How aggressively do you treat the ocular surface before cataract surgery in a patient with inconsistent K readings and mild dry eye who is otherwise ready for surgery and does this differ based on the type of IOL offered?

It is definitely recommended to manage mild dry eye first, as it may progress into a moderate dry eye in the postoperative period and increase the risks of complications.

In patients with mild dry eye who are in a hurry to get surgery, I usually place plugs and plan the surgery shortly.

Many times, I combine it with cyclosporine or other medications, but I would not necessarily wait 1-2 months.

Concerning the IOL calcs, in a normal axial length eye, 1D mean K reading variation can lead to a change in 1D in postoperative refractive errors.

If a patient does not mind glasses and has a dense cataract, and K readings are changing less than 1D, then I usually feel okay proceeding with cataract surgery.

Otherwise, I would encourage the patient to...

The ocular surface has to be optimized for the best biometry readings in preparation for cataract surgery. Distortions and disruptions of the tear film can lead to inaccurate readings, which could lead to an IOL miscalculation.

The process starts with medical history, examining the patient’s systemic medications, doing a thorough slitlamp exam, and looking for contributors to ocular surface disease, including meibomian gland dysfunction, blepharitis, blink dysfunction, and aqueous tear film deficiency.

Many diagnostics, as laid out in the ASCRS 2019 algorithm, may be helpful for determining the types of dry eye disease, including dry eye surveys, meibography, topography, and inflammatory marker testing.

Meticulous treatment is most importan...

From the time of the initial consultation to the measurement visit, I instruct patients to start artificial tears at least QID in both eyes. This is particularly stressed in patients interested in toric or other advanced optics lenses. For monofocal lenses, I am less strict, given the forgiving nature of most monofocal lenses and the expectation that the patient may still need glasses after surgery. If the readings are inconsistent but the patient is ready for surgery, counseling on the unpredictability of the outcome is important.

This answer really depends on the patient and what they desire out of cataract surgery.

For the patient who is just desiring typical standard IOL cataract surgery and has no expectations of getting away from glasses, I don't pre-treat dry eye at all. It's a waste of time for the patient.

For patients who want the refractive cataract experience (and I do not charge any kind of upcharge for anything other than premium IOLs, all my patients get OCT and topo/Pentacam prior to me seeing them for cataract evaluation), I will get aggressive if I feel the dry eye is impacting my ability to deliver on those expectations.

So your answer is mainly based on the patient and their desires for the surgery.