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This chapter outlines preoperative, intraoperative, and postoperative considerations with respect to dry eye (DE) and its impact on cataract surgery, to guide optimization of patient satisfaction with their refractive outcomes. A systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, PubMed, and Scopus, from the date of inception (1946) until 3rd June 2023, were searched. Dry eye and ametropia are among the most common causes of dissatisfaction after cataract surgery and also the most amenable to successful conservative management. Dry eye can reduce contrast sensitivity and increase dysphotopsias in multifocal intraocular lens patients. Several pathophysiological changes occur during and after surgery that influence DE manifestation postoperatively. Dry eye symptoms and signs generally normalize at around 3 months in both normal and DE patients, but a significant minority have ongoing discomfort. A number of systemic and ocular conditions are identified, which may aid in preoperative risk evaluation. Preoperative symptom evaluation, examination, and investigation techniques are also summarized and their influence on refractive outcomes emphasized. Current preoperative, intraoperative, and postoperative measures to decrease burden are additionally evaluated.
Discipline of Ophthalmology, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, Australia
King Fai Calvin Leung
Discipline of Ophthalmology, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, Australia
Jessica Xiong
Discipline of Ophthalmology, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, Australia
Pauline Khoo
Discipline of Ophthalmology, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, Australia
Stephanie Louise Watson
Discipline of Ophthalmology, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, Australia
*Address all correspondence to: kenneth.ooi@sydney.edu.au
1. Introduction
Cataracts and dry eye (DE) are both age-related conditions underpinned by increased oxidative stress with time and commonly presenting to clinicians [1, 2, 3]. Cataract surgery rates are increasing, and postoperative outcomes are improving worldwide [4, 5]. As the world’s population is forecasted to increase life expectancy by 4.4 years by 2040 for both men and women [6], and as we are becoming more adept at defining and diagnosing dry eye [7, 8], DE reporting rates are also expected to increase. Both cataracts and DE are associated with impaired vision [4, 9]. While rapid postoperative visual recovery is possible [4], with good visual outcomes in DE patients [10], surgery may lead to DE development or worsening [11]. This review focuses on pre-, intra-, and postoperative factors that clinicians can consider to optimize refractive outcomes in DE patients.
The pre-corneal tear film is the first refractive plane, and interference leads to unfavorable postoperative refractive results impacting satisfaction [12]. Patients may also have eye fatigue and foreign body sensation. This may lead to preserved artificial tear substitute overuse with resultant epithelial toxicity [13] and vicious DE cycle perpetuation.
Dissatisfaction with multifocal Intraocular lenses (IOLs) in particular can result in explantation [14]. Multifocality requires neuroadaptation to adjust to the change in the quality of the retinal image resultant from induced light energy dispersion [12]. Multifocal IOLs are associated with increased dysphotopsia and decreased contrast sensitivity compared with monofocal IOLs [12, 15, 16], as well as increased intraocular stray light [17]. As DE is associated with decreased contrast sensitivity [18], postoperative patients with DE may encounter compounded loss of contrast sensitivity. This can be especially debilitating in mesopic or scotopic conditions [12]. These patients also have increased dysphotopsia after multifocal IOL implantation [12, 13]. The most identifiable causes of multifocal IOL dissatisfaction are residual refractive error and DE with both as the most frequent concurrent complaints [19, 20].
A systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The following electronic databases were searched: MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, PubMed, and Scopus, from the date of inception (1946) until 3rd December 2020. The keywords and Medical Subject Headings (MeSH) used were cataract extraction, cataract, phacoemulsification, dry eye, dry eye syndrome, and keratoconjunctivitis sicca.
Duplicates were identified and removed with EndNote (version X9.3.3, Thomson Reuter, New York, USA). A two-stage process was used to identify eligible articles. First, two review authors (K.O. and P.K.) independently evaluated the titles and abstracts. The second stage involved obtaining full-text articles (for available studies) to assess its eligibility. This was independently assessed by K.O. and P.K. Cited articles identified from the search were also reviewed. Disagreements were resolved by discussion. Studies were included if they were full-text articles published about dry eye from cataract surgery. Reviews and editorials and publications not in English were excluded. Reference lists from the studies identified were also reviewed to identify any potential articles missed on the initial search (Figure 1).
Figure 1.
PRISMA diagram summarizing the study selection process.
Globally, a number of cross-sectional studies have investigated dry eye as a comorbidity of cataracts and cataract surgery as a risk factor for worsened dry eye [21, 22, 23, 24, 25]. Preoperatively, in a prospective, multicenter, observational 136-patient study (68 males; mean age 70.7 ± 7.8 years) scheduled to undergo surgery, DE incidence was 75.1%; 62.9% had tear breakup times (TBUT) of ≤5 seconds; 77% had positive corneal fluorescein staining (CFS), and 18% had Schirmer’s test (ST) with anesthesia (ST-1) ≤ 5 mm. As only 25.9% had a prior DE diagnosis, it was concluded that real-world setting incidence is higher than anticipated [26]. Similarly, in a study of 342 eyes, it was concluded that the 52% incidence of Meibomian gland (MG) dysfunction (MGD) was high in patients presenting for surgery with correlating lower lipid layer thickness (P < .05) and 56% having MG atrophy ≥ Arita grade 1.
One-week postoperatively in 92 patients (31 males; mean age 67.22 ± 8.26 years), DE incidence was 9.8% (95% confidence interval [CI]; 3.6–16.0%), 68.4% (95% CI; 52.9–83.9%) had TBUTs <10 seconds, and 11.9% (95% CI; 3.6–16.0%) had ≤10 mm of ST without anesthesia (ST-2). No correlations were found between postoperative DE and sex (P = .26) or age (P = .17) [11]. In 54 patients (14 males; mean age 68.02 ± 8.67 years) with monofocal IOLs, postoperative TBUT was reported lower at 2 months in dissatisfied (n = 27) patients at 5.4 ± 2.7 seconds as compared to those who were satisfied (n = 27) at 6.9 ± 3.0 seconds (P < .045). Visual Function Index −14, Ocular Surface Disease Index (OSDI), and Shortened Health Anxiety Inventory scores were also worse in the unsatisfied group (P < .002) [27].
