For cataract patients, ocular surface preparation and postoperative care facilitate target 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 Walter O. Whitley, OD, MBA, FAAO

In our profession, we are all judged by the comfort and quality of our patients’ vision, and we have great tools to help them throughout their journey. In a large multispecialty referral practice that covers the gamut of ocular needs, my colleagues and I have to utilize all the tools at our disposal to provide that comfort and quality. For patients with cataracts—our largest referral group—those tools include therapies to prepare the ocular surface for surgery and to manage it postoperatively.

Clinical signs of dry eye are common in cataract referrals, as shown in Trattler et al, where tear breakup times indicated dry eye for over 60% of patients and over 75% had positive corneal staining.¹ From diagnostics to multifaceted therapies, our practice’s protocols ensure the ocular surface is prepared to yield accurate biometry so doctors can select the right intraocular lens (IOL), perform surgery to the highest standards, and ensure clear vision and a healthy ocular surface for years to come.

Procedures for Screening and Diagnosis

The journey from referral to surgery is all about the protocols the practice (and co-managing practices) has set in place, which are essential for predictable success and efficiency. The first step for cataract patients happens before they set foot in the practice. We ask referring optometrists to address the ocular surface as their patients develop cataracts, introducing artificial tears, nutraceuticals, and prescription immunomodulators, anti-inflammatories, or anti-evaporatives. This gives us a head start with many patients for surgery, but we still see some patients who are left untreated or noncompliant with therapy.

All patients who come to us, regardless of treatment status, go through our cataract/refractive protocol for screening and diagnosis. They begin with a SPEED questionnaire. Next, technicians perform objective testing, including biometry, topography, tear osmolarity, meibography, and lifestyle IOL counseling. Patients are examined by our optometrists or ophthalmologists who evaluate the anterior segment, looking for Demodex blepharitis, expressing the meibomian glands, checking tear film stability, staining with vital dyes (NaFl, lissamine green), grading the cataracts, and ensuring the optic nerve and retina are stable and/or cleared for surgery.

If we rule out dry eye, the patient can proceed with surgery. If the patient has dry eye disease, then surgeons will choose to either treat it themselves or refer it internally to our optometrists. Most surgeons prefer to start the patient on an artificial tear and sometimes a nutraceutical. For more severe cases, they will also prescribe a dry eye pharmaceutical. They will then set the patient up for a dry eye evaluation and preoperative management.

Our surgeons educate the patient about cataract surgery and let them know they will be happy to perform the surgery once the dryness is addressed and they are cleared for surgery. Patients are fine with taking additional steps to ensure we get an accurate set of measurements before surgery, particularly if they’re anticipating the optimal results from advanced-technology IOLs.

Preoperative Treatment Protocol

Dry eye therapy can be tailored to the problems shown in a patient’s workup, but traditionally, many patients follow similar pathways to improving the ocular surface. This includes addressing the eyelids, meibomian glands, conjunctiva, and cornea, which can’t be overlooked for therapy to succeed.

We have all had patients in the past who were on pharmaceutical dry eye treatments but were still symptomatic. If we take a step back and reevaluate the lids and meibomian glands, we can fully address our patient’s underlying issues that may have initially been overlooked. If the history shows that a patient has been on numerous therapies, I discuss their experiences before planning treatment. I want to know what worked or didn’t and why—for example, if they’ve given medications a fair shot, if they’re using good quality over-the-counter (OTC) products, and if they’ve followed instructions for self-care.

Recently, the Tear Film & Ocular Surface Society published the latest Dry Eye Workshop (DEWS III) report, which provides more insight into the management and treatment of ocular surface disorders.² The report developed 3 management and treatment algorithms based on tear film deficiencies, eyelid abnormalities, and ocular surface abnormalities, along with evidence-based treatment options.

As I lay out a simple treatment plan, it’s important to offer strong recommendations for any prescriptions, procedures, and OTC products. In all dry eye cases—but especially when patients want to get better quickly so they can have surgery—we want patients to get products that work, without getting confused at the drugstore. Our practice also sells products directly at the office or on our website, which can help patients start therapy right away.

The preoperative treatment protocol includes the following categories.

