It is a case we see far too commonly in our postoperative refractive surgery visits: a patient who presents a few months post-op, still feeling like they are on a rollercoaster of fluctuating vision and looking to you for answers.
Dry eye disease (DED) does not typically begin as a postoperative complication. In most cases, especially for the age range of our cataract surgery patients, it is a preoperative condition—one that surgery likely did not create but absolutely amplifies. Our job, as optometrists with subspecialty training in the ocular surface, is to find it before the surgical referral is made, treat it aggressively, and then send that patient forward with a healthy, stable tear film that can give the surgeon the biometric data they need to give the patient the outcome they were promised.
The Gap in the Workup: How the Ocular Surface Commonly Gets Overlooked
Cataract and refractive surgery practices are, by design, high-volume environments. The typical presurgical workup is calibrated around measuring axial length, keratometry, anterior segment optical coherence tomography, corneal topography, and endothelial cell count. These are the inputs that drive intraocular lens (IOL) selection and surgical planning. The ocular surface is often treated as a backdrop, and if the patient does not voice symptoms of dry eye, it can often be neglected.
What is consistently remarkable in managing DED is how poorly patient-reported symptoms correlate with objective signs. Patients may experience extreme symptoms with minimal clinical signs, or, on the flip side, we may observe severe signs in asymptomatic patients, particularly in neurotrophic cases. Patients who have been managing their chronic discomfort for years, often without ever being formally diagnosed, with over-the-counter drops that provide only fleeting relief of their symptoms, simply accept their baseline as normal. The conversation about therapies that can treat the root cause of their ocular surface disease may have never been brought up.
What makes this oversight particularly consequential is the vital optical role the tear film plays. Somewhere between 65% and 70% of the eye’s total refracting power resides almost entirely at the air-tear film interface. A patient with a tear break-up time of 4 seconds has a primary refracting surface that is actively degrading between blink cycles. Every biometric measurement captured through that collapsing interface—keratometry, topography, wavefront aberrometry—is sampling a moving target. Even the most precise IOL calculation formula cannot compensate for inputs measured through an unstable optical surface.
The Presurgical Ocular Surface Evaluation
When I receive a referral for presurgical clearance, I do not consider it complete until I have a comprehensive picture of the ocular surface. These are the elements I consider nonnegotiable.
• Symptom Quantification
Before I examine the patient, I have them complete the Ocular Surface Disease Index (OSDI) because having a numeric baseline creates a documented starting point against which we can measure treatment response before clearing the patient for surgery.
I pay particular attention to the symptom-sign disconnect. A patient with an OSDI of 8 and a TBUT of 3 seconds is, to me, more concerning than a patient with an OSDI of 32 and a TBUT of 3 seconds. The latter knows their eyes are problematic and will advocate for themselves. The former has adapted to a degraded baseline and will be devastated when surgery makes it worse and they suddenly feel symptomatic.
• Tear Film Evaluation
Given the importance of a consistent tear film in regard to stable, clear vision postoperatively, a thorough evaluation of the tear film is where I like to start my assessment.
Tear break-up time is generally my first objective metric, and I measure noninvasive TBUT (NIBUT) as a standard part of every presurgical evaluation in my practice. I also like to look under the slit lamp with staining. A NIBUT under 10 seconds suggests instability; under 7 seconds is clinically significant; under 5 seconds in a surgical candidate is a flag that requires treatment before I trust any biometry.
The qualitative pattern of breakup matters as well. Pinpoint breakup in the central visual axis—the variant that will most directly affect surgical outcomes—suggests epithelial irregularity that must be treated and reassessed before the patient is cleared.
Tear meniscus height, which is easily assessed on the slit lamp or automated on most topographers, rounds out the tear film picture.
• Meibomian Gland Assessment
The prevalence of meibomian gland dropout increases sharply with age, and the correlation between gland dropout and postoperative dry eye symptoms after cataract surgery is well-established.
Meibography gives me a clear path on how I counsel patients. The degree of gland loss tells me how treatable the underlying disease is. A patient with grade 1 dropout and adequate expressible glands may benefit from a course of oral doxycycline along with adequate lid hygiene. A patient with grade 3 to 4 dropout and nonexpressible, toothpaste-consistency secretions has structural gland disease that can only be managed. That patient needs a different surgical conversation. For these patients, we perform a series of intense pulsed light (IPL) and thermal pulsation treatments with expression prior to any referrals for surgery. I always tell these patients that I have to reduce inflammation and get their tear film stabilized first to set them up for surgical success.
Having a meibography report prior to surgery is important because it becomes part of their continuing record. If a patient returns at month 6 post-op with dry eye complaints, we have objective documentation of what existed before, and I always note that I advised the patient to pursue treatment prior to surgery. This protects everyone and keeps the clinical picture honest.
• Corneal Staining and Epithelial Integrity
Vital dye staining is a clinical window into epithelial health. Central corneal staining is a red flag for a patient who is considering refractive surgery. Inferior staining generally indicates some form of lid laxity or incomplete closure, which is not uncommon for cataract surgery candidates. It is important to remember the pivotal role of the cornea as a refracting surface: Irregularity here introduces higher-order aberrations for which no IOL calculation or laser ablation pattern can fully compensate.
