Cetinkaya et al.

BMC Ophthalmology (2015) 15:68

DOI 10.1186/s12886-015-0058-3

RESEARCH ARTICLE Open Access

The course of dry eye after

phacoemulsification surgery
Servet Cetinkaya1,6*, Emine Mestan2, Nursen Oncel Acir3, Yasemin Fatma Cetinkaya4, Zeynep Dadaci3
and Halil Ibrahim Yener5

Abstract
Background: The aim of this retrospective study was to evaluate the course of dry eye syndrome after
phacoemulsification surgery.
Methods: One hundred and ninety-two eyes of 96 patients (30 males, 66 females) with chronic dry eye syndrome
and cataract, who had undergone phacoemulsification surgery were enrolled in this study.
Results: Their mean age was 68.46 ± 8.14 standard deviation (SD) (range 56–83) years . Thirty of them (31 %) were
males and 66 (69 %) were females. Ocular Surface Disease Index (OSDI) questionnaire scores increased postoperatively,
but arrived preoperative levels at the end of 3rd month following the surgery. Fluorescein staining patterns according
to Oxford Schema got worse postoperatively, however after postoperative 3rd month they got better and resembled
preoperative patterns. The mean postoperative 1st day, 1st week and 1st month Break-up Time (BUT) values were
significantly lower than preoperative BUT value (P < 0.001, P < 0.001, P < 0.001), however 3rd month, 6th month, 1st year
and 2nd year values were not significantly different from preoperative value (P = 0.441, P = 0.078, P = 0.145, P = 0.125).
The mean postoperative 1st day, 1st week and 1st month Schirmer Test 1 (ST1) values were significantly lower than
preoperative ST1 value (P < 0.001, P < 0.001, P < 0.001), however 3rd month, 6th month, 1st year and 2nd year values
were not significantly different from preoperative value (P = 0.748, P = 0.439, P = 0.091, P = 0.214).
Conclusion: Phacoemulsification surgery may aggravate the signs and symptoms of dry eye and affect dry eye test
values in chronic dry eye patients in short-term. However, in long-term, signs and symptoms of dry eye decrease and
dry eye test values return to preoperative values.
Keywords: Phacoemulsification, Dry eye, Break-up Time, Schirmer

Background body sensation, heaviness of the eyelids, redness, reflex

Dry eye syndrome is a multifactorial disease characterized lacrimation, ocular pain and fatigue. It may cause punctate
by dryness of the ocular surface due to tear deficiency and keratitis, persistent epithelial defect, filamentary kerato-
overevaporation [1, 2]. There are many causes and factors pathy, superior limbic keratoconjunctivitis and reduced
leading to dry eye, including aging, female gender, con- visual acuity [6, 7].
nective tissue diseases, Diabetes Mellitus, systemic hyper- Some surgical interventions related to anterior seg-
tension, contact lens usage, drugs like antihistamines, ment may also cause dry eye and aggravate the symp-
anticholinergics, antidepressants, oral contraceptives and toms in pre-existing dry eye, like PRK, LASIK and
topical eye drops containing preservatives and ocular dis- cataract surgery [8–10].
eases like blepharitis, chronic conjunctivitis, meibomitis In this study, we evaluated the course of dry eye syn-
and pterygium [3–5]. The symptoms observed in dry eye drome after phacoemulsification surgery.
syndrome include dryness, irritation, burning, foreign

* Correspondence: drservet42@gmail.com Methods

1
Ophthalmology Clinics, Turkish Red Crescent Hospital, Konya, Turkey The study protocol was approved by the local ethics
6
Turkish Red Crescent Hospital (Kizilay Hastanesi), Ophthalmology Clinics,
Sukran Mah. Taskapu Medrese Sok. No:15, Meram, 42200 Konya, Turkey commitee (Selcuk University,Faculty of Medicine Ethics
Full list of author information is available at the end of the article Commitee, Konya, Turkey). An informed written consent
© 2015 Cetinkaya et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Cetinkaya et al. BMC Ophthalmology (2015) 15:68 Page 2 of 5

