Dry eye is a multifactorial, heterogeneous disorder of the preocular tear film because of tear deficiency or excessive tear evaporation which causes symptoms of ocular discomfort. Many patients who have undergone cataract surgery have complained of dry eye and symptoms of irritation postoperatively. The aim of this study was to evaluate the incidence and severity pattern of dry eye after phacoemulsification [1] Dry eye is a disturbance of the Lacrimal Functional Unit (LFU), which is an integrated system comprising the lacrimal glands, ocular surface (cornea, conjunctiva and meibomian glands) and lids, and the sensory and motor nerves connecting them [2]. This functional unit controls the major components of the tear film in a regulated fashion and responds to environmental, endocrinological and cortical influences. The overall function of the LFU is to preserve the integrity of the tear film, the transparency of the cornea, and the quality of the image that is projected onto the retina [3]. Cataract is the leading cause of blindness in the world with the most common cause being age related. As both Cataract and Dry eye disease are common in older age, they often coexist. Several studies have revealed that cataract surgery can induce dry eye disease or exacerbate an existing dry eye. Hence a surgical intervention for cataractous lens extraction and intraocular lens implantation may worsen a symptomatic dry eye or may manifest symptoms in a previously asymptomatic dry eye. Despite a perfect surgery and a good Snellen’s visual acuity, the patient may remain dissatisfied. With increasing age in the normal human population, there is an increase in ductal pathology that could promote lacrimal gland dysfunction by its obstructive effect. These alterations include periductal fibrosis, interacinar fibrosis, paraductal blood vessel loss and acinar cell atrophy [4]. Cataract surgery has been shown to reduce tear meniscus height and tear breakup time (TBUT) and increase squamous metaplasia on conjunctival impression cytology [5]. A comparison of incidence and severity of postoperative dry eye symptoms in cataract patients with and without dry eye diagnosis preoperatively showed an aggravation of dry eye symptoms and decreased tear meniscus postoperatively in already diagnosed dry eye cases while worse dry eye symptoms, tear break up time and aqueous tear production in undiagnosed dry eye cases after phacoemulsification [6]. AIMS AND OBJECTIVES • AIM: To study the incidence of dry eye in normal patients following phacoemulsification OBJECTIVES • PRIMARY OBJECTIVE: To evaluate the incidence and level of dry eye in patients undergoing phacoemulsification • SECONDARY OBJECTIVE: To evaluate the course of dry eye and to score the dry eye following cataract surgery on basis of dry eye severity grading scheme REVIEW OF LITERATURE Hwang, Hyung Bin, Kim, Hyun Seung,Phototoxic Effects of an Operating Microscope on the Ocular Surface and Tear Film in a study performed on rabbits to evaluate the Potential damage to the ocular surface and tear film was found in the light-exposed groups as evidenced by decreased aqueous tear production, devitalized corneal and conjunctival epithelial cells, squamous metaplasia of conjunctival epithelial cells, decreased conjunctival goblet cell density, decreased expression of mucin 5AC, ultrastructural cellular damage to corneal and conjunctival tissues, and increased interleukin 1-beta expression in tears [7]. Peter Mark G. Chao, MD1 and Ruben Lim-Bon-Siong, MD study on Dry Eye after Clear Cornea Phacoemulsification observed that phacoemulsification is capable of decreasing tear production and tear film stability, leading to occurrence of ocular discomfort symptoms for the patients [8]. Liu Z, Luo L, Zhang Z, et al. Tear film changes after phacoemulsification Concluded that Phacoemulsification significantly alters the tear break-up time, S I t value, corneal fluorescein staining, tear film pattern and the height of tear meniscus [9]. W S Wilson, A J Duncan, J L Jay study on Effect of benzalkonium chloride on the stability of the precorneal tear film in rabbit and man says that Benzalkonium chloride, a surface-active preservative commonly used in eyedrop preparations, has been shown to hasten the drying of the precorneal tear film [10].

