The role of management in surgical outcomes: Treating dry eye before, during, and after

Dry eye disease (DED) has long occupied a somewhat uneasy place in the cataract and refractive surgery workflow. It is acknowledged as a complicating factor but is often addressed reactively rather than strategically. Three presentations at the 2026 ASCRS Annual Meeting in Washington, DC, attempt to shift that framing in meaningful ways, offering new data on how quickly existing and emerging therapies can relieve symptoms and what preoperative DED treatment can do for biometric accuracy in surgical candidates.

Together, they make a case for treating dry eye not as a side issue to be managed around surgery, but as a clinical priority in its own right—with direct implications for surgical planning and outcomes.

Lifitegrast: A Post Hoc Look at Who Responds Early and What It Means

Lifitegrast ophthalmic solution 5.0% has been a mainstay of anti-inflammatory dry eye therapy since its approval, but the clinical reality is that patient responses vary—and surgeons and patients alike want to know how quickly they can expect results and whether early response predicts long-term benefit. A post hoc analysis presented by Eric D. Donnenfeld, MD, FACS, draws on pooled data from the phase 3 OPUS-2 and OPUS-3 trials to answer those questions.

Using cluster analysis applied to percent change from baseline in eye dryness score (EDS) at days 14, 42, and 84, Donnenfeld and colleagues identified 5distinct response subgroups within the lifitegrast treatment arm. The most clinically informative of these is the early sustained responder group: patients who achieved at least 60% reduction in EDS at all 3 time points. This group comprised 17.7% of the treated population (n = 113) and was characterized by numerically lower baseline symptom scores across multiple domains, including eye pain, burning and stinging, foreign body sensation, and photophobia, compared with the other subgroups.

A second group of steady responders achieved progressively higher EDS reductions of ≥20%, ≥40%, and ≥60% at days 14, 42, and 84, respectively, also comprising 17.7% of patients. At the other end of the spectrum, 26% of patients had less than a 30% reduction in EDS by day 84.

The takeaway for clinicians is nuanced. The majority of patients treated with lifitegrast—those in the top 3 subgroups—achieved at least 60% EDS reduction by day 84, which is a meaningful benchmark for a population with established symptomatic disease. But the early sustained responders, who showed rapid and pronounced improvement within 2 weeks, tended to have less severe baseline symptoms, suggesting that initiating treatment earlier in the disease course, before symptoms become entrenched, may optimize the likelihood of rapid and durable response. For surgeons managing DED in the preoperative period, the implication is fairly practical: earlier intervention with anti-inflammatory therapy may yield faster stabilization ahead of surgery.

Acoltremon: Early Signal of Rapid, Broad Symptom Relief in Moderate-to-Severe DED

A second presentation by Rom Kandavel, MD, introduces a newer agent with a strikingly fast onset profile. Kandavel presented an interim analysis from the ASTRA study evaluating acoltremon ophthalmic solution 0.003% (TRYPTYR) in patients with moderate-to-severe DED, defined by OSDI scores between 25 and 50 and tear break-up time under 10 seconds.

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The results from the first 12 subjects who completed all visits are preliminary, but arresting, nonetheless. Mean total OSDI score fell from 61.8 at baseline to 24.8 at day 14, marking a 60% reduction, and to 16.5 at day 28, a 73% reduction from baseline. Item-level analysis showed the largest gains in light sensitivity (–2.6), difficulty reading (–2.5), gritty sensation (–2.4), painful or sore eyes (–2.3), and computer use (–2.2)—a spread across sensory, functional, and activity-based domains that suggests broad rather than narrow symptom relief.

The objective findings tracked with the symptoms. Mean tear break-up time increased from 5.38 seconds at baseline to 9.11 seconds at week 4 (69% improvement) while total corneal fluorescein staining decreased from 7.19 to 2.17 units over the same period, a roughly 70% reduction. The mean reported onset of first symptomatic improvement occurred at dose 7, with a range of 3 to 14 doses, and 80% of subjects reported improvement by week 2.