At 3 months, postoperative incidence of increased OSDI scores at week one (65.5) became normalized (14.1), comparable to preoperatively (10.5) in a 96-patient cohort (35 males; mean age of 63.1 ± 8.3 years). Week one TBUTs were 8.7 ± 0.48 (P < .001) seconds and improved to 14.3 ± 0.37 seconds at 3 months, comparable to preoperatively at 15.8 ± 0.31 seconds (P = .089). Baseline ST-1 of 24.5 ± 0.59 mm worsened at week one to 15.2 ± 0.64 seconds (P < .001) and trended toward baseline at 3 months but were still reduced at 21.8 ± 0.64 seconds (P < .001) [28]. Kasetsuwan et al. also reported mean OSDI scores (17.34) improvement and Oxford ocular surface staining (Grade 1) at 3 months returning toward baseline (12.57 and Grade 1, respectively) [11]. At 3 months, however, mean ST-1 and TBUT also reduced (9.83 mm, 5.11 seconds, respectively) compared to baseline (14.14 mm, 12.15 seconds, respectively) [11].
At a mean of 2.1 ± 3.4 years (0.5–21 years) postoperatively, corneal epitheliopathy frequencies in controls who had no cataracts (n = 1225) and patients who had cataract extraction in both eyes (n = 172) were 11% and 16.5% (P = .008). There was also a 57% increased prevalence of severe keratoconjunctivitis in pseudophakes compared to controls (P = .02). Among DE symptoms, sensitivity to bright light was different between cases and controls; multivariable-adjusted OR (95% CI) comparing pseudophakes with non-cataract patients was 0.56 (0.34–0.92) (P = .02). There was, however, a difference in mean age in years (SD) between controls and surgery patients at 65.4 (9.1) versus 75.4 (9.0) at P < .001 [29].
In 96 chronic DE patients (30 males; mean age 68.46 ± 8.14 years) at 3 months, it was reported that OSDI also increased postoperatively but returned to preoperative levels at 3 months [30]. Oxford scale CFS worsened but improved and resembled preoperative patterns at 3 months. Similar worsening occurred for TBUT and ST-1, but these also returned to baseline at 3 months (P = .078 and P = .748) and remained not different at 2 years (P = .124 and P = .214) [30].
In 30 patients, TBUT as well as MG expressibility worsened at 1 and 3 months (P < .05) [31]. Han et al. also demonstrated reductions in MG expressibility in their study of 48 patients at 1 and 3 months (P = .016), but no change in optical coherence tomography tear film meniscus height (TMH), depth, and area at 1 and 3 months was recorded (all P values > .05) [32]. One-week keratograph-measured TMH reductions also normalized at 3 months [33]. At 3 months, TBUT normalized to baseline in 19 normal patients after post-op therapy cessation but worsened in 48 with dry eye [34].
In a 34-patient cohort, meibum quality was scored by digital pressure over 8 MGs of the lower lids. Meibum secretion was graded as: 0, clear; 1, cloudy; 2, cloudy with granular debris; and 3, thick like toothpaste. Meibum quality was significantly worse in the DE group than in the no DE group at 1 month (2.9 ± 0.3, 0.5 ± 0.1, respectively) and 2 months postoperatively (3.5 ± 0.5, 0.5 ± 0.1, respectively) (P < .05, respectively) [35]. These results are partially consistent with our own findings at 1 month of a trend toward significance for worsening of meibum quality in MGD patients (Grade 2 versus grade 1, P = .079). We observed our non-MGD patients, however, to worsen from grade 0 (IQR 0-2) at baseline to grade 1 (IQR 0-1.3), P = .024 (Unpublished data).
One month interferometry lipid layer thickness was significantly thinner than at baseline (P = .004) in a 43-patient study. Lipid layer thickness was positively correlated with TBUT (r = .29, P < .001), while OSDI (r = −.38, P < .001), Oxford staining scores (r = −.30, P = .001), and meibum quality (r = −.21, P = .01) were negatively correlated [36]. Significantly increased thinning in cataract surgery patients of greater than 10 years of diabetic duration has also been noted at 1 month postoperatively.
Tear osmolarity at 1 week (n = 37) was shown to increase to 311.8 ± 14.85 mOsm/L as compared to fellow unoperated control eyes, which averaged 301.7 ± 11.84 mOsm/L (P = .013). After 1 month, study group tear osmolarity values decreased to control levels (P > .05) [37]. Gonzales-Mesa et al. have observed patients with preoperative tear osmolarity values of 312 mOsm/L or higher as more likely to have ocular discomfort postoperatively with worsened OSDI compared to those with less than 312 mOsm/L preoperatively (10.37 ± 11.11 versus 16.48 ± 8.08) at 3 months (P = .01) [38].
Tear-film decreases in multiplex assayed IL-1beta, IL-6, MCP-1, TNF-alpha, and IFN-gamma at 1 and 2 months postoperatively are reported as compared to day 1 elevations (P < .05, respectively). Corneal staining score was positively correlated, while TBUT was inversely correlated with IL-8, IL-6, IL-1beta, IFN-gamma, TNF-alpha, and MCP-1 concentrations at 1 month. One-month ST-1 scores inversely correlated with IL-6. The authors ascribed cytokines reductions to steroids and antibiotics usage [35]. Decreases in electrolytes, proteins, and mucins, represented as a significant decrease in tear ferning, have also been documented postoperatively [39].
5.2 Eyelid
At 1 and 3 months, Han et al. noted increased lid margin hyperemia (P < .001 and P < .001, respectively) as well as increased MG orifice plugging (P = .007 and P < .001, respectively). No exact mechanism is proposed, but ocular surface inflammation itself related to surgery and reduced blink rates from decreased corneal sensation, topical medications, or lid speculum usage lid dysfunction could contribute [32]. In 57 MGD patients, increased lid margin hyperemia and edge swelling was also sustained at 1 month (P < .05). Reduced MG expression correlated until Day 14 (P < .05) but returned to baseline at 1 month [40].
In our 20-patient cohort at 1 month, infrared meibography revealed no overall MG dropout change as quantified by meiboscore for both MGD (n = 10) and non-MGD (n = 10) patients compared to baseline (Unpublished data), which is consistent with the findings of Han et al. [32]. Park et al. also described no significant change in meiboscore, but MG changes were seen postoperatively, including gland dropout, shortening, distortion, and proximal dilation [35]. On meibography, upper lid MG loss is reported to be significantly higher at 1 and 3 months compared to preoperatively with a correlation between upper lid MG loss and OSDI score at 1 month (R = 0.37; P = .05) [31].