In my experience, the single greatest contributor to “unexplained poor visual outcomes” after cataract surgery, particularly with premium IOLs, is central corneal staining that was present preoperatively and either not detected or not treated before surgery. The multifocal IOL works as designed. The cornea cannot deliver what the IOL is asking of it.
I usually start these patients on a low dose steroid drop with taper over the course of about a month (with frequent IOP checks in between) to eliminate any preoperative keratitis to ensure a better surgical outcome.
• Lid Margin Assessment
I often tell fellow clinicians that I spend more time assessing the lid margins than I do in any other area when it comes to dry eye diagnosis. Lid margin irregularity, telangiectasia, and anterior blepharitis are extremely common in older presurgical age groups and often require treatment that, while straightforward, takes diligence. Anterior blepharitis and Demodex can drive postoperative inflammation that could have been easily preventable with proper maintenance when diagnosed and managed ahead of time.
The Biometry Problem: When Compromised Corneas Interfere with Accurate Measurements
The most compelling argument I make to referring surgeons, and the one that consistently opens the door to deeper collaboration, is not about patient comfort or DED as a chronic condition. It is about the accuracy of the measurements on which their surgical outcomes depend. Make sure you have set up a referral system with a refractive surgeon who values your expertise and opinion on ocular surface disease. This partnership is vital for your patients to get the best possible outcome when they return to your chair.
Automated keratometry and corneal topography are fundamentally measurements of the anterior corneal surface. In a patient with an unstable or irregular tear film, every data point collected by these instruments is contaminated by the tear film artifact at the moment of capture. Automated topographers are particularly susceptible because they capture a reflection of the tear film, rather than the corneal epithelium directly.
Multiple studies have quantified the magnitude of this effect.1-3 Keratometry values can shift by 0.5 to 1.5 D in patients with significant dry eye—well in excess of the measurement precision that is required for premium IOL calculations, which target refractive outcomes within 0.25 to 0.50 D. The practical consequence is that a patient with a 1-D keratometry error has a dramatically increased risk of residual refractive error after cataract surgery, regardless of how excellent the IOL formula and the surgical execution are.
In LASIK and PRK candidates, the stakes are equally high. The ablation pattern is calculated from the preoperative topography and wavefront data. An irregular topography reading in a patient with dry eye-related epithelial irregularity can be misread as true corneal asymmetry and raises concerns about keratoconus which could disqualify a candidate who would have been perfectly appropriate for refractive surgery after ocular surface optimization.
My protocol for any patient with a suspicious topography is straightforward: Treat the ocular surface aggressively for 4 to 6 weeks, then repeat all biometry. The protocol costs a few weeks. The alternative—operating on flawed data—costs far more.
Specific Populations That Deserve Elevated Scrutiny
Although every surgical candidate deserves a thorough ocular surface evaluation, certain populations warrant heightened clinical vigilance.
•The Patient Who Has Demodex: The Most Common, but Commonly Overlooked
Demodex blepharitis is in your chair every day, but are you looking for it? The prevalence data should reframe how every clinician thinks about the older surgical patient sitting across from them. Published studies report Demodex colonization in approximately 13% of children, 34% of young adults, 69% of those in their 30s and 40s, 87% of patients between 51 and 70, and approach 100% by age 70 and beyond. In all likelihood, your typical cataract surgery candidate in their mid-to-late 60s has Demodex. The question is never really whether it is present, but whether the load is high enough to be driving pathology.
Demodex-driven anterior blepharitis creates lid margin inflammation that does not respond to conventional therapy until the mite burden is addressed. Patients have often cycled through lid scrubs and warm compresses for years without resolution. Since the US Food and Drug Administration (FDA) clearance of lotilaner ophthalmic solution 0.25% (Xdemvy; Tarsus Pharmaceuticals), we now have a targeted, well-tolerated treatment that achieves meaningful mite eradication in a 6-week course—a timeline that fits neatly into a presurgical optimization window. Identifying and treating Demodex blepharitis before surgery removes a chronic inflammatory driver that would otherwise continue to undermine the ocular surface through the perioperative period and beyond.
• Women in the Menopausal Transition
Because androgens foster lipid production, their decline through menopause is a major driver of evaporative dry eye onset. Women are around 3 times more likely to experience symptoms of dry eye than men, and a large portion of those patients are peri- and postmenopausal.⁴-⁶ Women in this demographic who present for cataract surgery consultation without ever having been evaluated for dry eye deserve particular attention. In my practice, I ask every female patient over 45 about menopause status, hormone therapy, and whether they have noticed any change in eye comfort over the preceding few years. The answers are often revealing. I have also partnered with several OB/GYN doctors in my area and presented lectures on the correlation of menopause and DED, so they can start referring these patients over earlier on in the disease progression.
