Treatment of MGD and blepharitis is particularly important prior to surgery. Blepharitis is a common cause of cataract surgery cancelation and is a major risk factor for postoperative endophthalmitis [14].

Treatment of MGD can be initiated with regular warm compresses at home. Expression of glands at home is often difficult to perform adequately especially in the elderly. Bacterial blepharitis should be cleared with the use of regular lid cleaning soaps. Baby shampoo is often used in clinical practice but can lead to skin irritation in some. In cases of Demodex mite infection, lid scrubs with the addition of a tea tree oil component can produce significant improvement [15]. Patients need to be counseled not to use direct tea tree oil on the lids as it can cause severe burning and discomfort.

As warm compresses used at home often do not reach adequately high enough temperatures for enough time, the use of in-office thermal pulsation treatments are very beneficial in patients who are unable to achieve success with home therapy alone. At this time, the only FDA-approved system for thermal pulsation is LipiFlow (TearScience, Morrisville, North Carolina, U.S.A.), which is a 12-min procedure for heat and expression of the glands in-office [16].

Moderate to severe cases of lid margin disease can be managed with topical antibiotic ointments or oral tetracyclines [17]. Doxycycline is particularly useful, not only for control of deleterious free fatty acids and bacterial overgrowth but also for its inhibition of tear film cytokines including, most notably, MMP-9 [18]. Treatment with antibiotics will likely be required for at least 1 month before the patient has improved and is eligible for further cataract surgery evaluation [8]. Increasing dietary intake of omega-3 fatty acids will also improve lid health by reducing inflammation and improving the quality of oil secretions from the glands [19].

Tear film inflammation can be further suppressed with short-term use of topical steroids. Although topical steroids have immediate effectiveness in decreasing tear film inflammatory cytokines, their long-term use is limited due to known side effects. In the preoperative setting, where rapid rescue and improvement of the ocular surface is needed, steroids may play an important role. Clinicians can therefore have a lower threshold for initiation of steroids in cataract surgery candidates with OSD than they would for other patients with dry eye. Long-term control of surface inflammation can be maintained with the use of topical cyclosporine A (CsA) . CsA 0.05% used twice daily with an adjunctive topical corticosteroid has been reported effective in managing dry eye patients in the cataract setting, with symptomatic and clinical amelioration in as few as 2 weeks [20]. Newer anti-inflammatories targeting the specific inflammatory cascade in DES, such as lifitegrast, can also play an important role in long-term control of symptoms and signs of DES.

Aggressive lubrication with preservative-free artificial tears (PFATs) should be initiated in this patient. Preserved eye drops should be avoided—especially if used more than four times daily—as preservatives often promote further surface irritation and corneal damage [5]. Autologous serum eye drops have also shown to significantly improve ocular surface punctate erosions and improve the tear film [21].

As light enters the eye, the most powerful refraction or bending of light occurs at the air-tear film interface. This is the point with the greatest change in refractive index from 1.00 in air to 1.34 in tear film [22]. Montés-Micó estimated that small changes to the anterior radius of curvature of the tear film in DES can result in refractive power changes as high as 1.3 diopters [23]. Individuals with a hyperosmolar tear film can have significant variability of repeated keratometry measurements, with corresponding variation in astigmatism and intraocular lens (IOL) power calculations [24]. Hence, disturbances to the tear film in DES can interfere with refraction and potentially yield inaccurate preoperative measurements used for IOL selection and surgical planning. Stability of refractions, decrease in ocular surface staining, increase in TBUT, and normalization of the hyperosmolar and inflammatory marker tests in the tear film will be positive indicators of improvement.

Imaging modalities that can be used to assess tear film include topography and wavefront imaging. These tests are usually obtained during the workup of cataract or laser refractive patients and can be a first indication to the physician that there is irregularity of the tear film. The mires rings from the Placido images on topography can be irregular and show patches of missing rings when there is significant tear film disturbance. A Hartmann-Shack spot distortion can also be seen when trying to capture the wavefront image when there is tear film irregularity (Fig. 4.2). For optimal preoperative measurements, accurate biometry, and postoperative outcomes, these imaging tools can be used to ensure improvement of the tear film prior to proceeding with surgical planning.

The patient discontinues saline eye drops and switches to lipid-based PFATs an average of six to eight times daily. He adheres to daily lid hygiene measures and begins treatment with topical cyclosporine 0.05% BID and oral doxycycline 50 mg BID. At a 1-month follow-up, signs of lid margin disease have significantly improved. However, topography ( Fig. 4.3 ) reveals tear film abnormalities with Placido disc rings demonstrating significant irregularities. After continuing therapy for an additional 6 weeks, repeat topography demonstrates smooth rings and regular corneal curvatures, and all other preoperative indices remain stable. Accordingly, the decision is made to schedule cataract surgery in the patient’s right eye.

Various intraoperative measures can be taken to minimize surface damage and forestall the risk of postoperative dry eye. Anesthetic eye drop application and exposure to light from the operating microscope should be minimized. Use of light filters, delicate handling of the ocular surface, and avoidance of overly vigorous irrigation techniques may further mitigate the likelihood of postoperative dryness [4].

There is some evidence that the construction of grooved corneal incisions have been associated with persistent foreign body sensation, as well as pooling of mucus and debris in the groove [25]. Cho et al. noted an increase in the severity of postoperative dry eye after grooved incisions compared to single-plane incisions [2]. However, this was only significant in patients without pre-existing dry eye. The choice of incision architecture should be weighed against other important factors, such as the greater wound strength that can be achieved with grooved incisions. Additionally, a study by Donnenfeld et al. showed a decrease in corneal sensation in eyes that got limbal relaxing incisions at the 3 and 9 o’clock site that can result in worsening dry eye [26].

Femtosecond laser-assisted cataract surgery may also temporarily worsen postoperative dry eye symptoms when compared to conventional techniques [27]. This may be related to the patient interface used, and various platforms may have varying degrees of impact on the conjunctival goblet cells. Long-term effects have not been studied, and therefore the choice to use a femtosecond laser to improve refractive outcomes can be weighed against this potential short-term worsening in the dry eye symptoms.

Dry eye symptoms can worsen after cataract surgery—even in patients who have reestablished ocular surface health before surgery. Signs and symptoms of dryness tend to peak from as early as the first day through the first month postoperatively [4, 28]. Patients should continue therapy with PFATs, and individuals with MGD should maintain appropriate lid hygiene. The standard postoperative eye drop regimen may need to be modified in these patients. The use of preservative-free drops or newer formulations of NSAIDs and antibiotic drops with decreased ocular surface effects should be employed. As intracameral medications for cataract surgery develop and become mainstream, this postoperative drying effect from the preserved postoperative regimens may decline. Postoperative cyclosporine 0.05% twice daily, in particular, has been effective in limiting dry eye severity [29].

A 34-year-old woman with visually significant myopia is interested in LASIK. She has been a soft contact lens (CTL) wearer for the past 25 years. She uses daily-wear CTLs all day and sometimes sleeps in them. The patient reports worsening irritation with CTLs and no longer wishes to use them. In particular, she describes 3 months of persistent bilateral redness and frequent episodes of tearing, burning, foreign body sensation, and visual fluctuation. She recently saw another ophthalmologist, who recommended artificial tears and prescribed antivirals for presumed herpes simplex keratitis. Neither of these have alleviated her symptoms. Her past medical history is unremarkable, and she is taking no other medications. She is an attorney and spends the majority of the day working at a computer.