Cataract surgery is among the most commonly performed surgical procedures worldwide. Over time, it has evolved from a lens-extraction procedure into a refractive intervention that demands meticulous perioperative planning and precision to achieve optimal outcomes. Optimisation of the ocular surface prior to cataract surgery is a critical component of this process.
The cornea and tear film, key elements of the ocular surface, account for approximately two-thirds of the total refractive power of the eye. A stable and healthy ocular surface is therefore essential during preoperative assessment, particularly for keratometry and biometry, as inaccuracies at this stage can directly affect intraocular lens (IOL) selection and postoperative refractive outcomes.
Several studies have demonstrated that reduced tear film break-up time (TBUT) and increased corneal and conjunctival staining are significantly associated with greater variability in mean keratometry values and a higher incidence of refractive surprise exceeding 0.5 dioptres (D) [1,2]. In addition to refractive considerations, patients with ocular surface disease (OSD) may report postoperative dissatisfaction despite technically successful surgery and good visual acuity. Symptoms such as fluctuating vision, foreign body sensation and reduced contrast sensitivity can negatively impact perceived surgical success [3].
How do we assess the ocular surface prior to cataract surgery?
Routine screening for OSD should be embedded within the cataract pathway, as relying on symptoms alone will miss a proportion of patients with clinically relevant disease. Identifying OSD before keratometry and biometry are affected improves measurement reliability and allows tailored counselling and treatment planning [4].
History and symptom assessment
A targeted history should explore symptoms such as burning, stinging, foreign body sensation, fluctuating vision, reflex tearing and ocular fatigue. Validated questionnaires including the Dry Eye Questionnaire and the Ocular Surface Disease Index (OSDI) can help grade severity and monitor response to therapy.
Medication review is essential, as preserved topical glaucoma drops and systemic agents, such as antidepressants and antihistamines, can exacerbate OSD. Systemic and ocular associations should be considered, including rheumatoid arthritis, Sjögren’s syndrome, rosacea and thyroid eye disease. Demographic factors such as age, sex and menopausal status are relevant, and the patient specifically questioned about any previous laser refractive surgery due to the potential impact on ocular surface integrity and postoperative visual quality.
Clinical examination
Examination should include an inspection of the periocular skin for rosacea and a slit lamp assessment of the lids and lid margins for blepharitis and marginal gland disease (MGD). Treating lid disease is particularly relevant in the cataract setting, both for improving tear film quality and for reducing bacterial load at the lid margin. Tear film assessment typically includes tear meniscus height, TBUT and corneal and conjunctival staining with fluorescein, providing practical information regarding tear volume, stability and epithelial integrity.
Adjunctive diagnostic tests
Where available, adjunctive testing can refine diagnosis and guide management. Schirmer testing (without anaesthetic) may assist in suspected aqueous-deficient dry eye, while tear osmolality offers an objective measure of tear film homeostasis. Point-of-care testing for inflammatory biomarkers such as matrix metalloproteinase-9 (MMP-9) may help identify an inflammatory component. Non-invasive tear break-up time, meibography and corneal topography-based tear film analysis can be useful for characterising evaporative disease and monitoring response prior to proceeding to surgery.
Conventional treatment options
Preoperative treatment aims to restore tear film homeostasis, reduce inflammation and improve epithelial health, thereby improving biometric accuracy and postoperative comfort.
Conservative measures and lid therapy
Education, environmental modification and optimisation of blink behaviour are important baseline measures. Lid hygiene and warm compresses with lid massage are essential for blepharitis and MGD and should be routinely recommended. In selected patients, topical antibiotic or anti-inflammatory lid therapies may be appropriate, alongside management of rosacea and demodex infection where relevant.
Lubricants
Ocular lubricants remain the first-line therapy and should be tailored to severity and dry eye subtype. Options include low-viscosity artificial tears, lipid-containing formulations for evaporative disease, and gel or ointment preparations for more severe symptoms or nocturnal exposure. Preservative-free preparations are preferred in patients requiring frequent instillation or those with moderate-to-severe disease, and patients should be counselled on consistent dosing to achieve meaningful benefit.
Anti-inflammatory and advanced therapies
Short courses of topical corticosteroids can provide rapid improvement in signs and symptoms and may be used as induction therapy in the preoperative setting. For longer-term control, topical immunomodulators such as ciclosporin and lifitegrast are commonly used to reduce chronic inflammation and improve tear film stability.
Additional options include secretagogues where available, and autologous serum eye drops for severe or refractory disease. Autologous serum resembles natural tears in pH and osmolality and contains epitheliotrophic factors including epidermal growth factor, transforming growth factor-β, vitamin A and fibronectin, supporting epithelial repair and tear film quality [5]. Early recognition and timely escalation are important so that preoperative measurements are undertaken once stability is achieved.
Punctal occlusion remains a useful adjunct in aqueous-deficient dry eye, prolonging tear residence time on the ocular surface and improving symptoms in appropriately selected patients.
