|Year : 2020 | Volume
| Issue : 3 | Page : 167-172
The role of oral antioxidant supplementation in treatment of dry eye following phacoemulsification
Mohamed S Abd Elaziz, Mostafa K Nassar, Noha A.E.M Sharshar
Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||24-Sep-2019|
|Date of Decision||06-Dec-2019|
|Date of Acceptance||23-Jun-2020|
|Date of Web Publication||23-Sep-2020|
MD Mohamed S Abd Elaziz
Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia 32511
Source of Support: None, Conflict of Interest: None
Background Dry eye after uneventful phacoemulsification has been a common cause for patients’ dissatisfaction, despite good visual outcome. Tear film instability after cataract extraction has been attributed to multiple intraoperative and postoperative causes. Oral antioxidants have been proposed to decrease the objective and subjective symptoms of dry eye.
Objective The aim of this study was to evaluate the effectiveness of oral antioxidant supplementation on dry eye after phacoemulsification.
Patients and methods This is a randomized controlled clinical case series study that included 60 eyes of 60 patients. They were divided into two groups: group 1 was treated with oral antioxidants after surgery, whereas group 2 was not treated with oral antioxidants. The study was conducted at the Ophthalmology Department of Menoufia University Hospital in the period between January 2018 and January 2019. Follow-up for those patients were done by Schirmer’s test 1, break-up time test, and ocular surface disease index questionnaire preoperatively and at 1, 2, and 3 months postoperatively to evaluate oral antioxidant supplementation effect on dry eye after surgery.
Results Three months after oral antioxidant supplementation following phacoemulsification, statistically significant differences (P<0.001) were noted in break-up time test scores (9.80±0.86 and 8.50±0.88 s) in group 1 and group 2, respectively. In addition, Schirmer’s scores improved to 9.65±0.97 mm in group 1 versus 8.60±0.87 mm in group 2. However, no statistically significant difference (P=0.599) was noted in ocular surface disease index score between group 1 and group 2 (15.18±3.29 and 15.56±2, respectively) .
Conclusion Oral antioxidant supplementation caused significant improvement in objective manifestations of dry eye after phacoemulsification. Nevertheless, no significant difference was noted between the two groups in subjective symptoms.
Keywords: ocular surface disease index, oral antioxidant, postoperative dry eye
|How to cite this article:|
Abd Elaziz MS, Nassar MK, Sharshar NA. The role of oral antioxidant supplementation in treatment of dry eye following phacoemulsification. Delta J Ophthalmol 2020;21:167-72
|How to cite this URL:|
Abd Elaziz MS, Nassar MK, Sharshar NA. The role of oral antioxidant supplementation in treatment of dry eye following phacoemulsification. Delta J Ophthalmol [serial online] 2020 [cited 2021 Dec 6];21:167-72. Available from: http://www.djo.eg.net/text.asp?2020/21/3/167/295883
| Introduction|| |
Dry eye syndrome (DES) is described as a state of abnormal tear film that can be caused by a number of conditions that alter its composition and affect its stability. It is one of the most important factors influencing the quality of life in elderly population. Moderate and severe dry eye can impair the ability of patients to perform activities of daily life, affect work productivity, and influence mood and confidence .
With recent advances in cataract and refractive surgeries, postoperative dry eye has been implicated as the most important obstacle to patient’s satisfaction despite an excellent visual recovery. There was deterioration in corneal sensitivity and tear physiology which was seen immediately after phacoemulsification . The incidence of dry eye increased dramatically after cataract surgery . Subjective dry eye type symptoms after routine cataract extraction were also noted .
Dietary nutrients have been shown to be involved in the pathogenesis of DES ,. Essential fatty acids play a role in the inflammation process . Systemic omega-3 can mediate inflammation and has been used to treat DES, particularly in cases associated with Meibomian gland dysfunction ,. Oral antioxidants, such as vitamin A or multivitamins, can improve tear film stability and the health of the conjunctival surface ,. Free radicals can attack the cellular plasma membrane and cause cell damage and death . They can also damage the epithelial tissues of the conjunctiva, the lacrimal glands, and tear-secreting tissues. Exposure to ozone can degrade tear proteins and cause chronic dysfunction of the tear film . Antioxidants can protect against free radicals and may help conjunctival tissues in the provision of a stable tear film .
The aim of this study was to evaluate the effectiveness of oral antioxidant supplementation on dry eye after phacoemulsification.
| Patients and methods|| |
This nonrandomized case–control case series study was carried out at the Ophthalmology Department of Menoufia University Hospital in the period between January 2018 and January 2019. The study enrolled 60 eyes of 60 patients.
The study protocol was formally reviewed and approved by the Ethics Committee for Human Research at Menoufia Faculty of Medicine. A written informed consent was obtained from all participants, before the commencement of the study after thorough explanation of the study objectives, to participate in the study and for data publication.
