Changes in the tear film and ocular surface after cataract surgery

Effect of Strabismus Surgery on Meibomian Glands, Ocular Surface Parameters, and Conjunctival Impression Cytology

Background/Objectives: To investigate the effect of strabismus surgery on ocular surface parameters, meibomian glands, and conjunctival impression cytology. Methods: Preoperative and postoperative (10th day, first month, and third month) tear break-up time (TBUT) tests, Schirmer 1 tests, corneal staining scores (CSS), meibomian gland (MG) loss rates, ocular surface disease index (OSDI) scores, and conjunctival impression cytology (IC) results of 30 patients who underwent strabismus surgery were compared. Results: Significant differences were found between preoperative TBUT test results and those evaluated on the postoperative 10th day and at the postoperative first month (p < 0.0001 for both). There were also significant differences between the preoperative and postoperative first- and third-month Schirmer 1 test results (p = 0.02 and p < 0.0001, respectively). Furthermore, mean OSDI scores significantly differed between preoperative and postoperative 10th-day measurements (p < 0.0001). The mean postoperative 10th-day CSS was found to be significantly higher than the preoperative mean CSS (p < 0.0001). The stages in preoperative conjunctival IC samples were found to be significantly lower than those evaluated at all postoperative times (p < 0.0001 for all). Significant differences were observed between the preoperative lower eyelid MG loss rate and all postoperative MG loss rates (p < 0.0001 for the 10th day and first month and p < 0.001 for the third month). Lastly, the preoperative upper eyelid MG loss rate significantly differed from all postoperative MG loss rates (p < 0.0001 for the 10th day, p < 0.003 for the first month, and p < 0.0001 for the third month). Conclusions: We observed changes indicative of dry eye in the mean OSDI score, TBUT, Schirmer 1 test, MG loss rates, and conjunctival IC findings up to the postoperative third month in patients who underwent strabismus surgery. Therefore, we believe that patients undergoing strabismus surgery should be followed up for ocular surface diseases, particularly dry eye.

Prophylactic Therapy for Long-Term Ocular Discomfort After Cataract Surgery

PURPOSE

The cataract surgery dissatisfaction rate is 20% to 35% due to ocular surface discomfort. We investigate the ocular surface discomfort after surgical failure as a consequence of age-related parainflammation. We also aim to prevent it by immune-modulating prophylactic management.

METHODS

Monocentric clinical trial realized in a teaching hospital. Prospective, randomized, open-label, unmasked clinical trial. One hundred patients diagnosed with cataracts underwent phacoemulsification surgery. Groups A (<65 years; n = 25) and B (>75 years; n = 25) received surgery only. Groups C and D (both >75 years and both n = 25) used cyclosporine A 0.1% cationic emulsion (CE) eye drops or CE lubricating eye drops (both twice daily), respectively, for 30 days before surgery. Patients were followed up 90 days after surgery. The primary outcome was postoperative ocular surface failure; secondary outcomes examined the influence of prophylactic cyclosporine A 0.1% CE therapy on ocular surface outcomes.

RESULTS

Group B demonstrated greater severity regarding ocular surface signs and symptoms throughout the study period, versus all other groups. Signs/symptoms were typically lower in Group A. Group C achieved significant reductions in conjunctival Symptom Assessment in Dry Eye values ( P < 0.05), conjunctival hyperemia severity ( P < 0.01), and meibomian gland dysfunction ( P < 0.001) at Day 45, versus Group B, and tear break-up time was increased ( P < 0.001). Ocular surface inflammatory marker transcription (HLADR, intercellular adhesion molecule 1 [ICAM-1], and interleukin 6 [IL-6]) was significantly downregulated in Group C, versus Group B, at 90 days ( P < 0.05).

CONCLUSIONS

Cataract surgery induced ocular surface system failure with a clinically significant persistent inflammatory status (InflammAging) in patients older than 75 years. Prophylactic cyclosporine A 0.1% CE eye drops were associated with improved ocular surface homeostasis and reductions in inflammatory markers.

Applications of Diquafosol Sodium in Ophthalmology: A Comprehensive Review of Therapeutic Utility

Diquafosol sodium is a purinergic P2Y2 receptor agonist that is garnering much interest for its potential therapeutic benefits in ocular surface management. This review provides a comprehensive analysis of diquafosol's pharmacology, clinical effectiveness, and role in the evolving landscape of ocular surface management. Future research should focus on optimising formulations, treatment duration, and exploring potential combination therapies to maximise therapeutic outcomes. By targeting underlying pathophysiological mechanisms, diquafosol represents a significant advancement in ocular surface management and a valuable addition to existing therapies.

A Multicenter, Randomized, Clinical Trial Assessing the Effect of rTG-Omega 3 Supplementation on Meibomian Gland Dysfunction Patients after Cataract Surgery rTG-Omega 3 for Meibomian Gland Dysfunction

Background/Aims: To investigate the effectiveness of re-esterified triglyceride form of omega 3 (rTG-omega 3) on patients with meibomian gland dysfunction (MGD) after cataract surgery. Methods: This multicenter, randomized, investigator-blinded, clinical study was conducted between June 2021 and March 2023 and enrolled 107 patients with MGD who had undergone cataract surgery within 3 months at seven sites across South Korea. Patients were randomly assigned to rTG-omega 3 group or a control group. We compared (1) tear film break-up time (TBUT) (s), (2) corneal fluorescein staining score [National Eye Institute/Industry (NEI) scale], (3) conjunctival fluorescein staining score (NEI scale), (4) strip meniscometry (SM) tube score (mm), (5) MGD stage, (6) MG quality, (7) MG expressibility, (8) Standard Patient Evaluation of Eye Dryness (SPEED) score, and (9) Ocular Surface Disease Index (OSDI) scores at baseline and 6 and 12 weeks. Results: TBUT, corneal fluorescein staining score, and SM tube score were significantly improved in the rTG-omega 3 group compared with control group (P = 0.005, P = 0.003, and P = 0.0049, respectively). Subjective questionnaire responses were also improved significantly (SPEED score, P = 0.022; OSDI score, P = 0.0011). MGD parameters were not significantly different. However, during subanalysis, significant improvements in MG quality and expressibility were observed in the MGD stage 4 group with rTG-omega 3 supplementation (P = 0.0177 and P = 0.0205, respectively). Discussion: rTG-omega 3 supplementation facilitated improvements in both objective and subjective parameters. In particular, MG quality and expressibility were significantly improved in the severe MGD group.

Dry eye post-cataract surgery: a systematic review and meta-analysis

SIGNIFICANCE

Cataract surgery is one of the most performed surgical procedures worldwide. As a potential complication following cataract surgery, dry eye has the potential to impact visual outcomes, lower patient satisfaction, and be detrimental to quality of life.

PURPOSE

To evaluate the effect of cataract surgery on dry eye outcomes postoperatively.

METHODS

We searched Ovid MEDLINE and Embase from 01/01/2010 to 16/08/2021 and included observational studies of participants ≥ 18 years old undergoing any cataract surgical procedure. We compared postoperative dry eye outcomes with baseline including Ocular Surface Disease Index (OSDI), tear break up time (TBUT), Schirmer's I test (ST1), and corneal fluorescein staining (CFS) at short-term (< 1 week) and medium-term (≥ 1 week to 3 months) follow-up.

RESULTS

Our search yielded 11,133 records. After title and abstract, and then full text screening, we included 20 studies with 1,694 eyes. There was some evidence indicating a decrease in the TBUT during the short-term (within 1 week) and medium-term (1 week up to 3 months) periods following cataract surgery. There was a considerable degree of heterogeneity between studies across other outcomes. At medium-term follow-up most studies that reported ST1 and CFS showed deterioration of these outcomes but there was conflicting evidence of the effect of cataract surgery on OSDI. The review is limited by variability in follow-up timeframes which were unable capture potential clinical course like peak occurrence and duration.

CONCLUSION

Dry eye may persist up to three months postoperatively following cataract surgery. Further studies are required to determine if dry eye outcomes return to baseline at longer term follow-up.

