I recently had a colleague ask if I enjoyed private practice following my several-year detour through academia and comanagement administration. I honestly told her I am happier now that I'm doing what I feel I do best, which is care for my patients. She then asked what I saw most in my practice. I in turn asked if she had ever heard the 1986 Dwight Yoakam tune "Guitars and Cadillacs." With a curious look on her face, she nodded. I told her my practice was a lot of "contacts and cataracts." I'm sure a lot of us can say the same!

Probably like you, I am seeing an ever increasing number of cataract patients suffering from dry eye. I don't think it will come as a great epiphany that the patient's most likely to have dry eye are also the one's most likely to undergo ocular procedures like cataract surgery. Consider these numbers: 3 million Americans have cataract surgery each year, with the Federal government spending $3.4 billion through Medicare to treat cataracts.¹ Recent estimates indicate that approximately fifteen percent of the US population older than age 65 has dry eye.² To use Dr. Kelly Nichols calculations, "If you assume that two million cataract patients are older than 65, and 15% have dry eye, then approximately 300,000 of the patients who undergo cataract surgery each year will suffer from dry eye."²

Preoperative Care
Preoperative recognition of patients with ocular surface disease provides an opportunity to optimize the ocular surface before proceeding with cataract surgery. Fluctuating vision either before or following cataract surgery is almost always a sign of tear film insufficiency.³ A history of systemic collagen disease vascular disease or associated manifestations such as arthritis or dry mouth provides important clues for the possibility of concomitant ocular surface disease.⁴ Dry eye can also result in induced astigmatism which can affect IOL calculations. Dryness of the ocular surface can throw off lens biometry as well as cause problematic shifts in keratometric values.⁵

Management of OSD may be accomplished most effectively by following established treatment guidelines such as the DEWS or Delphi panel recommendations.⁶ In this stepwise approach, treatment begins with artificial tears which have been shown to diminish ocular symptoms and improve vision-related function and dry eye signs in the majority of cataract surgery patients.⁷ Anti-inflammatory agents play a major role in the treatment of moderate-to-severe dry eye because of the critical role inflammation plays in the pathogenesis of OSD.⁸

Management of lid disease is likewise essential for optimizing surgical outcomes. In one study, blepharitis was the number one reason for cancelling cataract surgery⁹ as blepharitis is thought to be a primary risk factor for endophthalmitis.¹⁰ Preoperative treatment starts with a prolonged commitment to eyelid hygiene. Topical antibiotics are used to control staphylococcal growth on the eyelids, and recent antibiotics such as topical azithromycin has been shown to effectively reduce signs and symptoms of blepharitis.¹¹

Intraoperative Care
Intraoperatively, the ocular surface is prone to damage from preservative-containing anesthetics and desiccation. Frequent irrigation by the surgeon with balanced salt solution, more viscous eye lubricants or viscoelastics can minimize the desiccating stress to the ocular surface.¹² The surgical incision may potentially impact the ocular surface after cataract surgery. A grooved incision can aggravate dry eye symptoms during the early postoperative period in patients without dry eye preoperatively.¹³ Long intraoperative microscopic light exposure times can have an adverse effect on dry eye.¹³ Small incision cataract wounds as well as limbal relaxing incisions seem to induce localized damage to the corneal nerves with subsequent reduced corneal sensation.¹⁴

Postoperative Care
Our job as a co-managing optometrist is just beginning following cataract surgery. After cataract surgery the signs and symptoms of ocular surface disease typically get worse. Following surgery, patients are using a number of topical drops, usually a steroid, antibiotic and an NSAID. Prolonged use of postoperative medications may be one of the contributing factors of the patient's dry eye symptoms. In patients with OSD, it is best to stop or taper medications when they are no longer needed. A 2007 study showed that the addition of an artificial tear QID for one week following surgery significantly improved symptoms of dryness in patients after cataract surgery.¹⁵

Conclusion
Your patient's ultimate success with cataract surgery depends on three factors:²

1. Realistic patient expectations
2. Accurate preoperative measurements, and
3. Minimal to no postoperative complications.

REFERENCES
1. Cataract statistics. Located at: http://www.statisticbrain.com/cataract-statistics/. Accessed 8/1/2012.
2. Nichols KK. Managing surgical patients. Optometric Management. 2010 Sept.
3. Roberts CW, Elie DR. Dry eye symptoms following cataract surgery. Insight 2007; 32: 14-21.
4. Movahedan A, Djalilian AR. Cataract surgery in the face of ocular surface disease. Curr Opin Ophthalmol 2012; 23: 68-82.
5. Luthe R. Dry eye screening and the cataract patient. Ophthalmology Management, Vol 16; May 2012;48-51.
6. Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea 2006; 25: 900-907.
7. Sanchez MA, Amiola-Villa Lobos P, Torralo-Jimenez P, et al. The effect of preservative-free HP-Guar on dry eye after phacoemulsification: a flow cytometric study. Eye 2010; 24: 1331-1337.
8. Pflugfelder SC. Anti-inflammatory therapy for dry eye. Am J Ophthalmol 2004; 137: 337-342.
9. Stead RE, Stuart A, Keller J, et al. Reducing the rate of cataract surgery cancellation due to blepharitis. Eye 2010; 24: 742.
10. Speaker MG, Milch FA, Shah MK, et al. The role of external bacterial flora in the pathogenesis of acute post-operative endophthalmitis. Ophthalmology 1991; 98: 639-649.
11. Luchs L. Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of posterior blepharitis. Adv Ther 2008; 25: 858-870.
12. Lindstrom, RL. The effects of blepharitis on ocular surgery. Ocul Surf 2009; 7: 519-520.
13. Cho YK, Kim MS. Dry eye after cataract surgery and associated intraoperative risk factors. Korean J Ophthalmol 2009; 23: 65-73.
14. Moon SW, Yeom DJ, Chung SH. Neurotrophic corneal ulcer development following cataract surgery with a limbal relaxing incision. Korean J Ophthalmol 2011; 25: 210-213.
15. Stefan C, Dumitrica CM. Systane and cataract surgery. Oftalmologia 2007; 51: 100-104.