Cataract surgery and dry eye disease: A review

Author: Naderi K., Gormley J., O’Brart D.

Geographical coverage: Not reported

Sector: Cataract surgery

Sub-sector: Dry eye

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background: Cataract surgery is the most common and successful procedure in medicine, delivering excellent visual outcomes and enabling rapid recovery. The focus is usually on preventing sight-threatening complications, while non-sight-threatening issues like dry eye disease (DED) are frequently overlooked despite their impact on quality of life. DED can be induced or exacerbated by cataract surgery, and it influences both postoperative comfort and surgical planning accuracy due to its effect on corneal measurements. A stable tear film is essential for optimal surgical outcomes, especially in patients receiving premium intraocular lenses. Yet pre-existing DED is common and often underdiagnosed. As expectations rise among both surgeons and patients, managing DED in patients undergoing cataract surgery becomes critically important.

Objective: To assess the intraoperative factors during cataract surgery that affect the ocular surface, particularly those that contribute to the development or exacerbation of pre-existing DED.

Main findings: The review identified 145 publications relevant to DED and cataract surgery. Among these, 58 studies directly addressed dry eye in the context of cataract surgery, while the remaining 87 provided additional context or background information.

Studies reported that DED incidence after cataract surgery ranged from 9% to 100%, depending on diagnostic criteria and follow-up duration. Some patients recover within three months, while others experience persistent symptoms for up to six months. A notable finding is the high prevalence of pre-existing DED in cataract patients, with up to 80% showing abnormal tear film parameters before surgery.

The pathophysiology of post-cataract surgery DED involves multiple factors. Corneal nerve damage from surgical incisions disrupts tear film stability and often takes months to heal. Toxic effects from preservatives in eye drops, such as povidone-iodine and anaesthetics, further harm the ocular surface. Prolonged intraoperative drying and irrigation contribute to epithelial damage, while microscope light exposure can cause phototoxicity. Additionally, femtosecond laser-assisted cataract surgery (FLACS) may worsen DED compared to conventional phacoemulsification due to trauma from the suction ring.

Effective management requires a multi-phase approach. Preoperatively, identifying and treating pre-existing DED (for example, by using lubricating drops and addressing meibomian gland dysfunction) improves surgical outcomes. During surgery, minimising incision size, using preservative-free solutions, and protecting the ocular surface with viscoelastic agents can reduce damage. Postoperatively, preservative-free lubricants, anti-inflammatory agents (e.g., cyclosporine), mucin secretagogues (e.g., diquafosol), and omega-3 supplements help alleviate symptoms. Bandage contact lenses may also provide relief in select cases.

Special considerations apply to patients receiving multifocal intraocular lenses (MIOLs), as DED can significantly impair visual quality. FLACS requires extra caution due to its potential for greater ocular surface trauma.

Methodology: The searches were conducted in PubMed; Web of Science; Medline (including Medline Daily Update, Medline In-Process and Other Non-Indexed Citations, and Medline Epub Ahead of Print); Embase; CENTRAL (including the Cochrane Eyes and Vision Trials Register); the metaRegister of Controlled Trials (mRCT); ClinicalTrials.gov; and the WHO International Clinical Trials Registry Platform. Studies published in English from the inception of each database until December 2019 were included if they reported the burden of dry eye disease (DED) before and after cataract surgery, highlighted the effects of cataract surgery on the ocular surface, described intraoperative measures to minimise ocular surface damage, or provided evidence on management options for postoperative dry eye. Additionally, the reference lists of the included studies were scanned to identify additional relevant publications.

Applicability/external validity: The review noted inconsistencies in DED definitions, diagnostic criteria, and measurement methods, as well as the multifactorial nature of DED and its complex relationship with cataract surgery. It emphasised the need for further research to refine diagnostic criteria and optimise treatment strategies.

Geographic focus: The authors did not apply any geographical limits; however, they did not report the geographical distribution of the included studies.

Summary of quality assessment: Overall, there is low confidence in the conclusions drawn by this review. Multiple databases were searched, and inclusion and exclusion criteria were clearly defined. A list of all identified studies was provided, and the characteristics of the included studies were presented. The reference lists of included studies were also scanned. The findings were synthesised narratively. However, the review did not mention whether screening and data extraction were conducted independently by multiple reviewers. It also only included English-language studies and did not report any assessment of the risk of bias in the included studies.