The Effect of Topical Rebamipide 2% in Managing Dry Eye Following Cataract Surgery

Purpose: To evaluate the potential advantages of using topical rebamipide 2% to manage dry eye following cataract surgery.Methods: Patients who underwent cataract surgery (phacoemulsification and intraocular lens insertion) were evaluated for dry eye 1 week postoperatively. Randomly selected patients were divided into the rebamipide group, who received 2% rebamipide eye drops, and the control group, who did not receive rebamipide. Various dry eye-related tests, including Schirmer’s test, the tear break-up time (TBUT), ocular surface staining, tear film osmolarity, tear lipid layer thickness, and the ocular surface disease index (OSDI) were performed in both groups 1 week, and 1 and 2 months postoperatively.Results: In the rebamipide group, we observed significant improvement in TBUT, the ocular surface staining score, and OSDI at 2 months postoperatively, as compared to 1 week (<i>p</i> = 0.002, 0.014, and 0.013, respectively). Schirmer’s test, tear film osmolarity, and tear lipid layer thickness remained unchanged in the rebamipide group. Throughout the entire follow-up period, the rebamipide group had a significantly prolonged TBUT (1 month: <i>p</i> = 0.007, 2 months: <i>p</i> = 0.000), and lower ocular surface staining score (1 month: <i>p</i> = 0.000, 2 months: <i>p</i> = 0.000), as compared to the control.Conclusions: Following cataract surgery, the use of rebamipide eye drops produced improvements in TBUT, ocular surface staining scores, and OSDI. This suggests that rebamipide offers benefits in managing dry eye that can occur after cataract surgery.

Repeatability of a Combined Adaptive Optics Visual Simulator and Hartman-Shack Aberrometer in Pseudophakic Eyes With and Without Previous Corneal Refractive Surgery

PURPOSE

To evaluate the intrasession repeatability of wavefront aberrations obtained by a combined adaptive optics visual simulator and Hartman-Shack aberrometer in pseudophakic eyes with and without previous corneal refractive surgery.

METHODS

Three consecutive measurements were performed in one eye of each individual. Total ocular aberrations were recorded up to the 5th Zernike order for a 4.5-mm pupil. Repeatability was assessed by calculating the within-subject standard deviation (Sw), the repeatability limit (R), and the intraclass correlation coefficient (ICC). Vector analysis was performed to assess astigmatism variability between scans.

RESULTS

The study enrolled 32 normal individuals and 24 individuals with a history of refractive surgery. In normal and eyes that had previous refractive surgery, respectively, the Sw values were 0.155 and 0.176 diopters (D) for sphere and 0.184 and 0.265 D for cylinder. The Sw values for all 3rd order terms ranged from 0.037 to 0.047 µm in normal eyes and 0.044 to 0.063 µm in eyes that had previous refractive surgery. The Sw for primary spherical aberration was 0.020 µm in normal eyes and 0.026 µm in eyes that had previous refractive surgery. ICC values for measurements of astigmatism yielded larger variability (ICC = 0.751 and 0.879). However, both groups demonstrated excellent repeatability (ICC > 0.9) for root mean square higher order aberrations (RMS-HOA) and total RMS values.

CONCLUSIONS

In pseudophakic eyes, the adaptive optics Hartmann-Shack device demonstrated acceptable repeatability for measurement of sphere and 3rd and 4th order HOAs with higher variability for astigmatism measurements, especially in eyes with a prior history of corneal refractive surgery. [J Refract Surg. 2024;40(9):e645-e653.].

Imaging assessment of conjunctival goblet cells in dry eye disease

Dry eye disease (DED) is a widespread, multifactorial, and chronic disorder of the ocular surface with disruption of tear film homeostasis as its core trait. Conjunctival goblet cells (CGCs) are specialised secretory cells found in the conjunctival epithelium that participate in tear film formation by secreting mucin. Changes in both the structure and function of CGCs are hallmarks of DED, and imaging assessment of CGCs is important for the diagnosis, classification, and severity evaluation of DED. Existing imaging methods include conjunctival biopsy, conjunctival impression cytology and in vivo confocal microscopy, which can be used to assess the morphology, distribution, and density of the CGCs. Recently, moxifloxacin-based fluorescence microscopy has emerged as a novel technique that enables efficient, non-invasive and in vivo imaging of CGCs. This article presents a comprehensive overview of both the structure and function of CGCs and their alterations in the context of DED, as well as current methods of CGCs imaging assessment. Additionally, potential directions for the visual evaluation of CGCs are discussed.

The effect of sodium hyaluronate on dry eye and corneal epithelial thickness following cataract surgery

PURPOSE

To evaluate the effects of sodium hyaluronate drops on dry eye parameters and corneal epithelial thickness following cataract surgery.

METHODS

The study included 84 patients who underwent uncomplicated phacoemulsification. In Group A, 0.15% sodium hyaluronate drops were added to the postoperative antibiotic/anti-inflammatory treatment. In Group B, only antibiotic/anti-inflammatory treatment was applied. Preoperatively and at 1 week and 1 month postoperatively, all the patients were evaluated in respect of tear break-up time (TBUT), the Schirmer test under anesthesia, the corneal fluorescein staining (CFS) score, mean central corneal thickness (CCT) and mean central corneal epithelial thickness (CCET), and the two groups were compared.

RESULTS

A statistically significant difference was determined between the two groups at postoperative 1 month in respect of TBUT, Schirmer test, CFS score, and CCET (p < 0.01). In Group A, a statistically significant increase was determined in the TBUT and Schirmer values at 1 month postoperatively (p < 0.01, p = 0.01, respectively) and in Group B, these values were decreased compared to preoperatively (p < 0.01). The CCET was determined to be significantly thinner in Group B 1 month postoperatively (p < 0.01). A significant increase in CCT was observed in both groups at postoperative 1 week (p < 0.01) and preoperative values were reached at 1 month postoperatively.

CONCLUSION

In the patient group using sodium hyaluronate, significant differences were determined in all dry eye parameters and CCET. The use of hyaluronate sodium drops after cataract surgery was seen to improve dry eye parameters and contribute to a healthy ocular surface by ensuring continuity of the corneal epithelium.

Sex Differences and Discordance Between Symptoms and Signs of Dry Eye Disease

PURPOSE

To examine the initial presenting symptoms in relation to sex and identify predictors of discordance between symptoms and signs of dry eye disease (DED) in Taiwan.

DESIGN

Retrospective cross-sectional study.

METHODS

This clinic-based cohort from a tertiary referral center in Taiwan included 1229 patients diagnosed with DED at Keelung Chang Gung Memorial Hospital in Taiwan between August 1, 2011, and July 31, 2018. Initial presenting symptoms were cross-sectionally and retrospectively collected. The composite score, indicating the discordance between symptoms and signs, was derived from the difference between the DED symptom severity score and the DED sign severity score.

RESULTS

Of 1229 patients, 975 (79.3%) were female, with a mean age of 56.7 ± 14.9 years. Initial presenting symptoms didn't show significant sex differences (all P > .05). In multivariate analysis, predictors of higher symptom severity score than sign severity score included being female (P = .011) and having a surgical history of cataract (P = .037), pterygium, or conjunctivochalasis (P = .014). Conversely, older age (P < .001) and artificial tear use (P < .001) were significant predictors of a lower symptom severity score than sign severity score.

CONCLUSIONS

Strong predictors of incongruity between DED symptoms and signs include age, gender, surgical history for cataract, pterygium or conjunctivochalasis, and artificial tear use. Ophthalmologists should prioritize symptoms for female patients and postsurgery cases. In addition, the absence of symptoms should not dismiss DED possibility in older adult patients and those using artificial tears. Notably, early recognition and enhancement of postoperative care can improve patient satisfaction and quality of life.

The efficacy of bandage contact lens in relieving the aggravation of dry eye disease after complicated cataract or/and IOL surgery

PURPOSE

In the present study, we aimed to evaluate the efficacy of the bandage contact lens (BCLs) in the treatment of dry eye disease (DED) after complicated cataract or/and intraocular lens (IOL) surgery.

METHODS

In this retrospective, single-centered, observational study, we collected data from 69 patients who underwent complicated cataract or/and IOL surgery. Of these, 35 cases wore their own BCLs immediately after the operation, while the other 34 cases did not have their own BCLs and were instead covered with gauze. The Ocular Surface Disease Index (OSDI) questionnaire, slit-lamp microscope examination, keratograph analysis, and Schirmer I test were measured at baseline, 1 week and 1 month postoperatively.

RESULTS

In the BCL group, the score of the OSDI questionnaire was significantly decreased at 1 week and 1 month postoperatively compared with baseline levels (P = 0.000, collectively). Moreover, the fluorescein staining score of the BCL group was remarkably decreased 1-week and 1-month postoperatively compared with the non-BCL group (P = 0.000 and P = 0.000, respectively). Furthermore, the redness score of the BCL group was also better compared with the non-BCL group at 1 week and 1 month postoperatively (P = 0.014 and P = 0.004, respectively).

CONCLUSIONS

Complicated cataract or/and IOL surgery would intensify the DED. Early application of BCLs postoperatively improved patients' comfort and alleviated dry eye-related symptoms and signs. Furthermore, this mechanism might involve the acceleration of corneal epithelial healing, the alleviation of ocular stress response and the stabilization of the tear film.

