Vision starts with the tear film, and any compromise in tear film integrity can result in IOL calculation errors, topographic abnormalities, and higher-order aberrations. It is estimated that 80% of the refractive integrity of the eye occurs at the air-tear interface. We have incredible tools to create quality vision from the inside, but a perfect 20% is still not enough when a higher yield can come from optimizing the ocular surface.

Proactive Diagnostics

Pretesting: Patient questionnaires (either Ocular Surface Disease Index [OSDI] or Standard Patient Evaluation for Eye Dryness [SPEED]) and tear osmolarity testing. Abnormal tear osmolarity correlates with variable IOL power calculations. Efficient screening for the busy cataract and refractive surgeon: OSDI or SPEED and tear osmolarity.

Detailed external examination: Rule out concomitant allergies, incomplete blink, lid seal insufficiency, blepharitis, meibomian gland dysfunction (MGD) and non-obvious MGD. Rule out dry eye disease (staining and Schirmer) and goblet cell deficiency (tear breakup time, tear wet/spread). Quantify tear instability preoperatively and show objective improvements when possible (video keratography, point spread function, topography, wavefront aberrations, etc.).

Restorative Therapeutics

Cyclosporine A: Prevents progression, prevents apoptosis of goblet cells and epithelial cells, prevents propagation of activated T cells. Enhances goblet cell density and tear film stability as soon as 6 weeks.

Loteprednol gel (Lotemax gel): Very low benzalkonium chloride (BAK) load and moisturizing glycerine helpful in anti-inflammatory effect, rapid disease state control, and minimal impact on BAK-sensitive cells (goblet and epithelial cells)

Preservative-free artificial tears, triglyceride fish oil supplements, warm compresses: Helpful for early/mild disease and as adjunctive treatment alongside pharmacologics 4. Treat MGD: warm compresses, lid massage, triglyceride fish oil, thermal pulsation (LipiFlow), etc.

References

1. Ning L, Lin F, Huang Z, He Q, Han W. Changes of corneal wavefront aberrations in dry eye patients after treatment with artificial lubricant drops. J Ophthalmology. 2016; (10):1-11.
2. 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.