Getting beyond the surface in ocular surface disease

Laura M. Periman, MDOcular surface disease (OSD) is a prevalent, chronic, and progressive condition with an often multifactorial etiology. A comprehensive approach to detection, treatment, and monitoring is required.

In its most severe forms, OSD can be associated with blurred or fluctuating vision, foreign body sensation, photophobia, stinging, itching, watery eyes, grittiness, burning, and irritation.^1-3 Among cataract surgery patients, presence of even mild OSD can lead to variability in average keratometry, anterior corneal astigmatism, and IOL power calculations.⁴

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In an era where patients are expecting more from their postsurgical vision, it behooves the ocular surgeon to take a proactive approach for managing the ocular surface.

OSD rarely presents as a solitary, easily identifiable entity, and there are often comorbidities and other factors present in patients with dry eye disease (DED) that contribute to or exacerbate the clinical presentation. For example, there is significant crossover in the signs and symptoms of dry eye disease and allergic conjunctivitis, blepharitis, and bacterial conjunctivitis.^5-7

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Furthermore, blepharitis is known to be both a cause of ocular surface symptoms as well as a contributor to DED.⁶ Meibomian gland dysfunction (MGD) can be a cause of blepharitis and a prominent underlying factor in DED.⁸ MGD can manifest as pure MGD or combined MGD/aqueous-deficient dry eye in 86% of DED patients, as seen in a multi-center study of 299 subjects.⁹

A number of risk factors for DED have been identified, including systemic medical issues (i.e., thyroid, hypertension, hypercholesterolemia, diabetes), use of systemic medication, and lifestyle (i.e., stress, work environment, excess computer use, poor ergonomics, poor make up habits, etc.).^3,10-12

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Prominently, inflammation plays an important role in DED, which “is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.”³ Abnormal tear osmolarity has been identified as a common feature of both aqueous deficient and evaporative dry eye.

Thus, while OSD (and DED in particular) warrants diligence in its own right, the associated impact of OSD inflammation pre- and postoperatively deserves consideration in cataract and other ocular surgeries.

Even gentle cataract surgery in eyes with mild forms of OSD can induce inflammatory responses that portend poor visual outcomes and exacerbation of symptoms that affect quality of vision and, in some cases, quality of life.

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