JOURNAL OF EVIDENCE BASED MEDICINE AND HEALTHCARE

Table of Contents

2019 Month : August Volume : 6 Issue : 31 Page : 2126-2129

TO ASSESS THE PROPORTION AND SEVERITY OF DRY EYE FOLLOWING CLEAR CORNEA PHACOEMULSIFICATION SURGERY

Udayaditya Mukhopadhyay1, Mahesh Chattopadhyay2, Sukanta Baidya3

1. Associate Professor, Department of Ophthalmology, North Bengal Medical College, Siliguri, West Bengal.
2. Postgraduate Medical Trainee, Department of Ophthalmology, Regional Institute of Ophthalmology, Kolkata, West Bengal.
3. Medical Officer, Department of Ophthalmology, North Bengal Medical College, Siliguri, West Bengal.

Corresponding Author:
Dr. Mahesh Chattopadhyay,
C/o. Dr. Udayaditya Mukhopadhyay,
CD 182, Salt Lake City,
Kolkata- 700064, West Bengal.
E-mail: baidya1984@gmail.com
DOI: 10.18410/jebmh/2019/433

ABSTRACT
BACKGROUND
Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film. Corneal nerves are important in the self-regulation of a tear since they provide the sensation in the feedback loop that signals tear production. In clear corneal phacoemulsification surgeries, the ocular surface may alter and disrupt normal tear function. We wanted to determine the proportion and severity of dry eye following clear corneal phacoemulsification surgery.

METHODS
Total hundred (100) eyes from consecutive hundred (100) patients fulfilling the inclusion criteria (without a pre-operative dry eye) were selected for clear corneal phacoemulsification surgery under peribulbar anaesthesia for age-related cataract (45-70 yrs.). McMonnies questionnaire was used for subjective dry eye testing. For objective dry eye testing Schirmer Test (ST-I), Tear Film Break Up Time (TBUT), Tear Meniscus Height (TMH) and Lissamine Green (LG) done. The parameters were recorded pre-operatively and post-operatively. Data was analysed using SPSS Software Version 20.

RESULTS
53% operated in the left eye and 47% in the right eye. The proportion of dry eye was assessed at POD 10 and we found 81 subjects had dry eye. The mean and standard deviation of McMonnies 1, 2, 3 were 5.21±2.143, 16.21±6.312, 5.26 ± 2.517; ST-I were 22.21±4.536, 8.06±4.401, 8.89±4.739, 16.40±6.615, 21.35±4.059 at 2 days preoperative, 5 days, 10 days, 1 month, 2 months postoperatively & TBUT was 17.52±2.918, 8.11±4.070, 9.60±3.676, 12.91±2.357, 17.19±1.942 at POD 2, POD 5, POD 10, 1 month, 2 months postoperatively. The mean and standard deviation of TMH were .93±0.256, 0.1±0.1, 0.01±0.1, 0.13±0.338, 0.95±0.219 at 2 days preoperative, 5 days, 10 days, 1 month and 2 months postoperatively. The mean and SD of LG staining of cornea and conjunctiva by Oxford grading was 0.00±0.00, 1.30±0.798, 1.27±0.777, 0.79±0.409, 0.00±0.00 at POD 2, 5 days, 10 days, 1 month and 2 months postoperatively. 48.65% had a dry eye in the age group 45-58 years and 100% had in the age group 59-70. At postoperative 1-month ST-I, TBUT results became normal and TMH, LG staining score showed a rising trend towards a normal level. But at 2 months all the subjects showed normal dry eye parameters.

CONCLUSIONS
Significant percentage of patients showing dry eye symptoms immediately after phacoemulsification surgery. Older age group (≥ 59 years) were more susceptible.

KEYWORDS
Dry Eye, Phacoemulsification, Schirmer Test-I (ST-1), Tear Break Up Test (TBUT), Tear Meniscus Height (TMH), Lissamine Green (LG) Stain of Cornea, Conjunctiva

How to cite this article

Mukhopadhyay U, Chattopadhyay M, Baidya S. To assess the proportion and severity of dry eye following clear cornea phacoemulsification surgery. J. Evid. Based Med. Healthc. 2019; 6(31), 2126-2129. DOI: 10.18410/jebmh/2019/433

