Make the Ocular Surface Healthy

Identify and treat dry eye disease in pre-cataract surgery patients

When I graduated from Nova Southeastern in 2001 DED was basically a footnote, with just mild palliative treatments, such as artificial tears, available. Fast forward, and DED is now a major focus of eye care and an ideal condition for optometrists, in particular, to identify and treat, given we are the primary eye care providers, and that the chronic and bothersome condition affects so many patients.

Specifically, according to the cross-sectional, population-based survey: Prevalence of Diagnosed Dry Eye Disease in the United States Among Adults Aged 18 Years and Older, 6.8% of the U.S. adult population is projected to have DED (16.4 million people), while an estimated 6 million have reported DED symptoms, though have not received a diagnosis.

Yet, despite these facts, many optometrists are not making the diagnosis and management of DED a priority, particularly when co-managing cataract patients. The result of this is that our ophthalmologist colleagues are doing it, increasing the chances of patients who have DED to question our value in the pre-surgical process: “Why did he/she miss that?”

O.D.s should diagnose and manage DED prior to cataract surgery (above).
Image courtesy of Johnny Gayton, M.D.

And, consider this: According to Customer Service Manager magazine, 91% of unhappy customers will cease doing business with those who make them unhappy, and they’ll tell up to 20 of their friends. Loss of customers is even worse from poor online reviews: According to Qualtrics Experience Managing, 94% say a negative review has convinced them to avoid a business. Translation: Failing to diagnose and manage DED in patients prior to cataract surgery can result in losing current and prospective patients.

As optometrists co-managing cataract surgery, we need to take an active role in diagnosing and managing pre-cataract surgery patients’ DED, so they can have the best possible outcomes and our practices can thrive. Here, I explain how O.D.s can accomplish this:


Many patients do not think they have DED because they have become accustomed to it. One of our duties as these patients’ primary care providers is to ask about related symptoms, such as fluctuating vision, burning, foreign-body sensation, photophobia and tearing, via the patient history/intake form.

Inquiring about these symptoms helps us identify possible DED patients and enables us to explain to patients that DED can lead to poor and inconsistent refractions, thus leading to errors in IOL calculations, as well as delayed post-op recovery time.


We have many tools to diagnose DED: They are patient questionnaires (e.g. the Dry Eye Questionnaire 5 (DEQ-5); vital dyes (fluorescein, lissamine green and Rose Bengal epithelial staining); the metalloproteinase-9 (MMP-9) in-office test; tear osmolarity testing, corneal topography; Schirmer’s Test; phenol red thread test; slit lamp biomicroscopy; AS-OCT; Sjögren’s syndrome test; meibography; meibomian gland expression; blink rate testing and TBUT evaluation. (For additional information on these diagnostic tests, visit .)


Depending on the severity of the patient’s DED, we have several ways to manage these patients. They include artificial tears; lid hygiene products (e.g. warm compresses, lid scrubs, masks and/or sprays); ocular nutritional supplements (omega-3 and omega-6); cyclosporine; lifitegrast; antibiotics; corticosteroids; cenergermin; punctal plugs, intense pulsed light; neurostimulation; thermal pulsation; scleral contact lenses; autologous serum and amniotic membranes. (For additional information on these treatments, visit .)


Whatever treatment plan we prescribe, we must always be professional and considerate of our patients, in terms of providing them with the rationale for their planned treatment, why alternative treatments are not preferred, a realistic assessment of benefits, adverse reactions, risks, consequences, side effects and, of course, the effect the treatment will have on the scheduling of the cataract surgery. Specifically, we need to communicate to those who have severe DED that their procedure may need to be postponed to allow for the DED treatment to take effect.

IT'S 2019

Diagnosing and treating DED before referring patients for cataract surgery increases the likelihood of a happy, returning patient and new patient referrals. The surgeon should not need to look for DED signs or symptoms. The year 2001 is far behind us. OM