• STUDY AREA: South India • STUDY POPULATION: Patients undergoing cataract surgery by temporal phacoemulsification • SAMPLE SIZE: 150 • STUDY DURATION: one year • STUDY DESIGN: Prospective observational study INCLUSION CRITERIA 1. Age [50 -70 years] 2. Uncomplicated surgery 3. Temporal clear corneal incision 4. Phacoemulsification with foldable PCIOL 5. OSDI normal scoring preoperative (0-12) EXCLUSION CRITERIA 1. Previously diagnosed with dry eye disease 2. Non age related cataract 3. Lid abnormalities 4. H/O corneal surgeries & corneal scars 5. History of herpetic keratitis or herpes zoster Ophthamicus and history of other neurotrophic Disorder. METHODOLOGY All patients with senile cataract, age between 50 to 70 years presenting to the cataract clinic in the study period were evaluated at baseline for ocular surface parameters before cataract surgery and at 1st week, 4th week and 6th week after cataract surgery. PREOPERATIVELY 1. The details of the patient’s name, age, sex, address and occupation have to be noted. 2. A detailed medical and ophthalmic history should be taken. 3. Anterior segment evaluation by slit lamp biomicroscope should be done. 4. Intraocular lens power calculation to be done. 5. A detailed evaluation of dry eye using parameters in Dry eye Evaluation and Grading Scheme. 1. OSDI SCORE: The patients will be asked to answer OSD Index questionnaire consisting of a set of 12 standardized questions that has been formulated so as to have a quick evaluation of severity of dry eye. OSDI score is assessed on a scale of 0 to 100. Higher scores represent greater disability. On the basis of final OSDI score, the dry eye disease severity would thereby be graded as mild, moderate and severe.11 2. SCHIRMER’S TEST-1: This test is done using Whatman filter paper no.44 measuring 5mm wide and 35mm long. The eyes are gently dried, the Whatman filter paper is folded at 5mm from one end and inserted at the junction of medial 2/3rd and lateral 1/3rd of the lower lid. The patient is asked to keep the eyes open and to blink as necessary while the paper is kept undisturbed for 5 minutes before being removed and the amount of wetting is measured. Schirmer’s test result would be evaluated in mm of wetting and graded as follows: 10-15 mm -------- normal. 5-10 mm ---------------- borderline. Less than 5mm------------abnormal 45 12 3. TEAR BREAK-UP TIME (TBUT): It assesses pre-corneal tear film stability. In this test fluorescein drop is instilled into the fornix and the patient is asked to blink several times. The tear film is examined with broad beam cobalt free filter in slit-lamp while the patient is asked to hold his/her eyes open. After an interval of time, black spot or line appears indicating the formation of dry areas. BUT is the interval between the last blink and the appearance of first randomly distributed dry spot. A BUT of less than 10 second is considered abnormal. 4. OCULAR SURFACE STAINING: Three systems for quantifying staining of the ocular surface are in current use, the Van Bijsterveld system, the Oxford system and a standardized version of the NEI/Industry Workshop system. The dye is instilled. Slit-lamp is set (eg, magnification with x10 oculars with Haag-Streit). Cornea: The upper eyelid is lifted slightly to grade the whole corneal surface, Conjunctiva: To grade the temporal zone, the subject looks nasally and vice versa. STATISTICAL METHOD In order to detect a, 9.8% (based on study by Kasetsuwan et al) [1] prevalence of dry eye among eventless phacoemulsification, with 5% absolute precision and 95% confidence interval, optimal sample size is calculated as follows. Sample size n = [N*p(1-p)]/ [(d2/Z21-α/2*((N-1)+p*(1-p))]   Population size(for finite population correction factor or fpc)(N): 10000 Hypothesized % frequency of outcome factor in the population (p): 9.8%+/-5 Confidence limits as % of 100(absolute +/- %)(d): 5% Sample size n = [10000*0.098(0.912)]/ [(0.05)2/1.962*(10000-1)+0.098*(0.912)]   = 136 46 In anticipation of a 10% of loss to follow-up at one month, the minimum number of phacoemulsification surgeries to be screened for postoperative dry eye 150 during the study duration. STATISTICAL ANALYSIS Plan Data is presented in number and figures. Descriptive statistics are presented in mean±1SD. Incidence of dry eye among eyes that have undergone phacoemulsification at one month were calculated and 95% confidence interval built around the estimate. Associated between the presence of dry eye and demographic variables were examined using a Chi square test. As the scores of dry eye tests did not follow normal distribution a non-parametric Friedman test (for repeated measures data) was used to analyze the change in dryness scores over follow-up from the baseline. A p value less that 0.05 is considered statistically significant.

