|Year : 2018 | Volume
| Issue : 3 | Page : 170-173
Tear film changes after cataract surgery: manual small-incision cataract surgery versus phacoemulsification
Saurabh Shrivastava, Brijesha Dudhat, Reshma Ramakrishnan, Varshav Gore
Department of Ophthalmology, Mahatma Gandhi Mission’s Medical College and Hospital, Kamothe, Navi Mumbai, Maharashtra, India
|Date of Submission||30-Jan-2018|
|Date of Acceptance||18-Apr-2018|
|Date of Web Publication||24-Sep-2018|
Ophthalmology, Asssociate Professor, Department of Ophthalmology, Faculty of Medicine, Melaka Manipal Medical College, [Manipal Academy of Higher Education (MAHE), Manipal] Jalan Batu Hampar, Bukit Baru,75150 Melaka
Source of Support: None, Conflict of Interest: None
Aim The aim was to identify if the type of surgical procedure has any bearing on dry eye syndrome and to find out the duration of postsurgical recovery of dryness in small-incision cataract surgery and phacoemulsification.
Patients and methods A prospective randomized study was conducted on 100 patients of cataract. Group A had 50 patients who underwent small-incision cataract surgery, and group B included 50 patients who underwent phacoemulsification. Patients with pre-existing ocular surface disease, for example, known case of glaucoma; taking topical antiglaucoma drugs; lid disorders; and grade 5 cataract (hard cataract in which it is difficult to do phacoemulsification) were excluded. Dry eye workup included Schirmer’s I, basic secretion test, tear film breakup time, and corneal sensation. The workup was done preoperatively and then on seventh, 21st, and 90th day postoperatively. The values were compared in the group itself and in-between the two groups.
Results In groups A and B, there was significant difference in the preoperative values of Schirmer’s I test, basic secretion test, and tear breakup time (TBUT) as compared with day 7 and day 21 postoperative values (P<0.05). However, the day 90 postoperative values were comparable to preoperative values, and there was no significant difference (P>0.05). There was significant difference in the Schirmer’s I test and basic secretion test values after 21 days of surgery between the groups (P<0.05), whereas there was no significant difference in TBUT and presence of corneal sensation values between the groups (P>0.05).
Conclusion Cataract surgery can cause or aggravate dry eye and affect the dry eye test values in the postoperative period up to 3 months. This holds true for both manual small-incision cataract surgery and phacoemulsification surgery. Therefore before surgery, patients must be informed about the possible aggravation of dry eye symptoms, and artificial tears should be prescribed for attenuating corneal damage and dry eye symptoms.
Keywords: dry eye, manual small-incision cataract surgery, phacoemulsification, Schirmer’s test, s test, tear film breakup time
|How to cite this article:|
Shrivastava S, Dudhat B, Ramakrishnan R, Gore V. Tear film changes after cataract surgery: manual small-incision cataract surgery versus phacoemulsification. Delta J Ophthalmol 2018;19:170-3
|How to cite this URL:|
Shrivastava S, Dudhat B, Ramakrishnan R, Gore V. Tear film changes after cataract surgery: manual small-incision cataract surgery versus phacoemulsification. Delta J Ophthalmol [serial online] 2018 [cited 2019 Jul 23];19:170-3. Available from: http://www.djo.eg.net/text.asp?2018/19/3/170/242148
| Introduction|| |
Dry eye syndrome (DES) is a complex disease that presents with many symptoms, including ocular discomfort, tear film instability, and visual changes . It can greatly effect patient quality of life by impairing the ability to drive, read, use a computer, and watch television among others . Literature shows three published reports on the prevalence of dry eye among hospital-based population from North and Eastern India, and the prevalence varies between 18.4 and 40.8% ,,,. One of the major risk factors for developing novel DES or exacerbating pre-existing DES is an ocular procedure, most commonly cataract  or laser-assisted in-situ keratomileusis (LASIK) surgery . By nature of the procedure, cataract surgery typically results in some denervation of the cornea and impaired corneal sensation. Decreased corneal sensation may lead to reduced lacrimal gland tear production, which in turn can lead to dry eye symptoms .
With the incidence of cataracts and number of cataract surgeries performed rapidly increasing , it is important to study the effects of this procedure. In the LASIK literature, dry eye symptoms after LASIK surgery adversely effected patient satisfaction and willingness to have the surgery again . Studies have shown that cataract surgery worsens dry eye symptoms in patients with pre-existing DES and induces dry eye symptoms in patients without pre-existing DES in at least the first 2 months after surgery ,.
Although the effects of cataract surgery on DES in the short term are well described ,,,,, there are only a few studies comparing the effect of the type of cataract surgery (manual small-incision cataract surgery or phacoemulsification) on causing dry eye disease.
