Christopher Starr, MD, FACS, on preventing the unhappy 20/20 patient

Ocular surface disease (OSD) is common among patients presenting for cataract surgery, yet it often goes unrecognized because many of these patients report few or no symptoms. In a prospective case series of 120 patients evaluated for cataract surgery at Duke University Eye Center and Weill Cornell Ophthalmology, 80% had at least one abnormal tear test result, as did 85% of the 46 patients who were asymptomatic.¹

To help surgeons identify and manage OSD throughout the surgical journey, Lumenis unveiled Preventing 20/Unhappy: A Field Guide for Cataract and Refractive Surgeons at the 2026 American Academy of Ophthalmology (AAO) annual meeting in New Orleans, Louisiana. The guide pairs a clinical section on preoperative screening, treatment selection, patient conversations and postoperative care with an implementation section on demonstrating value, building the team and gaining staff buy-in. It draws on insights from 5 cataract and refractive surgeons and findings from 6 studies, and includes 6 tear-out tools for clinical use.

Ophthalmology Times spoke with Christopher Starr, MD, FACS, associate professor of ophthalmology and director of ophthalmic education at Weill Cornell Medicine and associate attending ophthalmologist at NewYork-Presbyterian Hospital. Starr, a cornea, cataract, refractive and ocular surface disease specialist, led development of the field guide, coauthored the prevalence study and helped develop the American Society of Cataract and Refractive Surgery (ASCRS) preoperative OSD algorithm, first published in 2019 and updated in 2026. In the following Q&A, Starr discusses why OSD goes undetected before cataract surgery, how an unstable ocular surface affects biometry and intraocular lens (IOL) calculations, technician-led screening, when to delay surgery, premium IOL candidacy and the workup of the patient who sees 20/20 but remains dissatisfied.

This Q&A has been lightly edited for length and clarity.

Ophthalmology Times (OT): What prompted the development of a practical field guide on preoperative ocular surface care, and what gap in surgical practice is it meant to address?

Christopher Starr, MD, FACS: Since we published our original ASCRS Preoperative OSD Algorithm paper in 2019 in the Journal of Cataract & Refractive Surgery, there has been significant interest in optimizing the ocular surface prior to refractive and cataract surgery. The intent of the original paper, as well as the field guide and many other publications, is to remind busy surgeons to spend time evaluating and treating the ocular surface before surgery to improve patient outcomes.

The new field guide builds on this foundation by bringing together clinical evidence, guidance from our ASCRS Algorithm, insights from surgeons and practical strategies for incorporating ocular surface care into the surgical workflow.

OT: Why does ocular surface disease so often go undetected in patients presenting for cataract surgery?

Starr: The presurgical visit for cataract surgery is often time-consuming and complex, given the wide range of IOL options, refractive strategies, out-of-pocket fees, femtosecond lasers, etc. By itself, evaluating ocular surface disease can also be challenging and time-consuming. When you combine the two, this adds significant complexity to the visit. Historically, that is likely why ocular surface disease has been disregarded during the typical presurgical visit.

In addition, many studies have shown that patients in the cataract surgical age group often have significant signs of ocular surface disease, including corneal staining, but they often do not complain about it. We see a discordance between signs and symptoms in this patient population, and this may also cause ocular surface disease to be underdiagnosed in presurgical patients.

OT: How does an unstable ocular surface affect preoperative biometry and IOL power calculations?

Starr: The terms we coined for the ASCRS presurgical OSD algorithm paper were “visually significant ocular surface disease” and “non–visually significant ocular surface disease.” Visually significant ocular surface disease includes any subtype of OSD that might reduce the accuracy of presurgical IOL measurements, including astigmatism magnitude and axis, and affect IOL power calculations. In addition, any subtype of OSD that might increase the risk of a postsurgical infection, such as endophthalmitis, would be considered visually significant. Demodex blepharitis, which carries a higher load of gram-positive bacteria, would fall into that category. Visually significant ocular surface disease also includes anything that might progress after cataract surgery and become more visually significant, especially in the context of a multifocal or extended-depth-of-focus IOL.

We know that dry eye and ocular surface disease tend to worsen, or flare, for a period of time after cataract surgery. If the disease is at an early, non–visually significant stage prior to surgery, it may very well become visually significant after surgery. This possibility must be discussed with the patient, prophylactically treated and, in some cases, treatment should be increased postsurgically.

