How to manage cataracts with ocular surface disease


Ocular surface disease, including dry eye disease, is common in patients undergoing cataract surgery. It must be treated in order to optimise the ocular surface prior to surgery, and close follow-up in the postoperative period is important.

Reviewed by Jorge Alio

Take-home: Ocular surface disease, including dry eye disease, is common in patients undergoing cataract surgery. It must be treated in order to optimise the ocular surface prior to surgery, and close follow-up in the postoperative period is important.

Cataract surgery is one of the most-performed surgeries worldwide and patient expectations continue to rise as new developments and technology promise better outcomes. Ocular surface disease (OSD) in patients undergoing cataract surgery, which is often overlooked, plays an important role in determining the outcome of surgery and patient satisfaction.

(FIGURE 1) Meibomian gland capping and lid-margin telangiectasia in an asymptomatic patientThere is a high prevalence of dry eye disease (DED) in patients undergoing cataract surgery and studies have shown that 77% of patients have some corneal staining; however, 87% are asymptomatic.1 Studies have also shown that 86% of patients presenting with dry eye symptoms suffer from meibomian gland dysfunction (MGD).2

Given that the incidence and severity of DED have been shown to increase after cataract surgery, it is extremely important to identify these patients and treat them appropriately.3 Cataract is also common in patients with immune-mediated OSD, because of their age and use of topical steroids, and following severe keratitis and corneal perforation.

Recognition and appropriate management of OSD reduces the risk of postoperative complications such as poor visual outcomes, delayed healing, infections, melts and visual loss.




Surgeons should actively seek out signs and symptoms of OSD. A history of dry eye/mouth symptoms, collagen vascular disease and skin and joint problems may indicate the presence of OSD.

Fluctuating vision and an inability to read or watch television for prolonged periods are usually a sign of an unstable or insufficient tear film. It is useful to employ the Ocular Surface Disease Index grading to gauge the severity of disease and monitor progress prior to cataract surgery.4

Slit lamp assessment should include close inspection of the eyelid skin and margins. Rosacea, eczema, MGD, irregular and inflamed lid margins or tear film foam/debris may be present. Assessment of tears includes Schirmer’s test, tear meniscus height and tear film break-up time (TBUT). Wetting of ≤5 mm, tear meniscus height ≤0.2 mm and TBUT ≤5 seconds are highly suggestive of DED. Vital dye staining with fluorescein and/or lissamine green helps to quantify the extent of ocular surface damage.

These simple evaluations can be performed by all surgeons and may be complemented with measurement of tear osmolarity, detection of matrix metalloproteinases, lipid layer interferometry and keratography. These examinations, however, are expensive and are rarely performed as a preliminary to cataract surgery: they do have a role in other procedures such as refractive surgery.

Corneal topography and biometry may be inaccurate in patients with OSD and must be repeated after treatment with topical lubricants.




The aim is to optimise the ocular surface prior to surgery, and patient education remains key in successful management. Patients may have presented with the preconceived idea that their symptoms are due to cataract. Treatment for OSD may therefore be regarded as unnecessary, meaning that they find the delay in their visual rehabilitation frustrating. Explaining its importance and the associated risks helps to improve compliance and manage expectations, which is particularly relevant if considering the use of premium IOLs. DED significantly affects patients’ perception of quality during the postoperative period.

Blepharitis is a common cause of DED and often a reason for cancellation of cataract surgery.5 Hot eyelid compresses, lid hygiene, topical preservative-free lubricants and omega-3 supplements form the mainstay of treatment. Adjunct use of azithromycin, tetracyclines, short-term topical steroids or cyclosporine may be appropriate in patients with lid-margin inflammation and chronic symptoms.

A conjunctival swab and use of topical antibiotic ointment 7–10 days prior to surgery may also be advocated in patients with active ocular surface inflammation.

