For many cataract surgeons, the ultimate goal of a preoperative evaluation is to ensure the patient is a candidate for advanced-technology intraocular lenses (IOLs), such as toric, multifocal, or extended depth of focus lenses. Although, a critical variable often goes undetected during these screenings: dry eye disease (DED). When left untreated, DED can compromise biometric accuracy and lead to significant postoperative discomfort, creating a “stick” for the surgeon and a frustrating recovery for the patient.
Recent discussions among a diverse group of U.S. Cataract surgeons—ranging from high-volume practitioners performing over 3,000 cases annually to those in specialized “boutique” settings—have revealed a surprising gap in standard care. Despite a universal desire to increase the use of advanced IOLs, very few practices have established a revised approach to dry eye management that proactively diagnoses and treats the ocular surface before the patient ever enters the operating room.
The disconnect lies primarily in the preoperative phase. While most surgeons are in lockstep regarding how to handle DED once it appears postoperatively, the proactive identification of visually significant dry eye is frequently overlooked. In a review of various practice styles, it was found that only three practices routinely utilized fluorescein staining preoperatively to screen all patients, regardless of whether they reported symptoms.
The Gap in Preoperative Protocols
The structure of a surgical practice often dictates how DED is managed. In higher-volume clinics, the preoperative exam and the review of testing are frequently delegated to optometric colleagues and counselors. While this efficiency allows for greater patient throughput, it can create a blind spot in the diagnostic process. The data suggests that the larger the practice, the less likely it is that established, proactive protocols for DED diagnosis are in place.
Even in smaller “boutique” practices, where 90% or more of the cases involve upgraded IOLs, about 50% lacked standing protocols to diagnose dry eye proactively. This lack of standardization means that many patients are cleared for surgery with an unstable ocular surface, which can lead to inaccurate biometric measurements and a higher likelihood of postoperative complaints, such as intermittent blur or unexpected refractive errors.
Conversely, those surgeons who do proactively treat perioperative DED uniformly employ formal protocols. These protocols move beyond simple patient questionnaires, incorporating objective measures like fluorescein staining and, in rare cases, tear osmolarity checks to ensure the eye is optimized for the precision required by advanced IOLs.
Leveraging Pharmacotherapy for Better Outcomes
To bridge this gap, clinicians are looking toward targeted pharmaceutical interventions that can stabilize the ocular surface in the weeks leading up to surgery. Research led by John Hovanesian has highlighted the impact of using immunomodulators and specialized solutions to improve patient candidacy for advanced lenses.
In one study, Xiidra (lifitegrast ophthalmic solution 5%) was administered for 28 days preoperatively, paused during the immediate perioperative window, and resumed 28 days postoperatively. The results were significant: while 100% of the group showed corneal staining preoperatively, that number dropped to 63% postoperatively. More importantly for the surgeons, patient candidacy for advanced-technology IOLs increased by 60% in the treated group.
Similarly, the use of Miebo (perfluorohexyloctane ophthalmic solution) has shown promise in reducing the “stick” of postoperative discomfort. In Hovanesian’s data, preoperatively diagnosing DED and treating it with Miebo led to a dramatic improvement in the Ocular Surface Disease Index (OSDI) and the eye dryness visual analog scale, with OSDI scores dropping from 51.9 to 11.9 postoperatively.
Comparing Preoperative Treatment Impacts
| Medication | Primary Preop Goal | Key Result |
|---|---|---|
| Xiidra | Reduce corneal staining | 60% increase in advanced IOL candidacy |
| Miebo | Reduce patient symptoms | OSDI score reduction from 51.9 to 11.9 |
| Other Immunomodulators | Ocular surface stability | Variable; highly likely with Cequa/Vevye |
A Fresh Standard for Perioperative Care
The evidence suggests a clear pattern: the “carrot” of increased advanced IOL volume and the avoidance of the “stick” of postoperative complaints both depend on the same three steps. First, the practice must request the patient about symptoms. Second, a clinician must perform fluorescein staining during the preoperative exam. Third, the surgeon must prescribe a legitimate DED medication to treat positive findings.
This revised approach shifts the responsibility of DED management from a reactive post-surgical fix to a proactive preoperative requirement. By treating the ocular surface as a prerequisite for surgery rather than a complication of it, surgeons can improve both the clinical accuracy of their biometric data and the overall patient experience.
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Patients should consult with a board-certified ophthalmologist regarding their specific surgical candidacy and treatment plans.
As the field of cataract surgery continues to evolve toward more personalized and advanced lens options, the integration of ocular surface disease protocols is expected to become a standard of care. Further clinical data on the long-term stability of these preoperative treatments will likely inform updated guidelines for perioperative management in the coming year.
Do you use a formal protocol for preoperative dry eye screening in your practice? Share your experiences and thoughts in the comments below.
