What are the possible causes of burning sensation in the eye after cataract surgery and how should it be evaluated and managed?

Burning Eyes After Cataract Surgery

Burning sensation after cataract surgery is most commonly caused by dry eye disease, which develops or worsens in approximately one-third of patients beyond the normal 3-month postoperative period and requires both immediate symptomatic management and evaluation for underlying causes. 1

Primary Cause: Postoperative Dry Eye Disease

The burning sensation you're experiencing is likely dry eye syndrome, which is one of the main reasons for patient dissatisfaction following cataract surgery. 1 This occurs through multiple mechanisms:

• Corneal nerve transection during surgery disrupts normal tear production and ocular surface sensation 2
• Inflammatory cascade triggered by surgical trauma affects tear film stability 2, 3
• Goblet cell loss reduces mucin production necessary for tear film adherence 2
• Meibomian gland dysfunction can be exacerbated by perioperative medications 2

Immediate Evaluation Steps

Look for these specific clinical findings:

• Ocular surface signs: Decreased tear meniscus, increased tear break-up time, conjunctival injection, corneal or conjunctival staining 1
• Inflammatory signs: Anterior chamber reaction, corneal edema, or excessive redness that could indicate infection or severe inflammation 4, 5
• Medication-related toxicity: If using preserved eye drops, consider benzalkonium chloride toxicity causing additional ocular surface damage 4, 6

Critical red flags requiring urgent evaluation:

• Sudden vision changes, increasing pain, purulent discharge, or severe photophobia (rule out endophthalmitis) 5, 7

Management Algorithm

First-Line Treatment (Initiate Immediately)

Switch to preservative-free artificial tears if not already using them, as preserved formulations significantly worsen ocular surface toxicity, especially in post-surgical patients. 4, 6 Use frequently throughout the day.

If Symptoms Persist Beyond 1-2 Weeks

Add FDA-approved anti-inflammatory therapy for dry eye disease:

• Topical cyclosporine 0.05% or 0.09% 1
• Topical lifitegrast 0.5% 1
• Topical loteprednol 0.25% (low-dose steroid specifically approved for dry eye) 1

These medications improve both symptoms and clinical signs, though long-term treatment is typically necessary as dry eye is rarely curative. 1

Timing Considerations

Normal postoperative period: Dry eye symptoms are common in the first 3 months after cataract surgery and often subside with time. 1

Persistent symptoms beyond 3 months: Approximately one-third of patients experience ongoing dry eye requiring more aggressive management. 1 These patients need comprehensive dry eye evaluation including tear film assessment and meibomian gland examination. 1

Common Pitfalls to Avoid

Preserved eye drops in high-risk patients: Using preserved postoperative medications (antibiotics, steroids, NSAIDs) significantly increases ocular surface toxicity. 4, 6 High-risk patients include those with pre-existing dry eye, diabetes, contact lens use, or multiple topical medications. 6

Inadequate recognition of medication-induced toxicity: NSAIDs, while effective for preventing cystoid macular edema, can cause ocular surface abnormalities and worsen dry eye symptoms. 3 If burning persists despite dry eye treatment, consider discontinuing NSAIDs if beyond the first postoperative month. 4, 5

Dismissing symptoms as "normal": While some dry eye is expected, severe burning warrants evaluation to rule out infection, severe inflammation, or medication toxicity rather than assuming it will resolve spontaneously. 5, 2

Alternative Diagnoses to Consider

If dry eye treatment fails or symptoms are atypical:

• Infectious endophthalmitis: Pain with purulent discharge and vision loss (rare but vision-threatening) 7
• Severe postoperative inflammation: Excessive anterior chamber reaction requiring intensified steroid therapy 8, 9
• Steroid-induced complications: Elevated intraocular pressure causing discomfort 5, 6

Evidence Quality Note

The 2024 American Academy of Ophthalmology Dry Eye Syndrome Preferred Practice Pattern provides the strongest guidance, emphasizing that baseline ocular surface parameters predict patients at risk and that all cataract surgery patients should be evaluated and managed for dry eye both preoperatively and postoperatively. 1 No single test establishes the diagnosis; clinical examination with multiple tests is the gold standard. 1