Ideally, the conjunctival inflammation in patients with immune-mediated OSD, for example mucus membrane pemphigoid, Stevens–Johnson syndrome or graft-versus-host disease, should be controlled in the months preceding surgery.6 In some cases, systemic immunosuppression in the perioperative period may be required. These patients should also be treated for concomitant lid-margin disease, and all patients with OSD should be advised to instil preservative-free topical lubricants. Punctal occlusion may also be considered but must be used with caution in patients with MGD.




Preoperative medication should be carefully controlled and minimised.

Most cases can be treated effectively under local (topical and peribulbar) anaesthesia. Conjunctival manipulation must be kept to a minimum and sub-tenon anaesthesia and subconjunctival injections are best avoided. Eyelid retraction, symblepharon division and canthotomies may be required in some cases: general anaesthesia may be considered in such circumstances. Intraocular medication (1) may reduce the use of topical anaesthetics or mydriatics, which are highly toxic for the corneal epithelium.

Use of a cohesive ophthalmic viscosurgical device is useful to protect the corneal epithelium and maintain a good surgical view throughout surgery. In cases with a compromised surgical view, changing microscope illumination, using trypan blue for capsular staining or endoillumination may help improve visualisation.

Postoperative care


Postoperative care

As DED may worsen following surgery, it is of paramount importance to maintain close follow-up in the postoperative period. Preservative-free steroids, antibiotics and lubricants should be considered following surgery in all patients with DED. Topical cyclosporine is effective in managing OSD and improving corneal sensation after cataract surgery and may be considered if not prescribed preoperatively.7

(FIGURE 2) a) Non-healing epithelial defect and corneal staining following cataract surgery b) Healed epithelium following treatment with intensive lubricants, punctal occlusion and autologous blood.

It is important to identify any epithelial defects and grade the conjunctival inflammation in the postoperative period. Non-healing corneal epithelial defects may lead to melts, infection, perforations and sight loss. Aggressive systemic and local therapy may be required, including use of amniotic membrane, autologous blood and induction of ptosis.


OSD is highly prevalent in patients undergoing cataract surgery; surgeons must actively seek its signs and treat aggressively. In asymptomatic patients, this is key in producing the successful refractive outcomes that they expect. In those with established OSD, it will also aid maintenance of vision and avoid permanent visual loss.





W. Trattler et al., Poster, American Society of Cataract and Refractive Surgery Annual Symposium and Congress. San Diego; March 2011.

M.A. Lemp et al., Cornea 2012; 31(5): 472-428.

Y.K. Cho and M.S. Kim. Korean J. Ophthalmol. 2009; 23: 65-73.

R.M. Schiffman et al., Arch. Ophthalmol. 2000; 118: 615-621.

R.E. Stead et al.,Eye (Lond). 2010; 24(4): 742.

V.P. Saw and J.K. Dart. Ocul. Surf. 2008; 6(3): 128-142.

S. Hamada et al.,Cont. Lens Anterior Eye 2016; 39(1): 15-19.

B. Miljanović et al., Am. J. Ophthalmol. 2007; 143: 409-415.

S.E. Moss, R. Klein and B.E.K. Klein. Arch. Ophthalmol. 2000; 118: 1264-1268.

K.E. Han et al., Am. J. Ophthalmol. 2014; 157: 1144-1150.

M.Q. Salomão, R. Ambrósio Jr. and S.E. Wilson. J. Cataract Refract. Surg. 2009; 35: 1756-1760.

12 N. Kasetsuwan et al., PLoS One. 2013; 8: e78657.

13. J.L. Rodriguez-Prats et al.,J. Refract. Surg. 2007; 23: 559-562.

14. Labetoulle M, Findl O, Malecaze F, Alió J, Cochener B, Lobo C, Lazreg S, Hartani D, Colin J, Tassignon MJ, Behndig A; Intracameral Mydrane Study 2 Group.Evaluation of the efficacy and safety of a standardised intracameral combination of mydriatics and anaesthetics for cataract surgery.Br J Ophthalmol. 2015 Nov 3. pii: bjophthalmol-2015-307587

Amit Patel is consultant ophthalmologist at Spire Parkway Hospital in Solihull, West Midlands.

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