Dry eye disease (DED) and ocular surface disease (OSD) are increasingly recognised as central factors in contemporary intraocular surgery. As cataract, glaucoma and vitreoretinal procedures advance toward greater refractive precision, patient expectations have risen and tolerance for postoperative visual fluctuation has decreased.
Surgeons now acknowledge that both pre-existing and surgery-induced tear film instability can significantly compromise refractive accuracy, visual quality and patient satisfaction, even when surgical outcomes are technically successful [1,2].
Recent systematic reviews and meta-analyses demonstrate that cataract surgery commonly induces transient tear film instability, most consistently evidenced by reduced tear break-up time (TBUT) lasting weeks to months postoperatively [2,3]. Although many patients recover without intervention, a substantial subset develops symptomatic or persistent DED, especially those with undiagnosed preoperative OSD, meibomian gland dysfunction (MGD) or ocular surface inflammation [3,4].
How common is postoperative dry eye?
Although the reported incidence varies according to diagnostic criteria, patient demographics and timing of assessment, several consistent findings have been identified:
- Tear film instability is the most reproducible postoperative change. TBUT often decreases significantly within the first week and may remain altered up to three months [1,2].
- While not all patients develop symptomatic DED, a considerable proportion experience subjective discomfort, foreign-body sensation and fluctuating vision [1,5].
- Prior systematic reviews report postoperative DED in roughly one-third of previously asymptomatic patients, though some older studies report higher rates for specific subgroups [2,3].
Why it matters
Dry eye disease following intraocular surgery extends beyond patient comfort, as tear film instability directly influences several critical factors:
• Biometry and intraocular lens (IOL) selection: tear film instability can result in variable keratometry readings and unexpected refractive outcomes, particularly in candidates for toric, multifocal and extended depth of focus IOLs [4,6].
• Visual quality: Unstable tear films may cause blurred vision, fluctuating acuity, glare, halos and patient dissatisfaction that is disproportionate to objective surgical success [3,4].
• Patient trust and perceived surgical success: These factors are especially relevant in the context of refractive cataract surgery, where patient expectations are elevated [6,7].
Mechanisms linking intraocular surgery and dry eye
1. Corneal nerve disruption
Clear corneal incisions, surgical manipulation, suction during femtosecond laser-assisted cataract surgery (FLACS) and prolonged light exposure may transiently impair corneal sensory innervation. This impairment reduces reflex tearing and destabilises the lacrimal functional unit, resulting in shorter TBUT and intermittent visual blurring [2,3].
2. Post-surgical inflammation
Surgical trauma triggers cytokine release (e.g. IL-1, TNF-α), epithelial stress and goblet cell dysfunction. This inflammatory cascade contributes to tear film instability in the early postoperative period [4].
3. Preservative- and medication-related toxicity
Postoperative regimens often rely on multiple drops. Preserved medications, especially benzalkonium chloride (BAK), can cause epithelial toxicity, worsen MGD and compromise surface healing. Glaucoma patients on long-term preserved therapy are at particular risk [2,5].
4. Meibomian gland dysfunction and lid-related factors
MGD is prevalent among patients undergoing cataract surgery. Lid manipulation during surgery, decreased blink rate and perioperative inflammation can exacerbate MGD, thereby reducing lipid-layer quality and increasing evaporative DED [4,8].
5. Patient-specific factors
Advanced age, systemic diseases such as diabetes and rheumatoid arthritis, hormonal factors, history of refractive surgery and polypharmacy collectively diminish ocular surface resilience [5,9].
Practical perioperative approach
Preoperative: identify and optimise
Contemporary cataract and intraocular surgery workflows increasingly parallel refractive surgery protocols, emphasising screening, diagnosis and treatment prior to biometry [6,8].
1. All patients should be screened for OSD, regardless of symptom presence:
- Quick questionnaires (SPEED, DEQ-5)
- TBUT or non-invasive tear-film assessment
- Fluorescein staining
- MGD evaluation, meibography if available.
2. Modifiable OSD should be treated prior to obtaining preoperative measurements:
- Lid hygiene and warm compresses
- Meibomian gland expression ± in-office thermal or intense pulse light (IPL) treatments
- Lubricants (preservative-free preferred)
- Short-term topical steroids for significant inflammation
- Immunomodulators (cyclosporine or lifitegrast) for chronic or moderate disease.
