Inside the ASCRS preoperative ocular surface disease algorithm: Key updates

As expectations for refractive cataract surgery continue to rise, preoperative ocular surface optimization remains essential for achieving predictable outcomes. Christopher E. Starr, MD, FACS, highlighted updates to the ASCRS Preoperative Ocular Surface Disease (OSD) Algorithm, a project that began more than a decade ago and was first published in 2019.¹ Starr is associate professor of ophthalmology and cornea and ocular surface specialist at Weill Cornell Medicine in New York, NY.

Starr noted the continued importance of preoperative ocular surface optimization in the era of refractive cataract surgery, noting that “patients expect perfection.” He said that surgeons must “pay attention to the ocular surface,” both before and after surgery, particularly when implanting premium lenses such as extended depth of focus or multifocal IOLs. As he put it, “Ocular surface disease of dry eye plus multifocal optics is a recipe for disaster in some cases.”

The updated 2026 version retains the core framework of the original algorithm while incorporating refinements based on evolving diagnostic tools and clinical practice patterns. A key addition is guidance on the consistency of preoperative astigmatism and keratometry measurements across multiple devices. Starr said the revised algorithm now includes a reminder to assess whether modalities are consistent within “one diopter” of average keratometry and within “ten degrees of the steep axis of the astigmatism.”

He noted that many surgeons now use three or more tools for biometry and corneal topography, making data reconciliation an increasingly important part of the preoperative evaluation. Additional diagnostic modalities now referenced include osmolarity, MMP-9, lactoferrin, non-invasive tear break-up time, and non-contact corneal aesthesiometry.

A substantial update involves the evaluation of corneal nerve disorders, including neuropathic corneal pain and neurotrophic keratitis. Starr described non-contact aesthesiometry as “revolutionary” in identifying diagnoses that have historically been missed. The revised algorithm now makes clear that in patients with neuropathic corneal pain, “there is absolutely no … elective refractive surgery.”

The algorithm also adds updated guidance on Demodex blepharitis, reflecting the availability of FDA-approved treatment options not present in 2019. Starr underscored the importance of identifying collarettes during the preoperative exam and treating Demodex blepharitis before surgery.

Across all revisions, the central message remains consistent: identify ocular surface disease preoperatively, discuss it with the patient, and treat it before surgery to reduce postoperative complications and improve outcomes.

Reference

1. ASCRS Preoperative OSD Algorithm. ASCRS Cornea Clinical Committee. Accessed April 10, 2026. https://www.ascrs.org/clinical-education/cornea/ascrs-preoperative-osd-algorithm