was obtained from the patients for the cataract surgery. interval between last blink and first appearance of a dry
The study was carried out according to the tenets of the spot or tear film break-up was recorded, and this was
Declaration of Helsinki. repeated three times and the average was determined.
One hundred and ninety-two eyes of 96 patients with Values shorter than 10 s indicate dry eye syndrome. For
chronic dry eye syndrome and cataract were enrolled in ST1, Schirmer strip was inserted into the inferior fornix
this study. They had undergone uneventful phacoemulsi- beneath the temporal lid margin, after 5 min, strip was
fication and IOL implantation operation between January removed and the wetness was measured. Values lower
2010 and March 2011. Their medical records were evalu- than 5 mm are diagnostic for dry eye syndrome.
ated retrospectively. Their mean age was 68.46 ± 8.14 (SD)
(56–83) years. Thirty of them (31 %) were male and 66 Statistical analysis
(69 %) were female. They all had bilateral cataracts. All of For statistical analysis, SPSS version 22 programme was
the surgeries were performed by a single surgeon (SC). used. For comparison of the data, Chi-square test and
Under subtenon anesthesia, a 2.75 mm clear corneal inci- Paired t test were used. A P < 0.05 value was accepted as
sion was made. Anterior chamber was filled with a disper- statistically significant.
sive (hydroxypropylmethylcellulose, Easy Visc, Germany)
viscoelastic substance. After continuous curvilinear capsu- Results
lorhexis, hydrodissection and hydrodelineation was per- The time of dry eye diagnosis of these patients was
formed, then a sideport entrance was made. The nucleus approximately 1 to 5 years prior to the surgery. During
was removed by using the “divide and conquer” technique the time of diagnosis at the first examination, all of the
(Sovereing Compact, Phacoemulsification System, AMO, patients had complaints such as burning, stinging,
USA). The cortex was aspirated with coaxial irrigation/ redness, dryness, foreign body sensation, pain and fa-
aspiration. The capsular bag was filled with a cohesive tigue in their eyes. OSDI scores were between 25 and 50
(Na Hyaluronate 1.6, Easyluron, Germany) viscoelastic in 66 (69 %) patients and between 50 and 75 in 30
substance. A foldable monofocal posterior chamber IOL (31 %) patients. Fluorescein staining, BUT and ST1 tests
(Acriva, VSY, Turkey) was implanted in the capsular bag were performed. Twenty-four eyes (12 %) had grade 4,
through an injector system. The viscoelastic material was 42 eyes (22 %) had grade 3, 66 eyes (34 %) had grade 2
aspirated completely. The entrances were closed with stro- and 60 eyes (31 %) had grade 1 staining pattern accord-
mal hydration. After the operation patients used topical ing to Oxford Schema. BUT values were under 10 s in
antibiotic (Moxifloxacin 0.5 %, Vigamox, Alcon, USA) four 138 eyes (72 %) and under 5 s in 54 eyes (28 %). ST1
times a day for a week and topical steroid (Dexamethasone values were under 5 mm in 150 eyes (78 %) and under
Na Phosphate 0.1 %, Dexa-sine SE, Liba, USA) six times a 3 mm in 42 eyes (22 %). We commenced topical artifi-
day for a week and tapered for subsequent 3 weeks. These cial tears therapy for all of them and additional topical
two eyedrops did not contain any preservatives. They were cyclosporin A for 30 of them. Cyclosporin A therapy
all taking artificial tears therapy routinely and 12 of them was ceased and restarted according to the clinical
(12 %) were taking additional topical cyclosporin A. Their courses of the patients.
therapies were not interrupted due to the surgery. Their The frequency of women were significantly higher
full ophthalmological examinations were performed 1 week than that of men (P = 0.003). OSDI scores were under 25
before the surgery and 1st day, 1st week, 1st month, 3rd in 87 (91 %) patients and between 25 and 30 in 9 (9 %)
month, 6th month, 1st year and 2nd year after the surgery patients preoperatively. However, postoperatively in 1st
and additionally fluorescein staining, BUT and ST1 with- week, it was under 25 in 15 (16 %) patients, between 25
out anesthesia were performed owing to the chronic dry and 30 in 33 (34 %) patients, between 30 and 40 in 21
eye. OSDI questionnaire was applied 1 week before the (22 %) patients and between 40 and 50 in 27 (28 %)
surgery and 1st week, 1st month, 3rd month and 6th patients. In postoperative 1st month, it was under 25 in
month after the surgery. 30 (31 %) patients, between 25 and 30 in 39 (41 %)
OSDI score was calculated by this formula: Total patients and between 30 and 40 in 27 (28 %) patients. In
points of all answered questions x 100/Total number of postoperative 3rd month it was under 25 in 84 (88 %)
answered questions x 4. The range of OSDI scores is patients and between 25 and 30 in 12 (12 %) patients. In
between 0 and 100. Scores over 25 shows dry eye syn- postoperative 6th month it was under 25 in 90 (94 %)
drome. Fluorescein staining was classified according to patients and between 25 and 30 in 6 (6 %) patients.
Oxford Schema (Grade 0 to 5). Grade 2 and greater than According to Oxford Schema, preoperatively only 15
this level indicate dry eye syndrome. For BUT, a fluo- eyes had grade 2 fluorescein staining (7 %). But postop-
rescein strip was placed in the inferior fornix and the eratively on 1st day, 36 eyes had grade 2 (18 %), 24 eyes
patient was asked to blink several times and with slit had grade 3 (12 %) and 12 eyes had grade 4 (6 %) fluor-
lamp biomicroscopy by using cobalt blue filter, the escein staining pattern. In 1st week 24 eyes had grade 2
Cetinkaya et al. BMC Ophthalmology (2015) 15:68 Page 3 of 5

