Cataract predictability: Screen and treat unstable tear film in weeks


With a few key steps, surgeons can avert potential refractive surprises, and reduce postoperative dry eye for patients.

Patient expectations for cataract surgery are very high, especially when it comes to advanced-technology implants. To meet those expectations, we need accurate preoperative measurements as a basis for intraocular lens calculations, and we can’t have accurate measurements without a stable tear film.

Objective tests such as tear osmolarity and matrix metalloproteinase 9 (MMP-9) offer efficient ways to screen the tear film and, in turn, may act as predictors of whether preoperative measurements will be accurate. Studies show that cataract patients with abnormal tear film osmolarity have highly variable keratometric readings (up to nearly 3.5 D, taken 2 weeks apart).1

With treatment and stabilization of the tear film, more accurate measurements are captured, reducing residual refractive error.2 Here’s a look at how I screen my cataract patients, aggressively treat them before surgery, and initiate long-term therapy postoperatively for chronic dry eye disease.

Objective tear film screening 

Given the prevalence of dry eye disease in the cataract age group, we have to look at every cataract patient as a dry eye consultation. This is true even when patients are asymptomatic or don’t recognize mild symptoms of dry eye disease. Patients might have intermittent blurred vision that they blame on the cataracts or fatigue, when in fact the problem is tear film instability. If we don’t treat the condition before surgery, dry eye symptoms often worsen from the stress of surgery, at which point patients blame their surgeon for “giving them dry eye.”

Objective tests make dry eye screening accurate and efficient. I use an osmolarity test (TearLab Osmolarity System; TearLab Corporation), in which a score above 308 mOsm/L and/or an interocular difference of 8 mOsm/L or higher indicates an abnormal tear film. When the 2 eyes exhibit different numbers, the diagnosis and treatment decisions are based on the higher number.

In addition to osmolarity testing, I also perform meibography (LipiView; Johnson & Johnson Vision) to show patients their missing or architecturally abnormal gland structures. Another point of care test that our technicians perform is an MMP-9 test for inflammation (InflammaDry; Quidel Corporation). If that test shows a stripe ranging from faint pink to bright red, inflammation is present. We want to treat the inflammation before cataract surgery.

Finally, I educate patients about dry eye and their diagnostic test results. It is so important to make believers of them and engage them in their own treatment process before surgery. I give patients a card with their osmolarity number and a scale on the back with the color-coded interpretation of their number. I explain to them, “We have to tune your ocular surface to get the best results from cataract surgery,” and typically they’re highly motivated to adhere to their customized treatment for the next few weeks.

Preop: a few weeks of intensive therapy

When patients are ready for cataract surgery, they don’t want to wait months for their dry eye treatment to work, but they don’t mind waiting a few weeks to ensure a better outcome. I treat the tear film aggressively and schedule patients back for their measurements in about 3 weeks, depending on disease severity. I explain that they must be adherent, or I won’t be able to get reliable data for surgery.

I start patients on a topical steroid for 2 weeks to quell the inflammation (either Alcon’s Eysuvis or loteprednol if there are insurance coverage issues for Eysuvis). Patients start oral omega supplements, sometimes starting with a liquid formula before transitioning to capsules long term.

If meibography shows impacted meibomian glands, I perform thermal pulsation (LipiFlow; Johnson & Johnson Vision) to evacuate the inspissated meibum and allow the ingested omega fatty acids to filter through the cleaned meibomian gland orifices onto the ocular surface. If patients have blepharitis, I recommend microblepharoexfoliation of the lid margins (BlephEx; Alcon Inc) to debulk the debris, break up the biofilm, and minimize the risk of infection and endophthalmitis.

With the tear film stabilized, evidenced by an osmolarity score below 308 mOsm/L and an absent red line on the MMP-9 test, I am ready to take measurements, calculate the implant powers, and proceed with surgery.

Postop: transition to long-term treatments

Ocular surface disease is chronic; patients will need to use customized therapies long term. I explain to patients that to get the most from their new implants, they need to keep their tear film healthy. Postoperatively, patients continue their omegas, a heated moisture mask, lid scrubs, and an annual thermal and evacuation treatment if warranted.

For patients with meibomian gland dysfunction, I often perform intense pulsed-light therapy (Lumenis Ltd’s OptiLight or ESW Vision’s E>Eye). This 4-session treatment is scheduled every 2 to 3 weeks and can then be repeated as a single treatment semiannually for maintenance. Most patients perceive the benefits with decreased lid margin hyperemia and increased ocular comfort after the sessions are complete.

Additionally, for many patients’ long-term care, I prescribe cyclosporine (Allergan’s Restasis or Sun Ophthalmics’ Cequa), or lifitegrast ophthalmic solution (Xiidra; Novartis Pharmaceuticals Corporation) 5% eye drops, or varenicline solution (Tyrvaya; Oyster Point Pharma, Inc) nasal spray 0.03%. Each patient’s treatment needs must be customized and carefully monitored.

Predictable outcomes

When we stabilize the tear film, refractive surprises become less frequent. Moreover, patients don’t suddenly experience dry eye symptoms postoperatively and blame their surgeon. For the process to work, we have to ensure adherence by engaging patients in their surgical journey. I find this empowers them. They like tracking their osmolarity number. In addition, by starting a dry eye care routine leading up to surgery, patients are well prepared to continue their maintenance therapy after surgery.

Cynthia Matossian, MD, FACS, ABES


Cynthia Matossian, MD, FACS, ABES, specializes in refractive cataract surgery and dry eye disease. She is the founder of Matossian Eye Associates, located in Pennsylvania and New Jersey.


1. Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41(8):1672-1677. doi:10.1016/j.jcrs.2015.01.016

2. Matossian C. Impact of thermal pulsation treatment on astigmatism management and outcomes in meibomian gland dysfunction patients undergoing cataract surgery. Clin Ophthalmol. 2020;14:2283-2289. doi:10.2147/OPTH.S263046

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