TRIAL REGISTRATION

Trial registration ClinicalTrials, NCT04120389. Registered 10 October 2019-retrospectively registered.

Cataract surgery in setting of ocular surface disease

PURPOSE OF REVIEW

The purpose of this article is to review the available strategies to successfully identify and manage ocular surface disease (OSD) pre, intra and post-cataract surgery.

RECENT FINDINGS

Cataract surgery and OSD have an intricate relationship: the surgical procedure can induce or exaggerate OSD symptoms, while OSD can negatively impact surgical refractive outcomes and increase the rate of postoperative complications.

SUMMARY

Improving the health and stability ocular surface is the key to enhance post cataract surgery refractive outcomes and avoid complications. This is pivotal for patients affected by severe OSD, but is also important for patients with minimal signs or symptoms. A correct diagnosis and a stepwise approach are the keys to improve the quality of life of such patients.

Progress in the Application of Microneedles in Eye Disorders and the Proposal of the Upgraded Microneedle with Spinule

PURPOSE

In the local administration methods for treating eye diseases, the application of microneedles has great potential due to the shortcomings of low efficacy and significant side effects of local administration preparations. This article provides ideas for the research on the application of ophthalmic microneedle in the treatment of eye diseases.

RESULTS

This article analyzes the physiological structures of the eyes, ocular diseases and its existing ocular preparations in sequence. Finally, this article reviews the development and trends of ocular microneedles in recent years, and summarizes and discusses the drugs of ocular microneedles as well as the future directions of development. At the same time, according to the inspiration of previous work, the concept of "microneedle with spinule" is proposed for the first time, and its advantages and limitations are discussed in the article.

CONCLUSIONS

At present, the application of ocular microneedles still faces multiple challenges. The aspects of auxiliary devices, appearance, the properties of the matrix materials, and preparation technology of ophthalmic microneedle are crucial for their application in the treatment of eye diseases.

Application of three-dimensional visualization technology in phacoemulsification benefits the dry eye symptoms of patients after cataract surgery

Purpose

To investigate the effects of the three-dimension visualization system on dry eye in patients after cataract phacoemulsification.

Methods

Seventy-one patients (104 eyes) were enrolled in this study and assigned to the conventional microscopic group (CM group) or three-dimension group (3D group). Ocular Surface Disease Index, The Schirmer I test (SIt), lipid layer thickness (LLT), noninvasive tear breakup time (NIBUT) and other factors associated with dry eye were recorded before and 1 week and 1 month after surgery. The operation time and intraoperative light intensity (ILI) were also recorded.

Results

The ILI in the 3D group was significantly lower than that in the CM group (33% vs. 60%, p < 0.01). There was an interaction (group and time) effect for first NIBUT (NIBUT-F), average NIBUT (NIBUT-Ave), tear meniscus height (TMH) and the score of eye redness (Pinteraction < 0.05). The main effects of group on SIt, LLT, NIBUT-F, NIBUT-Ave and the score of eye redness were significant (Pgroup < 0.05). In the CM group, SIt, LLT, NIBUT-F, NIBUT-Ave, TMH were lower than those of the 3D group, the score of eye redness was higher than that of the 3D group at 1 week and 1 month after surgery (all p < 0.05). The changes in NIBUT-F and NIBUT-Ave between before surgery and 1 week after surgery showed negative correlations with ILI (p < 0.01).

Conclusion

Compared with microscopic surgery, the 3D visualization system can provide better tear film stability for patients after cataract surgery.

Trehalose and Dry Eye Disease: A Comprehensive Systematic Review of Randomized Controlled Trials

The purpose of the research project was to extensively review the efficacy and safety of a trehalose tear-substitute treatment in cases of dry eye disease (DED). A systematic review that included only full-length randomized controlled studies (RCTs) reporting the effects of trehalose tear-substitute treatment in three databases, PubMed, Scopus and Web of Science, was performed according to the PRISMA statement. The search period included papers published before 8 August 2023. The Cochrane risk-of-bias tool was used to analyze the quality of the studies selected. A total of 10 RCTs were included in this systematic review. Trehalose tear-substitute treatments achieved a higher improvement than did control group interventions in all reported variables. The mean differences between both groups were in favor of trehalose, and were as follows: ocular surface disease index (OSDI) questionnaire score of -8.5 ± 7 points, tear film breakup time (TBUT) of 1.9 ± 1 s, tear film thickness (TFT) of 0.25 ± 0.1 μm, tear meniscus height (TMH) of 0.02 ± 0.02 mm, Schirmer test (ST) of 0.8 ± 1.4 mm, corneal fluorescein staining (CFS) of -0.7 ± 0.1 points and visual acuity (VA) of 0.3 ± 2.1 letters. No adverse events after trehalose tear-substitute treatments were reported. Trehalose tear substitutes are a safe and effective treatment for DED. Therefore, trehalose tear substitutes should be recommended for patients with dry eye disease. In addition, there is specific evidence to support its use in the preoperative cataract surgery period.

Assessment of the eye surface and subjective symptoms after using 0.1% dexamethasone drops with and without preservatives in patients after cataract surgery

Cataract surgery can cause dry eye symptoms. One of the many factors compromising the ocular surface is the use of benzalkonium chloride (BAC)-preserved topical eye drops administered during the postoperative period. In this open-label, prospective, randomized, comparative clinical trial, 40 patients not previously affected by dry eye disease were assigned to receive either preservative-free (PFD) or preserved (PD) dexamethasone 0.1% eye drops for two weeks after a standard phacoemulsification procedure. Fluorescein break-up time, ocular surface staining score, Schirmer test, Ocular Surface Disease Index and anterior chamber (AC) cells were evaluated at baseline prior to the surgery and 2 weeks after surgery. No statistically significant differences in baseline assessments were observed between groups. At week 2, a significant increase in corneal staining scores (p = 0.003) and foreign body sensation (p = 0.04) was observed for the PD group only. The conjunctival staining score was significantly higher in both groups. The mean AC cell grading was higher in the PFD group than in the PD group (0.28 ± 0.30 and 0.07 ± 0.18, respectively; p = 0.013). Preservative-free dexamethasone eye drops after cataract surgery caused milder dry eye symptoms as compared with preserved dexamethasone. The AC inflammation control comparison may require a larger study group. Trial registration: ClinicalTrials.gov identifier NCT05753787, 03/03/2023.

The effects of chalazion and the excision surgery on the ocular surface

Purpose

To evaluate the effects of chalazion excision on the ocular surface, taking into account the subjective symptoms and the objective parameters of the tear film.

Methods

This prospective, interventional clinical study included 52 eyes from 26 patients with eyelid chalazion who underwent excision of the lesions between March and August 2022. Chalazion excision was performed on the patient's chalazion eye, and the contralateral eye served as the control. The following parameters were investigated both preoperatively and 1 week, 1 month, and 3 months postoperatively: the Ocular Surface Disease Index (OSDI), Schirmer I test, corneal fluorescein stain (CFS), tear meniscus height (TMH), noninvasive first breakup time (NifBUT), noninvasive average breakup time (NiaBUT), bulbar conjunctival redness score, the thickness of the lipid layer, and meibomian gland loss.

Results

Before surgery, the OSDI score of the chalazion eye was significantly higher than the contralateral eye. The bulbar conjunctival redness score (p = 0.043) and the OSDI score (p = 0.004) improved significantly in the first month after surgery. In the third month after surgery, the objective parameters showed significant improvements, including TMH (p = 0.032), NiaBUT (p = 0.028), bulbar conjunctival redness score (p < 0.001), the thickness of the lipid layer (p = 0.021), and meibomian gland loss (p = 0.005).

Conclusions

Our study revealed that chalazion excision can significantly improve the subjective symptoms and the objective tear film parameters of the ocular surface.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Effect of Irrigation Solution Temperature on the Corneal Endothelial Functions in Posterior Vitrectomy: Room Temperature Versus Cooled

PURPOSE

To compare the effects of cooled and room temperature irrigation on the preoperative and early postoperative corneal endothelial parameter values in posterior vitrectomy.

MATERIALS AND METHODS

In this prospective, randomized, comparative study, 68 patients underwent a standard 3-port, 23-G posterior vitrectomy operation by a single surgeon. Cooled irrigation solution was applied to 36 patients during surgery (group 1), and room temperature irrigation solution was applied to 32 patients (group 2). The patients were also divided into four groups according to their history of noncomplicated cataract surgery (phakic or pseudophakic) and the types of tamponade used (silicone or gas). The central corneal thickness (CCT), endothelial cell density (ECD), mean cell area (MCA), hexagonal cell percent, and coefficient of variation of cell area (CV) parameter values of the groups at preoperative and postoperative 1 month were compared.