(12 %) and 12 eyes had grade 3 (6 %) staining. In 1st impaired up to 1st month postoperatively, however, after
month 18 eyes had grade 2 (9 %) and 6 eyes had grade 3 1st month, they improved and they returned to preopera-
(3 %) staining. In 3rd month, only 6 eyes had grade 2 tive levels in 3rd month (Additional file 1).
staining pattern (3 %). The mean preoperative BUT
value was 11.65 ± 2.31 (SD) (7–16) seconds. Postopera- Discussion
tive 1st day value was 7.60 ± 1.24 (SD) (5–11), 1st week Cornea is innervated by long ciliary nerves of ophthal-
value 7.03 ± 0.97 (SD) (5–9), 1st month value 7.42 ± 0.79 mic branch of the fifth (trigeminal) nerve. In normal
(SD) (6–8), 3rd month value 11.76 ± 2.08 (SD) (9–16), conditions, these nerves send afferent stimuli to brain
6th month value 12.01 ± 2.05 (SD) (9–16), 1st year value stem and parasymphathetic and symphathetic signals
11.85 ± 2,01 (SD) (8–17) and 2nd year value was 11.95 ± stimulate lacrimal gland for tear production and secre-
1.92 (SD) (9–17) seconds. In comparison with preopera- tion [11–13]. For normal blinking and tearing reflexes,
tive value, the 1st day, 1st week and 1st month values intact corneal innervation is necessary. Damage of this
were significantly lower (P < 0.001, P < 0.001,P < 0.001), circuit causes dry eye. Surgical procedures like PRK,
however 3rd month, 6th month, 1st year and 2nd year LASIK, extracapsular cataract extraction and phacoe-
values were not significantly different from preoperative mulsification causing denervation of cornea result in
value (P = 0.441, P = 0.078, P = 0.145, P = 0.125). This is decreased blinking and reduction in tear production
shown in Fig. 1. thus leading to increased epithelial permeability, decreased
The mean preoperative ST1 value was 6.39 ± 1.42 (SD) epithelial metabolic activity and impaired epithelial wound
(4–9) mm. Postoperative 1st day value was 4.59 ± 1.06 healing [14, 15]. Inflammatory mediators released after cor-
(SD) (3–7), 1st week value 4.45 ± 0.95 (SD) (2–6), 1st neal incisions may also change the actions of the corneal
month value 4.50 ± 1.00 (SD) (3–6), 3rd month value nerves and reduce corneal sensitivity and result in tear film
6.42 ± 1.31 (SD) (4–9), 6th month value 6.46 ± 1.28 (SD) instability [16, 17]. In healing process, neural growth factor
(4–10), 1st year value 6.59 ± 1.38 (SD) (4–9) and 2nd year is released to regenerate the subepithelial corneal axon, this
value was 6.54 ± 1.29 (SD) (4–9) mm. In comparison with process is completed approximately within 1 month and
preoperative value, 1st day, 1st week and 1st month values this recovery of the nerves may explain why dry eye signs
were significantly lower (P < 0.001, P < 0.001, P < 0.001), and symptoms are prominent early after surgery and im-
however 3rd month, 6th month, 1st year and 2nd year prove thereafter [16]. This is in accordance with our study.
values were not significantly different from preoperative Incision site is larger in LASIK and extracapsular cataract
value (P = 0.748, P = 0.439, P = 0.091, P = 0.214). This is extraction in comparison with phacoemulsification, hence,
shown in Fig. 2. dry eye signs and symptoms are more prominent and last
By the way, the subjective symptoms of the patients re- longer in these patients [18, 19].
lated to dry eye increased postoperatively. But after post- Vigorous irrigation of the cornea intraoperatively and
operative 1st month, their complaints decreased gradually. ocular surface manipulation deteriorate tear film stabil-
As it was seen; fluorescein staining, BUT and ST1 were ity and may reduce goblet cell density and thus cause