5.3 Conjunctiva
Reduced goblet cell density (GCD) is reported by impression cytology in a prospective study (n = 50) who underwent phacoemulsification. Density was graded into 0+, 1+, 2+, and 3+ (Nelson’s classification of squamous metaplasia) and was reduced at 6 weeks (1.14 ± 0.88) compared to preoperatively (1.60 ± 0.93, P < .001) [13]. In 48 eyes, mean GCD calculated as the number of cells per square millimeter was reduced at day 1, 4 weeks, and 12 weeks (p < 0.001). Impression cytology demonstrated greater cell loss and conjunctival epithelium squamous metaplasia at day 1 compared to 1 and 3 months. Additionally, GCD decrease and surgery duration were correlated (r2 = .65) [41]. A similar study reported metaplasia as more evident in the lower lid-covered area at 3 months, suggesting drops induction [42].
5.4 Cornea
Punctate keratopathy is reported to be predominantly in central cornea at day 1 in 40% and at day 7 in 32.7% in a study of 55 eyes with no prior DE. At 1 month, those still with keratopathy showed inferior quadrant predominance (21.8%) thought to be due to topical treatment persistence and lack of upper lid protection in this area [43].
Corneal sensitivity esthesiometer threshold in millimeters is significantly lower in both DE and no DE control groups at day 1 with 2.85 mm keratome incisions (55.1 ± 1.8, 51.2 ± 0.9, respectively) than preoperatively (58.4 ± 1.7, 55.9 ± 1.4, respectively). Sensitivity was more slowly recovered in the DE group than controls at 1 month (57.8 ± 1.5, 54.1 ± 1.2, respectively) and 2 months (58.1 ± 1.7, 56.1 ± 1.3, respectively) (P < .05, respectively) [35]. In a cohort with 2.8 mm incisions, center and temporal incision site sensitivity decreased at day 1 (P = .021, P < .001, respectively) but returned to preoperative levels at 1 month [41]. In 18 patients with 4.1 mm incisions, sensitivity did not return to baseline until 3 months [44]. More recently with confocal microscopy, a significant decrease in corneal vortical maximum length and average density (P < .05) has been observed, which lasted approximately 3 months.
In femtosecond laser-assisted cataract surgery (FLACS) with sustained vacuum eye coupling to the laser delivery system, worsened OSDI and Subjective Symptom Questionnaires were documented at day 1 and weeks 1, 4, and 12 (all P < .001) in 38 patients without DE previously. At 3 months, coincidental CFS score increases did not return to baseline (P < .044) despite ST-1 and TBUTs recovering to preoperative levels (P = .062 and P = .306, respectively) [45]. In a study comparing patients with no DE undergoing FLACS (n = 150 eyes) and conventional phacoemulsification (n = 150 eyes), OSDI and CFS scores in the FLACS group at day 1 and week 1 increased more significantly than in the conventional group. Scores did return to preoperative levels along with TBUT and ST-I values at 3 months (all P > .05) [46]. These findings are similar to and expand on those in an earlier study where there was comparatively significantly increased CFS at 1 month in the FLACS arm [47]. Another similar study, however, reported no significant changes to dry eye indices after FLACS and conventional phacoemulsification surgery [48].
Increased DE is noted after sutureless large incision manual cataract extraction [49], but no differences in DE have been noted between manual small-incision and conventional phacoemulsification [50, 51, 52]. No significant differences in DE have been noted between small-incision temporal corneal and superior corneoscleral tunnel approaches either [53].
Few studies have investigated the local ocular surface and systemic conditions that cause DE and their impact post-surgery. With systemic disease, in a prospective, interventional case series comparing 174 diabetics without DE age-matched against 474 non-diabetics, diabetics had worse DE symptoms and TBUT after surgery. Incidence of DE was 17.1% in diabetics and 8.1% in non-diabetics at 7 days. In diabetics, DE incidence remained at 4.8% at 1 month but decreased to zero at 3 months. No DE was diagnosed in non-diabetics at 1 or 3 months [54]. In a small retrospective case series review of 15 patients, Sjogren’s syndrome patients had poorer visual outcomes and increased complications postoperatively such as endophthalmitis and peripheral keratolysis as compared to dry eye patients without connective tissue disease [55].
A number of systemic factors are associated with persistent DE-like symptoms and DE Questionnaire-5 scores of ≥6 at 6 months, otherwise defined as persistent postsurgical pain (PSP) (Table 1) [56, 57]. In 119 patients (53 males; mean age 73 ± 6 years) PSP has been reported in 34% at 6 months. Frequency of severe PSP (DE Questionnaire-5 score ≥ 12) was 18% [56]. In a similar study, DE-like symptoms were reported in 32% (n = 27) of individuals 6 months postoperatively with 10% (n = 8) having a DE Questionnaire-5 score ≥ 12 [57]. These patients had increased artificial tears usage (P < .0001), ocular pain (P < .0001), and neuropathic symptoms, including burning (P < .001), wind sensitivity (P = .001), and light sensitivity (P < .0001) [56]. These patients may be not be ideal multifocal IOL candidates.
Systemic association
OR
95% CI
P value
Antidepressants
3.17
1.31–7.68
.01[56]
Antihistamines
6.22
2.17–17.8
.0003[56]
Anti-insomnia medications
5.28
0.98–28.5
.047[56]
Anti-reflux medications
2.42
1.04–5.66
.04[56]
Anxiolytics
3.38
1.11–10.3
.03[56]
Autoimmune disorders
13.2
1.53–114
.007[56]
Female sex
2.68
1.20–6.00
.01[56]
Non-ocular chronic pain disorder (headache, migraine, low back pain, and fibromyalgia)
4.29 4.4
1.01–18.1 1.58–12.1
.06[56] .005[57]
Table 1.
Systemic associations with persistent postoperative dry eye symptoms.
One study by Min et al. examined the relationship between dry eye symptoms after cataract surgery and psychiatric status. They found higher OSDI scores at 3 months in the higher rather than lower depression and anxiety score groups. It was concluded that evaluation of patients’ psychiatric status may help predict the severity of DE symptoms after cataract surgery and prepare for any post-operative DE management [58].
