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TBUT                         - tear breakup time
BCVA                         - best corrected visual acuity
IOL                          - intraocular lens
PHACO - phacoemulsification


A healthy ocular surface and a stable tear film are essential to preserve the smooth optical surface of the cornea. Tears are made up of three layers: the lipid layer on the outside, the aqueous layer in the middle, and the inner mucus layer. The three layers together are known as the tear film. The main functions of the tear film are lubrication, nutrition and prevention of conjunctival and corneal infections.

Dry eye syndrome or keratoconjunctivis sicca is the most common ocular surface disease throughout the world [1]. This autoimmune disorder consists of qualitative and quantitative changes of the tear film. The cause of the tear film dysfunction is the alteration of tear aqueous, mucus and lipid component. It is estimated that 8 - 35% of the population has dry eye syndrome [1, 2].

Dry eye syndrome has a multifactorial origin and main risk factors are female gender, advanced age, and morphological changes in the lacrimal glands. Although the etiologies of dry eye are various, common to all ocular-surface disease is an underlying cytokine/receptor-mediated inflammatory process [3].

The Dry Eye Workshop, in 2007, defined dry eye as a multifactorial disease of tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface, which is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface [4]. The majority of dry eye symptoms (foreign body sensation, ocular fatigue, blurring, photophobia, red eye, feeling of heavy eyelids, epiphora etc.) are due to loss of tear film integrity.

Significant progress in the treatment of dry eye has been made in the last two decades; progressing from lubricating and hydrating the ocular surface with artificial tear to stimulating tear secretion; anti-inflammation and immune regulation [5].

Cataract surgery is a clinically effective and safe surgical procedure, and the risks of sight threatening complications are low. High rate of surgical success has created high expectations of patients regarding the vision outcome and improvement in vision related everyday activities [6, 7].

Dry eye has become a common problem after ophthalmic surgeries with a significant impact on the quality of life. Many patients who have undergone cataract surgery have complained of postoperative dry eye and symptoms of irritation [8, 9].

Dry eye is one of the risks associated with cataract surgery. Cataract surgery has been found to exacerbate pre-existing dry eye and to induce dry eye in patients with healthy corneas. This postoperative dry eye can negatively affect visual outcomes and visual recovery time [10]. Since the incidence of dry eye and cataract both increase with age, it is not a surprise that four out of five cataract patients may have moderate to severe dry eye symptoms [11].

The aim of this prospective study was to determine the incidence and natural course of dry eye, self reported dry eye symptoms, and to identify risk factors for development of dry eye after cataract surgery.

Material and Methods

This prospective study included 80 patients with senile cataract who underwent surgery at the Eye Clinic of the Clinical Center of Vojvodina in Novi Sad.

All patients underwent clinical and ophthalmological evaluation before cataract surgery with phacoemulsification (PHACO) and foldable intraocular lens (IOL) implantation (PHACO + IOL) and 7 days and 1 moth after the cataract surgery.

We recorded the self-reported dry eye symptoms (foreign body sensation, discomfort, dryness, redness of eye and watery eyes) preoperatively and after the surgery. Tear dynamics were assessed by Schirmer test. After placing a small strip of filter paper inside the inferior fornix, the eyes were closed for 5 minutes. The paper was then removed and the amount of moisture was measured. Both eyes were tested at the same time.

According to Schirmer test values, the patients were divided into 3 groups:

Group A. Mild (10 - 14 mm wetting of the paper after 5 minutes),

Group B. Moderate (5 - 9 mm wetting of the paper after 5 minutes),

Group C. Severe (< 5 mm wetting of the paper after 5 minutes).

To measure the tear breakup time (TBUT), 2% sodium fluorescein was instilled into the patient tear film, and all eyes were examined with a slit lamp under cobalt blue light. The TBUT was recorded as the number of seconds that elapsed between the last blink and the appearance of the first dry spot in the tear film. A TBUT under 10 seconds was considered abnormal.

The values of Schirmer test, TBUT, self-reported dry eye symptoms and visual acuity were evaluated before and after the cataract surgery. Patients with other general health problems (allergy, rheumatoid arthritis, stroke etc.) or any eye conditions accompanied with cataract (pterygium, cornea guttata, glaucoma, diabetic eye disease etc.) or any intraoperative and postoperative complications that may have contributed dry eye symptoms (corneal trauma, vitreous loss, corneal edema, Descemet folds, bullous keratopathy etc.) were not included in the study.


