We noticed you’re blocking ads

Thanks for visiting MillennialEYE. Our advertisers are important supporters of this site, and content cannot be accessed if ad-blocking software is activated.

In order to avoid adverse performance issues with this site, please white list https://millennialeye.com in your ad blocker then refresh this page.

Need help? Click here for instructions.

Astigmatism Basics | Mar/Apr '18

Optimizing the Ocular Surface

Several conditions must be addressed before refractive cataract surgery.

Dry eye disease (DED) and meibomian gland dysfunction (MGD) are common conditions that, in the setting of refractive cataract surgery, require attention prior to surgical intervention. The tear film is a refractive surface, and, with reduction in its quality, patients experience degradation of their visual function.

Recognizing DED before surgery is one of the most important things a clinician can do when evaluating a cataract patient. From clinical experience, many patients experience worsening of OSD after surgery. Theories as to why dry eye parameters may worsen postoperatively include toxicity from postoperative medications and stress to the corneal nerves after surgical intervention. Patients who suffer from DED postoperatively are often dissatisfied with their outcomes, even though they may be 20/20 on the charts.

Other conditions such as anterior basement membrane dystrophy (ABMD) or Salzmann nodules must be identified prior to refractive cataract surgery. Both of these conditions can cause irregular astigmatism. Superficial keratectomy is effective for treating ABMD and/or Salzmann nodules. Patients often have reduction in astigmatism after treatment and should be followed with serial topography and biometry after healing from superficial keratectomy. Once these measurements demonstrate stability, it is safe to proceed with cataract surgery.


DED can often lead to inflammation and subsequent degradation of the corneal epithelium. In my preoperative patients with dry eye, I want to balance rapid onset of action with improvement of the ocular surface. I generally start patients on a topical steroid drop and taper over 2 weeks. If the patient exhibits signs or symptoms that suggest he or she may have underlying chronic disease, I start a topical anti-inflammatory such as lifitegrast 5% (Xiidra; Shire) or cyclosporine 0.05% (Restasis; Allergan). These medications provide inflammation control for the long term, while the topical steroids are intended only for short-term use, given risks of IOP elevation.

For patients with MGD, my preferred initial treatment is thermal pulsation. Thermal pulsation has been shown to improve gland flow and tear break-up time and additionally can reduce ocular surface inflammation. I try to treat patients the same day I see them in clinic to make the decision for cataract surgery and have them return in a few weeks for repeat biometry measurements.

Video. Dr. Gupta discusses insights into astigmatism management, from optimizing the ocular surface to selecting the appropriate technology.


As with most things, patient education is paramount. If a patient presents for cataract surgery evaluation and concomitant dry eye is found, it is important to tell the patient about both diseases. Patients often have not received a formal diagnosis of DED, and many do not fully appreciate the impact dry eye can have on visual quality. It is also important to realize that dry eye is a chronic condition and can be exacerbated by surgery. I often spend time informing patients that they may experience worsening of symptoms in the early postoperative period and that compliance with dry eye treatments is essential, especially in this phase.


Overall, there are a few key pearls to keep in mind, as outlined below.

• Actively look for common conditions such as ABMD, Salzmann nodules, DED, and MGD prior to surgery.

• For any patient requesting a refractive outcome, consider superficial keratectomy to treat ABMD before surgery.

• Aggressively treating DED prior to surgery will allow for optimization of the corneal surface and tear film, which, in turn, will lead to better visual outcomes.

Ensuring the health of the ocular surface in the preoperative period is a key step in delivering the superior postoperative outcomes our patients have come to expect.

Preeya K. Gupta, MD
  • Associate Professor of Ophthalmology, Duke Eye Center, Durham, North Carolina
  • preeya.gupta@duke.edu; Twitter @preeyakgupta
  • Financial disclosure: Consultant (Alcon, Allergan, BioTissue, Kala, NovaBay, Shire, Sight Sciences, TearLab, TearScience)