Fig. 1 The course of BUT values

Cetinkaya et al. BMC Ophthalmology (2015) 15:68 Page 4 of 5

Fig. 2 The course of ST1 values

shortened BUT postoperatively [6, 20]. Exposure to cataract surgery. Han et al. [23] reported that Meibomian
microscope light may also aggravate dry eye symptoms gland function may be altered without accompanying
postoperatively [15]. In our study also, BUT values structural changes after cataract surgery.
decreased postoperatively. Movahedan et al. [24] reported that, maintaining a
The use of topical anesthesia, topical eye drops con- healthy ocular surface is essential for achieving the best
taining preservatives like benzalkonium chloride admin- visual outcome in cataract patients. Ocular surface prep-
istered preoperatively and postoperatively may cause aration is beneficial not only in patients with established
tear film instability and decrease the number of mucin ocular surface disease, but also in those with minimal
expressing cells and lead to dry eye postoperatively [21, 22]. signs or symptoms of surface disease. Chung et al. [25]
We did not use any topical eye drops containing preser- suggested that, cyclosporine 0.05 % can be an effective
vatives postoperatively for our patients not to increase treatment for dry eye after cataract surgery.
dry eye symptoms.
We did not divide the patients into subgroups accord- Conclusion
ing to their degree of dry eye severity. We evaulated the Phacoemulsification surgery may aggravate the signs and
patients as one group statistically. The use of means of symptoms of dry eye and affect dry eye test values in
this group’s test results might mask subgroups which chronic dry eye patients in short-term. However, in
might behave differently from the group as a whole. long-term, signs and symptoms of dry eye decrease and
That was our limitation in this study. dry eye test values return to preoperative values.
Khanal et al. [9] reported that deterioration in corneal
sensitivity and tear physiology was seen immediately
after phacoemulsification. Corneal sensitivity didn’t re- Additional file
turn to preoperative levels until 3 months postopera-
Additional file 1: STROBE Statement.
tively whereas the tear functions recovered within
1 month. Kasetsuwan et al. [20] reported that, signs and
syptoms of dry eye occured as early as 7 days post- Abbrevations
phacoemulsification and the severity pattern improved SD: Standard Deviation; OSDI: Ocular Surface Disease Index; BUT: Break-up
Time; ST1: Schirmer Test 1.
over time. In our study also, dry eye test values returned
to preoperative values after postoperative 3rd month. Competing interests
Oh et al. [19] reported that, the decrease in goblet cell The authors declare that they have no competing interest.
density, which was correlated with operation time, had
not recovered at 3 months after cataract surgery, there- Authors’ contributions
fore, microscopic ocular surface damage during cataract SC conceived the idea of the study, performed all examinations and
operations and wrote the article and performed the statistical analysis. EM,
surgery seems to be one of the pathogenic factors that NOA, YFC, ZD and HIY helped with design and methodology of the study.
causes ocular discomfort and dry eye syndrome after All authors read and approved the final manuscript.
Cetinkaya et al. BMC Ophthalmology (2015) 15:68 Page 5 of 5

Acknowledgments 23. Han KE, Yoon SC, Ahn JM, Nam SM, Stulting RD, Kim EK, et al. Evaluation
The authors report no conflicts of interest. There is no source of funding to of dry eye and meibomian gland dysfunction after cataract surgery.
disclose. The authors alone are responsible for the content and writing of Am J Ophthalmol. 2014;157:1144–50.
the paper. 24. Movahedan A, Djalilian AR. Cataract surgery in the face of ocular surface
disease. Curr Opin Ophthalmol. 2012;23:68–72.
Author details 25. Chung YW, Oh TH, Chung SK. The effect of topical cyclosporine 0.05 % on
1
Ophthalmology Clinics, Turkish Red Crescent Hospital, Konya, Turkey. dry eye after cataract surgery. Korean J Ophthalmol. 2013;27:167–71.
2
Department of Neurology, Dumlupinar University, Faculty of Medicine,
Kutahya, Turkey. 3Department of Ophthalmology, Faculty of Medicine,
Mevlana University, Konya, Turkey. 4Department of Ophthalmology, Ataturk
Training and Research Hospital, Ankara, Turkey. 5Konya Eye Centre Hospital,
Konya, Turkey. 6Turkish Red Crescent Hospital (Kizilay Hastanesi),
Ophthalmology Clinics, Sukran Mah. Taskapu Medrese Sok. No:15, Meram,
42200 Konya, Turkey.

Received: 29 January 2015 Accepted: 16 June 2015

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