JOURNAL

BY

Riska oktarinda utami,S.ked

(18360138)

Mentor : dr.Rahmad,Sp.M
Dry eye syndrome is a multifactorial disease of pre-corneal tear
film that results in ocular discomfort, visual disturbance, and
tear film instability, with potential damage to the ocular
surface.

Factors that are responsible for development of dry eye after

cataract surgeries include prolong use of antibiotic-steroid eye
drops, decrease tear film break-up time due to surface
irregularity at the site of the incision, decrease mucin
production from the conjunctiva secondary to incision
placement, decrease corneal sensation due to surgical inci-sion
which disrupts the cornea-lacrimal gland loop leading to
reduced tear secretion, poor tear film production and sta-bility
due to surgically induced ocular inflammation and exposure to
light from the operating microscope
Ninety six patients of senile cataract requiring cataract sur-gery
were selected consecutively. The patients were divided into two
study groups – Group 1 cases undergoing manual small incision
cataract surgery (SICS) and Group 2 patients undergoing clear
corneal phacoemulsification surgery. The dry eye related data
was collected preoperatively and at 1 week, 1 month and 3
months postoperatively
Tear film function was assessed by Schirmer test-1 (ST-I) and tear film break-up
time (TBUT) and the ocular symptoms by Ocular Surface Disease Index (OSDI)
score.
* 1. Schirmer’s Test-1
Wetting of the Schirmer’s strip 10 mm was considered dry eye and these
patients were excluded from the study. ST-1 was performed only once.

* 2. Tear film break-up time

TBUT assessment was done and the readings were ana-lyzed to assess the
stability of the pre-corneal tear film – the mucin component of the tear film. The
test was repeated three times, and the average was calculated. TBUT <10 sec
was indicative of dry eye. The time interval between ST-1 and TBUT was 10 min.

* 3. Ocular surface disease index

A structured symptom-based survey was conducted to identify patients with
symptoms suggestive of dry eyes and these patients were excluded from the
study. Accord-ing to the score of OSDI, which is based upon the response to a
questionnaire of 12 questions, subjective symptoms were graded as normal,
mild, moderate and sev-ere based on the guidelines of Dry Eye Workshop (DEWS)
report.
The above tests were done on all the patients at 1 week, 1 month
and 3 months after the surgery. DEWS grading was used to sub-
categorize the severity of dry eye into mild, moderate and severe.
We considered the discomfort severity and the frequency of the
symptoms, TBUT and ST-1 scores from the classification and the
final grading was done by add-ing the scores of the three tests.
Manual SICS with poly methyl methacrylate (PMMA) pos-terior
chamber intraocular lens (PCIOL) implantation was per-formed
with a scleral tunnel incision of 6–8 mm and a side port of 1 mm.
Phacoemulsification surgery with foldable PCIOL was done in the
other group of patients with a 2.8 mm clear corneal incision and
two side ports of 1 mm each. The patients who underwent an
uneventful and uncom-plicated surgery were only included in the
study
* One hundred eyes of 96 patients, including 35 (36.5%) men and 61
(63.5%) women, were enrolled in this study. The mean age was
63.1 (±8.3) years with a range of 46– 85 years. The majority of
women (48, 78.7%) were post-menopausal. The occupation of the
majority of men was agri-culture (20, 64.5%) while most of the
women were house-wives (32, 52.5%).
* Eighty nine per cent of eyes had preoperative best-corrected
visual acuity (BCVA) between 1/60 and 6/24. In the enrolled eyes,
the preoperative mean TBUT was 15.82 sec (±2.99, range 11–22
sec). The preoperative mean score for the ST-1 was 24.33 mm at
five minutes (±5.44, range 15–35 mm).
 CONTINUE...................................

The cataract surgery was performed using SICS technique in 64

eyes (64%) and phacoemulsification in 36 eyes (36%). The mean
duration of surgery was 27.5 min (±10.1, range 10–50 min). The
total microscope light exposure time was lit-tle longer (mean,
31.1 ± 10.5 min) than the duration of surgery.

