Monitoring of ocular surface disease does not end after cataract surgery
Optimizing the ocular surface before any type of refractive surgery is imperative, but dry eye treatment needs do not stop there.
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Making a diagnosis of visually significant ocular surface disease before refractive cataract surgery should be a standard component of the pre-cataract workup.
We know there is a high prevalence of preexisting dry eye in the cataract population. Trattler and colleagues found upward of 60% of routine cataract patients were asymptomatic, yet 50% had central corneal staining. My colleagues and I reported the incidence of ocular surface disease in patients presenting for cataract surgery to be more than 80%, and in those who were asymptomatic, more than 50% had an abnormal tear osmolarity or MMP-9 level.
We increasingly understand that treating it is required to ensure on-target refractive outcomes and premium results. Along with my colleagues on the Cornea Clinical Committee of the American Society of Cataract and Refractive Surgery, we recently produced an algorithm physicians can follow to prepare their patients for successful surgery.
Postoperative dry eye disease
We cannot overlook the fact, however, that the majority of our patients will be symptomatic and have a compromised tear film after surgery. Upward of 87% of cataract patients have been found to use artificial tears 1 month postop. This is in part due to the temporary decrease in corneal sensitivity, and studies have shown that reduced tear breakup time, increased corneal staining and other postoperative alterations in tear film parameters tend to last for 3 to 6 months after surgery.
In many patients, the ocular surface will return to normal. Nevertheless, we need to actively manage patients in terms of postoperative inflammation, but we also need to be sure we are aligning their expectations and educating them that their eyes might be drier for several weeks to months after surgery.
Educating and expectation setting
Preoperatively, when I am talking with patients about cataract surgery and dry eye disease, I emphasize that dry eye is a chronic condition, and as such, there will be times when they will feel worse and times when they are less symptomatic. I cannot overstate the importance of setting this expectation. When I examine patients after surgery and they have symptoms consistent with dry eye disease, I remind them that we diagnosed the condition before their procedure. Then, of course, I give them recommendations to help treat it.
The same treatment principles that apply preoperatively apply postoperatively, for the most part. One change I may make if the patient is symptomatic or has corneal staining and breakdown of their ocular surface is to stop the topical NSAID as it can worsen keratitis. If the patient has significant symptoms pre- or postoperatively, I have a low threshold to start them on an immunomodulator such as Xiidra (lifitegrast ophthalmic solution 5%, Novartis) or Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). If I know the patient is apprehensive about being on a chronic therapy, I might wait until they are off the topical postoperative medication to start the prescription and use supportive treatment with over-the-counter lubricating drops, but this may delay resolution of symptoms. Topical postoperative cataract surgery medications can create an acute exacerbation. Tear osmolarity testing (TearLab) and MMP-9 (Quidel) are important preoperative screening tools. In terms of postoperative measurements of these ocular surface vital signs, I prefer to repeat tear tests once patients have stopped all cataract surgery medications.
Conclusion
When we diagnose patients with dry eye disease before cataract surgery, it is easy for them to understand why it is important that we treat it before the procedure. It is equally as important, however, that we tell patients that dry eye is a chronic disease and it requires chronic maintenance. They should not be surprised if they are symptomatic after their cataract surgery.
- References:
- Roberts CW, et al. Insight. 2007;32(1):14-21;quiz 22-23.
- Starr CE, et al. J Cataract Refract Surg. 2019;doi:10.1016/j.jcrs.2019.03.023.
- Trattler WB, et al. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S120159.
- Yu Y, et al. Clin Exp Ophthalmol. 2016;doi:10.1111/ceo.12695.
- For more information:
- Preeya K. Gupta, MD, can be reached at Duke University, Department of Ophthalmology, Box 3802, Durham, NC 27710; email: preeya.gupta@duke.edu.
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