Don't Overlook Ocular Surface Disease Before Cataract Surgery

Sumit (Sam) Garg, MD


October 18, 2018

The diagnosis and management of ocular surface disease (OSD), which encompasses conditions like dry eye disease and meibomian gland dysfunction, has been a hot topic in the eye care community for the past several years.

It is well known that the health and appearance of the ocular surface can affect preoperative measurements for cataract surgery. Despite this, the diagnosis and treatment of OSD are often missed, overlooked, or ignored in the preoperative cataract surgery patient. This is confounded by the fact that the signs and symptoms of OSD do not always correlate. Many patients present complaining of symptoms consistent with OSD, which helps in establishing a diagnosis, but a large percentage are asymptomatic at the time of presentation.

In a recently published study,[1] Gupta and colleagues report the prevalence of OSD in patients presenting for cataract surgery at two academic medical centers. In contrast with previous analyses reporting similar endpoints, this study relied on a diagnosis of OSD by newer point-of-care (POC) testing (matrix metalloprotease-9 and tear osmolarity) and corneal surface slit-lamp evaluations.

Of note, they found a higher percentage of patients with abnormalities in one or both POC tests in those who were asymptomatic (compared with the total cohort), and that 80% of their entire population had evidence of OSD by either an abnormal POC test or examination.

The fact that the study population was elderly and had a higher percentage of females partly explains the high percentage of OSD observed. However, what I took away from this study was the finding that many patients who self-reported as not having OSD, or those with minimal findings on validated OSD questionnaires, still had objective signs of OSD as measured by newer POC tests.

The Importance of Diagnosing OSD Before Surgery

It is not uncommon for patients presenting for cataract surgery to have complaints of fluctuating vision (a key symptom of OSD) but to never have been diagnosed or treated for OSD. This is problematic for the cataract surgeon on many fronts.

First, OSD can affect keratometry and therefore impact the predictability of measurements. Depending on the needs and desires of the patient and the intraocular lens (IOL) technology being considered, it is important to normalize the ocular surface to improve measurement predictability and to ensure that the IOL choice is optimal to deliver the desired outcome. This process can delay surgery for several weeks or longer, depending on the status of the ocular surface and response to treatment.

Second, patients often have very high expectations for particular visual outcomes after cataract surgery. Despite improvements in IOL designs, two thirds of the focusing power of the eye comes from the cornea. Therefore, an unstable tear film and a cornea affected by OSD can have a dramatic impact on visual outcomes.

Third, OSD is often exacerbated by cataract surgery, so diagnosing it preoperatively is important, as patients will often blame cataract surgery as the reason for their OSD.

In my opinion, it is important for patients to be counseled to treat OSD pre- and postoperatively. It is our job as eye care providers to emphasize the importance of this treatment and make sure that we do not ignore obvious and nonobvious OSD.

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