We intend to study tear film changes after small-incision cataract surgery and/or phacoemulsification, to identify if the type of surgical procedure has any bearing on DES. We also aim to find out the duration of postsurgical recovery of dryness in both procedures.
| Patients and methods|| |
A prospective randomized study was conducted on 100 patients to assess the incidence and severity pattern of DES in patients undergoing small-incision cataract surgery or phacoemulsification. The patients were randomly divided into the following two groups of 50 patients each. Group A included 50 patients who underwent small-incision cataract surgery. Group B included 50 patients who underwent phacoemulsification. The ethical committee’s approval and a written informed consent from individual patients in their own language were taken. Inclusion criteria were patients between age of 60 and 80 with cataract. Exclusion criteria were pre-existing ocular surface disease/abnormality, pre-existing corneal degeneration, known cases of glaucoma taking topical antiglaucoma drugs, lid disorders (e.g. Meibomian gland More Details disease, ectropion, entropion, and trichiasis), nasolacrimal block, patients on systemic medication affecting tear film, and grade 5 nuclear cataract.
Patients with cataract attending the Ophthalmology OPD of the Mahatma Gandhi Mission Medical College were preoperatively questioned whether they are already diagnosed as having dry eye disease or if they are taking artificial tear substitutes. Then they underwent following workup: best-corrected visual acuity, slit lamp examination, dilated refraction and fundus examination, grading of cataract, intraocular pressure measurement by applanation tonometry, and sac syringing. After this, blood investigation and anesthesia fitness were done.
Patients with lens opacities classification system 2 cataract grading of nuclear 1–3, cortical cataract, and posterior subcapsular cataract (1–4) were allocated to phacoemulsication and small-incision cataract surgery randomly (by flip of coin).
Preoperative dry eye workup was done, which included Schirmer’s I, basic secretion test secretion with anesthesia, tear film breakup time, and corneal sensation.
The aforemention test was repeated on the postoperative day 7, day 21, and day 90.
A straight 6 mm external incision in the sclera, of 0.4 mm depth (5 mm posterior to superior limbus) is made with back cuts using a 15 no. blade. The scleral tunnel is then constructed using a crescent blade, extending 2 mm anteriorly into the cornea.The dissection is carried out towards the limbus on both the sides to create a funnel shaped’ pocket’. The crescent blade is then angled backwards to incorporate the back cuts into the pocket. Later the anterior chamber is entered with a keratome. The keratome is directed to include the area dissected by crescent blade. This creates a three plane wound which is water tight.
| Results|| |
Group A included 50 patients who underwent small-incision cataract surgery and group B included 50 patients who underwent phacoemulsification.
Most patients in group A and group B were in the age group of 61–70 years (46 and 34%, respectively). There was a male predominance in both the groups (78 and 64%, respectively);female patients constituted 22 and 36% of the study groups A and B, respectively. Most patients in groups A and B had grade 2 nuclear sclerosis (56 and 64%, respectively) grade 3 cortical cataract (42% in both groups), and grade 2 posterior subcapsular cataract (32 and 54%, respectively).
There was no significant difference in preoperative values and day 1 and day 7 postoperative values [Schirmer’s I test, basic secretion test, tear breakup time (TBUT), and presence of corneal sensation] between the groups A and B (P>0.05). However, there was significant difference in the Schirmer’s I test and basic secretion test values after 21 days of surgery between the groups (P<0.05), whereas there was no significant difference in TBUT and presence of corneal sensation values between the groups (P>0.05; [Table 1]). Again on postoperative day 90, there was no significant difference in the values [Schirmer’s I test, basic secretion test, TBUT, and presence of corneal sensation] between the groups (P>0.05).
|Table 1 Comparison of values between Group A and B after 21 days of surgery|
Click here to view
In group A, there was significant difference in the preoperative values of Schirmer’s I test, basic secretion test, and TBUT as compared with day 7 and day 21 postoperative values (P<0.05). However, the day 90 postoperative values were comparable to preoperative values, and there was no significant difference (P>0.05; [Table 2]). Similarly, in group B, there was significant difference in the preoperative values of Schirmer’s I test, basic secretion test, and TBUT as compared with day 7 and day 21 postoperative values (P<0.05). However, the day 90 postoperative values were comparable to preoperative values, and there was no significant difference (P>0.05; [Table 3]).
| Discussion|| |
The results of our study are comparable to the studies by Jayshree et al.  and Venugopal et al.  who evaluated dry eye in manual small-incision cataract surgery. Liu et al.  found significant reduction in TBUT and Schirmer’s test among 79 patients on first postoperative day after phacoemulsification. In their study Schirmer’s test became normal on seventh postoperative day and tear film stabilized on 30th postoperative day. On comparing the dry eye disease caused by the two procedures of cataract surgery, the study by Sinha et al.  was inconclusive, whereas the present study shows that there was significant difference in the Schirmer’s I test (group A: 18.14±4.39; group B: 20.46±2.82) and basic secretion test values (group A: 9.54±3.41; group B: 11.08±2.09) after 21 days of surgery between the groups.Regarding the pathophysiology, a study by Khanal et al.  reported deterioration in corneal sensitivity and tear physiology immediately after phacoemulsification. Corneal sensitivity did not return to preoperative levels until 3 months postoperatively, whereas the tear functions recovered within 1 month. Oh et al.  reported that the decrease in goblet cell density, which was correlated with operation time, had not recovered at 3 months after cataract surgery; therefore, microscopic ocular surface damage during cataract surgery seems to be one of the pathogenic factors that cause ocular discomfort and DES after cataract surgery. Han et al.  reported that Meibomian gland function may be altered without accompanying structural changes after cataract surgery. In the present study, there was reduced corneal sensation in the first postoperative week, which then returned to normal on day 21. Other plausible causes of dryness after cataract surgery can be exposure to microscopic light, vigorous intraoperative irrigation of the tear film, inflammatory factors in the tear film owing to ocular surfaces irritation, manipulation of ocular surface, and usage of postoperative topical eye drops containing preservatives.