New pharmacological therapies
Recent developments have expanded beyond traditional lubricants and broad anti-inflammatory agents, enabling mechanism-driven therapy for specific dry eye subtypes.
Neuro-stimulatory therapies
Varenicline solution nasal spray, Tyrvaya® (Viatris Inc, Pennsylvania, US) stimulates the trigeminal parasympathetic pathway to increase natural tear production via neural modulation rather than topical ocular delivery. It may benefit patients who find drops difficult to instil or who are intolerant of frequent instillation. Sneezing, coughing and throat irritation are among the most reported adverse effects [6]. Although currently approved in the US, availability in Europe and the UK may evolve.
Tryptyr® (Alcon Inc, Geneva, Switzerland) is acoltremon ophthalmic solution, a first-in-class neuromodulator acting as an agonist of transient receptor potential melastatin 8 (TRPM8) thermoreceptors. Activation of trigeminal pathways is thought to increase basal tear production. Phase 3 COMET-2 and COMET-3 trials demonstrated increased tear production and improvements in signs and symptoms compared with vehicle control [7].
Lipid layer-targeted therapy for evaporative disease
Perfluorohexyloctane ophthalmic solution is marketed as EvoTears® (Ursapharm, Saarbrücken, Germany) and Miebo® (Bausch + Lomb, New Jersey, US). These semi-fluorinated alkanes reduce tear evaporation and stabilise the lipid layer, representing a distinct approach compared with aqueous-based artificial tears. Phase 3 multicentre trials showed superiority over hypotonic saline for improving corneal fluorescein staining and patient-reported dryness, with good tolerability [8,9].
Novel therapies targeting MGD
AZR-MD-001 (Azura Ophthalmics, Tel Aviv, Israel) is a selenium sulphide ophthalmic ointment intended to treat MGD, with proposed keratolytic and sebum-modulating effects. A vehicle-controlled randomised trial reported improvements in meibomian gland secretion and patient-reported outcomes [10].
Refinements of established therapies
Water-free ciclosporin formulations, including Vevizye® (Théa Pharma, Clermont-Ferrand, France), use semifluorinated alkane vehicles designed to spread efficiently over the ocular surface and potentially reduce tear evaporation. A randomised clinical trial of water-free ciclosporin demonstrated improvements compared with vehicle, supporting this formulation approach in inflammatory dry eye [11].
New device-based interventions
Device-based therapies are increasingly used as adjuncts to topical treatment, particularly in moderate-to-severe evaporative dry eye and MGD not adequately controlled by lid hygiene and drops alone.
Canalicular occlusion
Injectable crosslinked hyaluronic acid canalicular gels such as Lacrifill® (Nordic Pharma Inc, Pennsylvania, USA) provide temporary, reversible occlusion. A multi-centre randomised trial demonstrated non-inferiority to punctal plugs for improving Schirmer scores and OSDI, with a favourable safety profile [12].
Thermal and light-based therapies for MGD
Thermal pulsation systems including LipiFlow® (Johnson & Johnson, New Jersey, US), iLUX® (Alcon Inc, Geneva, Switzerland) and TearCare® (Sight Sciences Inc, California, US) apply controlled heat with mechanical gland expression to clear obstruction and restore lipid secretion. These in-office procedures may be particularly useful when a rapid improvement in tear film stability is needed before keratometry and biometry. Evidence supports improvements in symptoms and objective measures following thermal pulsation treatment in MGD [13].
Intense pulsed light (IPL) therapy has gained traction for evaporative dry eye associated with MGD and ocular rosacea. Proposed mechanisms include reduction of peri-lid telangiectasia, decreased inflammatory mediator load and improved meibum quality. A systematic review and meta-analysis reported improvements in dry eye symptoms and objective signs following IPL therapy [14].
Thermomechanical eyelid heating devices provide another office-based option, and comparative studies suggest efficacy and safety comparable to established thermal pulsation systems. These interventions can be particularly helpful where gland obstruction persists despite conventional therapy, or where the timeline to surgery requires efficient optimisation to improve measurement repeatability and postoperative comfort.
Conclusion
Optimising the ocular surface prior to cataract surgery is essential for accurate refractive planning and postoperative patient satisfaction. A structured assessment can identify both symptomatic and asymptomatic OSD, enabling targeted intervention before keratometry and biometry are undertaken. Conventional measures remain foundational, but newer pharmacological and device-based therapies now permit more tailored, mechanism-driven management, particularly for evaporative disease and MGD. Integrating these strategies into routine cataract pathways can reduce measurement variability and support more predictable outcomes in modern refractive cataract surgery.
References
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Declaration of competing interests: Bita Manzouri has been reimbursed financially by Théa Pharma, Santen Ltd, Bausch & Lomb, Scope, Rayner, Johnson & Johnson, SunPharma, Medicom, Tarsus and Visufarma for (1) attending symposia, (2) as a speaker, (3) for organising an educational event and (4) for being part of an advisory board.