RESULTS

There were no statistically significant differences between the preoperative and postoperative corneal parameter values in groups 1 and 2 ( P >0.05). However, it was remarkable that the percentage of preoperative-postoperative change in all the corneal parameter values was higher in group 2. When the results of the subgroup analyses of the patients who were pseudophakic and used gas tamponade (Group D) in group 2 were examined, it was determined that the negative effects were significantly higher in the postoperative values for the ECD, MCA, CV, and CCT parameters compared with the preoperative values ( P <0.05).

CONCLUSION

In patients with pseudophakia and gas tamponade, cooled irrigation was found to be more advantageous for corneal parameters.

Effects of cataract surgery on blinking

PURPOSE

To assess the effects of cataract surgery on the spontaneous blinking pattern and blinking kinematics.

SETTING

FISABIO Oftalmología Médica Eye Hospital, Valencia, Spain.

DESIGN

Observational descriptive clinical study.

METHOD

Patients with senile cataract were evaluated before (visit 1) and at 1 month (visit 2) and 3 months (visit 3) after undergoing phacoemulsification cataract surgery. The blinking of patients was recorded for 90 seconds using an eye-tracking device. Blinks were analyzed by means of image analysis to obtain a noninvasive detailed description of blinking including blink rate, number of complete and incomplete blinks, percentage of incomplete blinks, and kinematic parameters, including amplitude, closing, contact, opening, and total durations and closing and opening speeds.

RESULTS

50 patients were included in this study. The blink rate was significantly smaller at visit 3 compared with baseline ( P = .03) and visit 2 ( P = .001). Likewise, the number of complete blinks was significantly smaller, and the percentage of incomplete blinks was significantly higher at 3 months postoperatively compared with baseline ( P = .02 and P = .01, respectively), although no differences were observed at 1 month postoperatively ( P > .05). Conversely, no differences in the number of incomplete blinks or any kinematic parameter were observed between visits ( P = .12).

CONCLUSIONS

Cataract surgery significantly altered the blinking pattern at 3 months postoperatively, although kinematic parameters remained unvaried. Clinicians should be aware of potential alterations in blinking after phacoemulsification cataract surgery and the implications this may have on the ocular surface of patients.

Dry Eye Following Femtosecond Laser-Assisted Cataract Surgery: A Meta-Analysis

This study investigates the dry eye effect after femtosecond laser-assisted cataract surgery (FLACS) and also compares the risk of postoperative dry eye between FLACS and manual cataract surgery (MCS). We searched various databases between 1 January 2000 and 15 October 2022 and included peer-reviewed clinical studies in our review. Dry eye parameters were extracted at baseline and postoperative day one, week one, one month, and three months. Parameters included were the ocular surface discomfort index (OSDI), tear secretion (tear meniscus height, Schirmer's test), microscopic ocular surface damage (fluorescein staining), and tear stability (first and average tear breakup time). Additionally, the differences of each parameter at each time point were compared between FLACS and MCS. In total, six studies of 611 eyes were included. On postoperative day one, increased, pooled standardised mean differences (SMDs) were noted in the OSDI, tear secretion, tear film instability, and microscopic damage. During postoperative week one, dry eye worsened. Fortunately, dry eye achieved resolution afterwards and nearly returned to the baseline level at postoperative three months. When the parameters were compared between FLACS and MCS, those of FLACS had higher severities, but most were not statistically significant. Dry eye impact was approximately the same in FLACS and MCS at postoperative three months.

Alterations in the ocular surface and tear film following keratoplasty

The purpose of this study was to evaluate any alterations in the tear film and ocular surface beyond the early postoperative period following penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK). This cross-sectional, contralateral-eye study compared ocular surface and tear film parameters of eyes with a previous PK or DALK in one eye and no prior surgery in the contralateral eye. Overall, 14 (87.5%) participants underwent PK, and 2 (12.5%) underwent DALK using a mechanical dissection. The median time from surgery was 3.4 years (range 1.5 to 38.7 years). The indication for unilateral keratoplasty was keratoconus in 15 (94%) participants, and corneal scarring in 1 (6%) eye, secondary to microbial keratitis. Operated eyes exhibited poorer non-invasive tear film breakup time, lower corneal sensitivity, lower sub-basal nerve density and more severe fluorescein staining scores than unoperated fellow eyes (all Q < 0.05). There were no significant differences in tear film lipid layer quality, tear meniscus height, conjunctival hyperaemia, lissamine green staining score, or meibography grade between operated and fellow eyes (all Q ≥ 0.20). Higher corneal esthesiometry threshold (lower corneal sensitivity) was correlated with shorter non-invasive tear film breakup time (Spearman’s rho =  − 0.361, p = 0.04) and increased fluorescein staining score (Spearman’s rho = 0.417, p = 0.02). Keratoplasty can induce persistent changes in the ocular surface and tear film, including: increased fluorescein staining, decreased tear film breakup time, decreased corneal sub-basal nerve plexus density, and reduced corneal sensitivity.

The preoperative management of meibomian gland dysfunction prior to corneal refractive surgery

PURPOSE OF REVIEW

To describe the significance of meibomian gland dysfunction (MGD) in corneal refractive surgery and to describe available approaches to preoperative evaluation and treatment based on current research.

RECENT FINDINGS

There are several methods available for the evaluation and treatment of MGD. These are relevant for refractive surgeons to understand, as the presence of MGD preoperatively plays a role in the severity of MGD after corneal refractive surgery. Refractive surgery itself can exacerbate MGD. Treatment of MGD prior to surgery may have a meaningful impact on postoperative MGD.

SUMMARY

Surgeons should include meibomian gland assessment in the preoperative refractive evaluation and should treat MGD proactively prior to performing refractive surgery. Relevant information in this field is growing; additional prospectively designed studies are needed to further enhance our understanding.

Alpha-Glycerylphosphorylcholine and D-Panthenol Eye Drops in Patients Undergoing Cataract Surgery

Cataract surgery is widespread. The surgical procedure is associated with damage to the epithelial barrier and interruption of the corneal innervation. In addition, pathological events sustain signs and symptoms that may persist for a long time. Recently, a fixed combination of alpha-glycerylphosphorylcholine and D-Panthenol (Oftassiale) has been available as eye drops. The present study investigated the effects of an Oftassiale therapy in 20 patients undergoing cataract surgery. A comparison group included 20 patients treated with topical hyaluronic acid. Standard prophylactic and anti-inflammatory treatment was prescribed to all patients. Clinical signs and symptoms were assessed over time. In vivo confocal microscopy (IVCM) was performed accordingly. Oftassiale treatment significantly reduced clinical features and improved IVCM outcomes. In addition, therapy was well-tolerated, and no clinically significant adverse events occurred. In conclusion, this study confirmed that IVCM helps assess the tunnel after cataract surgery due to its ability to provide microscopic details in vivo. Topical therapy with alpha-glycerylphosphorylcholine and D-Panthenol eye drops promoted and stabilized the reepithelialization process. This fixed combination also accelerated and modulated the repair of the corneal innervation. Moreover, this treatment was well-tolerated and safe.

Prevalence and Characteristics of Dry Eye Disease After Cataract Surgery: A Systematic Review and Meta-Analysis

Dry eye disease (DED) after cataract surgery is associated with various risk factors, while causing a wide range of heterogeneous symptoms including decreased quality of vision. This systematic review and meta-analysis aimed to determine the prevalence and characteristics of DED after cataract surgery. We searched PubMed and EMBASE and included studies on patients with DED after cataract surgery, between January 2011 and June 2020. Study-specific estimates (DED prevalence rates after cataract surgery in patients without preexisting DED) were combined using one-group meta-analysis in a random-effects model. We included 36 studies published between 2013 and 2020. We included nine of these in the meta-analysis of DED prevalence after cataract surgery. Overall 37.4% (95% CI 22.6-52.3; 206/775) of patients without preexisting DED developed DED after cataract surgery. The risk factors for DED after cataract surgery included age, female sex, systemic diseases, systemic medications, psychiatric conditions, preexisting DED, meibomian gland dysfunction, preservatives in eye drops, surgery techniques, and lifestyle. DED severity peak occurred 1 day postoperatively and persisted for at least 1-12 months following cataract surgery; therefore, consistent follow-up for DED is warranted for at least 1 month after cataract surgery. Topical administration of preservative-free diquafosol tetrasodium solution and preoperative meibomian gland treatment were effective in preventing and treating DED following cataract surgery. As more than one-third of patients develop DED after cataract surgery, careful DED management and treatment is needed after cataract surgery to improve satisfaction and vision quality.

