Optometrists need to manage ocular surface amidst increasing prevalence of cataracts
Cataracts are the leading cause of blindness in adults older than age 50 worldwide.
The global prevalence of cataracts has surged from about 42 million affected individuals in 1990 to about 97 million in 2019 (Shu et al.). By 2030, about one in six people will be aged 60 years or older (WHO), further amplifying the number of cataract cases and increasing pressure on health care systems.
As an aging global population compounds the increasing prevalence of cataracts, addressing coexisting ocular surface disease (OSD) is essential to achieving successful surgical outcomes and maintaining visual quality after surgery. Treating ocular surface health before cataract surgery minimizes the likelihood of postoperative complications and the need for additional treatments.
Cataract surgery increasingly resembles refractive surgery in the need for precision, so optimal visual outcomes hinge on exceptional preoperative measurements. Because the air-tear film/cornea interface accounts for two-thirds of the eye’s refracting power, instability caused by OSD compromises visual clarity and the accuracy of presurgical measurements (Meek et al.). Managing OSD before cataract surgery ensures accurate biometry measurements, improves IOL calculations, and enhances surgical precision and outcomes.
Educating patients, identifying coexisting conditions
In my clinic, I use a combination of anterior segment photos, objective data and practical questions to improve my patients’ understanding of dry eye and its impact on their vision. I show them “before” and “after” photos and testing results to visually and objectively demonstrate changes in their ocular surface health (Figure). For instance, I may highlight staining on the corneal surface to show patients the “dry patches” affecting their vision or point out a rapid tear breakup time, helping them connect symptoms like blurred vision to dry eye.
To help identify if dryness contributes to visual issues beyond cataracts, I ask practical screening questions like, “Does your vision fluctuate or improve when you blink?” If they answer yes, this suggests dryness that needs attention, as untreated dry eye can cause blurry vision that persists even after cataract surgery.
Up to 80% of cataract patients scheduled for cataract surgery have OSD, with studies showing that more than 60% have asymptomatic dry eye disease (DED) (Gupta et al., Trattler et al., Stapleton et al., Graae Jensen et al.). Cataract surgery often exacerbates underlying DED, and about 37% of patients develop noticeable dryness after cataract surgery (Miura et al.). Other corneal conditions, such as epithelial basement membrane dystrophy (EBMD), Salzmann’s nodular dystrophy (SND) and pterygia, must also be addressed before surgery.
OSD treatments vary by condition
Managing OSD in cataract patients requires a comprehensive approach. I typically begin with over-the-counter treatments to improve the ocular surface, including eyelid sprays or scrubs and warm compresses for lid hygiene, artificial tears and omega-3 supplements. While these foundational treatments serve as strong initial steps, they often take weeks to months to show effectiveness and may not fully address all of a patient’s ocular issues.
For more advanced cases or those unresponsive to basic treatments, I may consider prescription options. For example, severe blepharitis, whether caused by Demodex or bacteria, is a leading cause of cataract surgery delays due to a significant risk for complications, including endophthalmitis and postoperative infections. Treatment may include a combination of Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals), antibiotics and/or topical corticosteroids to effectively manage the condition before cataract surgery.
In patients with significant evaporative dry eye caused by meibomian gland dysfunction, I may consider advanced treatments like intense pulsed light therapy, radiofrequency or thermal pulsation for comprehensive management in addition to prescription options like Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb).
For patients with additional ocular surface issues, such as significant superficial punctate keratitis (SPK), corneal nerve damage or an unstable tear film, amniotic membranes can offer a rapid and effective intervention that stabilizes the ocular surface and supports recovery. Cryopreserved amniotic membranes (CAMs) can help to treat several OSDs, including DED, EBMD, SND, SPK and pterygia. Given that OSDs often require prolonged treatment, it is crucial to address these issues promptly while foundational therapies take effect. In cases of corneal nerve damage or when rapid healing is necessary, amniotic membranes may provide a valuable solution to accelerate recovery and restore ocular health.
When I need to rapidly improve the ocular surface from the eyelids to the cornea, I will pair the use of a CAM with in-office procedures like NuLids Pro and Rinsada to debride the lids and flush the ocular surface of any proinflammatory debris.
Timely management of OSD
Managing OSD for cataract patients is often time sensitive, with surgery typically scheduled weeks away and vision already affected. This urgency requires swift, effective treatment to optimize the ocular surface quickly. Amniotic membranes are particularly valuable for stabilizing and preparing the ocular surface for cataract surgery, providing a rapid and effective solution. I prefer Prokera (BioTissue) because it is FDA approved for ocular wound healing.
Cryopreservation retains amniotic membrane integrity and key healing factors, such as the HC-HA/PTX3 complex, which provides anti-inflammatory, anti-fibrotic and anti-angiogenic benefits, promoting enhanced recovery. Unlike dehydrated membranes, which lose key bioactive components during processing, CAMs retain their full efficacy and work quickly (Rodríguez-Ares et al., Cooke et al.). They often improve the ocular surface within 3 days, with benefits lasting up to 3 months (McDonald et al.). Therefore, incorporating CAMs into presurgical interventions and maintaining their use during postsurgical care can speed up ocular surface recovery.
Educating patients on OSD’s impact on cataract surgery is key to managing expectations and improving satisfaction. A personalized approach that combines foundational and advanced treatment in a timely manner ensures effective OSD management, enhancing outcomes and ocular health.
References:
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For more information:
Cory J. Lappin, OD, MS, FAAO, is in the process of opening The Dry Eye Center of Ohio, a dedicated dry eye and ocular surface disease clinic in Cincinnati. He can be reached at coryjlappin@gmail.com and on Instagram at @cory.lappin and LinkedIn at Cory Lappin, OD, MS, FAAO.
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