Inclusion criteria of the selected cases included age over 20 years with significant cataract indicated for surgery, without pre-existing dry eye, or disorders in the eye lids with no past ocular surgeries. Patients were excluded from the study if they have pre-existing dry eye, corneal scarring, previous eye surgery, eyelid disorders, or coexistence of ocular pathology other than cataract.
The enrolled patients were divided into two groups: group 1 was treated by oral antioxidants and group 2 was not treated by oral antioxidants. General patient information and detailed history of systemic and ocular diseases were recorded, and thorough evaluation was carried out in all patients. One day before cataract surgery, Schirmer’s test 1 (ST-1), break-up time test (BUT), and ocular surface disease index (OSDI) ([Figure 1])  were evaluated.
First, ST-1 was evaluated without corneal anesthesia by using a standardized tear strip. In a quiet room, with dimmed light, the patient was made to sit comfortably and the strip was inserted into the lower temporal lid margin, after folding it at the notch and asking the patient to look up and in. After 5 min, the strip was removed, and the length of the moistened area was recorded. Next, the stability of the tear film over the conjunctiva and cornea was assessed by the BUT using a slit lamp with a cobalt blue filter and sodium fluorescein. The interval between ST-1 and BUT was at least 10 min. A fluorescein strip was applied in the lower palpebral conjunctiva, and the patient was asked to blink five times, after which he/she was asked to refrain from blinking. The appearance of black spots or lines indicated the onset of dry spots, and the interval between the last blink and the first randomly distributed dry spot was taken as the BUT. The average of three measurements was recorded, and a value less than 10 s was taken as abnormal.
All patients underwent phacoemulsification surgery under subtenon’s anesthesia using 3 ml of 2% lidocaine (Debocaine 2%; DBK Pharmaceutical, Cairo, Egypt). Ringer’s lactate solution (EIPICO, Alexandria, Egypt) was used as an irrigating solution and hydroxylpropyl methylcellulose (Eye Visc PFS; Biotech, Kerala, India) as a viscoelastic material. Combination of Gatifloxacin and Nepafenac eye drops were instilled four times a day, 1 day before surgery. Mydriasis was achieved using cyclopentolate HCl 50 mg+phenylephrine HCl 500 mg eye drops (Cyclophrine eye drops; Kahira Pharm, Cairo, Egypt) 1 h before the surgery. A standard surgical technique was used in all patients. A 3.2 mm superotemporal corneal incision was made just anterior to the vascular arcades of the corneoscleral limbus using a keratome. A paracentesis incision of 1 mm was made 60° apart with MVR blade at both 3 and 9 o’clock positions. A phacoemulsification tip was used to emulsify the cataract using a stop and chop technique. A foldable intraocular lens was implanted inside the capsular bag. All patients received a standard postoperative regimen of topical steroid, antibiotic, and nonsteroidal anti-inflammatory drugs in tapering doses for 4 weeks. In the event of any intraoperative complication or if any other drug was used in the perioperative period, they were excluded from the study.
A total of 30 patients received 3-month regimen of oral antioxidant medication in the form of OCTATRON (Nerhadou International, 6 October City, Egypt) single cap/day [composition: vitamin A 3000 IU, d-alpha Tocopheryl acid; (vitamin E) 15 IU, Ascorbic acid (vitamin C) 90 mg, Zinc (amino acid-chelated chelate) 11 mg, Molybdenum (amino acid chelated) 45 µg, Selenium (amino acid chelated) 55 µg, Biotin 10 µg and mixed Bioflavonoid 100 mg].
In the postoperative period, ST-1, BUT, and dry eye symptoms by OSDI were examined on day 7 and at 1, 2, and 3 months in the same manner and sequence as in the preoperative period in both groups.
All data were collected, tabulated, and statistically analyzed using SPSS 19.0 for windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for windows (MedCalc Software BVBA, Ostend, Belgium). Data were statistically described in terms of mean and standard deviation, median and range, or frequencies and percentages as appropriate. Preoperative and postoperative values were compared using paired t-test. SD was presented if relevant. P values less than 0.05 were considered statistically significant.
