it can be treated with lotilaner to quickly restore healthier eyelid conditions.¹⁰

Some patients present with more profound corneal involvement, such as staining of the central cornea or suspected nerve compromise. In such cases, biologic therapy, particularly cryopreserved amniotic membrane (CAM), becomes invaluable. The regenerative and anti-inflammatory properties of amniotic membrane allow for fast corneal rehabilitation, with data from one study showing that CAM-treated patients were able to schedule their cataract surgery within 2 to 4 weeks of completing treatment.^11,12 When timelines are especially tight, I may combine a topical steroid with CAM to promote rapid epithelial healing. I often treat the more symptomatic eye first, reassess, and then treat the fellow eye shortly thereafter.

Troubleshooting nonresponsive cases

In general, when patients do not respond to dry eye therapy as expected, I reconsider the diagnosis and consider potential dry eye masqueraders such as allergic conjunctivitis, conjunctivochalasis, floppy eyelid syndrome, or the influence of cosmetics, lotions, or unreported drops.⁹ Neurotrophic keratopathy (NK) is another essential consideration, and persistent corneal staining despite appropriate therapy should immediately raise suspicion of NK. Corneal sensitivity testing, performed before any anesthetic or dye is used, can confirm whether nerve impairment is a contributing factor.⁹ Even mild NK shifts the treatment plan toward biologic therapy due to its characteristic nerve dysfunction.

In one notable case, a 72-year-old woman presented to me for a cataract evaluation (Figure). She had a history of dry eye and had minimal response to previous topical therapy. Upon examination, she was found to have superficial punctate keratitis and normal corneal sensitivity. After treatment with CAM, her ocular surface was sufficiently prepared for cataract surgery.

Questions often arise about managing patients with elevated IOP. Steroids can still be used with caution, and loteprednol is often preferred over prednisolone, dexamethasone, or fluorometholone in these cases.¹³ Alternatively, biologic therapy, such as with CAM, offers a potent anti-inflammatory and regenerative effect in patients in whom IOP is a concern.¹²

Pearls for comanaging optometrists

The most important advice I have to offer to other optometrists who are preparing their patients for cataract surgery is that ocular surface optimization should begin before the patient sees the surgeon. When we identify staining, tear film instability, or corneal irregularities up front and initiate treatment early on, the surgical process is smoother for everyone involved. Another important consideration is that once the patient enters the surgical workflow, preoperative care must be more aggressive than routine dry eye management. Warm compresses, nutritional supplements, and lubricants alone are rarely sufficient to adequately quiet the ocular surface of a patient preparing for premium IOLs or even monofocal IOL surgery, especially when high expectations are present.

Conclusion

Cataract surgery is one of the most impactful procedures we provide, and patients understandably expect excellent outcomes. Rapid ocular surface optimization ensures that those outcomes rest on a solid foundation. By identifying ocular surface disease early on, treating it aggressively, and incorporating advanced therapies such as biologics, when necessary, we can give our patients the best chance for accurate measurements and optimal visual outcomes.

Damon Dierker, OD, FAAO

is director of optometric services at Eye Surgeons of Indiana and an adjunct faculty member at Indiana University School of Optometry. He practices consultative optometry with a special interest in ocular surface disease, glaucoma, retina, and perioperative care. Dierker has developed a dedicated dry eye clinic within his practice and helps colleagues across the country in this area as the creator of Dry Eye Boot Camp and co-founder of Eyes on Dry Eye.

Dierker reports affiliations with AbbVie, Alcon, Azura Ophthalmics, Bausch & Lomb, BioTissue Ocular, Inc, Dompé, Nordic Pharma, NuSight Medical, ScienceBased Health, Sight Sciences, Sun Pharma, Tarsus Pharmaceuticals, Thea Pharma, and Viatris.

References

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2. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018;44(9):1090-1096. doi:10.1016/j.jcrs.2018.06.026

3. Akpek EK, Wirta DL, Downing JE, et al. Efficacy and safety of a water-free topical cyclosporine, 0.1%, solution for the treatment of moderate to severe dry eye disease: the ESSENCE-2 randomized clinical trial. JAMA Ophthalmol. 2023;141(5):459-466. doi:10.1001/jamaophthalmol.2023.0709

4. Charters L. AOA 2025: lifitegrast 5.0% shows positive effect on clinical signs and biomarkers in patients with dry eye disease. Optometry Times. June 6, 2025. Accessed December 8, 2025. https://www.optometrytimes.com/view/aoa-2025-lifitegrast-5-0-shows-positive-effect-on-clinical-signs-and-biomarkers-in-patients-with-dry-eye-disease

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8. Giannaccare G, Rossi C, Borselli M, et al. Outcomes of low-level light therapy before and after cataract surgery for the prophylaxis of postoperative dry eye: a prospective randomised double-masked controlled clinical trial. Br J Ophthalmol. 2024;108(8):1172-1176. doi:10.1136/bjo-2023-323920

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10. Davey PG, Farid M, Karpecki P, et al. Lotilaner ophthalmic solution, 0.25%, for the treatment of Demodex blepharitis. Healthcare (Basel). 2024;12(15):1487. doi:10.3390/healthcare12151487

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12. McDonald M, Janik SB, Bowden FW, et al. Association of treatment duration and clinical outcomes in dry eye treatment with sutureless cryopreserved amniotic membrane. Clin Ophthalmol. 2023;17:2697-2703. doi:10.2147/OPTH.S423040

13. Kemer ÖE, Mekala P, Dave B, Kooner KS. Managing ocular surface disease in glaucoma treatment: a systematic review. Bioengineering (Basel). 2024;11(10):1010. doi:10.3390/bioengineering11101010