The 135 patients included in the study were aged 53.1±4.9, ranging from 41 to 60 years. There were more (41.5%) number of patients in the >55 age group compared to 27.4% and 21.5% in the 51-55 and 46-50 age groups respectively. Majority (60.0%, n-81) of the subjects were male. The gender distribution across the age groups was not statistically significantly different (p-0.734) even though the proportion of women in the <=45 age group was little on the higher side (Figure 9). A little over half (54.1%, n-73) of the surgeries were performed on the right eye. SCHIRMERS TESTS: The mean mm of wetting was 25.7±3.7 ranging from 19.0 to 33mm. Preoperatively all eyes had normal aqueous tear production (>15mm after 5 mins) (Figure 11 ). More than two thirds (67.4%) of the eyes produced tears from 21 to 27mm, preoperatively. Incidence of Dry Eye Syndrome This section presents the change in the aqueous tear production, if any, post cataract surgery based on the four dry eye severity grading schemes. OSDI Score the changes in OSDI Score is presented in Table 6. The mean OSDI score was 6.9±1.9 preoperatively which progressed to 8.2±6.6 at 1 week, implying that increase in OSDI score was highly varying (range: 8 to 32) between patients. Since the Scores do not follow normal distribution, the median and percentiles are presented and the median OSDI score (dotted line in Figure 12.) remained at large at 6.0 throughout Weeks 1, 4 and reached 7.0 at 6th week. The changes in the OSDI score was not statistically significant (p-0.180; Friedman Test) from preoperative levels to postoperative 6th week. Table 6. Changes in OSDI Score of the Eyes in the Study Time of Measurement Mean SD Minimum 25th 50th (Median) 75th Maximum Preoperative 6.9 1.9 3.0 6.0 6.0 8.0 11.0 1 Week Postoperative 8.2 6.6 4.0 5.0 6.0 8.0 32.0 4 Weeks Postoperative 7.4 3.8 3.0 5.0 6.0 8.0 20.0 6 Weeks Postoperative 6.9 2.1 2.0 5.0 7.0 8.0 12.0 However, during the observed postoperative period, 15 (11.1%) developed mild or moderate dry eye at 1 Week (Figure 13.). The score evened out at 4th week where all the 15 were having mild dry eye scores. At 6 weeks, all eyes had OSDI score <=12.0. INCIDENCE OF DRY EYE Based On OSDI SCORE Overall, 15 eyes developed dry eye symptoms over the 2 follow ups at 1st and 4th weeks post cataract surgery. The incidence of dry eye based on OSDI score is 11.1% (95% CI:6.4 to 17.7). SCHIRMER’S TEST SCORE: The changes in Schirmer’s test score is presented in Table 7. The mean Schirmer’s test score was 25.7±3.7 preoperatively which reduced to 20.5±6.7 at 1 week, implying that chenge in Schirmer’s test score was highly varying (range: 1 to 32) between patients. Median Schirmer’s test score (dotted line in Figure 14.) remained at large between 22.0 and 23.0 throughout Weeks 1, 4 and 6th week. The changes in the Schirmer’s test score was statistically significant (p<0.0001; Friedman Test) from preoperative levels to postoperative 6th week. During the observed postoperative period, 15 (11.1%) developed mild or moderate dry eye at 1 Week (Figure 15.). The score evened out at 4th week where all the 15 were having mild dry eye scores. At 6 weeks, 5 (3.7%) eyes had Schirmer’s test score 5-15. Incidence of Dry Eye based on Schirmer’s Test