The tear film plays a crucial role in maintaining ocular surface integrity and ensuring clear vision. Disruption of this finely balanced system can lead to dry eye disease (DED), a condition that causes ocular discomfort and, in more severe cases, damage to the cornea and conjunctiva. Particularly among the elderly, DED significantly affects quality of life, presenting with symptoms such as foreign body sensation, eye fatigue, and redness.[1]

DED is a multifactorial disorder of the tear film and ocular surface, characterized by discomfort, visual disturbances, and tear film instability, which may lead to ocular surface damage. It is commonly associated with increased osmolarity of the tear film and ocular surface inflammation.[2] Globally, DED is among the most prevalent ocular conditions, affecting millions of individuals—especially those over the age of 65.[3]

Cataract remains the leading cause of reversible blindness worldwide.[4–7] Phacoemulsification is now the standard surgical technique for cataract removal due to its safety profile, rapid postoperative recovery, and minimal induced astigmatism. Clear cornea phacoemulsification, in particular, is widely performed as an outpatient procedure with excellent visual outcomes and low complication rates when uneventful.

However, even when uncomplicated, phacoemulsification may cause transient ocular surface disturbances, including reduced tear production and instability. These changes are attributed to factors such as surgical trauma, postoperative inflammation, topical medications, and corneal nerve disruption.[8,9] Previous studies have reported slight reductions in Schirmer test values and tear breakup time after phacoemulsification,[10] alongside a marked increase in dry eye symptoms following surgery.[11] This highlights the need for thorough evaluation of tear film changes in cataract patients.

Although various studies have investigated tear film changes after ocular surgeries, limited data exist on the specific effects of uneventful phacoemulsification. Existing reports often lack standardized diagnostic criteria and focus on patients with pre-existing tear dysfunction or systemic comorbidities.[12] This leaves a gap in our understanding of dry eye outcomes in otherwise healthy individuals undergoing routine cataract surgery. The purpose of this study was to evaluate the incidence and severity of dry eye symptoms following uneventful phacoemulsification surgery.

Objective

• The aim of this study was to evaluate the incidence and severity of dry eye symptoms following uneventful phacoemulsification surgery.

This prospective observational study was conducted at the Department of Ophthalmology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, between August 2007 and July 2008. A total of 50 patients who underwent uneventful phacoemulsification surgery were included.

Inclusion Criteria

• No pre-existing dry eye disease (OSDI <23, TBUT ≥10 sec, Schirmer I ≥10 mm)
• Scheduled for routine phacoemulsification with intraocular lens implantation
• Willingness to attend all follow-up visits

Exclusion Criteria

• History of pre-existing dry eye disease or abnormal tear function (OSDI ≥23, TBUT <10 sec, Schirmer I <10 mm).
• Presence of ocular surface or eyelid disorders.
• Use of systemic or topical medications known to affect tear production (e.g., antihistamines, antidepressants, retinoids).

This study evaluated patients undergoing uneventful phacoemulsification using standardized surgical protocols: clear corneal incisions under topical anesthesia (proparacaine 0.5%) with preservative-free viscoelastics and in-the-bag IOL implantation. Dry eye parameters were assessed preoperatively and at 1-week, 1-month, and 3-month follow-ups using OSDI questionnaires (symptom severity), fluorescein-assisted TBUT (tear film stability), and unanesthetized Schirmer I tests (aqueous production), with dry eye diagnosis requiring OSDI ≥13 + TBUT ≤5 sec + Schirmer I ≤10 mm. Severity was graded at peak incidence (1 week) as mild (OSDI 13-22 + TBUT 6-9 sec), moderate (OSDI 23-32 + TBUT 4-5 sec), or severe (OSDI ≥33 + TBUT ≤3 sec). Statistical analysis employed SPSS v20.0, with paired t-tests comparing preoperative versus postoperative parameters (significance: p<0.05).

Table 1: Demographic Characteristics of the Study Population (n = 50)

Table 1 summarizes the demographic profile of the 50 participants in the study. The mean age of the participants was 62.1 ± 8.85 years, with the majority (46.0%) falling within the 60–69 age group, followed by 50–59 years (24.0%), 70–79 years (20.0%), and 40–49 years (10.0%). The gender distribution revealed that 60.0% of participants were male and 40.0% were female.