A total of 80 patients were included in this study, 45 (56.2%) females and 35 (43.8%) males. The mean age of patients was 61.5 years (SD [+ or -] 6.2, range 57 - 70 years). According to maturity, an immature cataract was found in 47 (58.75%) eyes, intumescent cataract in 6 (7.5%), mature cataract in 23 (28.75%), and hypermature in 4 (5%) eyes (Figure 1).

At the time of surgery, best corrected visual actuivity (BCVA) was 0.4 or lower in 70 (87.5%) patients. A significantly better postoperative BCVA was established in most patients; 68 (85%) eyes achieved a BCVA of 0.5, or better (median 0.7, range 0.5 - 1.0). The remaining 12 (15%) eyes had a BCVA of 0.2, or better (median 0.3, range 0.2 - 0.4). The main preoperative and postoperative BCVA values are shown in Figure 2.

The mean TBUT in cataract patients before surgery was 12.4 seconds, 7 days after the surgery 8.2 seconds (p<0.05) and 1 month after the surgery 11.1 seconds. The mean values of TBUT are shown in Figure 3.

The majority of patients had mild (47.5%) and moderate (33.75%) Schirmer test values. Dry eye with wetting < 5 mm after 5 minutes were found in 16.2% before cataract surgery, and 23.75% 7 days (p < 0.05) and one month after the surgery 21.25%. Schirmer test values in A, B and C groups before and after the surgery are shown in Table 1.

Foreign body sensation and watery eye were the most commonly reported symptoms before the cataract surgery. Seven days after the surgery, foreign body sensation was present in 48.75%, and watery eye in 40%. There were more self reported dry eye problems 7 days and 1 month after the surgery. Self reported dry eye symptoms in cataract patients are shown in Table 2.


Cataract surgery has become one of the most frequently performed and most successful surgical procedures with positive outcome [12]. Advances in new technology have led to the development of small incision PHACO surgery. These techniques have increased the efficacy of surgery with faster rehabilitation and reintegration in daily life activities.

High rate of surgical success has led to high expectations of patients regarding the vision outcome and improvement in vision related everyday activities [13]. In our study, visual acuity after cataract surgery was improved in the majority of the operated eyes. The largest group achieved good visual results after cataract surgery, 85.2% of operated patients with BCVA > 0.5.

Epitropoulos et al., in the research on the effect of tear osmolarity on repeatability of keratometry for cataract surgery planning, showed that taking care of dry eye syndrome before cataract surgery provides patients not only with more comfortable eyes but also better vision after surgery [14].

The prevalence and risk factors associated with dry eyes were evaluated in many studies. Lee et al., in their population based study, reported most dry eye symptoms in 40-49 year age group (37.6%), and a significant increase in dry eye symptoms was found with increasing age. The prevalence of dry eye was 1.4 times higher in men than in women [15].

In our study, 13/80 (16.2%) cataract patients had severe dry eye evaluated using Schirmer test with values 5 mm or less. The mean age of patients was 61.5 years (SD [+ or -] 6.2, range 57 - 70 years) and 45 (56.2%) were females.

Increased age and dry eye has also been reported in the study of Moss [16] and McCarty [17], although Schein et al. [18] found no age correlation et all.

In our study, the Schirmer test values showed significant changes 7 days after the surgery in the group with severe values before the cataract surgery (group C).

Barabino et al. conducted a study including forty subjects undergoing PHACO for cataract extraction and reported that Schirmer test values did not show any significant changes throughout the study, but statistically significant changes in symptoms, corneal fluorescein staining, lissamine green conjunctival staining, and TBUToccurred at day 1 and 7 after the surgery. This study indicates that cataract surgery may induce a clinical picture similar to dry eye, pointing out possible risks in patients with previous ocular surface diseases [19].

The mean TBUT of patients in our study was 12.4 seconds and 7 days after the surgery 8.2 seconds (p < 0.05). There were more self reported problems like foreign body sensation, discomfort, dryness and redness 7 days and 1 month after the surgery.

Self-reported dry eye (discomfort, dryness and watery eyes) up to 6 months after surgery was described to be among the most common complaints after cataract surgery in the study of Recchioni et al. [20].

Many reports of dry eye syndrome have focused on patients who had undergone PHACO and subsequently developed dry eye. Kasetsuwan et al. reported that the incidence of dry eye after PHACO was 9.8%. Symptoms and signs of dry eye occurred as early as seven days post-surgery and the severity pattern improved over time. According to the Schirmer test, 88.89% had a normal test [21].

