Accelerated dry eye management before cataract surgery ensures optimal refractive outcomes

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.

By John Gallagher, OD

When I was fresh out of my residency, I entered a private multispecialty surgical practice, where I was mentored by a corneal surgeon who taught me many useful lessons of clinical practice. One of the most important lessons was the number 1 reason for patient dissatisfaction after surgery, which was not incorrect intraocular lens selection but untreated ocular surface disease (OSD), which resulted in inaccurate preoperative measurements and caused patients to experience an increase in fluctuating vision postoperatively. Every day, our patients were paying for premium cataract surgery, with lenses costing $5,000 or more per eye, even after Medicare payments, and we needed to meet their high expectations. After seeing the postoperative results myself, I developed a passion for the complex process of managing OSD, as I saw just how powerful proper management is for a patient’s quality of life.

While ocular surface management is essential prior to cataract surgery because it is critical to a good outcome, I have found that proper ocular surface management poses a particularly tough challenge for those in busy clinics. From that beginning, I developed an approach to managing dry eye and other ocular surface issues that allows me to optimize preoperative measurements needed for cataract surgery within a 1-month period from initial evaluation to surgery day. In my experience, patients are happy to get on board when I explain that this initial investment of optimizing the surface prior to surgery helps us ensure they achieve an optimal refractive outcome.

Treating Dry Eye Before Surgery

The process always starts with an exam that includes both sodium fluorescein and lissamine green staining. In a thorough slit lamp examination, I check for conjunctival and corneal staining and evaluate the lid margin for signs of meibomian gland dysfunction, blepharitis, and Demodex. During my exam, I ask patients how their eyes feel every day (eg, itchy, gritty, burning, constantly watering, or worse at the end of the day).

The findings generally fall into the categories of blepharitis and dry eye disease that is evaporative, inflammatory, or a combination of both. Although cases fall along a spectrum of mild, moderate, or severe, I don’t use the regimen for mild treatment preoperatively, instead opting to raise all preoperative cases one level of severity above their diagnosis to quickly get patients ready for surgery according to the following routines.

Treating blepharitis. One of the most visually devastating complications of cataract surgery is endophthalmitis from exogenous bacteria on the surface of the eyelids, which makes managing the bacterial load very important. If I see signs of blepharitis (collarettes, redness, demodex), I start bringing it under control quickly before surgery.

• Mild: For nonsurgical and postoperative patients with mild blepharitis, I use hypochlorous acid spray (Oasis TEARS or Avenova). Patients directly spray the product onto their closed eyes twice a day and let it dry. Given the spray’s simplicity and patients’ ability to use it throughout the entire postoperative period, compliance tends to be good, and patients are happy to use it.
• Moderate: Elevating the severity level for surgical patients to moderate or severe, I have them use lid scrubs containing tea tree oil to help remove bacteria and scurf. For patients without sensitive skin, I use OcuSoft Allergy, which contains tea tree oil. If patients have sensitive skin and/or rosacea, I use OcuSoft Oust, which has both tea tree oil for Demodex as well as coconut oil to smooth out the periorbital area, making it well tolerated by my more sensitive patients.
• Severe: In addition to at-home lid scrubs, I might do in-office lid scrubs if the presentation is severe enough. Additionally, I prescribe either doxycycline 100 mg twice daily for 2 weeks or azithromycin 250 mg once per day for 1 week, and we start the pre-approval process for XDEMVY (Tarsus). I see the patient back at 2 weeks, when the patient starts XDEMVY if it’s approved and still deemed medically necessary.

Treating evaporative dry eye. When fluorescein staining reveals diffuse punctate epithelial erosions on the corneal surface, I know that there is an evaporative component to the patient’s dry eye.

• Mild: For nonsurgical and postoperative patients with mild fluorescein staining, I want artificial tears to immediately help with lubrication to improve the corneal surface. My preference is the Refresh line (AbbVie), particularly the preservative-free Refresh Optive Mega-3. I also start patients on HydroEye (ScienceBased Health), which is a clinically validated supplement¹ providing GLA (gamma-linolenic acid from black currant seed oil), omega-3s (EPA and DHA from fish oil), and other nutrients designed to improve both meibum quality and systemic inflammation. My patients start to feel the effects around week 3 or 4, and they’re feeling the full effects around week 6 to 8, right when they are experiencing the height of inflammation from cataract surgery.
• Moderate: I add warm compresses (microwave, electric, or disposable) once or twice per day, depending on severity. I also place soluble collagen punctual plugs in the lower eyelids.
• Severe: Adding to the aforementioned therapies, I place punctal plugs in the upper lids as well. Soluble collagen options are essential to prevent any infection risk related to silicone plugs. I have had multiple discussions with various oculoplastic surgeons, all of whom have decried silicone punctal plugs due to a relatively increased infection risk and difficulty of removal, as they will often break and further dislodge into the canaliculus.

