Date of Award

Winter 1-2024

Document Type


Degree Name

Doctor of Philosophy



First Advisor

Sara LaBelle, PhD

Second Advisor

Michelle Miller-Day, PhD

Third Advisor

Keith Weber, EdD

Fourth Advisor

Marjan Farid, MD


Millions of cataract surgeries are performed every year in the United States, yet both surgeon reports and patient reports indicate that practices are not utilizing the diagnostic tests and treatments that are advocated in the medical literature to identify and manage ocular surface disease prior to surgery. As a result, patients risk suffering several significant consequences with regard to their vision, comfort and safety. Personal observations from my 25 years of experience working with ophthalmologists and optometrists led to curiosity regarding the root cause of undertreatment of ocular surface disease. Specifically, I had the impression that eye care providers held strongly to the belief that ocular surface disease should be managed preoperatively, yet this belief was not reflected in their behavior. The overall aim of this dissertation is to ascertain the validity of my unscientific observations and to provide a customized tool that can be used in a single cataract surgery clinic to increase goal-congruent behavior among eye care providers. Phase One involved interviews with 42 ophthalmologists and optometrists on preoperative ocular surface disease management in cataract surgery patients. Using the Health Belief Model (Rosenstock, 1966) as a guide, these results helped characterize the misalignment between beliefs and behaviors while establishing the ethical imperative to proceed in the direction of intervention development. Phase Two was a rigorous case study of a high-volume cataract surgery care center. This included observations, a review of artifacts, and interviews with seven doctors, three staff members and five patients. Using Nudge Theory (Thaler & Sunstein, 2008) as a guide, these results elucidated decision-making processes and elements of the practice’s choice architecture that either limit or support preoperative ocular surface disease management in cataract surgery patients. Finally, Phase Three presents theory-driven recommendations in the form of a practical and easy-to-read intervention guide. Six action items are presented as strategies to help the doctors and staff overcome the specific challenges that lead to the undertreatment of ocular surface disease.

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Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Available for download on Sunday, November 30, 2025