• Eyelid care. I recommend that all patients use a Bruder mask for 5 to 10 minutes daily and clean their eyelids at night with products such as hypochlorous acid spray (eg, HypoChlor by OCuSOFT). If the patient has Demodex collarettes, I also prescribe Xdemvy (Tarsus) for 6 weeks.
• All patients also start a nutraceutical to improve the tear film from the inside and reduce inflammation. My patients use HydroEye (ScienceBased Health) because it is clinically proven to improve both signs and symptoms of dry eye in a randomized, controlled trial.³ The supplement takes a 2-pronged approach with omega-6 gamma-linolenic acid as well as omega-3s, which together address inflammation. In my experience, patients are satisfied with the results and keep taking HydroEye, which is essential because we want patients to use nutraceuticals continuously in the long term. Additionally, there is a 60-day money-back guarantee for ScienceBased Health products.
• Artificial tears. Another universal recommendation is a preservative-free, lipid-based artificial tear. I offer patients several good options, including Systane PRO PF (Alcon) and Refresh Optive MEGA-3 (AbbVie).
• Anti-inflammatory or immunomodulator. Depending on the presentation, I might prescribe an anti-inflammatory before surgery, such as a short-term steroid for moderate-to-severe inflammation or cyclosporine (0.05%, 0.09%, or 0.1%) or lifitegrast (Xiidra, Bausch + Lomb) for moderate cases. Hovanesian et al recently presented a study that showed cyclosporine 0.09% (Cequa, Sun Ophthalmics) significantly improves higher-order aberrations and signs and symptoms of dry eye in as few as 7 days in patients presenting for cataract surgery.⁴ Similarly, lifitegrast improves preoperative corneal measurements after 6 weeks of use.⁵ Ultimately, the choice of a specific medication can depend on insurance coverage, which varies.
• Additional novel options include either intranasal varenicline (Tyrvaya, Viatris) or topical acoltremon (Tryptyr, Alcon). Both are indicated for the treatment of the signs and symptoms of dry eye disease. These products stimulate the lacrimal functional unit to increase tear production. Cases where I would consider neuromodulators would be patients with decreased tear meniscus and tear film instability but no signs of corneal and conjunctival staining.
• Anti-evaporatives. I would consider prescriptions such as perfluorohexyloctane (Miebo, Baush + Lomb) in patients with meibomian gland dysfunction with tear film instability. This is also indicated for the signs and symptoms of dry eye disease, with data showing significantly reduced overall symptom severity at the primary endpoint of day 7.⁶
• In-office procedures. There are numerous dry eye procedures available to prepare patients for surgery, as well as to provide relief for nonsurgical dry eye patients. Often, pharmaceutical and nutraceutical treatments are not enough, which is where these procedures fit in. From microblepharoexfoliation to intense pulsed light to thermal pulsation, these procedures address the lid biofilm, blepharitis, and meibomian glands—an especially important category, as Yeu et al found meibomian gland atrophy affects up to 95% of patients presenting for cataract surgery evaluation.⁷

Postoperative Care and Ongoing Management

The preoperative goal is to prepare the ocular surface for surgery, but after recovery from cataract surgery, patients need to continue managing chronic, multifactorial dry eye disease long-term. In the immediate postoperative period, dry eye symptoms can worsen due to the surgery itself as well as postoperative drops and their preservatives. Studies show that the incidence of dry eye is 42% at 1-week follow-up and occurs in up to one-third of patients 3 months after surgery.^8,9

In our clinic, we have patients discontinue their prescription dry eye medications for 1 month after their procedure and restart after that time. Even for patients who were not diagnosed with dry eye preoperatively, we will prescribe dry eye treatment options as needed. In rare cases where patients are not happy with their visual outcomes, we have to rule out causes for reduced vision after surgery, including cystoid macula edema, residual refractive error, and posterior capsular opacification, but the most common cause is ocular surface disease.

For most patients, ocular surface disease related to surgery and postoperative medications improves over the first month, but it can be more challenging for patients with preexisting dry eye disease. Prior to surgery, identifying patients with signs and symptoms is important so the patient understands their condition. If we don’t, and patients recognize their dry eye symptoms after surgery, they will feel that we caused the dry eye, which may take numerous visits to address in addition to patient frustration.

After surgery, we direct patients to their referring providers for future care. If patients need continuous dry eye treatment that is not provided by their referring doctor, we will co-manage their dry eye condition, while emphasizing that their optometrist handles routine exams. We have many other treatment options for these patients after surgery, including in-office therapies and newer prescription medications—tools we can use to continue optimizing the comfort and quality of their vision. Either way, our patients are the ones who benefit from dry eye optimization prior to surgery.

Walter O. Whitley, OD, MBA, FAAO, is Director of Optometric Services at Virginia Eye Consultants in Virginia Beach. Disclosures: Alcon, AbbVie, Bausch + Lomb, Bruder Healthcare, Harrow, ScienceBased Health, Sun Pharmaceuticals, Tarsus Pharmaceuticals, and Viatris.

References

1. Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The prospective health assessment of cataract patients’ ocular surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430. doi:10.2147/OPTH.S120159
2. Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III management and therapy report. Am J Ophthalmol. 2025:279:289-386. doi:10.1016/j.ajo.2025.05.039
3. 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
4. Hovanesian JA, Berdy GJ, Epitropoulos A, Holladay JT. Effect of cyclosporine 0.09% treatment on accuracy of preoperative biometry and higher order aberrations in dry eye patients undergoing cataract surgery. Clin Ophthalmol. 2021;15:3679-3686. doi:10.2147/OPTH.S325659
5. Yang Y, Gouvea L, Mimouni M, et al. Treatment of dry eyes with lifitegrast 5% before cataract surgery: a prospective trial. Pan Am J Ophthalmol. 2024;6(3):98. doi:10.4103/pajo.pajo_34_24
6. Bacharach J, Kannarr SR, Verachtert A, et al. Early effects of perfluorohexyloctane ophthalmic solution on patient-reported outcomes in dry eye disease: a prospective, open-label, multicenter study. Ophthalmol Ther. 2025;14(4):693-704. doi:10.1007/s40123-025-01097-z
7. Yeu E, Koetting C, Calvelli H. Prevalence of meibomian gland atrophy in patients undergoing cataract surgery. Cornea. 2023;42(11):1355-1359. doi:10.1097/ICO.0000000000003234
8. Ishrat S, Nema N, Chandravanshi SCL. Incidence and pattern of dry eye after cataract surgery. Saudi J Ophthalmol. 2019;33(1):34-40. doi:10.1016/j.sjopt.2018.10.009
9. Iglesias E, Sajnani R, Levitt RC, Sarantopoulos CD, Galor A. Epidemiology of persistent dry eye-like symptoms after cataract surgery. Cornea. 2018;37(7):893-898. doi:10.1097/ICO.0000000000001491