Overall, 15 eyes developed dry eye symptoms over the 2 follow ups at 1st and 4th weeks post cataract surgery. The incidence of dry eye based on Schirmer’s test score is 11.1% (95% CI:6.4 to 17.7). TBUT Score 5 - 15 >15 The changes in TBUT is presented in Table 8. The mean TBUT was 11.1±2.2 preoperatively which increased to 11.8±2.2 at 1 week. Median TBUT (dotted line in Figure 16.) remained at large between 11.0 and 12.0 throughout Weeks 1, 4 and 6. The changes in the TBUT was statistically significant (p<0.0001; Friedman Test) from 1 week postoperative to 6th week. During the observed postoperative period, 16 (11.9%) developed dry eye at 1 Week (Figure 17.). At 6 weeks, 1 (0.7%) eyes had TBUT >10 seconds. Incidence of Dry Eye based on TBUT Overall, 16 eyes developed dry eye symptoms at follow ups post cataract surgery. The incidence of dry eye based on TBUT is 11.9% (95% CI:6.9 to 18.5). OSS Score The changes in the OSS test score is presented in Table 9. Median Schirmer’s test score (dotted line in Figure 18.) remained at large at 20.0 throughout Weeks 1, 4 and 6th week. The range of scores at 1st week which was 1 to 7.0 reduced to 1.0 to 3.0 at 6th postoperative week. The changes in the OSS test score was statistically significant (p-0.001; Friedman Test) from preoperative levels to postoperative 6th week. Table 9: Changes in OSS Score of the Eyes in the Study Time of measurement Mean SD Minimum 25th 50th (Median) 75th Maximum 1 Week Postoperative 2.2 1.5 1.0 1.0 2.0 3.0 7.0 4 Weeks Postoperative 2.2 1.3 1.0 1.0 2.0 3.0 7.0 6 Weeks Postoperative 1.7 0.8 1.0 1.0 2.0 2.0 3.0 During the observed postoperative period, 15 (11.1%) developed dry eye at 1 Week (Figure 18.) and remained so in 4th week. At 6 weeks, none of the eyes had OSS score >3.0. Incidence of Dry Eye based on OSS 6 Weeks Postoperative Dry Eye (4-9) Normal (0-3) Overall, 15 eyes developed dry eye symptoms over the 2 follow ups at 1st and 4th weeks post cataract surgery. The incidence of dry eye based on OSS score is 11.1% (95% CI:6.4 to 17.7). Incidence of Dry Eye Detection of dry eye based on atleast one of the four tests in one of the postoperative visits was counted as one. By this definition, 18 eyes were found to have dry eye during 6 week postoperative period. Hence, the incidence of dry eye in 6 week postoperative period is 13.3% (95% CI:8.1 to 20.3). Age at Surgery and Incidence of Dry Eye The age at surgery was associated with incidence of dry eye furing the 6 week follow up period. None of the patients who were aged below 45 years had dry eye postoperatively (Figure 20.). However, dry eye was observed in the 45+ groups increasingly. Of patients who were older than 55 years 17.9% (n-10) developed dry eye, compared to 16.2% (n-6) in the 51 55 age group. Despite such observations, there is no statistically significant difference in the incidence of dry eye between age groups (p-0.231), implying not association between age group and incidence of dry eye. Gender and Incidence of Dry Eye Post Cataract Surgery Nine (16.7%) eyes among female and 9(11.1%) among male developed dry eye during the 6 week postoperative period (Figure 21). There was no statistically significant association between gender and incidence of dry eye (p-0.352).