The Effect of Past Cataract Surgery within the Medium to Long-Term Period on Patients with Dry Eye Disease

This study investigates the effects of cataract surgery on dry eye parameters of patients with dry eye disease (DED) in the medium- to long-term post-surgical period (6 months to 5 years). A cross-sectional study was conducted on 438 eyes on first visit to a tertiary clinic (219 eyes with cataract surgery within timeframe, i.e., pseudophakic dry eye group, 219 comparison eyes without such history, i.e., comparison dry eye group). Parameters evaluated include Ocular Surface Disease Index (OSDI) and standard examination for DED. A significantly greater proportion of pseudophakic dry eye group (50%) experienced frequent blurred vision (≥1 episode per week) compared to dry eye control group (38%) (OR = 1.66, 95%CI 1.13, 2.44). Those with ocular discomfort before surgery were more likely to experience blurring at least once a day. However, a significantly greater proportion of the pseudophakic dry eye group (34%) had Schirmer’s I >8mm compared to the comparison group (25%) (OR = 0.605, 95% CI 0.398, 0.921), though the difference was not clinically significant (7.51 mm versus 6.51 mm, p > 0.05). Other DED signs (e.g., overall OSDI score, Tear Break-up Time) were not found to be worse among pseudophakic dry eye group. Pre-operative counselling and preventative measures should be undertaken, especially those with suggestive symptoms pre-operatively.

Dry Eye Disease after Cataract Surgery: Study of its Determinants and Risk Factors

Objectives

To study the incidence of dry eye and its determinants in patients undergoing cataract surgery.

Materials and Methods

One hundred twenty patients with senile cataract underwent Schirmer's test, tear break-up time (TBUT) test, lissamine green staining of the cornea and conjunctiva, and Ocular Surface Disease Index (OSDI) for evaluation of dry eye preoperatively and again at first and second follow-up examinations at 1 week and 1 month after cataract surgery.

Results

Mean age of the patients was 59.25+9.77 years and 73 (60.8%) were men. None of the patients had dry eye at the time of enrollment as per the criteria of our study. Postoperatively, Schirmer's test values ranged from 12-35 mm and 8-24 mm at first and second follow-ups, respectively. Mean TBUT was 13.16±2.45 and 9.64±2.20 seconds, while lissamine green staining score was 3 in 67 (55.8%) and 1 in 67 (55.8%) subjects at first and second follow-up, respectively. OSDI values ranged from 1-30 and 10-33 with a mean of 25.97±5.34 and 11.96±7.47 respectively at first and second follow-up. At first follow-up, 89.1% of the 56 patients who underwent phacoemulsification were found to have grade 2 dry eye (p<0.001), while 92.2% of the 64 patients who underwent small-incision cataract surgery (SICS) had grade 2 dry eye (p<0.001). At second follow-up, grade 0 dry eye was observed in 92.2% of the patients who underwent phacoemulsification and 82.1% of the patients who underwent SICS (p<0.001).

Conclusion

The incidence of dry eye after cataract surgery was high and mostly independent of demographic and anthropometric profile, type of surgical procedure, time of microscope exposure, and amount of energy used. This dryness was transient in nature and showed a declining trend, tending to achieve normalization by the end of 1 month.

Effect of 0.15% Preservative-free Sodium Hyaluronate on Dry Eye Disease after Femtosecond Laser-assisted Cataract Surgery

Purpose: The efficacy of using preservative-free 0.15% sodium hyaluronate eyedrops for dry eye disease after femtosecond laser- assisted cataract surgery (FLACS) was evaluated. Methods: This prospective randomized study was conducted on patients with dry eye who were scheduled for FLACS among those with Tear Film & Ocular Surface Society Dry Eye Workshop II Dry Eye Levels 1 and 2. In total, 37 eyes scheduled for FLACS were randomized to the treatment group (n = 19) or control group (n = 18). Corneal and conjunctival fluorescein staining (CFS), tear breakup time (TBUT), Schirmer I test (SIT) value, ocular surface disease index (OSDI), meibomian gland evaluation result, and lipid layer thickness were evaluated for all patients, preoperatively and at 1 and 3 months postoperatively. Results: In the treatment group, the OSDI and CFS scores were significantly lower at 3 months postoperatively than at baseline, but the TBUT and SIT values were significantly increased. In the control group, TBUT was significantly shorter at 3 months postoperatively than at baseline, SIT values were significantly decreased at 1 and 3 months postoperatively compared with the baseline, and meibum quality was significantly aggravated at 1 month postoperatively compared with the baseline. In the treatment group, OSDI improved significantly from baseline at 1 and 3 months. TBUT increased significantly in the treatment group at postoperative 3 months. Meibomian gland quality showed clinically better results in the treatment group than in the control group at postoperative 3 months. There were no significant differences in corneal and CFS, lipid layer thickness, and other dry eye disease parameters between the treatment and control groups. Conclusions: Preservative-free 0.15% sodium hyaluronate eyedrops were effective for improving dry eye symptoms and tear film stability after FLACS.

Dry Eye and Phacoemulsification Cataract Surgery: A Systematic Review and Meta-Analysis

Purpose: To evaluate whether dry eye deteriorates after phacoemulsification cataract surgery, and to explore the influential factors.

Methods: Studies published before February 2020 indexed on PubMed and the Cochrane Central Register of Controlled Trials were retrieved. A meta-analysis, including meta-regression, a sensitivity analysis, and a subgroup analysis, were performed.

Results: Twenty studies with 2,247 eyes were included in the meta-analysis, dry eye-related parameters were investigated preoperatively and 1 month postoperatively. Patients with pre-existing meibomian gland dysfunction (MGD) had worsened subjective symptoms of dry eye (1.31, 95% confidence interval (CI) [0.66, 1.95], P < 0.0001), a reduced tear break-up time (BUT) (−2.27, 95% CI [−2.66, −1.88], P < 0.0001), and a worse corneal fluorescein staining (CFS) score (0.75, 95% CI [0.5, 1.0], P < 0.0001) after phacoemulsification cataract surgery, whereas in the general population, the subjective symptoms score and CFS remained unchanged and BUT decreased slightly after surgery. Patients without diabetes showed significantly reduced total tear secretion after phacoemulsification cataract surgery (−1.25, 95% CI [−1.62, −0.88], P < 0.0001).

Conclusion: Dry eye generally remained unchanged 1 month after phacoemulsification cataract surgery. Notably, worsened symptoms and signs of dry eye were observed more frequently in patients with pre-existing MGD. Patients without diabetes were more susceptible to reduced tearing postoperatively.

Clinical Trial Registration: Identifier: PERSPERO (2020: CRD42020203316).

Changes in Tear Osmolarity after Cataract Surgery

BACKGROUND

The purpose of this study was to examine changes in the ocular surface before and after phacoemulsification with small incisions and to examine the changes in tear osmolarity.

METHODS

This was a prospective, observational study involving 55 eyes of 39 patients (19 male, 20 female patients; average age 72.0±7.3 years) who had cataract surgery at a Nippon Medical School Hospital between December 2013 and June 2018. Compromised tear dynamics were determined by the Schirmer test or the tear break-up time (BUT). An abnormal ocular surface was identified by positive vital staining with fluorescein or lissamine green. Moreover, tear osmolarity (Tosm) and corneal sensitivity were measured. All assessments were done preoperatively and 1 and 4 weeks (P1W and P4W) after the surgery.

RESULTS

None of the operations had any complications. Operating time was 17.8±9.3 minutes. BUT was significantly decreased at P1W, and it recovered at P4W. The Schirmer test did not change significantly. The fluorescein staining score (FSS) increased significantly at P1W and recovered at P4W. The Lissamine green score (LSS) did not change significantly. Tear osmolarity increased significantly at P1W and did not recover at P4W. Corneal sensitivity decreased significantly at P1W and recovered at P4W.

CONCLUSION

In the present study, there were temporary changes in dry eye-related examinations including tear osmolarity after cataract surgery. In particular, tear osmolarity increased significantly 4 weeks after surgery compared to before surgery, and it showed long-term changes, unlike other factors. After cataract surgery, tear osmolarity, BUT, and FSS increase, resulting in dry eye symptoms. Therefore, it is necessary to pay attention to discomfortable eye symptoms of patients after cataract surgery.

Relationship between ocular surface disease and patient's satisfaction among cataract surgical patients in Nigeria

PURPOSE

To determine the effect of clinical and cytological features of ocular surface disease on patient's satisfaction following small incision cataract surgery at a tertiary eye care centre.