3. Biometry should be repeated once the tear film has stabilised, typically two to four weeks following initiation of therapy [6].
4. For patients with glaucoma, temporary reduction of preserved medications or transition to preservative-free formulations should be considered when clinically appropriate [2,5].
Intraoperative: minimise ocular surface trauma
- Ensuring adequate corneal lubrication throughout the surgical procedure is essential [8].
- Utilise smaller, precise incisions and minimise unnecessary manipulation of the conjunctiva and eyelids [6].
- Patients undergoing FLACS should be counselled about the increased incidence of early postoperative dry eye symptoms [2,4].
- Choose intracameral antibiotics and sustained-release anti-inflammatory agents when appropriate to reduce drop burden [6,7].
Postoperative: protect and monitor
- Preservative-free postoperative drops should be prioritised when available [2,6].
- The duration of regimens involving multiple topical medications should be minimised [2].
- Tear break-up time, ocular surface staining and patient symptoms should be reassessed at one week, one month and three months postoperatively [1,2,5].
- Treat persistent symptoms :
- Lubricants
- Lid therapy for MGD
- Anti-inflammatory therapy (cyclosporine, lifitegrast, soft steroids)
- Tear retention strategies (punctal plugs or intracanalicular implants)
- Autologous serum drops or regenerative therapies for severe disease [5,9,10].
Perspective: future directions (2025–2030)
Significant advancements in ocular surface management surrounding intraocular surgery are anticipated over the next decade.
1. Faster-acting immunomodulators
Innovative cyclosporine vehicles, water-free emulsions, higher-concentration formulations and new anti-inflammatory small molecules are expected to provide faster onset and improved tolerability, which is particularly advantageous during the brief preoperative period [4,6].
2. Expanded treatment algorithms for MGD
Enhanced in-office technologies, including IPL, low-level light therapy and automated gland expression are becoming increasingly standardised. Formal staging of MGD may soon inform preoperative protocols in a manner analogous to glaucoma staging for surgical planning [4,8].
3. Regenerative ocular surface therapies
Biologic therapies, including cryopreserved amniotic membrane extracts, amniotic membrane rings and serum or platelet-rich plasma tears, are transitioning from use in severe OSD to roles in pre-surgical optimisation, particularly for patients with fragile epithelial surfaces [9,10].
4. Next-generation tear retention strategies
Biodegradable intracanalicular inserts and biocompatible duct fillers have the potential to provide extended tear retention, which may be particularly beneficial for patients with aqueous deficiency undergoing cataract surgery [10].
5. AI-enhanced diagnostics and biometry
Artificial intelligence–driven topography smoothing and tear-film analytics may reduce the refractive impact of mild OSD and help surgeons interpret measurements even when the tear film is partially unstable [6,7].
6. Reduced postoperative medication burden
Preservative-free combination drops, intracameral antibiotics and sustained-release steroid implants are expected to further reduce reliance on multiple topical medications, thereby enhancing ocular surface health [2,6].
7. Standardised ‘ocular surface clearance’ protocols
Cataract surgery pathways are anticipated to increasingly incorporate routine OSD screening and treatment, paralleling refractive surgery protocols. This transition is essential for achieving consistent refractive precision [6,7].
Conclusion
In the era of advanced intraocular surgery, managing the ocular surface is no longer optional, it is integral to delivering precise, high-quality visual outcomes and ensuring patient satisfaction. Evidence from recent studies underscores that a significant proportion of patients experience postoperative tear-film instability and those with pre-existing OSD are particularly vulnerable [1–10].
A systematic approach encompassing screening, preoperative optimisation, preservative-free perioperative management and attentive postoperative care can prevent and mitigate much of the dry eye burden associated with cataract and other intraocular procedures.
As emerging therapies, improved diagnostics and regenerative technologies mature, ophthalmologists will have an expanding toolkit to protect the ocular surface. The future points toward more personalised, proactive and sophisticated management ensuring that patients achieve not only clear vision, but also comfort and sustained ocular health.
References
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Declaration of competing interests: None declared.