In our study none of the patients who were aged below 45 years had dry eye postoperatively. However, dry eye was observed in the 45+ groups increasingly. Of patients who were older than 55 years 17.9% (n-10) developed dry eye, compared to 16.2% (n-6) in the 51-55 age group. This is in agreement with clinical experience and studies according to which dry eye is more common in older patients (53) because of a reduction in tear production, an increase in evaporation (54) meibomian gland anomalies (55) with age. Several studies have been conducted to assess the causes of this deterioration, quantify this deterioration and also to look into the measures to check this deterioration. Our study intends to quantify incidence of dry eye in normal patients posted for phacoemulsification cataract surgery. The study was done on 135 patients attending the outpatient department with cataract and were scheduled for cataract operation using Phacoemulsification technique.135 patients meeting the inclusion criteria underwent a detailed cataract workup along with evaluation of dry eye using the parameters of Dry Eye Evaluation and Grading Scheme. Patients were taken up for temporal phacoemulsification cataract surgery (same surgeon). These patients were followed up every week for a period of 6 weeks using the parameters of Dry Eye Evaluation and Grading Scheme. In our study performed on 135 patients the percentage of male patients was found to be 60% and females was 40% which is in accordance to the findings of some studies which state that dry eye is apparently more common in women. In the Melbourne study (50) women were almost twice as likely to report severe symptoms of dry eye as men. In the Beaver Dam study, the age adjusted 59 prevalence of dry eye was 16.7% in women versus 11.7% in men. However this preference for dry in women is not a universal finding. The Salisbury study (51) found no significant gender difference for dry eye. An Indonesian study (52) found an increased prevalence of dry eye of 1.4 times for men compared with women. In our study Nine (16.7%) eyes among female and 9(11.1%) among male developed dry eye during the 6 week postoperative period. There was no statistically significant association between gender and incidence of dry eye. The role of sex hormones in ocular surface homeostasis has been recognized. Androgen levels decrease with aging in both men and women.(56)Sex steroid deficiency specifically involving androgens, has been associated with dry eye in several distinct clinical entities such as Anti- androgen treatment, Sjogren Syndrome, Premature Ovarian failure. In our study the preoperative Schirmer’s test value per 5 minute The mean mm of wetting was 25.7±3.7 ranging from 19.0 to 33mm. Preoperatively all eyes had normal aqueous tear production (>15mm after 5 mins). More than two-thirds (67.4%) of the eyes produced tears from 21 to 27mm, preoperatively. The median OSDI score was 6.0 (mean ± SD: 6.9 ± 1.9) ranging from 3 to 11 preoperatively. All eyes had OSDI scores in the normal category (0-12) preoperatively. Majority (63.0%) of the eyes had OSDI between 5 and 7. In our study the range of scores at 1st week which was 1 to 7.0 reduced to 1.0 to 3.0 at 6th postoperative week. The changes in the OSS test score was statistically significant (p-0.001; Friedman Test) from preoperative levels to postoperative 6th week. During the observed postoperative period, 15 (11.1%) developed dry eye at 1 Week and remained so in 4th week. At 6 weeks, none of the eyes had OSS score >3.0. During the observed postoperative period according to Schirmers test 15 (11.1%) developed mild or moderate dry eye at 1 Week. The score evened out at 4th week where all the 15 were having mild dry eye scores.At 6 weeks, 5 (3.7%) eyes had Schirmer’s test score 5-15. The incidence of dry eye based on Schirmer’s test score is 11.1% (95% CI:6.4 to 17.7). In our study according TBUT test 16 (11.9%) developed dry eye at 1 Week. At 6 weeks, 1 (0.7%) eyes had TBUT >10 seconds. 