Table 2: Baseline Ocular Surface Parameters of the Study Population (n = 50)

Table 2 presents the baseline ocular surface parameters of the 50 study participants before undergoing uneventful phacoemulsification surgery. The mean Ocular Surface Disease Index (OSDI) score was 18.7 ± 1.9, indicating mild dry eye symptoms preoperatively. Tear film break-up time (TBUT) averaged 14.0 ± 0.6 seconds, while the Schirmer I test value was 18.8 ± 1.2 mm, both reflecting normal tear production and ocular surface stability at baseline.

Table 3: Postoperative Ocular Surface Parameters and Dry Eye Incidence at Different Time Points

Table 3 illustrates the postoperative changes in ocular surface parameters and the incidence of dry eye at 1 week, 1 month, and 3 months following uneventful phacoemulsification surgery in 50 patients. OSDI scores progressively declined, indicating an improvement in subjective symptoms over time. TBUT values showed gradual recovery of tear film stability, while Schirmer I test results reflected improving aqueous tear production. The incidence of dry eye decreased steadily from 44.0% at 1 week to 20.0% at 3 months, suggesting that postoperative dry eye symptoms were transient and improved with time.

Table 4: Changes in Ocular Surface Parameters Over Time Post-Phacoemulsification Surgery

Table 4 summarizes the temporal changes in key ocular surface parameters, including OSDI scores, TBUT, and Schirmer I test results, following uneventful phacoemulsification surgery. Significant improvements were observed across all parameters from baseline to 3 months postoperatively. OSDI scores decreased from 18.7 ± 1.9 at baseline to 8.3 ± 1.5 at 3 months (p < 0.001), indicating a reduction in dry eye symptoms. Similarly, TBUT and Schirmer I test results demonstrated notable improvement, with values increasing from 4.2 ± 0.3 sec and 13.5 ± 1.6 mm at 1 week to 8.4 ± 0.5 sec and 16.8 ± 1.3 mm at 3 months, respectively (both p < 0.001).

Table 5: Severity of Dry Eye Symptoms at 1 Week Post-Phacoemulsification Surgery

Table 5 illustrates the distribution of dry eye severity one week after uneventful phacoemulsification surgery. The majority of patients (56%) reported no symptoms of dry eye, while 28% experienced mild symptoms. Moderate and severe dry eye symptoms were observed in 12% and 4% of patients, respectively, highlighting that although postoperative dry eye is common, it is predominantly mild and transient in nature.

This study explores the incidence and severity of dry eye symptoms following uneventful phacoemulsification surgery in a tertiary care setting in Bangladesh. Although phacoemulsification is considered a safe and routine procedure, transient ocular surface changes can still occur postoperatively, affecting patient comfort and visual satisfaction. By assessing changes in tear film stability, aqueous production, and symptom severity over time, this study reveals that dry eye symptoms are relatively common in the early postoperative period but tend to improve significantly within three months. These findings underscore the importance of proactive monitoring and patient education to mitigate discomfort and enhance surgical outcomes.

In this study, the demographic profile of the participants showed a mean age of 62.1 ± 8.85 years, with the majority (46%) falling within the 60–69-year age group. The gender distribution revealed a higher proportion of males (60%) compared to females (40%). These findings are consistent with previous studies, such as that of Li et al.[13], which involved participants aged 55–75 years (21 men and 16 women, 50 eyes), and Ram et al.[14], where the mean age was 59.6 ± 10.05 years (range 40–79 years) with a similar gender distribution (13 men and 10 women). Likewise, Liu et al.[15] reported a mean age of 64.3 years in their cohort of 25 patients (16 males and 9 females), while Khanal et al.[16] documented an average age of 70.83 ± 10.66 years, comprising 7 males and 11 females. The age range in our study is reflective of the typical cataract surgery population, with older patients being more prone to developing dry eye symptoms postoperatively. The male predominance observed in our sample aligns with trends in other cataract studies, although gender differences in dry eye incidence post-surgery have been noted in various studies. These demographic similarities suggest that our study sample is comparable to other cataract surgery cohorts, providing a solid foundation for analyzing the incidence and severity of dry eye following uneventful phacoemulsification surgery.