Percentage change represents a degree of change over time. Positive values indicate a percentage increase, whereas negative values indicate a percentage decrease. The percent change for each measured parameter can be calculated manually via the following formula: percent change=(new value−original value)/original value×100.
| Results|| |
There was no statistically significant difference between group 1 and group 2 regarding ST-1, BUT, and OSDI at one day before operation. The mean value of ST-1 was 10.75±0.76 mm in group 1, whereas in group 2, it was 10.50±1.41 mm. The mean value of BUT was 11.00±1.02 s in group 1, whereas in group 2, it was 10.90±0.71 s. The mean value of OSDI was 9.15±1.41 in group 1 and 9.15±1.41 in group 2 ([Table 1]).
|Table 1 Comparison between antioxidant treated and control groups one day before operation|
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There was no statistically significant difference regarding the mean values of ST-1 at 1 week after operation between group 1 (7.85±0.97 mm) and group 2 (8.00±0.79 mm). However, the mean values of ST-1 were significantly higher in group 1 than in group 2 at 1 month postoperatively (8.45±0.86 and 8.00±0.79, respectively), at 2 months postoperatively (9.10±0.78 and 8.60±0.87, respectively), and at 3 months postoperatively (9.65±0.97 and 8.60±0.87, respectively) (P≤0.001, [Table 2]).
|Table 2 Comparison between antioxidant treated and control groups regarding Schirmer’s test at different times after operation|
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There was no significant difference regarding the mean values of BUT at 1 week after operation between group 1 (8.25±0.83 s) and group 2 (7.90±0.84 s). However, the mean values of BUT were significantly higher in group 1 than in the control group at 1 month (8.65±0.88 and 7.90±0.84 s, respectively), at 2 months (9.20±0.79 and 8.15±0.85 s, respectively), and at 3 months (9.80±0.86 and 8.60±0.87 s, respectively) postoperatively (P≤0.001, [Table 3]).
|Table 3 Comparison between antioxidant treated and control groups regarding break-up time at different times after operation|
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There was a statistically significant higher mean value of OSDI in group 1 (22.28±3.69) than in the control group (20.39±3.54) at 1 week after operation. On the contrary, there were no significant differences between both groups regarding the mean values of OSDI at 1 month (19.97±3.33 and 18.93±2.78 in group 1 and 2, respectively), at 2 months (18.10±3.44 and 17.66±3.06 in group 1 and 2, respectively), and at 3 months postoperatively (15.18±3.29 and 15.56±2.17 in group 1 and 2, respectively) (P=0.599, [Table 4]).
|Table 4 Comparison between antioxidant treated and control groups regarding ocular surface disease index at different times after operation|
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To elucidate the effect of oral antioxidants on different assessment parameters, percent change was calculated for both treatment and control groups ([Table 5]).
|Table 5 Percentage change in different parameters in antioxidant treated and control groups|
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| Discussion|| |
Ocular dryness after different ocular surgeries is a major concern to maintain patient satisfaction as well as visual outcome.
In the current study, after phacoemulsification, a decrease in values of ST-1 by 23.8% and BUT by 27.5% and an increase in OSDI by 122.8% were observed in the control group one week after operation. This is slightly in agreement with Hawaiian Eye 2011 meeting , a report that discussed the results of a prospective multicenter study that assessed the prevalence of dry eye in 272 eyes that underwent cataract surgery. The study found that more than 60% of eyes had abnormal tear break-up time (TBUT), 50% of eyes had central corneal staining, and 21.3% of eyes had low ST-1 results, all of which are diagnostic signs of dry eye or DES. When Ram et al.  compared Schirmer’s scores and TBUT in 25 eyes before and after surgery, they noticed a decrease in both values at various time intervals up to 2 months after operation. In addition, Li et al.  demonstrated a similar deterioration of both Schirmer’s score and TBUT in 50 eyes, when followed up for 3 months. Besides the aforementioned 2 tests, Cho and Kim  included the tear meniscus height in their study that was conducted on 70 eyes of 35 patients after phacoemulsification and noticed a decline in all three test values, on a follow-up period of 3 months.
The present study found that there was aggravation of subjective symptoms after surgery, which is in agreement with Cho and Kim . who concluded that there was indeed an aggravation of dry eye symptoms after cataract surgery. Roberts and Elie  also demonstrated that a clinically significant proportion of cataract surgery patients experienced some degree of dry eye symptoms after surgery.
The significant reduction in TBUT, seen in the current study, indicates tear film instability in the operated eye, possibly resulting from either a surface irregularity at the site of the section, which induces a faster break-up of the tear film, or from a decreased mucin production by the conjunctiva or by toxic effect of postoperative drugs, which agree with the study conducted by Sahu et al. , who found a significant deterioration of all dry eye test values following phacoemulsification surgery along with an increase in subjective symptoms. These values started improving after 1 month postoperatively, but the preoperative levels were not achieved till 2 months after surgery. Correlations of dry eye test values were noted with the operating microscope light exposure time and cumulative dissipated energy.