METHOD

This is a prospective observational study of 70 consecutive consenting patients who underwent manual small incision cataract surgery(MSICS) at a tertiary eye care centre. All participants underwent ocular surface profile assessment using Schirmer I test (ST1), tear film break-up time (TBUT), conjunctival impression cytology (CIC) and ocular surface disease index (OSDI) at pre-operative visit, 1-week and 4-week post-operative visit. Patient's satisfaction with surgical outcome was evaluated at 6-week post-operative visit using a rating scale of 1 to 10. Data were analysed using IBM Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM Corp., Armonk, NY USA).

RESULTS

The mean age was 68 ± 9.4 years with a male/female ratio of 1:1.1. The mean OSDI score decreased significantly (p < 0.001) from 33.1 ± 8.4 pre-operatively to 20.8 ± 7.4 four weeks after surgery. The TBUT was 12 ± 4.1 s pre-operatively, but significantly reduced to 11.2 ± 3.9 s (p < 0.001) at 4-week post-operative period. At 6 weeks, patients with normal CIC reduced from 53 (75.8%) pre-operatively to 8 (11.4%) (p < 0.001, z = - 7.24). Fifty percent of patients with severe post-operative ocular surface disease reported dissatisfaction with their surgical outcome (p = 0.024).

CONCLUSION

Manual small incision cataract surgery can significantly impair the ocular surface health profile of patients. The presence of ocular surface disease in patients pre-operatively can negatively impact their level of satisfaction with surgical outcome.

Trehalose/sodium hyaluronate eye drops in post-cataract ocular surface disorders

Purpose

Prospective, randomised, open-label, comparative study to evaluate efficacy of trehalose/sodium hyaluronate eye drops for post-operative discomfort and tear film stability in patients undergoing cataract surgery.

Methods

Patients with healthy ocular surface, subclinical, or mild dry eye were enrolled. Tear breakup time (TBUT), Schirmer test, dry eye symptoms, corneal fluorescein staining (CFS), and ocular surface disease (OSDI) evaluation were performed pre-operatively and at two and four weeks after surgery. Patients were assigned to receive trehalose/sodium hyaluronate eye drops b.i.d (Group A), or 0.9% unpreserved sodium chloride eye drops b.i.d for 4 weeks (Group B).

Results

One hundred and thirty-five patients were randomised, 66 patients in Group A (73.2 ± 4.5 years) and 69 patients in Group B (74.3 ± 3.8 years), 60.8% females. Fifteen patients (8 Group A) were lost at follow-up. Pre-operatively, no between-group differences were observed, and TBUT increased in Group A between the pre-operative and 2 and 4 week evaluations and was higher in group A than in Group B at 4 weeks. Schirmer test and CFS showed an improvement only in Group A four weeks post-operatively. In Group A an improvement was observed after two and four weeks in foreign body and puncture sensation, whilst a difference in blinking discomfort was observed after four weeks. In Group B we observed an improvement in puncture sensation two and four weeks after surgery. Mean OSDI scores differences between the two groups were significant at four weeks.

Conclusions

Trehalose/sodium hyaluronate eye drops were effective in reducing signs and symptoms of dry eye and improving tear film stability

Ocular Surface Changes Associated with Ophthalmic Surgery

Dry eye disease causes ocular discomfort and visual disturbances. Older adults are at a higher risk of developing dry eye disease as well as needing for ophthalmic surgery. Anterior segment surgery may induce or worsen existing dry eye symptoms usually for a short-term period. Despite good visual outcomes, ocular surface dysfunction can significantly affect quality of life and, therefore, lower a patient’s satisfaction with ophthalmic surgery. Preoperative dry eye disease, factors during surgery and postoperative treatment may all contribute to ocular surface dysfunction and its severity. We reviewed relevant articles from 2010 through to 2021 using keywords “cataract surgery”, ”phacoemulsification”, ”refractive surgery”, ”trabeculectomy”, ”vitrectomy” in combination with ”ocular surface dysfunction”, “dry eye disease”, and analyzed studies on dry eye disease pathophysiology and the impact of anterior segment surgery on the ocular surface.

Preoperative Management of MGD with Vectored Thermal Pulsation before Cataract Surgery: A Prospective, Controlled Clinical Trial

Purpose: To investigate the efficacy of preoperative monocular treatment in elderly cataract patients with Meibomian Gland Dysfunction (MGD) utilizing vectored thermal pulsation treatment.Materials and Methods: This study was a prospective, examiner-masked contralateral eye clinical trial. Patients previously diagnosed with MGD undergoing uncomplicated cataract surgery in two eyes were enrolled. The eye perceived by the patient to be more symptomatic of MGD received a 12 min vectored thermal pulsation treatment using the LipiFlow Thermal Pulsation System, and was referred to as the LipiFlow-surgery eye. The contralateral eye then served as the nonLipiFlow-surgery eye. Patients with MGD not undergoing cataract surgery were enrolled as the control group. Within the control group, the eye that received LipiFlow treatment was considered the LipiFlow-nonsurgery eye, while the contralateral eye served as the nonLipiFlow-nonsurgery eye. All patients were examined before treatment and at one-week, one-month, and three-month intervals after treatment. Clinical parameters included dry eye symptoms, average lipid layer thickness (LLT-ave), tear breakup time (TBUT), corneal staining, Schirmer I tests, Meibomian glands yielding liquid secretion (MGYLS), and meibomian gland dropout.Results: A total of 32 patients (64 eyes) were examined during the three-month follow-up. There was a significant reduction in dry eye symptoms in non-surgery patients with monocular treatment of MGD, while no change in surgery patients was observed. Significant improvement of MGYLS in LipiFlow-surgery and LipiFlow-nonsurgery eyes during the follow-up time (p < .001) was reported, while no difference was observed in nonLipiFlow-surgery and nonLipiFlow-nonsurgery eyes. A statistically significant difference was seen in TBUT between LipiFlow-surgery and nonLipiFlow-surgery eyes at one-week and one-month intervals (p = .019 and 0.019, respectively). Differences in other clinical parameters were not statistically significant.Conclusions: Our findings suggest that although subjective symptoms were not alleviated, a single application of LipiFlow treatment before cataract surgery is effective in alleviating blockage of meibomian glands and preventing the decline of TBUT after cataract surgery.

Iatrogenic Dry Eye Disease: Dealing with the Conundrum of Post-Cataract Discomfort. A P.I.C.A.S.S.O. Board Narrative Review

The incidence and prevalence of dry eye disease (DED) after cataract surgery is greatly underestimated. The severity of dry eye symptoms has been reported to peak 7 days after cataract surgery and may persist for months, significantly affecting patients' quality of life (QoL). The importance of considering surgical outcomes not only in terms of visual acuity, but also in terms of the patients' QoL, necessitates the assessment and evaluation of the ocular surface by the cataract surgeon prior to the procedure. This narrative review, drafted by the P.I.C.A.S.S.O. (Italian Partners for the Correction of Ocular Surface Alterations) board, analyses the physiopathology of post-cataract surgery DED and highlights the pre-, intra- and postoperative risk factors that may alter ocular surface homeostasis; it proposes a practical comprehensive algorithm for the prevention, treatment and management of DED associated with cataract surgery. Particular attention needs to be paid to the pre- and intraoperative risk factors to reduce the incidence of postoperative dry eye and to improve cataract surgery outcome.

Iatrogenic corneal diseases or conditions

Any prescribed or self-administered therapy carries inherent risks of secondary adverse events. While the volume of treatments being administered through healthcare systems has been increasing, scientific advancements in our understanding of the mechanisms of pharmaceutical side effects and complications from procedures now allow us to reduce the risk of non-intentional damage to ocular health. This review summarizes the most common and leading causes of iatrogenic visual impairment, corneal diseases, and conditions that present in a general ophthalmologic practice, including a comprehensive analysis of their pathophysiology and recommendations for management and prophylaxis.Iatrogenic corneal diseases and conditions can arise from topical drugs, contact lens use, eye surgeries and procedures, systemic drugs, non-ophthalmological events, and cosmetic procedures. Topical and systemic drugs may disturb tear film homeostasis or result in ocular surface deposits. The use of ill-fitted contact lenses can trigger eye discomfort and poor hygiene conditions that can predispose to severe infections. Procedures to the eye may result in a variety of anatomical and functional complications that ophthalmologists should be aware of how to avoid or at least be prepared to manage if they occur. Even non-ophthalmological events such as non-invasive ventilation, radiation therapies and, immune-based conditions, or cosmetic procedures such as eyelash growth and fillers, can result in unwanted damage to the ocular surface.