Regarding local conditions, 20 conjunctivochalasis patients were studied by our group. We recorded TMH as well as conjunctivochalasis fold height preoperatively using the Oculus Keratograph 5 M linear rule function and Meller and Tseng grading and observed unilateral clear corneal incision effects. At 1 month, there were increases in middle conjunctivochalasis fold height and absolute fold height to TMH ratio (0.35 ± 0.36 mm and 0.6 ± 0.7,) compared to baseline (0.2 ± 0.1 mm and 1.0 ± 0.9, P = .029 and .041, respectively). There was no significant difference in total and location-specific grade (both P > .05). Additionally, no statistically significant differences were noted in TBUT, osmolarity, Oxford staining, and ST-1 scores (Unpublished data). Sub-Tenon’s blocks are associated with chemosis and subconjunctival hemorrhage [59]. We postulate that changes may relate to surgical influence, eyelid speculum, or local anesthesia but without significant DE impact at 4 weeks. Mimura et al. evaluated total change in severity after superior sclerocorneal incisions in 36 patients. Total grade increased significantly from 4.0 ± 1.9 at baseline to 4.8 ± 2.1 at 1 week (P = .0048) and decreased at 4 (4.3 ± 2.0) and 12 weeks (4.0 ± 1.9) [60].
6.2 Clinical diagnosis
A comprehensive algorithm that aids in preoperative DE diagnosis has been published [61]. More recently, the Ocular Surface Fraility Index, which incorporates 10 DE risk/contributing factors, has been published as a tool to predict the likelihood of DE symptoms at 1 and 3 months postoperatively [62]. Signs and symptoms of DE are, however, known to poorly correlate, and preoperative patients can often be asymptomatic even with advanced ocular surface disease (OSD) signs [61, 63]. It is also recognized that many, especially more elderly with significant cataracts, either do not have DE symptoms or feel the need to report them [61]. Nevertheless, symptom assessment is an integral part of preoperative work-up and is complementary to a focused examination as per the ASCRS Cornea Clinical Committee [63].
6.3 Investigations
Cataract surgery investigations aid prognostication of DE impact on outcomes. Biometry is influenced by DE such that it may be considered a DE investigation. Anterior corneal curvature is a major component of all IOL power calculation formulas [64]. An abnormal keratometry (K) reading can affect the accuracy of calculations and result in submaximal refractive results. Keratometry is sensitive to poor tear films as standard keratometers rely on good corneal reflection of mires [65]. Corneal power error differences of 1.0 diopter (D) result in approximately a 1.0 D error in postoperative refraction [66]. In 50 hyperosmolar subjects, higher average K reading variability (P = .05) and percentage of eyes with ≥1.0 D difference in corneal astigmatism (P = .02) was found as compared to 25 normals. Additionally, a higher percentage of eyes in the hyperosmolar group had IOL power differences of >0.5 D (P = .02). These findings signify that repeatable and reliable keratometry is necessary, especially with toric IOLs [64]. Lubricant viscosity can also adversely affect readings; thus, measurements should be made after 5 minutes [67]. Prior tear film stabilization is therefore crucial.
A systematic review of four studies has been conducted by Biela et al. that evaluated the effect of dry eye disease on biometric measurements before cataract surgery and postoperative refractive errors. The results unanimously indicated that refractive errors can be reduced by pre-treatment with substances such as topical Dexamethasone, Cyclosporin A, Loteprednol, and Lifitegrast [68]. A more recent study has been a single center, prospective, open-label study of 35 dry eyes prior to surgery, which has investigated baseline biometry and again after Rebamipide 2% suspension qid for 28 days. Improvement in anterior corneal tear film optical quality was demonstrated by significantly improved TBUT, superficial punctate keratopathy, and corneal higher order aberrations, which in turn increased accuracy of preoperative anterior corneal power measurements with significantly improved spherical equivalent refractive error prediction [69].
Corneal topography is able to confirm magnitude and axis of corneal astigmatism and is advocated prior to multifocal IOL insertion [65, 70]. Central corneal thickness measurements in one study comparing 34 DE patients and 28 healthy subjects have been shown to fluctuate in DE (repeated-measures analysis of variance, P < .001). Artificial tears improved measurement repeatability after 5 minutes [71]. In 33 female DE patients, central and mean mid-peripheral corneal thicknesses measured higher after artificial tears for 1 month (P = .001, P = .02) [72]. Not only are these responses to artificial tears useful in evaluating DE treatment but also examining the smoothness and spacing of reflected topography images for poor image quality can identify significant OSD [65, 72]. VERION™ keratometry allowing for intraoperative astigmatism axis digital marking is also affected with DE patients exhibiting more residual astigmatism if not lubricated 30 minutes prior [73].
6.4 Management
A number of recent studies have reported positive preoperative DE management results in optimization of postsurgical ocular surface health and refractive outcomes (Table 2), and it is advocated that OSD be treated aggressively preoperatively [65]. It is also suggested that surgery be delayed until OSD is managed to reduce postoperative complications, which are increased in DE disease [82]. Those with severe and/or progressive OSD are not good multifocal IOL candidates, but their use in selected, appropriately counseled, patients on a “case-by-case” basis has been ratified [65]. These patients, especially, would benefit from preoperative management. A comprehensive algorithm for management is published by Starr et al. [61].
Moist air 40°C, warmer mask 20 minutes, massage, Oc Tobramycin 0.3%/Dexamethasone 0.1% ointment bd pre-op + conventional post-op G Tobramycin 0.3/Dexamethasone 0.1% and 0.1% Sodium hyaluronate versus Conventional post-op therapy
At 1 month, pre-op therapy arm presented higher noninvasive TBUTs, lower ocular symptoms scores, less lid margin abnormalities, and increased meibum quality and expressibility (All P < .001).
Hydroxypropyl guar (HPG) and hyaluronic acid (HA) tds 1 week pre-op and 2 months post-op + conventional post-op G Nepafenac, Dexamethasone and Tobramycin
HPG and HA 2 months post-op + conventional post-op therapy
Conventional post-op therapy
In groups 1 and 2, SPEED scores were significantly lower than in group 3 in the whole 8-week post-op period. In group 1, SPEED scores were lower than in group 2, at 1 and 4 weeks after surgery (P < .001 and P = .021, respectively). TBUT in groups 1 and 2 was higher than in group 3 in the whole post-op period (P < .001). In group 1, TBUT was higher than in group 2, at 4 week (P = .016).
Liposomal nanodispersion solution of omega 3, vitamins D and A tds (VisuoEvo, VISUfarma, Netherlands) 2 weeks pre-op to 2 weeks post-op + conventional post-op therapy of G Dexamethasone and Ofloxacin versus Conventional post-op therapy
At 1- and 2-weeks, pre-op therapy arm TBUT was higher than baseline (P < .01). At 1- and 2-weeks, pre-op therapy arm OSDI was lower than baseline (P < .027). Post-op CFS showed a much higher proportion of patients with optimal ocular surface protection in the VisuEvo group. The two groups did not show any significant differences in osmometry and ST-1.