The length of incision in the SICS group ranged from 6 to 8 mm

(mean, 6.67 ± 0.79 mm) depending on the size of lens nucleus.
Similarly, the length of main incision in the pha-coemulsification
group was 2.8 mm.
Dry eyes were found in 42% eyes at 1 week follow-up. 15% and 9% of the eyes were
dry at 1 month and 3 months after the surgery, respectively

Development of dry eyes at 1 week, 1 month and 3 months postoperatively.

* At one week postoperative follow-up, there were 34 (53.1%) and 8 (22.2%) dry
eyes in the SICS and the phacoemulsification groups, respectively . Moreover, the
severity of the dry eye was more in the SICS group.

Dry eye Preoperative Postoperative follow up

1-week 1-month 3-months

Absent 100 (100%) 58 (58%) 89 (89%) 76 (89.4%)

Mild Nil 27 (27%) 12 (12%) 6 (7.1%)
Moderate Nil 11 (11%) 3 (3%) 3 (3.5%)
Severe Nil 4 (4%) Nil Nil
Total 100 100 100 85

Table 1. Prevalence of dry eye at 1 week, 1 month and 3 months postop-eratively

after cataract surgery.

trend towards the decrease in the severity of dry eye was noted on subsequent
follow-up visits. None of the patients had severe dry eye at 3 month
postoperatively. Out of the nine dry eyes at this visit, 6 (66.7%) had mild and 3
(33.3%) eyes moderate grades of DEWS scores.
* Among 42% patients with dry eyes at 1 week follow-up, the
severity was mild in the majority (27/42, 64.3%). Moder-ate DEWS
score was found in 11 eyes (26.2%) and only four had severe dry
eyes at 1 week postoperatively

Severity of dry eye at one week postoperatively.

Tear film break-up time and Schirmer’s test results
preoperatively and postoperatively after cataract surgery .

Preoperative Postoperative
Tests for dry eye values values

1-week 1-month 3-months

TBUT* (in sec) 15.8 ± 0.31 8.7 ± 0.48 11.2 ± 0.39 14.3 ± 0.37

(p < 0.001) (p < 0.001) (P = 0.089)

Schirmer’s test (in
mm) 24.5 ± 0.59 15.2 ± 0.64 19.7 ± 0.60 21.8 ± 0.64

(p < 0.001) (p < 0.001) (p < 0.001)

Dry eye after cataract surgery 37

Tear film break-up time and Schirmer’s test results
one week after phacoemulsification and small
incision cataract surgery.

Surgical procedure SICS* Phacoemulsification p-

(n = 64) (n = 36) value

Dry eyes 53.1% 22.2% 0.003

TBUT^ (in sec) 10.0 ± 0.55) 13.9 ± 0.70 <0.001

Schirmer’s test (in 19.1 ± 0.89 20.7 ± 0.81) 0.241

mm)

•Small incision cataract surgery. ^ Tear film break-up time.

 * Preoperative OSDI score of 10.5 corresponded to normal or no dry eye.
At 1 week, 1 month and 3 months postopera-tive visits, OSDI score kept
on decreasing (Fig. 3) and the symptoms of dry eye showed a trend
toward improvement-at 1 week 65.5 (that corresponded to moderate dry
eyes), at 1 month 32.5 (mild dry eyes) and at 3 months 14.1 (normal
value).

Fig. 3. Bar graph showing the scores of the Ocular Severity Disease Index (OSDI)
preoperatively, and at 1 week, 1 month and 3 months postoperatively.
Cataract surgery is capable of triggering dry eye symp-toms and
affecting dry eye test values. Dry eye after cataract surgery is
mainly because of tear film instability. The inci-dence of dry eyes
is higher and more severe after SICS than after
phacoemulsification surgery.