| Conclusion|| |
Moderate to severe dryness of eye was seen from first to third week postoperative period after both manual small-incision cataract surgery and phacoemulsification, with values of basic secretion test lower in manual small-incision cataract surgery group on day 21 as compared with phacoemulsification group. Thus, cataract surgery can cause or aggravate dry eye in the postoperative period up to 3 months. This holds true for both manual small-incision cataract surgery and phacoemulsification surgery. Therefore, before surgery, patients must be informed about the possible aggravation of dry eye symptoms, and artificial tears should be prescribed for attenuating corneal damage and dry eye symptoms.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lemp MA, Baudouin C, Baum J. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop. Ocul Surf 2007; 5:75–92.
Miljanović B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol 2000; 143:409–415.
Gupta SK, Gupta V, Joshi S, Tandon R. Subclinically dry eyes in urban Delhi: an impact of air pollution? Ophthalmologica 2002; 216:368–371.
Sahai A, Malik P. Dry eye: prevalence and attributable risk factors in a hospital based population. Ind J Ophthalmol 2005; 53:87–91.
Gupta N, Prasad I, Jain R, D’Souza P. Estimating the prevalence of dry eye among Indian patients attending a tertiary ophthalmology clinic. Ann Trop Med Parasitol 2010; 104:247–255.
Basak SK, Pal PP, Basak S, Bandyopadhyay A, Choudhury S, Sar S. Prevalence of dry eye diseases in hospital-based population in West Bengal, Eastern India. J Indian Med Assoc 2012; 110 789–794.
Li XM, Hu L, Hu J, Wang W. Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. Cornea 2007; 26:16–20.
Asano-Kato TN, Komai-Hori Y, Tsubota K. Dry eye after laser in situ keratomileusis. Am J Ophthalmol 2001; 132:1–7.
Donnenfeld ED, Solomon K, Perry HD. The effect of hinge position on corneal sensation and dry eye after LASIK. Ophthalmology 2003; 110:1023–1030.
Foster A. Vision 2020: the cataract challenge. J Community Eye Health 2000; 13:17–19.
Hovanesian JA, Shah SS, Maloney RK. Symptoms of dry eye and recurrent erosion syndrome after refractive surgery. J Cataract Refract Surg 2001; 27:577–584.
Cho YK, Kim MS. Dry eye after cataract surgery and associated intraoperative risk factors. Korean J Ophthalmol 2009; 23:65–73.
Movahedan A, Djalilian AR. Cataract surgery in the face of ocular surface disease. Curr Opin Ophthalmol 2012; 23:68–72.
Ram J, Gupta A, Brar GS, Kaushik S, Gupta A. Outcomes of phacoemulsification in patients with dry eye. J Cataract Refract Surg 2002; 28:1386–1389.
Oh T, Jung Y, Chang D, Chang D, Kim J, Kim H. Changes in tear film and ocular surface after cataract surgery. Jpn J Ophthalmol 2012; 56:113–118.
Jayshree MP, Shivkumar H, Monalisha P, Mallikarjun S. A prospective study of dry eye after manual small incision cataract surgery in rural population of Bagalkot. J Clin Res Ophthalmol 2017; 4:25–29.
Venugopal KC, Krishnaraj PA, Chandan N. Evaluation of dry eye after manual small incision cataract surgery with corneoscleral tunnel incision. J Clin Diagn Res 2012; 6: 1029–1033.
Liu Z, Luo L, Zhang Z, Cheng B, Zheng D. Tear film changes after phacoemulsification. Zhonghua Yan Ke Za Zhi 2002; 38: 274–277.
Sinha M, Sinha A, Chowdhury B. Comparative evaluation of dry eye following cataract surgery: a study from North India. IOSR J Dent Med Sci 2014; 13:13–18.
Khanal S, Tomlinson A, Esakowitz L, Bhatt P, Jones D, Nabili S. Changes in corneal sensitivity and tear physiology after phacoemulsification. Ophthalmic Physiol Opt 2008; 28:127–134.
Han KE, Yoon SC, Ahn JM. Evaluation of dry eye and meibomian gland dysfunction after cataract surgery. Am J Ophthalmol 2014; 157:1144–1150.
[Table 1], [Table 2], [Table 3]