Protecting the Ocular Surface at the Time of Cataract Surgery: Intracameral Mydriatic and Anaesthetic Combination Versus A Standard Topical Protocol

Introduction

An intracameral mydriatic and anaesthetic combination has been approved for injection into the anterior chamber in order to provide rapid and stable mydriasis and sustained intraocular anaesthesia during cataract surgery.

Methods

In this prospective study, conducted at the Eye Clinic, University of Florence, Italy, we compared phacoemulsification using the standard mydriatic-anaesthetic eye-drop protocol with that using the standard protocol in terms of corneal changes, ocular surface parameters and visual quality. Sixty patients (60 eyes) were included in the study, with 30 eyes receiving Mydrane®, a novel injectable intracameral solution, during phacoemulsification (Mydrane protocol, MP) and 30 eyes receiving the standard mydriatic-anaesthetic eye drops (standard protocol, SP). The following parameters were assessed using in vivo confocal microscopy (IVCM): central corneal thickness (CCT); flare and cells in the aqueous humor (Flare); keratocyte activation (KA), Langerhans’ cell density (LCD), nerve fibre density (NFD) and endothelial cell density (ECD). The Ocular Surface Disease Index (OSDI) score, tear breakup time (TBUT) and Schirmer’s test I (STI) were also evaluated. The Optical Scattering Index (OSI) and its standard deviation (OSI-SD) were assessed using the Optical Quality Analysing System (Visiometrics SL, Terrassa, Spain).

Results

In the MP group, CCT, Flare, KA and LCD values returned to baseline values within 15 postoperative days. The mean ECD and NFD decreased significantly in both groups from baseline at all follow-up assessments, with no statistically significant difference between groups. TBUT returned to the preoperative level at postoperative day 15 in the MP group. OSDI scores and STI were significantly worse in both groups at all follow-up assessments compared to baseline. At postoperative day 15 OSI and OSI-SD values were significantly better in the MP group than in the SP group.

Conclusions

The use of Mydrane during cataract surgery showed a good safety profile and few toxic side effects, ensuring better optical quality and tear film stability.

The Effect of Lifitegrast on Refractive Accuracy and Symptoms in Dry Eye Patients Undergoing Cataract Surgery

Purpose

To determine the effect of lifitegrast ophthalmic solution 5% on improving the tear film, biometry/keratometry, and refractive accuracy for dry eye patients scheduled for cataract surgery.

Patients and Methods

Multicenter, prospective, open-label study of 100 eyes of 100 patients undergoing cataract surgery who had a confirmed diagnosis of dry eye. Patients underwent biometry at baseline and again after a 28-day course of lifitegrast 5% BID. Primary outcome was an improvement in the accuracy of preoperative anterior corneal power measurements at predicting postoperative spherical equivalent (SE) pre- and post-lifitegrast treatment. Secondary outcomes included changes in dry eye symptoms and corneal staining.

Results

The accuracy of the biometry readings for the achieved refractive SE: within 0.25 D in 47% and 50% of eyes before and after the initial lifitegrast treatment, respectively; within 0.5 D in 71% and 79% of eyes before and after the initial lifitegrast treatment; and within 0.75 D in 81% and 91% of eyes before and after the initial lifitegrast treatment (p < 0.04).

Conclusion

Lifitegrast 5% significantly improved preoperative corneal surface measurement accuracy in patients with confirmed dry eye who were scheduled for cataract surgery.

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Prevalence of Ocular Demodicosis and Ocular Surface Conditions in Patients Selected for Cataract Surgery

The aim of the study was to analyze the prevalence of ocular demodicosis and ocular surface conditions in patients selected for cataract surgery. Eyelashes from 73 patients selected for cataract surgery were evaluated at × 40 and × 100 magnification using light microscopy. The anterior segment was assessed with the slit lamp. Additionally, Schirmer I and break up time (BUT) tests were carried out before surgery and 1 and 3 months postoperatively. A specially designed questionnaire containing e.g. information about chronic skin and eye diseases, previous ophthalmic surgeries, and patient's hygiene habits was used to assess the demographic variables. A majority of patients were at the age of 70-79 years, and there were more females (83%) in the study group. Demodex folliculorum was found in 48% of the patients. There was a correlation between the number of parasites and the presence of blepharitis, discharge at eyelid margins, and conjunctival hyperemia. Schirmer I and BUT test results were lower in patients with Demodex infestation before and after cataract surgery. The higher number of mites was correlated with lower Schirmer I test results postoperatively. The presence of Demodex mites influences the conjunctiva and lid margins leading to inflammation. The higher number of Demodex mites disturbs the tear film over time after cataract surgery.

An algorithm for the preoperative diagnosis and treatment of ocular surface disorders

Any ocular surface disease (OSD), but most commonly, dry-eye disease (DED), can reduce visual quality and quantity and adversely affect refractive measurements before keratorefractive and phacorefractive surgeries. In addition, ocular surgery can exacerbate or induce OSD, leading to worsened vision, increased symptoms, and overall dissatisfaction postoperatively. Although most respondents of the recent annual American Society of Cataract and Refractive Surgery (ASCRS) Clinical Survey recognized the importance of DED on surgical outcomes, many were unaware of the current guidelines and most were not using modern diagnostic tests and advanced treatments. To address these educational gaps, the ASCRS Cornea Clinical Committee developed a new consensus-based practical diagnostic OSD algorithm to aid surgeons in efficiently diagnosing and treating visually significant OSD before any form of refractive surgery is performed. By treating OSD preoperatively, postoperative visual outcomes and patient satisfaction can be significantly improved.

Cataract surgery and dry eye disease: A review

AIM

To review published literature concerning cataract surgery and dry eye disease (DED).

METHODS

A search was undertaken using the following: PubMed (all years), Web of Science (all years), Ovid MEDLINE(R) (1946 to 12 December 2019), Ovid MEDLINE(R) Daily Update 10 December 2019, MEDLINE and MEDLINE non-indexed items, Embase (1974-2019, week 49), Ovid MEDLINE (R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily (1946 to 12 December 2019), CENTRAL (including Cochrane Eyes and Vision Trials Register; Cochrane Library: Issue 12 of 12 December 2019), metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). Search terms included 'cataract surgery', 'phacoemulsification' and 'cataract extraction', combined with 'dry eyes' and 'ocular surface'. Relevant in-article references not returned in our searches were also considered.

RESULTS

Publications identified included systematic reviews, meta-analysis, randomized controlled trials, cohort studies, case series and laboratory-based studies. Published data highlighting the burden of DED both prior and following cataract surgery were reviewed as well as studies highlighting the effects of cataract surgery on the ocular surface, intra-operative measures to reduce deleterious effects on the ocular surface and current evidence on the management options of post-operative DED.

CONCLUSIONS

DED is common and can be exacerbated by cataract surgery. Ophthalmologists need to assess for pre-existing DED and instigate treatment before surgery; be aware of reduced accuracy of measurements for surgical planning in the presence of DED; limit intra-operative surgical factors damaging to the ocular surface; and consider management to reduce DED post-operatively.

Toxicity of Povidone-iodine to the ocular surface of rabbits

Background

We evaluated the toxicity of 5% (w/v) povidone-iodine (PI) applied to the ocular surface of rabbits.

Methods

Twenty-three white rabbits were divided into four groups; these were a control group and three study groups in which the ocular surface was exposed to PI for different times. In control group, one drop of phosphate-buffered saline (PBS) was applied once for 10 min. In study groups, one drop of 5% (w/v) PI was topically applied once for 1 min, 3 min, and 10 min, and then the animals were observed for 7 days. The Schirmer test, Rose Bengal staining, corneal fluorescein staining and conjunctival impression cytology were performed on day 0, 3, and 7. After 7 days, the rabbits were sacrificed and conjunctiva and cornea were collected and evaluated by light and electron microscope. Immunofluorescence staining was also performed to detect mucin 5 subtype AC (MUC5AC).

Results

The decrease in goblet cell density, reductions in MUC5AC level and histopathological and ultrastructural changes of conjunctiva and cornea were more prominent in the 5% (w/v) PI groups than the control group (p < 0.05). Moreover, these changes were more prominent when PI was applied for 3 and 10 min rather than 1 min (both p values < 0.05).

Conclusions

5% (w/v) povidone-iodine caused damages to the ocular surface in a time-dependent manner. Therefore, we should be aware of that excessive PI exposure during ophthalmic procedures could be a pathogenic factor of dry eye syndrome after surgery.

Prevalence of Dry Eye and its Subtypes in an Elderly Population with Cataracts in Indonesia

Purpose

To describe the prevalence of dry eye disease (DED) and its subtypes in elderly population with cataracts prior to surgery in Jakarta, Indonesia.

