A Quick Way to Diagnose and Treat Dry Eye Disease Patients Prior to Their Cataract Surgery Measurements

Craig McCabe, MD, PhD, FACS

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Drmccabe QuickdiagtreatcataractCataract surgery stands as one of the most frequently performed major surgeries, with an estimated 4 million procedures expected to be performed this year. Patient expectations of excellent vision post-surgery are on the rise. It is important to note that one of the most common causes for patient dissatisfaction after uncomplicated cataract surgery is the presence of poor, uncorrected visual acuity arising from inaccuracies in preoperative measurements of corneal topography and axial length.1 Among these measurements, keratometry is particularly susceptible to errors, most often due to a dry ocular surface.

Erroneous topography data on individuals with dry eye disease (DED) can lead to incorrect selection of IOL spherical diopter power, as well as in IOL toric power and axis placement. This results in suboptimal uncorrected visual acuity for the postoperative cataract patient,2 which disappoints both patients and physicians alike. Therefore, to increase patient and physician satisfaction and decrease enhancement rate, it’s essential for the referring physician and/or surgeon to identify and address a patient’s DED before conducting preoperative measurements for cataract surgery.

The identification of DED patients before cataract surgery measurements involves three straightforward steps. First is obtaining a comprehensive history of ocular surface disease. This can be facilitated through a questionnaire that may trigger measurements of topography, tear osmolarity, or inflammatory markers. Second, during the slit lamp examination, signs of DED including corneal surface lustre, punctate epithelial erosions, tear meniscus height, conjunctival hyperemia, and meibomitis should be evaluated. To further confirm the diagnosis, additional assessments using common dyes for tear film breakup time and epithelial health, such as fluorescein, lissamine green, or rose bengal, may be performed.

Mccabe Fig1
Figure 1. Placido disc image of patient with preclinical DED. Irregular mires indicated with yellow arrowheads.

Challenges arise in diagnosing DED among pre-clinical DED patients who do not yet have symptoms and chronic mild DED patients who may have developed sympton tolerance or reduced corneal sensation. Nevertheless, the majority of DED patients tend to report symptoms of scratchy, red, or fatigued eyes, along with intermittent blurry vision—particularly while watching TV, reading, or using various digital displays after several minutes. Their topography placido images typically show imperfections in the reflected mires (Fig. 1), often one of the earliest associated signs of pre-clinical and mild dry eye disease. Notably, a majority of unsatified post-cataract surgery patients who subsequently experienced dry eye issues and resultant poor vision displayed slightly irregular mires in their initial corneal topography evaluation. Moderate blepharitis, conjunctivochalasis, eyelid malposition, and Demodex eyelash infestation appear more linked with moderate to severe chronic DED and may necessitate consideration if initial DED treatment proves inadequate.

Once a DED diagnosis is established in a cataract patient, prompt correction is crucial to prevent errant data on preoperative topography measurements. This correction is easily accomplished within two weeks for preclinical, mild, and moderate DED patients. I implement a combination of preservative-free artificial tears four times a day, preservative-free steroid eye drops four times a day, and lower lid punctal occlusion. The use of preservative-free eye drops helps minimize toxic effects of benzalkonium chloride on a dry ocular surface. Steroid eye drops effectively suppress cytokine and matrix metalloproteinase production mitigating ocular surface irritation, prolonged inflammation and epithelial cell damage. Based on my experience, punctal occlusion is critical in DED management, increasing the meibum and aqueous volume of the tear film immediately and between eye drop applications.3

I recommend the Vera180™ dissolvable punctal plugs for preclinical to mild DED patients, and the nondissolvable VeraPlug™ Flow plugs with a central lumen for moderate DED patients. In my hands, these punctal plugs are the easiest and most comfortable plugs to insert. The Vera180™ intracanalicular plugs provide extended temporary occlusion with excellent retention lasting approximately 180 days, while the VeraPlug™ Flow’s low-profile dome enhances patient comfort and provides proper anatomic fit. The treatment protocol of a preservative-free artificial tear drop followed by a five-minute interval and then a preservative-free steroid eye drop four times daily, coupled with punctal occlusion, consistently offers prompt and sustained relief for preclinical, mild and moderate DED patients.

Two weeks after initiating this DED treatment, patients can be re-evaluated for ocular surface improvements. The resolution of previous DED symptoms combined with the absence of distorted topography mires from the prior examination confirm the patient’s readiness for accurate preoperative keratometry measurements. Of course, these topography measurements should be performed first without any anesthetic or dilating drops. Axial length measurements can then be conducted, providing both the technician and physician reassurance regarding accurate keratometry data. Should signs and symptoms show inadequate improvement, a more severe form of DED may be present. In such cases, I recommend inserting a pair of Vera180™ temporary dissolvable plugs into the upper eyelid puncta, continuation of the previously used eye drops, treatment for other potential causes of dry eye disease, and possibly reducing or discontinuing oral medications known to cause significant ocular surface dryness. For severe cases, patients should return to the clinic in another two weeks for reevaluation.

In the vast majority of cases, this initial 14-day regimen of preservative-free lubricating and steroid eye drops, with punctal occlusion, significantly enhances preoperative keratometry accuracy. More importantly, this quick DED diagnosis and treatment protocol leads to improved postoperative uncorrected vision, heightened patient satisfaction, and a decreased enhancement rate in most DED patients desiring optimum cataract surgery results.4,5,6

1. Miller, K. The Ideal Multifocal Candidate. Cataract & Refractive Surgery Today, May 2019.
2. McCabe, C.F. Shamie, N (Chair), Mah, FS, Trattler, MD, and Warring, GO: Can Improved Ocular Surface Care Really Impact Cataract and Refractive Outcomes? Case Study Reviews, EyeWorld Supplement, October, 2013.
3. McCabe, C.F. and McCabe, S.E.: “How punctal occlusion improves multifocal IOL satisfaction. “Ophthalmology Times. 8(9): May 1:20-23, 2013.
4. McCabe C.F.: “Plugs Reduce Dry-Eye Symptoms, Improve Vision.” Review of Ophthalmology. November:55-58, 2009.
5. McCabe C.F.: “Building the Dry Eye Part of Your Practice Reaps Rewards.” Ophthalmology Times, May:50-52, 2007.
6. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after multifocal intraocular lens implantation. J Cataract Refract Surg. 2009;35:992-997