Our preoperative assessment confirmed excellent ocular surface health (OSDI: 18.7 ± 1.9; TBUT: 14.0 ± 0.6 sec; Schirmer I: 18.8 ± 1.2 mm), establishing an optimal baseline for surgical impact evaluation. The marked TBUT reduction at 1 week (4.2 ± 0.3 sec) corresponds with Pisella et al.'s [17] findings regarding preservative effects from postoperative medications, with subsequent recovery to 8.4 ± 0.5 sec by 3 months demonstrating characteristic tear film restoration. Similarly, the transient Schirmer I fluctuation (13.5 ± 1.6 mm to 16.8 ± 1.3 mm) aligns with Calvillo et al.'s [18] and Sitompul et al.'s [19] documentation of corneal nerve regeneration patterns following refractive procedures, indicating common neurotrophic recovery pathways. These synchronized improvements in both tear film stability and aqueous production confirm postoperative dry eye as a self-limiting condition, mediated primarily by temporary neural disruption and medication-related effects that resolve with time.

Our longitudinal data demonstrate consistent dry eye resolution following phacoemulsification, with OSDI scores improving from 14.5 ± 1.7 (1 week) to 8.3 ± 1.5 (3 months) (p<0.001). This trend contrasts with Liu et al.'s [11] report of worsening symptoms, highlighting our cohort's distinct recovery pattern. The TBUT nadir at 1 week (4.2 ± 0.3 sec) reflects Pisella et al.'s [17] findings on preservative toxicity, while its subsequent recovery to 8.4 ± 0.5 sec by 3 months demonstrates natural tear film stabilization. Schirmer I values (13.5 ± 1.6 mm to 16.8 ± 1.3 mm) mirror Calvillo et al.'s [18] and Sitompul et al.'s [19] documentation of neural regeneration patterns, suggesting shared corneal nerve repair mechanisms between phacoemulsification and refractive surgeries. The declining dry eye incidence (44% → 20%) further supports Donnenfeld et al.'s [20] characterization of post-surgical dry eye as transient, with recovery kinetics influenced by surgical precision (e.g., minimized incision trauma) and preoperative ocular surface optimization.

This study demonstrated significant improvement in all measured dry eye parameters following uneventful phacoemulsification surgery. The OSDI score decreased markedly from 18.7 ± 1.9 preoperatively to 8.3 ± 1.5 at 3 months postoperatively (p < 0.001), indicating substantial relief of subjective symptoms. Objective measures showed parallel recovery: TBUT values improved from 4.2 ± 0.3 seconds at 1 week to 8.4 ± 0.5 seconds at 3 months (p < 0.001), reflecting restored tear film stability, while Schirmer I test results increased from 13.5 ± 1.6 mm to 16.8 ± 1.3 mm (p < 0.001), demonstrating recovery of aqueous tear production. The incidence of dry eye decreased progressively from 44% at 1 week to 20% at 3 months, confirming that postoperative dry eye manifestations are typically transient, with most patients achieving near-complete resolution within the three-month follow-up period. These consistent trends across both subjective and objective measures underscore the self-limiting nature of post-phacoemulsification dry eye in patients with healthy preoperative ocular surfaces.

In this study, the severity of dry eye symptoms at one week following uneventful phacoemulsification surgery was assessed to evaluate the early postoperative impact on the ocular surface. Among the 50 participants, 44% experienced some degree of dry eye, with 28% classified as mild, 12% as moderate, and 4% as severe. The remaining 56% reported no symptoms, indicating that over half of the patients did not experience noticeable ocular surface discomfort during this early recovery phase. These findings suggest that while phacoemulsification can lead to temporary disturbances in tear film stability, the severity of symptoms is generally mild to moderate, with severe cases being rare. This supports the overall safety of the procedure and reinforces its minimal impact on postoperative ocular surface health.

Limitations of the study

This study had some limitations:

• The study was conducted in a selected tertiary-level hospital.
• The sample was not randomly selected.
• The study's limited geographic scope may introduce sample bias, potentially affecting the broader applicability of the findings.

This study shows that dry eye symptoms are a common but generally mild and temporary consequence of uneventful phacoemulsification surgery. While a significant proportion of patients experienced dry eye symptoms in the immediate postoperative period, the severity and incidence of symptoms decreased progressively over time. Most patients reported minimal to no symptoms, with only a small percentage experiencing moderate or severe symptoms. Overall, the results suggest that while dry eye is a frequent postoperative concern, it typically resolves within a few months, indicating that phacoemulsification surgery is generally well-tolerated in terms of ocular surface health.

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