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Optimizing the ocular surface to achieve full visual potential continues after surgery


Ophthalmologists should instruct their patients to pay attention to their eye health for the long term.

Although it is always important to consider optimizing the ocular surface for all patients to improve their vision, it is of critical importance before cataract surgery. As has often been stated, cataract surgery is a form of refractive surgery. All our patients expect excellent postoperative results with clear and stable vision regardless of the type of lens implant we are using.

Garbage In, Garbage Out

I counsel my patients that an optimized ocular surface supports accurate preoperative measurements including refractions, keratometry, corneal topography, and biometry, and that with a healthy tear film and smooth corneal surface, they can achieve their full visual potential. On the other hand, a dry ocular surface with an increased tear breakup time, punctate staining, or desiccation will affect the reliability, reproducibility, and accuracy of the measurements—garbage in, garbage out. This increases the chances of the surgeon making an inappropriate IOL recommendation or selecting the wrong IOL power and the patient experiencing a suboptimal outcome. In fact, a poor ocular surface can have a profound effect on the corneal topography measurements.

Multifocal presbyopia-correcting lens implants offer patients the greatest chance for freedom from glasses after surgery; however, they are the most sensitive to ocular surface disease. This means patients with significant dry eye who receive this IOL technology tend to have more variability in the quality of their vision than those who receive a monofocal or toric lens.

Further, patients must be made aware that it is not enough to optimize their ocular surface before surgery, but they must continue to take care of it postoperatively as well. If ocular surface disease recurs, vision will be adversely impacted.

Keys to the Evaluation

No matter where patients are coming from—an outside referral or within the practice—it is incumbent upon the surgeon to ensure their corneal health preoperatively. When I evaluate patients, I still do what I learned as a corneal fellow: Observe the patient for clues before starting the slit lamp exam. They may be blinking frequently to clear their vision or perhaps they have skin manifestations of rosacea that would predispose them to blepharitis. They might have an incomplete blink, lagophthalmos, or like to rub their eyes. I ask about contact lens wear and level of comfort, and probe for symptoms of dry eyes or blepharitis. All of this is helpful in guiding my exam and helping in my ultimate IOL recommendation.

When I perform the slit lamp exam, I look at the lid margins for signs of anterior blepharitis or meibomian gland dysfunction. I assess the quality of the tear film and tear breakup time with fluorescein. I look for punctate staining, keratitis, or other forms of irregular corneal such as anterior basement membrane corneal dystrophy.

Stepwise Therapy

When it comes to treatment, I explain the nature of dry eye disease and why it needs to be treated. I start patients with newly diagnosed disease on artificial tears 4 times a day and consider punctal plugs at that first visit; I use collagen DuraPlugs (Katena) that dissolve after 3 to 4 months.

I have become much more inclined to add nutraceutical options such as HydroEye (ScienceBased Health) very early on in my treatment regimen. The patented formulation’s key ingredient is the unique anti-inflammatory fatty acid gamma linolenic acid (GLA), derived from black currant seed oil.1 GLA is a precursor to the anti-inflammatory prostaglandin PGE1 and has been validated in a variety of clinical trials for improving dry eye symptoms in a range of patient populations.2-8

The supplement includes a specific balance of other omegas and nutrient cofactors to provide dry eye relief, and may change the chemistry of the meibomian glands as they start producing normal lipids, stabilizing the tear film and relieving symptoms. Another benefit is patients’ acceptance. They are comfortable taking a natural option for the long term and I make sure they understand that its anti-inflammatory effects can have systemic benefits as well. I am leaning toward getting people to take nutraceuticals sooner rather than later because there are so many benefits, including not needing to take as many as other topical medications.

I discuss environmental changes with patients such as eliminating overhead fans and not allowing air vents to blow directly in their face. I also remind them that prolonged reading and binge watching television or videos will exacerbate dry eyes. If there is lid margin disease, I recommend hypochlorous acid–containing lid scrubs such as Avenova or OCuSoft, as well as a reusable warm compress such as a Bruder mask. I impress upon them that we cannot take the preoperative measurements for cataract surgery until we see some significant improvement in their ocular surface and visual symptoms.

If necessary, I can add low-dose oral doxycycline, especially if there is meibomian gland disease. It has anti-inflammatory effects and it can change the function of the meibomian glands for the better. Our practice has had success with heat and pulsation-type devices such as LipiFlow (Johnson & Johnson Vision) or the TearCare System (Sight Sciences). Often, we are able to break the cycle of lid margin and dry eye disease. In patients who do not have lid margin disease, I will try a topical drop such as cyclosporine 0.05% (Restasis; Allergan, an AbbVie Company), lifitegrast 5% (Xiidra; Novartis Pharmaceuticals Corporation), cyclosporine 0.09% (Cequa; Sun Pharmaceutical Industries), or corticosteroids (loteprednol 0.5% or fluorometholone 0.1%). Although these are not a cure-all, about half my patients will respond.


I am honest and forthright when explaining to patients that the ultimate outcome of their cataract surgery depends on how they care for themselves. I point out that if they want to have reliable vision and be less dependent on glasses, they need to invest in their eyes and take the time and effort to prepare for surgery. I remind them that this is a lifetime commitment because there is no cure for dry eye disease. This means they cannot totally abandon caring for their ocular surface.

Steven I. Rosenfeld, MD

E: StevenR@delrayeyecare.com

Rosenfeld is in practice with Delray Eye Associates, PA, in Delray Beach, Florida, and is a voluntary professor at Bascom Palmer Eye Institute in Miami, Florida. Rosenfeld disclosed no relevant financial relationships.


1. Kapoor R, Huang YS. Gamma linolenic acid: an anti-inflammatory omega-6 fatty acid. Curr Pharm Biotech. 2006;7(6):531-534. doi:10.2174/138920106779116874

2. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linolenic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101. doi:10.1097/00003226-200303000-00002

3. Macrì A, Giuffrida S, Amico V, Iester M, Traverso CO. Effect of linoleic acid and gamma-linolenic acid on tear production, tear clearance and on the ocular surface after photorefractive keratectomy. Graefes Arch Clin Exp Ophthalmol. 2003;241(7):561-566. doi:10.1007/s00417-003-0685-x

4. Aragona P, Bucolo C, Spinella R, Giuffrida S, Ferreri G. Systemic omega-6 essential fatty acid treatment and PGE1 tear content in Sjögren’s syndrome patients. Invest Ophthalmol Vis Sci. 2005;46(12):4474-4479. doi:10.1167/iovs.04-1394

5. Kokke KH, Morris JA, Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye. 2008;31(3):141-146. doi:10.1016/j.clae.2007.12.001

6. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-264. doi:10.1097/ICO.0b013e318033d79b

7. Brignole-Baudouin F, Baudouin C, Aragona P, et al. A multicentre, double-masked, randomized, controlled trial assessing the effect of oral supplementation of omega-3 and omega-6 fatty acids on a conjunctival inflammatory marker in dry eye patients. Acta Ophthalmol. 2011;89(7):e591-e597. doi:10.1111/j.1755-3768.2011.02196.x

8. 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

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