BACKGROUND

Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play an etiological role.1

Dry eye is characterized by various degree of discomforts such as burning, stinging, grittiness, foreign body sensation, photophobia, and blurriness. Dry eye is one of the most important factors influencing the quality of life in the elderly population. Moderate and severe dry eye can impair the ability of patients to perform activities of daily living, impact work productivity and influence mood and confidence.2 The overall impact of moderate dry eye on patients has in fact been quantified as being similar to the impact of moderate angina.3

Epidemiological studies have reported that more than 6% of the population over the age of 40 suffers from dry eye, with the prevalence increasing to 15% of the population over the age of 65.3,4,5 Corneal nerves are important in the self-regulation of a tear since they provide the sensation in the feedback loop that signals tear production. A cataract is the leading cause of reversible blindness in our country. In clear corneal phacoemulsification surgeries, the ocular surface may halter and disrupt normal tear function.6,7

       We wanted to assess the proportion and severity of dry eye following clear corneal phacoemulsification surgery.

 

METHODS

Institution-based longitudinal, prospective observational study performed in 100 eyes of 100 adult patients (Age- 45-70 yrs.) of both sex group who had undergone clear corneal phacoemulsification study by a single surgeon. 3.2 mm superior or superotemporal clear corneal incision was made just anterior to vascular arcades of the corneoscleral limbus using a keratome. 1 side port incision of 1 mm was made 600 apart. In the post-operative period, the patients were advised to instill antibiotic (Moxifloxacin 0.5%) eye drop one drop 6 times daily for 1 week. Then 1 drop 4 times daily for next 1 week. Steroid eye drop (Prednisolone Acetate 1%) 1 drop 6 times daily for 2 weeks. Then 1 drop 4 times daily for 1 week, 1 drop 3 times daily for 1 week, 1 drop 2 times daily for 1 week, 1 drop once for 1 week. In case of Anterior chamber reaction Tropicamide (0.5%) eye drop was given once daily for 1 week. Dry eye parameters (McMonnies questionnaire method and Schirmer test, tear meniscus height, tear break up time and lissamine green stain) are examined from January 2018- June 2018.

 

Inclusion Criteria

  • Senile cataract
  • Age 45-70 yrs.

 

Exclusion Criteria

  • Past History of Lid pathology (meibomian gland dysfunction, eyelid aperture disorder or lid/globe incongruity, blink disorder, ocular surface disorder etc.,)
  • Past History of any Conjunctival disorder (Vitamin A deficiency related disorder, Past history of pterygium surgery etc,).
  • Past History of Corneal Pathology (Keratitis, HZO, Scar, opacity, dystrophy, degeneration etc,).
  • Systemic disease (Diabetes, thyroid orbitopathy, Sjogren syndrome, Autoimmune disease).
  • History of using the anti-glaucoma drug, artificial eye drops with preservatives.
  • Past history of Contact lens use, any punctal occlusion, any type of refractive surgery.
  • DES
  • Uncooperative patient.

 

The questionnaire was then filled up as per McMonnies questionnaire and graded with a scoring system. Higher score determined the worst condition. By Questionnaire asked to patient and data was collected at POD 2 days, POD 10 days and post-op 2 months. Index score ranging from 0 to 45. For diagnosis of dry eye score, more than 14.5 is recommended. These examinations were repeated on the day-5, day-10, 1-month and 2-months. All data were collected and checked for accuracy on a daily basis. Data were collected &entered in SPSS version 20 IBM corporations, Qualitative data were expressed by percentages with confidence intervals, whereas quantitative data and score were expressed by the mean and standard deviation. Chi-square t-test was used for normally distributed data

 

RESULTS

100 patients underwent phacoemulsification surgery in NBMC& H, from January 2018 to April 2018 postoperatively followed up to 2 months and assessment for the development of dry eye on the basis of ST-I, TMH, TBUT, LG Staining, and McMonnies questionnaire. Postoperatively first 10 days results were deteriorated then normal levels achieved later. Postoperatively 1-month ST-I and TBUT tests were normal. Mean objective duration of the surgery was 13.9±5?min. The mean CDE was 19.39 seconds (SD = 13.06).

