We noticed you’re blocking ads

Thanks for visiting CRSToday. Our advertisers are important supporters of this site, and content cannot be accessed if ad-blocking software is activated.

In order to avoid adverse performance issues with this site, please white list https://crstoday.com in your ad blocker then refresh this page.

Need help? Click here for instructions.

Digital Supplement | Sponsored by CorneaGen

Ocular Surface: Pristine Makes Perfect

Be critical of the ocular surface preoperatively, every time.

With any refractive surgery procedure, a poor ocular surface can complicate postoperative results. Not addressing the ocular surface prior to surgery can lead to dysphotopsia; halos and starbursts; poor visual clarity and quality; and ocular irritations such as discomfort, redness, tearing, and foreign body sensation.

Knowing this, we are pretty critical of the ocular surface preoperatively, every time and with every patient. This entails always conducting sufficient preoperative measurements and not shying away from delaying surgery until the symptoms are treated and mitigated.

When a patient with a poor ocular surface is interested in the KAMRA inlay ( CorneaGen), for instance, we will not implant one until the ocular surface is pristine. We have followed this strict rule since we started using the inlay, and we have never had an issue with poor postoperative results.


We follow the same basic preoperative course for all patients presenting for refractive surgery. If we detect any symptoms of dry eye disease (DED), we flag it and treat it prior to advancing to surgery.

The challenge, however, is that every patient presents with a slightly different form or symptom of DED. With that said, the best thing you can do for patients is to educate them about the signs and symptoms that are involved with DED. We hear a plethora of questions, from “Doc, if my eyes are dry, why do they water?” to “Why does it always feel like I have something in my eye?” to “Why does my vision get blurry?” Explaining to patients the mechanisms for why their eyes water, why they have that foreign body sensation, or why their vision gets blurry, is extremely comforting to the patient. Therefore, education is probably the first line of therapy.

After that, it is important to inspect the lids and the ocular surface and to decide whether or not there is a deficiency in tear production. Each treatment must be tailored to the patient, as not everyone presents the same way. However, the bottom line is that the ocular surface must be considered, it must be examined, and it must be treated when necessary prior to any refractive surgery, including corneal inlay implantation.


It is important to remember that inlay patients are reading patients. They want to read, and they want to read without glasses. One of the most effective ways for us to provide patients with this result is the KAMRA corneal inlay. It is our duty to ensure that the ocular surface is optimized to the best of our ability long before that inlay is implanted (Figure 1). Our jobs will be easier, and our patients will be happier in the long run.

Figure 1. Like ripples in water distort reflections, ocular surface irregularities degrade image quality for patients.

For some reason, DED goes underdiagnosed in most ophthalmology and optometric clinics in the world. When we take time to examine the ocular surface and to educate our patients preoperatively, it is amazing how many can achieve excellent postoperative results—all as result of simple question and answer and good, old-fashioned medical detective work.

KAMRA is a trademark of CorneaGen. All other trademarks are property of their respective owners.

Ephraim Atwal, MD
Ephraim Atwal, MD
  • dratwal@gmail.com
  • Financial disclosure: Lecture fees (AcuFocus)

Q: How many KAMRA inlays have you implanted?
A: I've done about 100.

Q: What are you able to achieve on average for near and far acuity?
A: I'm disappointed if my patients are not J1 at near, and I'm disappointed if they are not 20/25 or better at distance. If a patient is not, typically we look at the ocular surface, placement of the inlay, and centration to make sure that it's in line with the visual axis.