Notably, the study is small and ongoing, with statistical analysis planned upon completion of 50 subjects, and these conclusions should be interpreted accordingly. But the consistency of signal across symptom scores, tear film stability, and staining, combined with an onset profile measured in days rather than weeks, makes acoltremon a therapy worth watching closely as the full dataset matures.

Perfluorohexyloctane Before Cataract Surgery: Stabilizing the Tear Film Improves Biometric Accuracy

A third presentation closes the loop by connecting DED treatment directly to surgical planning. Presented by Jason Bacharach, MD, the results were from a prospective, multicenter, phase 4 study evaluating whether 30 days of preoperative treatment with perfluorohexyloctane ophthalmic solution (PFHO) affected the accuracy of biometry and keratometry measurements in cataract surgery candidates with DED.

PFHO works by forming an anti-evaporative monolayer at the tear film surface, reducing tear film instability without the pharmacological mechanisms of anti-inflammatory agents. This mechanistically distinct approach makes it particularly well suited to the preoperative stabilization context. The study enrolled 97 patients (75.3% female; mean age 68.6 years) who instilled PFHO 4 times daily for 30 days before surgery, with a second 30-day course beginning approximately 1 month postoperatively.

The primary end point of mean difference in absolute deviations from predicted refractive error before versus after presurgical PFHO treatment was –0.027 ±0.167 D (P = .1385), indicating that PFHO did not alter the accuracy of biometry measurements at the group level, an important safety finding for a drug being used in the preoperative window. But the more clinically actionable result is in the IOL power calculation data: the percentage of patients with calculated IOL power within ±0.50 D of the correct power increased from 72.1% before PFHO treatment to 83.7% after, denoting an 11.6-percentage–point improvement that has direct implications for refractive outcomes. Additionally, 94.2% of study eyes had a difference in predicted refractive error within 0.3 D before and after PFHO treatment, confirming some measurement stability. Tolerability was favorable, with only 2 mild treatment-related adverse events reported across the full cohort.

For cataract surgeons, these numbers translate to a straightforward clinical argument: in DED patients where tear film instability is likely to compromise biometric reliability, a preoperative course of PFHO might improve the quality of measurements used to select IOL power without introducing refractive unpredictability of its own. In an era where premium IOL implantation demands increasing precision from every step of the surgical workflow, stabilizing the ocular surface before measurements are taken is not merely good practice. The data suggest it is measurably consequential.

The Unified Message

What unites these 3 presentations is a slight reframing of DED’s place in the anterior segment surgeon's clinical calculus. Donnenfeld's analysis establishes that earlier anti-inflammatory treatment may produce faster and more sustained symptom relief, relevant to both the standalone DED patient and the surgical candidate in a preoperative stabilization window. Kandavel's interim data introduce an agent with an unusually rapid onset profile that, if confirmed in larger numbers, could meaningfully expand options for patients with significant symptom burden. And Bacharach's study provides prospective evidence that treating the tear film before surgery is not just about patient comfort—it demonstrably improves the accuracy of measurements used to determine refractive success.

REFERENCES
1. Donnenfeld E, et al. Early Symptom Relief with Lifitegrast Ophthalmic Solution, 5.0% in Patients with Dry Eye Disease: Post Hoc Analysis of Two Randomized Trials. Presented at: ASCRS 2026; April 10-13; Washington, DC.
2. Kandavel R, et al. Early Symptom and Ocular Surface Response to Acoltremon Ophthalmic Solution 0003% in Dry Eye Disease: ASTRA Interim Analysis. Presented at: ASCRS 2026; April 10-13; Washington, DC
3. Bacharach J, et al. Preoperative Perfluorohexyloctane Ophthalmic Solution in Patients with Dry Eye Disease Undergoing Cataract Surgery: Refractive Outcomes. Presented at: ASCRS 2026; April 10-13; Washington, DC.