Cyclosporine 0.05% bd 1 month pre-op to 2 months post-op in 1 eye + conventional post-op therapy of Gatifloxacin, Ketorolac, and Prednisolone qid versus Artificial tear containing polyethylene glycol (Systane Free) in the other eye + conventional therapy
At 2 months post-op, the cyclosporine group had lower mean uncorrected and corrected distance visual acuity and CFS than the artificial tear group (P = .045, P = .005 and P = .034) Treatment with cyclosporine Significantly more patients preferred the eye treated with cyclosporine 0.05% to the eye treated with artificial tears (57.1% versus 14.3%; P = .007).
Retrospective, compartive, observational case series
Diquafosol 3% 6 times a day 1 week pre-op and 3 months post-op + conventional therapy of Gatifloxacin qid and Pred Forte qid for 4 weeks
Conventional post-op therapy
In group I, TBUT, OSDI and OSS showed improvement at one- and three-months post-op (P = .002 for BUT at 1 and 3 months, P = .023 and P = .049 for OSDI at 1 month and 3 months and P = .001 and P = .026 for OSS at 1 and 3 months) but not group 2. In both groups, ST-I decreased at 3 months post-op (P = .011, group I and P = .034, group 2), compared to baseline. No differences between the groups for corneal aberration.
M22 Optimal Pulsed Technology pre-op and at 1- and 2-months post-op + conventional post-op drops therapy of Levofloxacin and cortisone
Significant improvements in TBUT, CFS, TMH and MGYSS at 3 months post-op compared to baseline (All P < .05)
Table 2.
Clinical trials in the treatment of dry eye pre-cataract surgery.
Preoperative MGD management is reported in a prospective, randomized clinical trial of 120 moderate obstructive MGD patients. Sixty were assigned routine postoperative anti-inflammatory tobramycin 0.3/dexamethasone 0.1% drops. Thirty received preoperative warm moist compress (moist air and warmer mask, 40°C, 20 minutes) and massage (down or upward mild eyelid compression with finger, 10 minutes) as well as lid margin tobramycin 0.3%/dexamethasone 0.1% ointment bd and routine postoperative anti-inflammatory drops. The last 30 received enhanced postoperative anti-inflammatory treatment consisting of tobramycin 0.3%/dexamethasone 0.1% eye drops 6 times daily in the first week and qid in the second with frequency decreased by half every week the following 2 weeks. All received 0.1% sodium hyaluronate qid for 1 month. At 1 month, MGD showed aggravated status in Cohorts I and III but resolved by 3 months. At 1 month, Cohorts II and III presented higher noninvasive TBUTs, lower ocular symptoms scores, less lid margin abnormalities, and increased meibum quality and expressibility (Cohort II vs. I: all P < .001, respectively; Cohort III vs. I: P = .011, P = .024, P = .046, P = .045, and P = .012, respectively). Additionally, Cohort II had better lid margins and meibum quality and expressibility than Cohort III at 1 month (P = .031, P = .026, and P < .001, respectively). At 3 months, Cohort II presented higher noninvasive TBUTs than Cohorts I and III (P < .001 and P = .001, respectively) [74].
Cataract surgery outcomes in graft-versus-host disease (GVHD) have been studied with respect to DE as it is the most common ocular occurrence of this condition [83]. Along with DE, cataracts are a common cause of visual loss in GVHD [84]. Four studies, cumulatively examining 128 eyes of GVHD cataract surgery patients, demonstrated that maximal preoperative DE and other ocular surface therapy can gain significant mean visual acuity improvements. Local therapies included preservative free lubricants, 10% acetylcysteine and autologous serum eye drops, topical corticosteroids, cyclosporine-A and 0.1% tacrolimus in ointment form, bandage contact lens with topical antibiotics, scleral lenses, punctal occlusion, and moisture chamber goggles. Systemic therapies included omega-3-dietary supplements, steroids, cyclosporine-A, mycophenolate, and oral pilocarpine and cessation of systemic medications that could reduce tear production [85, 86, 87, 88]. One study measured DE disease severity and OSDI pre- and post-surgery and observed a nonsignificant trend toward worsening [86]. Within 2 weeks, Balaram et al. noted worsening of OSD in 2 patients with one proceeding to corneal thinning. Both cases neglected restarting topical lubricants [85]. At 4 weeks, recurrence of ocular surface inflammation occurred in 7 eyes with cessation of topical and systemic immunosuppressive therapy in one study [85], while in another, 1 sterile corneal ulcer and 1 infected ulcer with perforations were reported in 2 severely DE patients along with band keratopathy [86]. Late corneal melts occurred in 2 patients some months later [88]. Penn and Soong reported no ocular surface complications [87].
Stevens-Johnson syndrome (SJS) patients undergoing cataract surgery are also reported to achieve good visual good outcomes following aggressive ocular surface stabilization preoperatively. Local therapeutic modalities are similar to those in GVHD but also include amniotic membrane grafting, symblepharon release, lash epilation/electrolysis, lid margin mucous membrane grafting, tarsorrhaphy, entropion correction, MGD management, and dacryocystectomy [89, 90]. Oral therapies include corticosteroids and methotrexate [90]. In 40 chronic SJS sequelae eyes, median preoperative LogMAR best-corrected visual acuity (BCVA) was 1.61 (IQR, 0.80 to 2.78). Median BCVA increased to 0.60 (IQR, 0.30 to 1.48, P < .0001). The ocular surface remained stable in 35 eyes (87.5%), but breakdown occurred in four (10%). Another study of 3 SJS eyes also reported BCVA gain and maintenance of ocular surface integrity [89].
Topical anesthesia can generate shorter admissions and lower cost phacoemulsification [91]. Tetracaine 0.5% absorption and duration is slow and short acting, necessitating repeated administration with corneal epithelial damage toxicity risk including punctate keratopathy and persistent epithelial defects. Lidocaine gel 2% is shown to allow significantly less administration while being more effective in relieving pain compared to tetracaine 0.5% due to greater concentration and longer epithelial contact time [92].
Eyelid speculums may cause MGD through lid dysfunction and inadequate meibum release [35]. A significant reduction in both levator function and marginal reflex distance 1 at 1, 30, and 90 days, which normalizes at 180 days, is reported [93]. Aspirating speculums also increase conjunctival staining at day 1 (P = .001), conjunctivochalasis grades at day 1 and 7 (P < .001), and OSDI at day 7 (P = .011) and reduce TBUT at days 1 and 7 (P < .001), perhaps through conjunctival aspiration through the suction holes. In comparison, non-aspirating speculums showed only TBUT and conjunctivochalasis grades significance at day 1 (P < 0.001). All parameters returned to baseline in both groups at 1 month [94].