 

Age Group

Frequency

Percent

45-58

37

37.0

59-70

63

63.0

Total

100

100.0

Table 1(a). Distribution of The Study Subjects

According to Age Group (n=100)

 

Gender

Frequency

Percent

Male

44

44.0

Female

56

56.0

Total

100

100.0

Table 1b. Distribution of The Study Subjects

According to Gender (n=100)

 

Problem Eye

Frequency

Percent

Right

47

47.0

Left

53

53.0

Total

100

100.0

Table 1c. Distribution of The Study Subjects

According to Operated Eye (n=100)

 

Dry Eye

Frequency

Percent

Present

81

81.0

Absent

19

19.0

Total

100

100.0

Table 1d. Distribution of The Study Subjects According to the Proportion of Dry Eye (n=100) at Postoperative 10 Days

 

Descriptive Statistics

 

N

Minimum

Maximum

Mean

Std. Deviation

McMonnies-1

100

2

12

5.21

2.143

McMonnies-2

100

2

30

16.21

6.312

McMonnies-3

100

2

13

5.26

2.517

Table 2a. McMonnies Score at Different Time Intervals (n= 100)

(McMonnies-1= McMonnies score 2 days preoperative, McMonnies-2= McMonnies score 10 days postoperatively, McMonnies-3= McMonnies score 2 months postoperative)

 

 

 

N

Minimum

Maximum

Mean

Std. Deviation

ST1

100

12

35

22.21

4.536

ST2

100

4

24

8.06

4.401

ST3

100

4

25

8.89

4.739

ST4

100

8

30

16.40

6.615

ST5

100

14

30

21.35

4.059

Table 2b. Schirmer Test-I Values of Study Subjects at Different Time Intervals (n= 100)

(ST1= Schirmer Test 2 days preoperative, ST2= Schirmer Test 5 days postoperative, ST3= Schirmer Test 10 days postoperative, ST4= Schirmer Test 1 month postoperative, ST5= Schirmer Test 2 months postoperative)

 

 

N

Minimum

Maximum

Mean

Std. Deviation

TBUT1

100

12

22

17.52

2.918

TBUT2

100

4

18

8.11

4.070

TBUT3

100

4

18

9.60

3.676

TBUT4

100

10

20

12.91

2.357

TBUT5

100

12

24

17.19

1.942

Table 2c. Values of Tear Break Up Time Test at Different Time Intervals (n=100)

(TBUT1=Tear Break Up Time 2 days preoperative, TBUT2=Tear Break-Up Time 5 days  postoperative, TBUT3=Tear Break-Up Time 10 days postoperative, TBUT4=Tear Break-Up Time1 month postoperative, TBUT5=Tear Break-Up Time 2 months postoperative)

 

 

N

Minimum

Maximum

Mean

Std. Deviation

TMH1

100

0

1

.93

.256

TMH2

100

0

1

.01

.100

TMH3

100

0

1

.01

.100

TMH4

100

0

1

.13

.338

TMH5

100

0

1

.95

.219

Table 2d. Values of Tear Meniscus Height Test at Different Time Intervals (n=100)

(TMH1= Tear Meniscus Height 2 days preoperative, TMH2= Tear Meniscus Height 5 days postoperative, TMH3= Tear Meniscus Height 10 days postoperative, TMH4= Tear Meniscus Height 1 month postoperative, TMH5= Tear Meniscus Height 2 months postoperative)

 

 

N

Minimum

Maximum

Mean

Std. Deviation

LG1

100

0

0

.00

.000

LG2

100

0

3

1.30

.798

LG3

100

0

3

1.27

.777

LG4

100

0

1

.79

.409

LG5

100

0

0

.00

.000

Table 2e. Values of Lissamine Green Grading at Different Time Intervals (n=100)

(LG1= Lissamine Green grading value 2 days preoperative, LG2= Lissamine Green grading value 5 days postoperative, LG3= Lissamine Green grading value 10 days postoperative, LG4= Lissamine Green grading value 1 month postoperative, LG5= Lissamine Green grading value 2 months postoperative. where n=100)

 

Age Group

Dry Eye

Total

Present

Absent

45-58

18

19

37

59-70

63

0

63

Total

81

19

100

Table 3a. Association of Dry Eye with Age Groups of The Study Subjects (n=100) at Postoperative 10 Days

* Chi-square value- 39.940, p value =0.001, df= 1

 

Sex

Dry eye

Total

Present

Absent

Male

38

6

44

Female

43

13

56

Total

81

19

100

Table 3b. Association of Dry Eye with Gender of The Study Subjects (n=100) at Postoperative 10 Days