Patients and Methods

Forty-nine eyes of 49 patients (16 males, 33 females; mean age: 66.6 years) planned for phacoemulsification surgery were consecutively recruited from two tertiary eye hospitals in this hospital-based cross-sectional study. Symptoms were assessed using the Ocular Surface Disease Index (OSDI) questionnaire, and the patient was defined as symptomatic if their OSDI score was ≥13. Objective examinations included the noninvasive tear film break up time (NIBUT) and Schirmer tests. The results were deemed abnormal if they were <10 seconds and <10 mm for NIBUT and Schirmer, respectively.

Results

Participants were classified into four groups: DED (positive symptoms and short NIBUT), preclinical dry eye (positive symptoms without short NIBUT), predisposition to dry eye (short NIBUT without symptoms), and normal group. Median OSDI score was 12.5 (0–45.0), NIBUT was 10.4 (5.1–28.9) seconds, and Schirmer score was 8.0 (2.0–28.0) mm. The prevalence of DED, preclinical dry eye, and predisposition to dry eye were 22.5%, 22.5%, and 26.5%, respectively, while the other 28.5% subjects were normal. The DED group had significantly lower Schirmer test results (4.0 [2–17] mm) compared to all other groups. Older age (>70 years) was associated with poorer NIBUT and Schirmer test results and a significant difference between age groups was observed, especially in males.

Conclusion

Dry eye is a common problem among the elderly population with cataracts in Indonesia. Almost half of the subjects presented with dry eye symptoms and either categorized as DED or preclinical dry eye, while more than one quarter were predisposed to dry eye. Care must be taken prior to cataract surgery to rule out existing dry eye with additional attention on those presenting without any symptoms as dry eye may develop after surgery.

Clinical efficacy of eyelid hygiene in blepharitis and meibomian gland dysfunction after cataract surgery: a randomized controlled pilot trial

The purpose of this randomized clinical trial is to evaluate the effect of eyelid hygiene on subjective symptoms, anterior blepharitis, and meibomian gland dysfunction (MGD) after cataract surgery. Subjects with obstructive MGD who underwent cataract surgery were randomly divided into two groups. In the eyelid hygiene group, eyelid hygiene was performed twice a day for 10 days from 3 days before to 1 week after cataract surgery. The control group did not perform eyelid hygiene. A subjective symptom questionnaire of SPEED, anterior blepharitis grade, and meibum quality and quantity was evaluated at baseline and at postoperative 1 and 4 weeks. The eyelid hygiene group (n = 36) showed decreased SPEED score after cataract surgery and the control group (n = 33) did not. Anterior blepharitis grade was worse 1 week after surgery in the control group but not in the eyelid hygiene group. The control group had significantly decreased meibum quality and quantity in both the upper and lower eyelids after cataract surgery, but the eyelid hygiene group did not. Eyelid hygiene before/after cataract surgery improved postoperative subjective symptoms and prevented postoperative exacerbation of anterior blepharitis and MGD. Thus, perioperative eyelid hygiene is recommended for patients with obstructive MGD who undergo cataract surgery.

Cataract Surgery Destabilises Temporary the Tear Film of the Ocular Surface

BACKGROUND

Symptoms due to dry eye in the form of keratoconjunctivitis sicca (KCS) are often seen after cataract surgery. We investigated the influence of cataract surgery on tear film stability on the ocular surface.

MATERIAL AND METHODS

60 eyes of 60 patients who underwent cataract surgery were included in a prospective study in 2017 at the Eye Hospital in Hanoi (Vietnam National Institute of Ophthalmology). The mean age of the patients was 65 ± 10 years. The phacoemulsification was performed under topical anaesthesia by a clear corneal incision and implantation of a foldable IOL. The parameters for the evaluation of the change of the tear film included subjective patient data using the Ocular Surface Disease Index questionnaire (OSDI), findings of the Schirmer I test, the tear break-up time (TBUT) as well as the tear meniscus height (TMH) measured noninvasively with the Keratograph 5M (Oculus). In addition, conjunctival and corneal changes were examined after vital staining with fluorescein for the cornea and rose bengal for the conjunctiva. Data were collected preoperatively, at 1 week, 1 month and 3 months postoperatively. According to DEWS, the disease is classified into 4 groups: mild, moderate, severe and very severe.

RESULTS

One week after surgery, the total score according to OSDI was significantly increased with a total value of 14.4 ± 4.2 (p = 0.001). Schirmer I was 15.8 ± 4.3 mm preoperatively and decreased significantly in the first postoperative week (p = 0.001), before reaching the preoperative level again after three months. TBUT was 12.6 ± 1.5 s preoperatively, decreased significantly to 9.7 ± 1.5 s during the first postoperative week, and normalized to 12.4 ± 1.3 s by the end of the third month. The meniscus height was 0.245 ± 0.055 mm preoperatively, significantly lowered to 0.229 ± 0.057 mm in the first postoperative period and nearly normalised by the third postoperative month to 0.241 ± 0.051 mm. In the first postoperative week, the rate of mild KCS was observed in 30% of patients. At one month, this decreased to 10% and at three months was no longer demonstrable in any patient.

CONCLUSION

One of three patients experienced mild KCS after cataract surgery. The symptoms lasted up to three months. This should be taken into account preoperatively and appropriate therapy should be planned.

Effects of cataract surgery on symptoms and findings of dry eye in subjects with and without preexisting dry eye

PURPOSE

To compare dry eye symptoms and findings in post cataract surgery eyes' with and without preexisting dry eye.

STUDY DESIGN

Prospective, observational case-control study.

METHODS

Sixty-seven eyes that had undergone cataract surgery were included; 48 were classified into group D (preexisting dry eye) and 19 into group N (no preexisting dry eye). No subjects received perioperative treatment for dry eye. We evaluated between-group differences in symptom scores, corrected distance visual acuity (CDVA), tear film breakup time (BUT), tear film breakup pattern (BUP), and ocular surface fluorescein staining scores, at 1 week, 1 month, and 3 months postoperatively.

RESULTS

Symptoms were unchanged in group N, but improved in group D (P < .001) postoperatively. CDVA was improved after surgery in both groups (P < .001). BUT was shorter preoperatively in group D than in group N although this difference was absent 1 month postoperatively. Fluorescein staining scores significantly increased at 1 month postoperatively in group N (P = .01), but did not change in group D. During the perioperative period, the predominant BUP was the random break pattern in both groups (≥ 85%). From 1 week to 3 months, dimple break patterns decreased in group D (P = .007), whereas spot break patterns increased (P = .01).

CONCLUSIONS

Cataract surgery has an influence on tear film stability and the ocular surface. There was either a transient improvement or worsening of ocular surface wettability in some patients without preexisting dry eye.

Oculoplastic considerations for refractive procedures

PURPOSE OF REVIEW

Refractive surgery is one of the most popular elective procedures performed in the world. Given that dry eye is a common complaint following keratorefractive surgery, evaluation, and treatment of periocular conditions that further predispose the patient to dry eye symptoms is an important part of the presurgical assessment. Periocular conditions and surgeries can also affect the ocular surface and keratometry, and should be addressed. For example, ptosis, orbital fat herniation, ectropion, and eyelid masses have been shown to induce corneal topography changes and astigmatism. The oculoplastic considerations for refractive surgery include both the contribution of eyelid position on dry eye, ocular surface damage, refractive error, and outcomes, as well as the timing of oculoplastic surgery in relation to the refractive surgery. In this review, the recently published literature on eyelid and orbital surgery in relation to keratorefractive surgery is reviewed to elucidate the relationship of periocular factors with refractive surgery outcomes and complications. To improve keratorefractive surgery outcomes, a literature review is presented, discussing evaluation, management, and timing of management of oculoplastics conditions.

RECENT FINDINGS

Dry eye syndrome is a well known complication of keratorefractive procedures. This is exacerbated with concurrent eyelid or orbital disorders, such as ectropion, lagophthalmos, and thyroid eye disease. In addition to impacting dry eye and ocular surface damage, eyelid surgeries can also affect corneal topography and refraction. Studies have found that patients with ptosis have topographic corneal aberrations from the eyelid exerting pressure on the cornea, while ptosis repair and blepharoplasty patients may undergo an astigmatic change postoperatively. Finally, the corneal flap created in laser-assisted in situ keratomileusis may be at risk for displacement or damage postoperatively with this risk changing, depending on method of flap creation, and time elapsed since keratorefractive surgery.

SUMMARY

Eyelid and orbital conditions that predispose to dry eye syndrome and refractive changes should be evaluated and optimized prior to keratorefractive surgery. Patients electing to have oculoplastic surgery, like ptosis repair, should be fully healed prior to any refractive surgery to allow both refractive changes and eyelid positions to stabilize prior to the refractive surgery.