The surprising side effect of eye surgery

Modern surgery can do wonders for eye problems. It can correct your vision, remove cataracts, slow glaucoma, or fix droopy eyelids. But after eye-related surgery, many people discover an unpleasant new problem: a burning, gritty, or even itchy feeling in the eyes known as dry eye disease.

What is dry eye disease?

Dry eye disease involves a loss of balance in the tear film — the layer of oils, mucus, and water on the surface of the eye. The tear film has many important functions, such as protecting your eyes from bacteria and irritants, helping your eyelids glide over your eyes smoothly and without irritation, and focusing light for clear vision.

"If there is a change in the way tear film ingredients are produced, maintained, or drained off the surface of the eye, you can develop dry eye or experience worse symptoms if dry eye disease already exists," says Dr. Nandini Venkateswaran, a corneal and cataract surgeon at Harvard-affiliated Massachusetts Eye and Ear.

Common causes of dry eye disease include aging, chronic exposure to a dusty environment, medication side effects, underlying conditions, wearing contact lenses, and a habit of not blinking enough — something most of us do when we stare at electronic screens. Any type of eye-related surgery can also trigger dry eyes.

The link with surgery

Surgery can disrupt the delicate balance of the tear film in a number of ways. For example, in surgery to replace a cloudy eye lens (a cataract), the surgeon makes incisions on the surface of the eye, which can irritate nerves and cause inflammation that affects how the tear film and eyelid interact.

Also, the many eye drops that are used before, during, and after eye-related surgery can promote dry eyes. "Some eye drops have preservatives in them, which can contribute to inflammation on the surface of the eye. And any factor that increases inflammation on the eye surface can lead to signs and symptoms of dry eye disease," Dr. Venkateswaran says.

Dry eye disease is even more likely to occur after surgery if you have an existing eye condition, such as glaucoma; if you've been using eye drops with preservatives for a long time; or if you've had eye surgeries in the past.

But for the majority of people Dr. Venkateswaran sees, the main culprit is simply undiagnosed problems with the tear film. "In many cases, people have had dry eye disease for a long time and didn't know it," she says. "Some evidence suggests that up to 80% of people have dry eye when they come to the office interested in cataract surgery."

What you can do

There's no way to know if dry eye after eye-related surgery will be temporary or permanent, especially if you already had tear film problems before the procedure. Dr. Venkateswaran advises that you go into any eye surgery expecting a degree of eye dryness afterward, and that you work with your doctor for treatments. "Expect a stepwise approach that ranges from over-the-counter treatments to prescription therapeutics based on the severity of your dry eye," she says.

Over-the-counter remedies include preservative-free artificial tears, eye gels or ointments used at night, and warm compresses or heated eye masks (which encourage the production of oils that help reduce friction when you blink and help keep the tear film from evaporating).

If those conservative approaches don't relieve dry eye discomfort, doctors can offer other treatments:

Prescription eye drops. Some eye drops reduce inflammation. Examples include cyclosporine (Restasis, Cequa, or Vevye), lifitegrast (Xiidra), and topical steroids. Other eye drops, such as perfluorohexyloctane (Miebo), help stop tears from evaporating.

Prescription nasal sprays. Nasal sprays such as varenicline (Tyrvaya) are used to stimulate tear production.

Implants. Your doctor can insert punctal plugs in the openings of the tear ducts to help retain tears on the eye surface.

Heat treatments. Delicate equipment used to gently warm the eyelids (treatments such as Lipiflow or Tear-Care) promotes oil production from the eyelids.

Blood-based eye drops. This treatment is derived from platelets or serum from your own blood. These blood components contain vitamins, proteins, or growth factors that might reduce surface eye inflammation.

Amniotic membranes. In an office procedure, your doctor applies membranes extracted from placental tissue. "These membranes are placed on the surface of the eye, dissolve over time, and help reduce inflammation," Dr. Venkateswaran says.

Keep in mind that not all of these treatments are covered by insurance (some can cost hundreds of dollars out of pocket), and that it may take time to find the remedy that works best for you.

Before you agree to surgery

Before you have any eye-related surgery, weigh the benefits of the procedure with the risks of developing dry eye or making an existing case even worse.

"Ask your doctor to help you decide which is the bigger problem — dry eye or cataracts, for example. If you have more symptoms from dry eye than from cataracts, establish a regimen that controls your dry eye disease well before surgery, so that the disease remains well controlled afterward," Dr. Venkateswaran says. "And remember that you need to invest time and effort into controlling dry eye. If you're willing to put in the work, you'll have less discomfort and better vision quality."

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