December 05, 2019
3 min read

Lifitegrast preoperatively improves refractive outcomes

Dry eye must be addressed for best results in cataract surgery.

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The accuracy of cataract surgery is “profoundly” affected by the condition of the corneal surface, according to John A. Hovanesian, MD, FACS.

“If you’re concerned about an unsatisfactory outcome for your patients, you can double the odds of them being happy by treating their dry eye,” Hovanesian told Ocular Surgery News, summing up a study he presented at the American Academy of Ophthalmology annual meeting in San Francisco.

Hovanesian and colleagues measured biometry in patients with cataract and significant dry eye before and after 4 weeks of treatment with Xiidra (lifitegrast ophthalmic solution 5%, Novartis) to determine the treatment’s effects on predictive accuracy of postoperative outcomes. As well, they looked at the effects on higher-order aberrations of the cornea and dry eye symptoms.

By reimplementing lifitegrast treatment after their patients’ cataract surgery treatment course was completed, the researchers also sought to determine whether patients benefited from continued dry eye treatment.

John A. Hovanesian


Patients underwent an initial exam with biometry before being treated with lifitegrast for 1 month. After treatment, patients underwent a second biometry exam and then cataract surgery. At 1 month postoperatively, spherical equivalent refractive error was measured, and patients underwent a second course of lifitegrast for 28 days before final examination to assess the longer-term benefits of the dry eye treatment, Hovanesian said.

The spherical equivalent measured after surgery was compared with the spherical equivalent predicted by each of the preoperative biometry measurements before and after lifitegrast treatment. The absolute prediction error was compared between these two sets of biometry measurements along with the root mean square higher-order aberration in the central 6 mm of the cornea. Other measurements included SPEED scores, tear breakup time, corneal staining, conjunctival hyperemia and root mean square higher-order aberration at baseline, 1 month preoperatively and at the end of the second course of lifitegrast.


Biometry was significantly more accurate when performed after lifitegrast treatment (P < .04) than before lifitegrast. Seventy-nine percent of patients based on post-lifitegrast biometry were within 0.5 D of their refractive targets compared with 71% of patients based on pre-lifitegrast biometry. Also, 91% of patients were within 0.75 D of their refractive targets based on post-lifitegrast biometry compared with 81% based on pre-lifitegrast biometry.

Patient satisfaction

Lifitegrast treatment before surgery led to a statistically significant improvement in higher-order aberrations. Hovanesian, OSN Cataract Surgery Section Editor, said that 56% of patients experienced improvements in higher-order aberrations after lifitegrast treatment compared with 23% who experienced no change and 21% who worsened.


“Higher-order aberrations and refractive accuracy are linked. When you have a less aberrated cornea, you have an easier one to measure, a more predictable one to measure. If my error in measuring the corneal curvature is 1 D off, then I’ll be 1 D off in my final refractive results, so we have to get this right,” Hovanesian said.

Lifitegrast-treated patients were more likely to be satisfied with visual quality after refractive cataract surgery. Based on their higher-order aberrations, about two-thirds of 77 patients were multifocal candidates after lifitegrast treatment compared with one-third of patients who were multifocal candidates before lifitegrast, Hovanesian said.

Additionally, lifitegrast significantly reduced corneal staining and dry eye symptoms before surgery and postoperatively, significantly reduced redness and significantly improved tear breakup time, he said.

“We need to treat dry eye before we do measurements, and we need to treat it after surgery to retain the benefits of better vision. When educating patients, you need to have a conversation with them about this being a lifelong disease and not something that’s fixed with cataract surgery. Whether it’s a surgeon or another doctor who will help them maintain their dry eye treatment, it’s vital that it continues to be a part of their repertoire and will continue to be part of their future,” Hovanesian said. – by Robert Linnehan

Disclosure: Hovanesian reports he is a consultant to Novartis. The study was funded by a grant from Novartis.