In our study, 7 days after cataract surgery 26/80 (32.5%) patients had Schirmer test values 5- 9 mm (group B) and 19/80 (23.7%) < 5 mm (group C). There were no statistically significant changes in Schirmer test values 1 month after the surgery.

The study of Ishrat et al. concluded that the incidence of dry eye is higher in small incision cataract surgery (SICS) than PHACO due to tear film instability. Dry eyes were found in 42% (p < 0.001) of patients at 1 week follow-up. Fifteen percent of eyes were showing symptoms of dry eye at 1 month and 9% at 3 months after surgery. The majority of eyes in their study (27/42, 64.3%) had mild dryness. They also reported the significant differences in TBUT at 1 week, 1 month and 3 months postoperatively [22].

Optimization of the ocular surface before moving the patient to the operating room is essential for achieving the best surgical outcome. An impaired ocular surface has an impact on preoperative planning for cataract surgery [23]. Patients with cataract and concomitant dry eye disease require special consideration in order to prevent impairment of the existing symptoms, as well as being properly informed of the risks of dry eye associated with cataract surgery [24].

While several supportive measures have been developed and clinically applied, effective treatment and prophylaxis of dry eye has not yet been established. Further studies are necessary for a better comprehension of the consequence of cataract surgery on the ocular surface.


Concerning the results of many previous clinical studies and results of our study, cataract surgery with intraocular lens implantation in patients with dry eye syndrome is an effective and safe surgical procedure with good visual outcome. The risk of developing postoperative dry eye problems is related to preoperative qualitative and quantitative tear film status. Patients with concomitant dry eye disease require preoperative and postoperative treatment of dry eye to prevent impairment of symptoms that may affect the visual outcome after the cataract surgery.


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[22.] Ishrat S, Nema N, Chandravanshi SCL. Incidence and pattern of dry eye after cataract surgery. Saudi J Ophthalmol. 2019;31(1):34-40.

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Stefan BRUNET (1), Vladimir CANADANOVIC (1,2), Nikola BABIC (1,2), Aleksandar MILJKOVIC (1,2), Sandra JOVANOVIC (1,2) and Sava BARISIC (1)

Clinical Center of Vojvodina, Eye Clinic, Novi Sad (1)

University of Novi Sad, Faculty of Medicine Novi Sad (2)

Corresponding Author: Dr Stefan Brunet, Klinicki centar Vojvodine, Klinika za ocne bolesti, 21000 Novi Sad, Hajduk Veljkova 1-7, E-mail:,

Rad je primljen 21. III 2019.

Recenziran 7. IV 2019.

Prihvacen za stampu 25. IV 2019.

Table 1. Schirmer test values (80 eyes)
Tabela 1. Vrednosti Sirmerovog testa (80 ociju)

Schirmer test values        Before surgery       7 days after
Vrednosti Sirmerovog testa  Pre operacije   7 dana posle operacije

A (10 - 14 mm)                    40                  35
B (5 - 9 mm)                      27                  26
C (< 5 mm)                        13                  19

Schirmer test values        1 month after surgery
Vrednosti Sirmerovog testa  1 mesec posle operacije

A (10 - 14 mm)                      38
B (5 - 9 mm)                        25
C (< 5 mm)                          17

Table 2. Self reported dry eye symptoms
Tabela 2. Licna procena simptoma suvog oka

Self-reported symptoms            Before surgery  7 days after surgery
Licna procena simptoma suvog oka  Pre operacije   7 dana posle operacije

Foreign body sensation                 24         39 (p < 0.05)
Osecaj stranog tela
Discomfort/Neprijatnost                12         24 (p < 0.05)
Dryness/Suvoca                         14         21
Redness/Crvenilo                        6          9
Watery eyes/Suzenje oka                20         32 (p < 0.05)

Self-reported symptoms            1 month after surgery
Licna procena simptoma suvog oka  1 mesec posle operacije

Foreign body sensation                  27
Osecaj stranog tela
Discomfort/Neprijatnost                 21
Dryness/Suvoca                          19
Redness/Crvenilo                         7
Watery eyes/Suzenje oka                 23
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Article Details
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Author:Brunet, Stefan; Canadanovic, Vladimir; Babic, Nikola; Miljkovic, Aleksandar; Jovanovic, Sandra; Bari
Publication:Medicinski Pregled
Article Type:Clinical report
Date:Mar 1, 2019

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