Povidone-iodine antiseptic preparations cause DE. Epithelial cell cytotoxicity is linked to low iodine pH, osmolarity, and presence of lauromacrogol, which is a surfactant. Repeated ocular surface irrigation may also impact GCD and tear-film stability [95]. Ophthalmic viscosurgical devices (OVDs) may reduce cataract surgery trauma caused by ocular surface inflammatory mediator release [96, 97]. Intraoperative use of hydroxypropyl methocellulose (HPMC) 2% has been shown to significantly reduce balanced saline solution (BSS) application frequency intraoperatively in a HPMC group of 30 eyes compared to 30 eyes irrigated only with BSS (p = 0.001). Incidence of DE was significantly reduced in the HPMC group in both senile and diabetic patients. Subjective symptom scores were higher in the BSS group at day 1 (P = .003) and day 3 (P = .043). Noninvasive TBUTs were higher in the HPMC group at days 1 and 3 (P = .012 and P = .024, respectively). Values for TBUT did not significantly change postoperatively in the HPMC group, while they were significantly lower in the BSS group [98]. A similar study of 149 male eyes randomly assigned to receive HPMC 2% or BSS demonstrated that week 1 ST-1 values in the HPMC group were higher than those in the BSS group (P = .019). Patients with DE before surgery had 1-month post-op ST-1 values in the HPMC group higher than in the BSS group (P = .037). Additionally, in preoperative DE patients with surgical times longer than median, patients’ CFS in the HPMC group was superior to that of the BSS group (P = .032) [96]. A polysaccharide gel of hydroxypropyl methylcellulose, xanthan gum, and carrageenan (eyeDRO; Alchimia, Italy) on the cornea in 28 eyes achieved return of TBUTs to preoperative levels by day 5 as compared to day 30 in the BSS group of 26 patients. Concordantly, OSDI returned to preoperative values after 15 days in the gel group and 30 days in the BSS group [99]. Reductions in TBUT, corneal ocular staining score, and OSDI are also reported with DisCoVisc (Alcon Laboratories, Fort Worth, TX, USA) in 13 patients (All P < .01) as compared to a BSS group 1 week postoperatively [100].
Corneal incisions reduce corneal sensitivity, which gradually recovers [35, 41, 44]. On corneal wounding, nerves are excited and local inflammation is produced through neuropeptide release. They also become sensitized by local inflammatory mediators and demonstrate spontaneous activity and enhanced responses to new stimuli generating spontaneous pain and hyperalgesia. Injured nerves also regenerate and form microneuromas that exhibit abnormal responsiveness and spontaneous discharges, which may also lead to spontaneous pain, DE sensations, and other dysesthesias [101]. Corneal innervation or lacrimal functional unit feedback disruption can lower tear production and blink rate with resultant tear film instability [11, 102]. Sufficient regeneration, however, results in DE transience postoperatively [13, 103]. Today’s microincisions are assumed to generate less reduction in corneal sensitivity [35, 101].
Given that the large long ciliary nerves enter the limbus predominantly at 9 and 3 o’clock and corneal sensation is significantly greater at the temporal and nasal limbus, Cho et al. examined corneal incision location and impact on DE indices [104, 105]. No significant differences were found between superiorly versus temporally placed incisions with respect to TBUT, DE symptoms, ST-1, and TMH in both DE and non-DE groups [104].
Surgery duration affects the ocular surface commencing from operating microscope usage. Correlation of DE signs and symptoms have been shown to inversely correlate with microscope light exposure duration up until week 6 in a prospective study of 50 eyes with no DE signs or symptoms. These include means of OSDI (P < .015), ST-1 (P < .003), TBUT (P < .011), and CFS grades (P < .003) [13]. In another prospective study of 28 eyes with preoperative DE and 70 without preoperative DE, significant correlations were detected in the DE group between light exposure time and TBUT and DE symptoms at day 1 but not from day 3 onward. In the non-DE group, significant correlations were noted between light exposure time and DE symptoms at 1, 3, and 10 days and 2 months and in TBUT at 2 months [104]. A prospective observational study of 100 eyes also observed correlations of DE test values with light exposure time, but they were not significant [106].
Prolonged operating can increase cumulative dispersed energy with correlations found between DE test values and phacoemulsification energy used. In Kohli et al.’s study, a correlation was found between increased effective phacoemulsification time, which was used as a measure of phacoemulsification energy and reductions in OSDI (P < .020), Schirmer’s I values (P < .002), TBUT (P < .001), and CFS grades (P < .001) up until 6 weeks [13]. Sahu et al. recorded cumulative dissipated energy, and although this was negatively correlated with ST-1, TBUT, and TMH, this was not statistically significant [106]. No correlations are also reported between energy and TBUT, DE symptoms, ST-1, and TMH in both DE and non-DE cohorts [104].
Eyedrops containing active agents/preservatives can adversely affect epithelium [95]. Intraoperative anterior chamber intracameral dexamethasone drug-delivery suspension (Dexycu; Icon Bioscience Inc., Newark, CA) was evaluated in a prospective, randomized 2:1, open-label, multicenter Phase III that may minimize postoperative drops use. Dexycu 517 μg 5 μL was administered to 126 patients through cannula insertion into the ciliary sulcus after IOL placement, and 55 patients received prednisolone 0.1% drops (1 drop 4 times daily for 3 weeks). At day 8, 51.6% of Dexycu eyes and 50.9% of prednisolone eyes had anterior chamber cell clearing; more than 98% had clearing at 90 days. There was no significant difference in endothelial cell density between groups. Steroid-related intraocular pressure rise was the most common adverse event (11.1%), then iritis (6.3%). In those receiving Dexycu, 68.7% strongly agreed that no eyedrop usage was very convenient, while 39.2% of those using prednisolone strongly agreed that they would prefer dropless therapy [107]. A similar Phase III study comparing 5 μl injections of 342 or 517 μg Dexycu showed comparable efficacy between both groups, with significantly increased anterior chamber cell and flare clearing compared to placebo [108].
A bandage contact lens (PureVision; Bausch & Lomb Inc., Rochester, NY) at surgery completion in 30 patients with mild MGD was shown on 1 week removal to improve OSDI, subjective evaluation scores, TBUT and CFS compared to 30 MGD controls without contact lens, especially on days 7 and 14 (P < .001, P < .001; P = .031, P = .009; P = .021, P = .028; and P = .03, P = .032, respectively). At days 30 and 90, there were no significant differences between groups and in BCVA or Schirmer values [109].