OT: What does an efficient preoperative ocular surface screening look like in a busy surgical clinic, and which steps can technicians own?

Starr: The OSD presurgical algorithm, which we updated at the ASCRS meeting earlier this year, provides busy surgeons with a fairly simple, reproducible, step-by-step, algorithmic process that can be used during each preoperative encounter.

Because we recognize how time-consuming these visits are, we created the algorithm to rely heavily on the technician and office staff rather than placing all the burden on the surgeon.

The first step of the algorithm involves collecting refractive measurements, such as tomography, topography and keratometry. The technician notes whether the various modalities are in agreement or not. It is very common with visually significant ocular surface disease for each modality to be off or inconsistent, and it is important for that to be noted by the technician performing the tests.

We also created an OSD presurgical questionnaire that can help detect not only dry eye disease, but also other subtypes of OSD that may be visually significant. The questionnaire includes a series of red boxes, which serve as “red flags.” After the patient fills it out, the technician scores the questionnaire and records the results at the bottom of the form. The surgeon can then quickly see how significant the patient’s symptoms are and whether the refractive measurements align or are discordant.

The next part of the algorithm, again performed by technicians, is the ocular surface screening battery, which can include point-of-care testing, such as tear osmolarity and tear MMP-9 testing, as well as any other tests the office already performs. For example, we added noncontact corneal esthesiometry as a new test in our office.

Every ocular surface patient encounter, of course, involves a slit lamp exam, for which we created a quick, easy and reproducible methodology. We call it the LLPP, or the Look, Lift, Pull, Push exam, which is followed by staining.

Both the technician-led screening process and the Look, Lift, Pull, Push exam are featured in the new field guide.

OT: When should surgery be delayed to treat the ocular surface, and how should that delay be explained to patients?

Starr: After performing the various steps of the algorithm, the surgeon then has all the information needed to assess:

• Whether or not visually significant ocular surface disease is present
• What the patient’s desired IOL and refractive strategy is
• Whether or not the patient expects uncorrected visual acuity postoperatively

If the surgery is scheduled within the next week or two, visually significant ocular surface disease has been detected and the patient wants to be spectacle-free after surgery, then the ocular surface should be aggressively treated, and the surgery should be delayed until the visually significant ocular surface disease is converted to non–visually significant ocular surface disease. Generally, that requires a 6- to 8-week delay, but sometimes it can be longer, depending on the severity of the ocular surface disease. We recommend treating each driver or subtype of ocular surface disease simultaneously, which often requires a multifaceted regimen that may include prescription medications and procedural interventions.

OT: How should premium IOL candidacy factor into decisions about preoperative ocular surface treatment?

Starr: Generally, premium IOL candidacy increases the stakes and elevates patient expectations for postoperative vision. Therefore, ocular surface issues should be addressed aggressively and completely before finalizing the surgical plan and IOL calculations.

Even if a standard IOL is used and patient expectations are low, it still behooves all surgeons to identify, treat and discuss the diagnosis with patients. They should let patients know that it might progress after surgery and may require additional treatment afterward. If this is not mentioned prior to surgery and it becomes a problem postoperatively, it will be viewed as a complication rather than a preexisting condition.

OT: What is the most effective approach to working up a patient who sees 20/20 but remains dissatisfied after surgery?

Starr: When dissatisfaction is related to ocular surface issues, visual quantity and quality often fluctuate throughout the day. If the patient reports that sometimes they’re happy with their vision and other times they are not, and/or if a lubricant or other eye drop temporarily improves visual quality, the ocular surface is likely the culprit. The same aggressive treatment approach should be used to address each driver of ocular surface disease to convert the condition from visually significant to non–visually significant as quickly as possible.

The field guide addresses this exact scenario, outlining how to evaluate patients who achieve 20/20 vision but remain dissatisfied after surgery, including how to identify ocular surface disease and rule out other potential causes.

Reference
1. Gupta PK, Drinkwater OJ, VanDusen KW, Brissette AR, Starr CE. Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. J Cataract Refract Surg. 2018;44(9):1090-1096. doi:10.1016/j.jcrs.2018.06.026