Treating inflammatory dry eye. Lissamine green is retained by devitalized conjunctival epithelial cells, showing that the patient’s dry eye is inflammatory in nature. The problem may be lacrimal gland inflammation or systemic inflammation from rosacea or autoimmune disease. These underlying causes have different treatments and often require consultation with the patient’s primary care physician.

• Mild: For nonsurgical and postoperative patients with mild lissamine green staining, I start the patient on HydroEye with a thicker artificial tear like Refresh Celluvisc or Oasis Tears Preservative-Free. Depending on the presentation, I consider adding a light steroid like loteprednol or fluorometholone twice a day for 2 weeks.
• Moderate: I add punctal plugs and often prescribe a stronger steroid, sometimes using prednisolone once or twice a day for 2 weeks. If the steroid doesn’t bring down the inflammation as expected, we need to probe the potential for undiagnosed underlying conditions.
• Severe: After the 2-week course of steroids, if the patient shows notable improvement in clinical signs and/or symptoms, I add an immunomodulatory drop like XIIDRA (Novartis) or one of the cyclosporine options (CEQUA, RESTASIS, VEVYE), which have a range of concentrations we can select based on the patient’s severity.

Treating combination dry eye. When significant lissamine green and fluorescein staining point to combination dry eye, that’s my cue to check for more complex underlying problems, such as Sjögren’s syndrome, floppy eyelid syndrome, or lagophthalmos. By its nature, there really is no mild combination dry eye, so all cases get moderate to severe treatment regardless of whether surgery is scheduled.

When these patients present, I combine my protocols listed previously, employing multiple conservative agents on the initial visit, including HydroEye, artificial tears, warm compresses, and punctal plugs. I often put these patients on a steroid pulse to break the inflammatory cycle, choosing the agent based on severity of clinical presentation, and then I add an immunomodulatory agent for longer-term therapy.

Follow-Up and Timing With Surgery

When patients present for their initial exam or are referred to our practice by other physicians, follow-up visits prior to surgery are typically required. Once the need for cataract surgery has been established, I often schedule a dry eye follow-up in 2 weeks prior to their preoperative consult with their ophthalmologist (4 weeks from their initial visit). At that follow-up visit, I reassess clinical signs and symptoms and, if additional treatments are needed, add them and push back that surgical consult by 2 more weeks. While it may be mildly inconvenient for the patient, I stress to them that we have 1 opportunity to get these measurements right, and patients are often understanding.

Regarding patients I put on steroids, they stop their steroids at 2 weeks, and, if significant improvement is noted, I often switch them to cyclosporine agents (CEQUA, RESTASIS, VEVYE) or XIIDRA to continue the anti-inflammatory effects. They can stay on these medications after surgery, but it can get confusing for patients when they’re also taking postoperative medications. I tell them to focus on the surgical drops, and about half of them manage to comply with dry eye drops throughout their postoperative period.

At their 1-month visit, when patients are off their postoperative drops, I see the most marked improvements in their symptoms. The therapy has had time to take effect, and the removal of the postoperative steroid and NSAID greatly improves the ocular surface on its own. I explain that if they want to keep seeing as clearly as they’re seeing now, they need to stick to their dry eye management plan. They can stay on the same routine, or if they had mild dry eye and we followed the moderate approach before surgery, we can revert to the mild approach at this point.

I see patients back at 3 months after their final postoperative visit, where we decide whether to stick to a 3-month schedule or switch to 6 months (in cases without quarterly punctal plug replacement). Because dry eye is chronic and patients are on indefinite therapy, I want to make it easy and practical for them long-term based on their needs. At each visit, we go through their regimen and check for adjustments, focusing on the things they feel work the most and balancing the patient’s cost versus compliance.

By being proactive and aggressive about managing dry eye before surgery, we’re setting up cataract patients for success in the optometrist’s chair. Taking that extra time upfront pays long-term dividends and offers overall better patient outcomes. Rather than dealing with dissatisfied patients and playing catch-up to treat severe dry eye postoperatively, we’re enabling patients to get the most out of surgery and creating a positive experience from beginning to end.

John Gallagher, OD, is a residency-trained optometrist in private group practice at Center for Advanced Eye Care in Fort Pierce, Florida. He has nothing to disclose.

Reference

1. Sheppard JD, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304. doi:10.1097/ICO.0b013e318299549c