A number of DE treatments have been trialed with varying measures of success (Table 3). There appears to be scope for further trials with the newer anti-inflammatories appearing on the market potentially in severe DE cataract patients. More cost-effective combination therapies could also be trialed across the spectrum.
At day 14, absence of anterior chamber cells in insert arm greater than placebo (52.3% versus 31%; P < .0001). At day 8, absence of ocular pain in insert arm greater than placebo (79.6% versus 61.3%; P < .0001). Insert arm showed no increase compared with placebo in incidence of all adverse events or ocular adverse events.
Intracanalicular 0.4 mg Dexamethasone suspended in a dried polyethylene glycol hydrogel insert. The hydrogel is conjugated with fluorescein to assist visualization versus Placebo
At day 8 20.7% of patients in insert arm with absence of anterior chamber cells compared with 10.0% in placebo group (P ≤ .1495). At day 8, absence of ocular pain in insert arm greater than placebo (79.3% versus 30.0%; p < .0001) and at all other timepoint versts through 30 days post-op (P < .0002). At several timepoints through 30 days, absence of anterior chamber cells, anterior chamber flare, and pain was greater in insert arm than placebo (P ≤ .0251).
Fluorometholone 0.1% PF qid, Sodium hyaluronate PF 0.1% qid + Gatifloxacin 0.3% qid for 4 weeks then all tds for 4 weeks versus Preserved Fluorometholone 0.1% (Ocumetholone), Preserved Sodium hyaluronate 0.1% (Lacure) + Gatifloxacin 0.3% on same schedule
At 2 months, OSDI, TBUT, ST-I, CFS, impression cytology, and GCD were better in Group 1 than in Group 2 (All P < .05). At 2 months, interleukin-1b and tumor necrosis factor-a concentrations were less in the tears of Group 1 than in the tears of Group 2, and catalase and superoxide dismutase 2 fluorescence intensities were greater in the tears of Group 1 than in the tears of Group 2 (All P < .05).
Cyclosporine 0.05% bd 1 week post-op (Restasis; Allergan Inc., Irvine, CA) for 3 months versus Normal saline 0.9% bd 1 week post-op for 3 months
At 3 months, greater improvement in ST-I in Cyclosporine arm compared with control (P = .02). At 1 month, improvement in TBUT with Cyclosporine and increases seen at 2 and 3 months (P = .04, P < .01, respectively). No significant increases seen in control group at any timepoint. At 3 months, Cyclosporine arm showed improvement for each OSDI score (P < .01, P = .01, P = .02, respectively).
Cyclosporine 0.1% bd + CMC 0.5% tds 1-week post-op for 8 weeks versus CMC 0.5% tds 1-week post-op for 8 weeks
Treatment in both groups cyclosporine 0.1% + artificial tears 0.5% and artificial tears 0.5% led to improvement in OSDI at 4 and 8 weeks (P < .0001) Difference between the mean values of the two groups was significant both at 4 (P < .0001) and 8 weeks (P < .0001)
Diquafosol 3% qid 1-week post-op for 8 weeks versus Normal saline 0.9% qid 1-week post-op for 8 weeks
At 8 weeks, TBUT, and CFS improved in Diquafosol arm (P < .01, P < .01) and were better than normal saline (P < .01, P < .01). ST-1 did not improve (P = .26). All symptom questionnaire scores improved in eyes treated with 3.0% Diquafosol (All P < .01).
Diquafosol 3% (Diquas; Santen Pharmaceutical Co, Ltd., Osaka, Japan) qid for 12 weeks versus Sodium hyaluronate (SH) 0.1% (Kynex, Alcon) qid for 12 weeks.
Conjunctival squamous metaplasia grade was lower at 12 weeks, and GCD was higher at 4 and 12 weeks in the Cyclosporine group than in the hyaluronate group (P < .05). Cyclosporine group showed lower OSDI scores at 4 and 12 weeks; longer TBUT at 1, 4, and 12 weeks; lower keratoepitheliopathy scores at 1 and 12 weeks; and lower spherical aberrations at 4 weeks after surgery (P < .05).
Diquafosol 3% 6 times a day 4 weeks post-op for 4 weeks versus Artificial tears 6 times a day 4 weeks post-op for 4 weeks
TBUT was prolonged in the DQS group (P = 0.015), but not in the AT group. Fluorescein staining score was significantly improved in both groups (P,0.001).
Diquafosol 3% 6 times a day (Diquas®; Santen Pharmaceutical Co, Ltd., Osaka, Japan) for 12 weeks post-op versus Sodium hyaluronate 0.1% 6 times a day for 12 weeks post-op
Diquafosol showed superior TBUT (P < .001), CFS (P < .045), and conjunctival staining (P < .001) compared to Sodium hyaluronate throughout the study period. TBUT (P < .001) and change in HOAs (P < .018) recovered more quickly in the Diquafosol group.
Sodium hyaluronate 0.15% PF 6 times a day (All groups for 12 weeks) (*Diquas-S; ^Diquas; Santen Pharmaceutical Co, Ltd., Osaka, Japan)
Group 1 improved TBUT, OSDI, CFS scores, lid margin abnormality, and meibum quality over time. Groups 1 and 2 had superior TBUT, MGD grade, and MGE throughout the study than Group 3 (All P < .001). Group 1 Meibum quality was better than Group 2 at 3 months (P < .001).
Diquafosol 3% 6 times a day 1-week post-op to 3 months post-op versus Cyclosporine A 0.05% bd 1-week post-op to 3 months post-op
Diquafosol showed higher TBUT outcomes than Cyclosporine A at 1 (P < 0.001) at 3 months (P = .001). Cyclosporine A showed more decreased vertical coma and total HOAs than Diquafosol at 3 months (Both P < .01).
Diquafosol 3% 6 times a day (Diquas®; Santen Pharmaceutical Co, Ltd., Osaka, Japan) 4 weeks post-op for 4 weeks versus Artificial tears 6 times a day (Mytear®; Senju Pharmaceutical Co., Ltd., Osaka, Japan) 4 weeks post-op for 4 weeks
Diquafosol increase in TBUT was greater than artificial tears at 8 weeks (P = .014). Diquafosol showed lower HOA fluctuations and changes than artificial tears at 8 weeks (Both, P = .004).
