Unhappy 20/20: A New Challenge for Cataract Surgery

<b>Background/Objectives:</b> Cataract surgery has evolved into a refractive procedure aimed at optimizing both vision quality and quantity. Modern patients, particularly "baby boomers", expect superior outcomes, increasing demand for premium intraocular lenses (IOLs). However, ocular surface dysfunction (OSD), especially dry eye disease (DED), compromises postoperative satisfaction, with up to 35% of patients dissatisfied despite achieving 20/20 visual acuity. This study aimed to characterize postsurgical ocular surface system failure (OSSF) and explore strategies to improve perioperative management. <b>Methods:</b> An open observational study was conducted at the Ophthalmology Complex Operative Unit, University Campus Bio-Medico, Rome, Italy, enrolling 20 patients with stage N2-3 and C1-2 lens opacities. Patients with diabetes, prior surgeries, or ocular inflammatory diseases were excluded. Preoperative and postoperative assessments included OSDI, SANDE scores, Schirmer test, TBUT, and fluorescein staining. Follow-ups occurred at 1 week, 1 month, and 3 months postoperatively. Statistical analysis used two-way ANOVA (<i>p</i> < 0.05). <b>Results:</b> Despite achieving a BCVA of 20/20, 44% of patients reported OSSF symptoms. Postoperative evaluations revealed significant worsening in OSDI and SANDE scores (<i>p</i> < 0.001), Schirmer test (preoperative mean 19.92 ± 10.06; <i>p</i> < 0.001), and TBUT (preoperative mean 5.88 ± 2.64 s; <i>p</i> < 0.001). Meibomian gland dysfunction and conjunctival hyperemia also worsened. <b>Conclusions:</b> Postsurgical OSSF results from neurogenic inflammation, tear film instability, and meibomian gland dysfunction, exacerbated by surgical trauma. Preoperative and postoperative management, including artificial tears, lid hygiene, and preservative-free regimens, are essential to improve outcomes and patient satisfaction. Comprehensive strategies can mitigate symptoms and enhance the benefits of cataract surgery.