In the current study, after 3 months, there was a significant improvement in objective symptoms of dry eye as tested by ST-1 and BUT values in group 1 (that was treated with oral antioxidants after surgery) compared with group 2, which did not receive oral antioxidants. The BUT scores improved by 15.81% with antioxidant versus 7% without antioxidant (P≤0.001), and Schirmer’s scores improved by 18.65% with antioxidant versus 6.9% without antioxidant (P≤0.001). This is slightly compatible with the study conducted by Drouault-Holowacz et al. . After 12 weeks of supplementation with oral antioxidants, Oxybiane, both BUT scores (27.3±8.4 with Oxybiane vs 3.61±4.3% with the placebo, P=0.017) and Schirmer’s scores (26.9±14.2% with Oxybiane vs −4.7±3.4% with the placebo, P=0.037) were significantly increased. They also found a significant improvement in ocular symptoms with oral antioxidants than with the placebo, which does not agree with the present study, as we found no significant difference between the two groups. In the present study, the OSDI value, after 3 months, was 15.18±3.29 with antioxidant versus 15.56±2.17 without antioxidant. A study conducted by Huang et al. , which compared the effects of an antioxidant supplement with placebo on patients with DES, assessed dry eye symptoms, visual acuity, ST-1, tear film break-up time, cornea and conjunctiva fluorescein staining, serum anti-SSA/anti-SSB (anti-Sjögren’s-syndrome-related antigen A,B) antibodies, and the level of reactive oxygen species in tears. They found that the tear film break-up time scores and the ST-1 without topical anesthesia significantly improved in the treatment group, which agrees with our results. Overall subjective impression revealed a significant improvement with treatment compared with placebo, which disagrees with the results of the current study.
| Conclusion|| |
Oral antioxidant supplementation caused significant improvement in objective manifestations of dry eye after phacoemulsification. Nevertheless, no statistically significant difference was noted between the two groups regarding subjective symptoms.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Friedman NJ. Impact of dry eye disease and treatment on quality of life. Curr Opin Ophthalmol 2010; 21:310–316.
Khanal S, Tomlinson A, Esakowitz L, Bhatt P, Jones D, Nabili S et al.
Changes in corneal sensitivity and tear physiology after phacoemulsification. Ophthalmic Physiol Opt 2008; 28:127–134.
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:S16–S20.
Roberts CW, Elie ER. Dry eye symptoms following cataract surgery. Insight 2007; 32:14–21.
Sommer A. Nutritional factors in corneal xerophthalmia and keratomalacia. Arch Ophthalmol 1982; 100:399–403.
Brown NA, Bron AJ, Harding JJ, Dewar HM. Nutrition supplements and the eye. Eye 1998; 12:127.
James MJ, Gibson RA, Cleland LG. Dietary polyunsaturated fatty acids and inflammatory mediator production. Am J Clin Nutr 2000; 71(1 Suppl):343S–348S.
Hodge W, Barnes D, Schachter HM, Pan Y, Lowcock EC, Zhang L et al.
Effects of Omega-3 Fatty Acids on Eye Health. Summary, Evidence Report/Technology Assessment: Number 117. AHRQ Publication No. 05-E008-1, July 2005. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/clinic/epcsums/o3eyesum.htm
[Accessed 14 May 2019].
Macsai MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis) Trans Am Ophthalmol Soc 2008; 106:336–356.
Sommer A. Effects of vitamin A deficiency on the ocular surface. Ophthalmology 1983; 90:592–600.
Patel S, Plaskow J, Ferrier C. The influence of vitamins and trace element supplements on the stability of the pre-corneal tear film. Acta Ophthalmol 1993; 71:825–829.
Dröge W. Free radicals in the physiological control of cell function. Physiol Rev 2002; 82:47–95.
Schmut O, Gruber E, El-Shabrawi Y, Faulborn J. Destruction of human tear proteins by ozone. Free Radic Biol Med 1994; 17:165–169.
Burton GW, Foster DO, Perly B, Slater TF, Smith IC, Ingold KU. Biological antioxidants. Philos Trans R Soc Lond B Biol Sci 1985; 311:565–578.
Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol 2000; 118:615–621.
Ram J, Gupta A, Brar G, Kaushik S, Gupta A. Outcomes of phacoemulsification in patients with dry eye. J Cataract Refract Surg 2002; 28:1386–1389.
Cho YK, Kim MS. Dry eye after cataract surgery and associated intraoperative risk factors. Korean J Ophthalmol 2009; 23:65–73.
Sahu PK, Das GK, Malik A, Biakthangi L. Dry eye following phacoemulsification surgery and its relation to associated intraoperative risk factors. Middle East Afr J Ophthalmol 2015; 22:472–477.
] [Full text]
Drouault-Holowacz S, Bieuvelet S, Burckel A, Rigal D, Dubray C, Lichon JL et al.
Antioxidants intake and dry eye syndrome: a crossover, placebo-controlled, randomized trial. Eur J Ophthalmol 2009; 19:337–342.
Huang J-Y, Yeh P-T, Hou Y-C. A randomized, double-blind, placebo-controlled study of oral antioxidant supplement therapy in patients with dry eye syndrome. Clin Ophthalmol 2016; 10:813–820.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]