(*Mucosta; Otsuka Pharmaceutical Co, Ltd., Tokyo, Japan)
Group 1 mean (± SD) GCD before surgery was 257.0 ± 188.7 cells/mm2, and it decreased significantly to 86.5 ± 76.7 cells/mm2 at 1 month (P = .002). Groups 2, 3, and 4 showed no significant differences in GCD at 1 month.
Carboxymethylcellulose sodium (CMC) 1% qid (Refresh Liquigel; Allergan, Inc., Irvine, CA) + Conventional therapy of Prednisolone acetate 1% qid and Levofloxacin 0.5% qid versus Conventional therapy
CMC group had increased TBUT compared with control at day 7 (P = .0475) and day 30 (P = .0258). CMC group with a pre-surgical diagnosis of DE had increased TBUT (P < .001 at both day 7 and 30). Control group with no prior diagnosis of DE had decreased TBUT (P < .02 at both day 7 and 30).
Sanchez et al.
48 eyes
Single-center RCT
HP-Guar (Systane UD, Alcon Cusí, Spain) qid post-op for 1 month + conventional therapy of G Tobramycin and G Dexamethasone qid tapering over 4 weeks versus Conventional therapy
At 4 weeks, HP-Guar group showed better TBUT (P < .0004), OSDI (P < .0002), ocular symptoms (P < .0004), vision-related function (P < .0002) and reduced expression of CD3 (P < .011), and HLA-DR (P < .0002) inflammatory markers.
Sodium hyaluronate 0.1% qid and CMC 0.5% qid post-op for 5 weeks + conventional therapy of 4 weeks of tapering Tobramycin 0.3% and dexamethasone acetate 0.1% versus Conventional therapy
At 5 weeks, TBUT was higher in the study group than in controls (P < .0003). At 5 weeks, dry-eye symptoms improved in the study group compared with controls (P < .001). At 5 weeks, CFS was significantly reduced in the study group compared with controls (P < .002 versus P < .05, respectively).
Trehalose group showed a significantly greater TBUT increase compared to hyaluronate group at day 30 (P < .001). Trehalose group showed a significantly greater improvement in OSDI compared to hyaluronate group at day 30 (P < .001).
Sodium hyaluronate 0.1% preservative-free (Tearin free) and Fluorometholone 0.1% eyedrops preservative-free (Humeron) versus Sodium hyaluronate 0.1% with preservatives (Lacure) and Fluorometholone 0.1% eyedrops with preservatives (Ocumetholone) Both groups at qid for the 1st month and then bd for the 2nd month
At 2 months, OSDI, TBUT, ST-1, CFS score, impression cytology findings, and goblet cell count were significantly better in Group 1 than in Group 2 (P < .05). At 2 months, IL-1beta and TNF-alpha concentrations were significantly less in Group 1 patient tears than in Group 2 patient tears, and catalase and superoxide dismutase 2 fluorescence intensities were significantly greater in Group 1 patient tears than in Group 2 (P < .05).
Treatment group of artificial tears (Artelac; Bausch & Lomb, Rochester, NY, USA), topical steroid (betamethasone 1%) drops and eye shampoos (constituents: Rewopol, Rewoteric, HEC, PEG-40 hydrogenated castor oil) containing tea tree oil 4 weeks after surgery versus Control group of artificial tears, topical steroids, and eye shampoos without tea tree oil 4 weeks after surgery
Tear breakup time, osmolarity, and OSDI scores in the treatment group were significantly better than those in the control group (P < .05) at 8 weeks. Demodex decreased only in the treatment group after treatment (P < .001) at 8 weeks. There was no significant difference between the two groups in the pre- and post-ST test results (P > .05) at 8 weeks.
Omega-3 dietary supplement every 8 hours (1000 mg Advanced® Canada, each capsule containing 180 mg EPA and 120 mg DHA) + Conventional therapy of artificial tears qid (Artelac; Dr. Gerhard Mann Chem-pharm Fabrik GmbH, Berlin, Germany) versus Conventional therapy only control
No significant difference between control and treatment groups in mean postoperative time at trial start (1.61 ± 1.60 and 1.57 ± 1.57 years, respectively, P > .930). Omega-3 improvement in OSDI was higher than control at 1 month, (P = .026). Omega-3 increased TBUT more than control at 1 month (P = .038). Mean pre-treatment tear film osmolarity in the treatment group was 315.40 ± 17.06 (range: 279–340), which improved to 296.90 ± 14.39 (range: 260–310) at 1 month (P < .001). Mean tear film osmolarity in the control group improved insignificantly at 1 month.
Re-esterified triglyceride form of Omega-3, 2 tablets bd (total = 1680 mg EPA/506 mg DHA) for 8 weeks (PRN Dry Eye Omega Benefits softgels; PRN Physician Recommended Nutriceuticals, Plymouth Meeting, Pennsylvania, USA) + lubricant qid versus Lubricant qid
OSS was lower in the omega-3 group than in the control group (P < .05). There was an improvement of OSDI and DEQ in the omega-3 group (Both P < .05). The ratio of increasing MMP-9 level in the omega-3 group was lower than that in the control group (P = .027).
Oral lactoferrin 350 gm versus Without oral lactroferrin control
At day 60, TBUT of control group was 7.86 (±0.86) seconds as compared to 13.9(± 0.99) seconds in the lactoferrin group. At day 60, ST-1 values also showed a statistically significant difference between the two groups - 15.86 (± 5.83) seconds in the control group versus 30.9 (± 1.66) in the lactoferrin group.
Table 3.
Clinical trials in the treatment of dry eye post-cataract surgery.
Successful cataract surgery is a rewarding experience, but patients and surgeons may be dissatisfied when DE predominates recovery. Patients can be reassured that ocular surface normalization usually occurs within 3 months, but persistent DE is a risk for a clinically significant minority. This can detract from vision quality and manifest as persistent surgical pain. It may be especially problematic in multifocal IOL patients where premium prices have been paid and no highly expected quality of life improvement has been forthcoming. An understanding of the pre-, intra-, and postoperative factors that influence the refractive results in OSD allows both clinicians and patients to have more reasonable expectations and tailored strategies to achieve desired outcomes. This review of the English literature sets the scene for more holistic care and research of cataract surgery patients with DE as more advances are made available to us in the ever-evolving premium lens and DE landscapes.
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Written By
Kenneth Gek-Jin Ooi, King Fai Calvin Leung, Jessica Xiong, Pauline Khoo and Stephanie Louise Watson
Submitted: 26 July 2023Reviewed: 29 July 2023Published: 24 October 2023
Open access peer-reviewed chapter