* Chi-square value- 1.469, p value =0.226, df= 1

DISCUSSION

Cataract surgery has widely been seen to adversely affect the tear film status in the early postoperative period, hence leading to the development of the dry eye in various studies.8,9 At the Hawaiian Eye 2011 meeting, a report has discussed the results of a prospective multicentre study which assessed the prevalence of dry eye in 272 eyes that underwent cataract surgery. The study found that > 60% of eyes had abnormal TBUT, 50% of eyes had central corneal staining and 21.3% of eyes had low Schirmer test results.9

Our study was a single -center, longitudinal, prospective, observational clinical study. In our study we found Male: Female ratio (M: F) was 0.79: 1.47% of study subjects got operated in right eye and rest operated in the left eye and then subsequently assessed for dry eye. The proportion of dry eye was assessed at postoperative 10 days and we found 81 subjects had dry eye and 19 subjects don’t have dry eye. No other study published earlier assessed the proportion of dry eye after cataract surgery by phacoemulsification. The mean and standard deviation of McMonnies 1, 2, 3 assessed at 2 days preoperatively, 10 days postoperative and 2 months postoperative period were 5.21±2.143, 16.21±6.312, 5.26 ± 2.517. It showed an increase in mean value from 5.21 to 16.21 that came down to 5.26. So it shows a rising trend initially and then it comes to near normal when assessed at postoperative 2 months.

Sahu PK et al exhibited a sharp rise on the 5th postoperative day, followed by a very slow steady rising trend.6 Sinha M et al. in their study compared OSDI (Ocular Surface Disease Index) between study subjects who had undergone manual small incision cataract surgery and those who had undergone phacoemulsification. It suggested that both in SICS and Phaco surgery OSDI score steadily decreased in the follow-up period up to 3 months.10

In our study tests done to assess dry eye were Schirmer Test (ST-I) without anaesthesia, Tear Break Up Time (TBUT), Tear Meniscus Height(TMH), Lissamine Green (LG) staining of cornea and conjunctiva with their grading. The mean and standard deviation of ST-I were 22.21±4.536, 8.06±4.401, 8.89±4.739, 16.40±6.615, 21.35±4.059 at 2 days preoperative, 5 days, 10 days, 1 month, 2 months postoperatively. So, there is a progressive decrease in ST-I value postoperatively on day 5 and day 10, after which, however, a gradual rising trend was seen towards normal value up to our last follow-up of 2 months.

Sahu PK et al. in a study showed postoperatively, it progressively decreased when assessed on day 5 and day 10, after which, however, a gradual rising trend was seen up to their follow-up of 2 months.6 Kasetsuwan N et al. in a study showed on day 7 postoperatively, the mean scores Schirmer I without anesthesia (preoperatively vs. postoperatively, 14.14 vs. 7.57) showed a trend toward dry eye syndrome.11

In our study, the mean and standard deviation of Tear Meniscus Height (TMH) were .93±0.256, 0.1±0.1, 0.01±0.1, 0.13±0.338, 0.95±0.219 at 2 days preoperative, 5 days, 10 days, 1 month and Ophthalmology months postoperatively. It shows the initial decreasing trend on day 5, day 10 and 1 month postoperatively. But it then gets a rising trend and attains near normal or preoperative value at 2 months postoperative.

Liu Z et al. in a study of 68 consecutive patients with age-related cataract (79 eyes) who underwent phacoemulsification. The height of tear meniscus was measured preoperatively and 1 day and 2, 7, 14, 30, 180 days postoperatively.12 The tear break-up time, corneal fluorescein staining scores and the grades of tear film pattern all recovered at 30 days postoperatively (P >0.05).

In our study association of dry eye was assessed according to different age group before postoperative 1 month. In the age group of 45-58 years, 18 subjects (48.65%) had dry eye and 19 subjects (51.35%) don’t have dry eye before postoperative 1 month. In the age group of 59-70 years, 63 subjects (100%) had dry eye before postoperative 1 month. So, in the age group of 45-70 years, 81 subjects (81%) had dry eye and 19 subjects (19%) don’t have dry eye before postoperative 1 month. But at postoperative 2 months, all the parameters to assess dry eye showed results like normal preoperative value.

 

CONCLUSIONS

In this study, there is a significant percentage of patients showing dry eye symptoms immediately after phacoemulsification surgery but at postoperative 2 months all the parameters to assess dry eye trends towards a normal level. Dry eye symptoms were found mainly in the older age group (≥59 years). Dry eye symptoms were found more in females than males.

 

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