Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation

Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation


Preeya K.GuptaMDOwen J.DrinkwaterBS, BAKeith W.VanDusenBSAshley R.BrissetteMD, MScChristopher E.StarrMD


The Article WAS Published in Journal of Cataract & Refractive Surgery Volume 44, Issue 9, September 2018, Pages 1090-1096

Under a Creative Commons license



To report the prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation.


Duke University Eye Center and Weill Cornell Ophthalmology, single-medicine practices.


Prospective case series.


Consecutive patients presenting for cataract surgery were identified. Patient information including demographics, medical history, slitlamp findings, osmolarity tear, and tear matrix metalloproteinase-9 (MMP-9) levels were recorded. Patients were considered to have ocular surface dysfunction if any of the following outcomes were present: visually significant abnormal corneal surface examination, positive MMP-9 test, or abnormal osmolarity values ​​(> 307 mOsm / L or> 7 mOsm / L intereye difference). Patient symptoms were recorded using the Eye Disorder Index (OSDI) or Symptom Assessment in Dry Eye Questionnaires.


There were 120 patients (69% women), mean age 69.5 years ± 8.4 (SD). Abnormal osmolarity was found in 68 patients (56.7%) and abnormal MMP-9 in 76 patients (63.3%). Clinical findings showed that 47 patients (39.2%) had positive corneal staining on presentation, 9 patients (7.5%) had epithelial basement membrane dystrophy, and 2 patients (1.6%) had Salzmann nodules. Questionnaire data showed 54 (54.0%) of 100 patients reported symptoms suggestive of ocular surface dysfunction. In the asymptomatic group of 46 patients, 39 (85%) had at least 1 abnormal tear test (osmolarity or MMP-9) and 22 (48%) both had abnormal tests. Overall, 96 (80%) of 120 patients had at least 1 abnormal tear test suggestive of ocular surface dysfunction and 48 patients (40%) had 2 abnormal results.


Objective ocular surface dysfunction findings were common among patients presenting for cataract surgery, yet many presented undiagnosed. Clinicians should be aware of this high prevalence and consider screening with tear testing before surgery.


Ocular surface dysfunction includes a spectrum of diseases that impair the ocular surface leading to a constellation of clinical signs and patient symptoms. Dry-eye disease is probably the most common subtype of ocular surface dysfunction; however, many others may be present along with dry-eye disease or masqueraded as dry-eye disease. These include blepharitis, epithelial basement dystrophy, Salzmann nodular degeneration, allergic conjunctivitis, conjunctivochalasis, floppy eyelid syndrome, and others. The prevalence of dry eye disease varies in the literature but has been reported to be as high as 35% in some populations.1, 2, 3, 4


Cataract surgery is one of the most common procedures performed in the United States with a growing annual incidence.5 The typical age of patients with cataract surgery is over 50 years. Dry-eye disease and meibomian gland dysfunction are very common, and prevalence significantly increases with age.6 In the setting of preoperative cataract surgery, dry-eye disease and meibomian gland dysfunction can impair critical refractive measures such as keratometry values ​​worsening surgical outcomes .7


In addition, the ocular surface dysfunction has been reported to increase after cataract surgery.8,9,10,11,12 One study found that up to 62% of patients presenting for cataract surgery had a tear breakup time (TBUT) of less than 5 seconds, and 76% had corneal staining.13 Another study showed worsening of corneal fluorescein staining patterns for up to 3 months after cataract surgery. In addition, TBUT was found to be significantly reduced postoperatively compared with baseline preurgery for up to 1 month after cataract surgery.14 Dry-eye disease has also been found to increase postoperatively, especially in patients with femtosecond laser-assisted cataract surgery compared to manual phacoemulsification.9 The altered tear filmcaused by dry eye disease can impair important aspects of visual quality and function,


It is well known that there is a poor association between the signs and symptoms of ocular surface dysfunction, making it difficult to accurately diagnose.19,20 Common tools used to diagnose ocular surface dysfunction, and in particular dry eye disease, in addition to slitlamp evaluation includes traditional tests (fluorescein staining, TBUT, Schirmer test) and validated questionnaires (OSDI) and Symptom Assessment in Dry Eye [SANDE]). Some traditional tests such as the TBUT and Schirmer invasive test have been shown to have low sensitivity and specificity21 and may be subject to error in interpretation; However, newer point-of-care diagnostics such as tear osmolarity and matrix metalloprotease-9 (MMP-9) testing have been shown to have high sensitivity and specificity in the diagnosis of ocular surface dysfunction.22, 23,


Given that ocular surface dysfunction has been shown to have an adverse effect on visual function and can worsen after surgery, it is critical to identify and address any tear film and ocular surface abnormalities prior to cataract surgery. Little has been reported about the prevalence of tear film and ocular surface abnormalities using modern diagnostic tests preoperatively in patients with cataract surgery. The aim of this study is to report the prevalence of visually significant ocular surface dysfunction as evidenced by either an abnormal tear-film paramenter (elevated MMP-9 or abnormal osmolarity) or corneal surface slitlamp assessment findings in patients presenting for cataract surgery assessment.


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