• The Premium IOL Patient
Patients electing trifocal, extended depth of focus, or toric IOLs are self-selecting for the highest refractive expectations. These technologies have very little tolerance for ocular surface irregularity. These patients should be evaluated more thoroughly before surgery than standard monofocal candidates because the margin for error is smaller.
• The Longtime Contact Lens Wearer
Extended contact lens wear can produce patterns of conjunctival goblet cell loss, meibomian gland morphology changes, and superior epithelial lesions. Patients presenting for refractive surgery consultations are often looking for an “out” if they have been noncompliant with their contact lenses. It is imperative to do a thorough assessment of the cornea and perform topography and biometry to ensure you are selecting the right candidates.
• The Patient on Systemic Medications
The list of systemic medications associated with dry eye is lengthy and underappreciated: isotretinoin, antihistamines, diuretics, beta blockers, selective serotonin reuptake inhibitors, antipsychotics, antiandrogens, and so many more. I pull a complete medication list on every presurgical patient and flag anything that may be contributing to ocular surface compromise. In some cases—for example, an antihistamine being taken seasonally—the timing of surgery can be adjusted. In others, the medication cannot be changed, and the patient needs to understand that their baseline ocular surface condition is medication-related and will require ongoing management.
• Post-LASIK Eyes Presenting for Cataract Surgery
Patients presenting 15 or 20 years after LASIK for cataract surgery often have a long-established pattern of dry eye that has been incompletely addressed. Their topographic appearance may be misleading due to the altered corneal shape, and their biometry requires modified calculation approaches. These are complex cases that benefit from genuine ocular surface subspecialty input and management prior to cataract surgery referral.
Treatment Before Clearance: A Protocol Overview
The presurgical window is not just diagnostic; it is also therapeutic. When I identify DED of clinical significance in a surgical candidate, I initiate treatment immediately and establish a timeline for re-evaluation before I provide clearance.
For patients with access to IPL therapy—which I use routinely in my practice for meibomian gland dysfunction—the presurgical window is an ideal time to initiate a treatment series. Devices that are cleared for DED have published data demonstrating improvement in TBUT and reduction in inflammatory mediators on the lid margin. Four treatments spaced out every 2 weeks before surgery can meaningfully improve tear film quality in time for final biometry.
Another integral piece of technology is dynamic muscle stimulation (Dmst) paired with radiofrequency (RF). For almost all cataract surgery candidates there is going to be some level of lid laxity, which can be addressed with Dmst: it strengthens and tones the orbicularis oculi to achieve proper lid closure. The RF component provides controlled heat to facilitate melting meibum. I manually express glands immediately after RF while the tissue is still warm.
The nonnegotiable principle is this: I will not provide surgical clearance based on biometry obtained in the setting of uncontrolled dry eye. An unstable tear film prior to surgery must be addressed and discussed in depth prior to any referrals. The patient and surgeon are entitled to make their own decisions from here, but they make them with my full clinical findings.
A Call for Systematic Integration
What I am advocating for, ultimately, is a restructuring of how presurgical comanagement works among ODs, cornea specialists, and cataract and refractive surgeons.
Every surgical comanagement protocol should include a mandatory ocular surface evaluation that uses objective technology such as noninvasive TBUT, meibography, vital dye staining, and osmolarity when indicated, and should document baseline disease severity in a standardized format that travels with the patient. Surgical clearance should be contingent on treatment response, not merely on the passage of time. And the treating optometrist should communicate findings to the surgical team in language that is clinically actionable, not generic.
The technology, knowledge, and treatment options exist. The missing ingredient, in most markets, is a systematic commitment to using them.
The thorough evaluation of the ocular surface before surgery deserves the same rigorous evaluation as after it. Our patients’ outcomes are counting on it.OM
References
- Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41(8):1672-1677. doi:10.1016/j.jcrs.2015.01.016
- Sullivan BD, de la Torre MP, Yago I, et al. Tear film hyperosmolarity is associated with increased variation of light scatter following cataract surgery. Clin Ophthalmol. 2024;18:2419-2426. doi:10.2147/OPTH.S484840. PMCID: PMC11366549.
- Lončar VL, Mikulić D, Aljinović-Vučić V, Vatavuk Z, Vicković IP. Impact of dry eye disease and lipid-containing artificial tears on keratometric reproducibility and intraocular lens calculation in cataract patients. Medicina (Kaunas). 2025;62(1):179. doi:10.3390/medicina62010179. PMCID: PMC12843478.
- Farrand KF, Fridman M, Özer Stillman I, Schaumberg DA. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol. 2017;182:90-98. doi:10.1016/j.ajo.2017.06.033
- Schaumberg DA, Uchino M, Christen WG, Semba RD, Buring JE, Li JZ. Patient reported differences in dry eye disease between men and women: impact, management, and patient satisfaction. PLoS One. 2013;8(9):e76121. doi:10.1371/journal.pone.0076121
- Stang A, Schmidt B, Schramm S, et al. Synergism between coexisting eye diseases and sex in increasing the prevalence of dry eye syndrome. Sci Rep. 2024;14:314. doi:10.1038/s41598-023-50871-1. PMCID: PMC10764946.