16 eyes developed dry eye symptoms at 60 follow ups post cataract surgery. The incidence of dry eye based on TBUT is 11.9% (95% CI:6.9 to 18.5). In our study according to OSDI 15 eyes developed dry eye symptoms over the 2 follow ups at 1st and 4th weeks post cataract surgery. The incidence of dry eye based on OSDI score is 11.1% (95% CI:6.4 to 17.7). Our study shows that although there is an improvement in the dry eye parameters over a period of 4 and 6 weeks in comparison to the first postoperative week. This is supported the study ‘Dry eye after clear cornea phacoemulsification’ (57) by Chao PMG, Siong RLB who showed that a temporary reduction in physiological tear levels is seen one week post-surgery that gradually returns to near- normal baseline levels by third post-operative month. Our study documented that alteration of the normal tear physiology was common after clear cornea phacoemulsification with tear production and tear stability reduced, and Schirmer and TBUT values significantly decreased at 1 week after surgery. During the immediate postoperative period, tear film stability was significantly compromised as supported by low TBUT values and schirmers and high OSDI score.This finding could not be attributed to clear cornea phacoemulsification alone. The low FTBUT values were likely to be the result of the use of topical eye drops with preservatives as they could cause toxicity to the cornea and conjunctiva. In addition to transection of the corneal nerves and damage to the corneal epithelial cells, vigorous intra operative irrigation of the tear film exposure to microscopic light, elevation of inflammatory factors in the tear film due to ocular surface irritation, use of topical anesthesia intra-operatively and topical eye drops administered postoperatively and its preservatives can cause dry eye after phacoemulsification

The commonest etiologies for both cataract and dry eye are age related. This is the reason for their coexistence in several elderly patients presenting to ophthalmologists cataract being the most gratifying surgery in the field of ophthalmology addresses to the complaint of diminution of vision in these patients. In our study It was observed, however, that phacoemulsification is capable of decreasing tear production and tear film stability, leading to occurrence of ocular discomfort symptoms for the patients. The observed changes in tear physiology were temporary, and a gradual recovery to near normal tear function level was observed We concluded that dry eye symptoms can develop immediately after phacoemulsification and the severity can peak on day 7. Both symptoms and signs of dry eye can improve over time. However, it is important that ophthalmologists assess dry eye before and after phacoemulsification to ensure proper treatment, quality of vision, and quality of life for their patients. LIMITATIONS • Study population is less • Study not done in patients diagnosed with dry eye • Younger patients prone for dry eye not included in study • Study period is less RECOMMENDATIONS • Post-operative lubricating eye drops can given routinely to all patients • Pre-operative evaluation of dry eye

1. Dhawan M, Kaur G, Singh SP. Dry eye after phacoemulsification. The Official Scientific Journal of Delhi Ophthalmological Society. 2018;29(1):25–30. 2. Stern ME, Beuerman RW, Fox RI, Gao J, Mircheff AK, Pflugfelder SC. The pathology of dry eye: the interaction between the ocular surface and lacrimal glands. Cornea. 1998;17(6):584–589. 3. Pflugfelder SC, Solomon A, Stern ME. The diagnosis and management of dry eye: a twenty-five year review. Cornea. 2000;19(5):644–649. 4. Damato BE, Allan D, Murray SB, Lee WR. Senile atrophy of the human lacrimal gland: the contribution of chronic inflammatory disease. Br J Ophthalmol. 1984;68(9):674–680. 5. Li XM, Hu L, Hu J, Wang W. Investigation of dry eye disease and analysis of the pathogenic factors in patients after cataract surgery. Cornea. 2007;26(9 Suppl 1):S16–S20. 6. Sinha D, Sinha A, Chowdhury B. Comparative evaluation of dry eye following cataract surgery: a study from North India. IOSR Journal of Dental and Medical Sciences. 2014;13:13–18. 7. Hwang H, Kim H. Phototoxic effects of an operating microscope on the ocular surface and tear film. Cornea. 2014;33:82–90. 8. Dry eye after clear cornea phacoemulsification. Philippine Journal of Ophthalmology. 2019. Available from: https://paojournal.com/article/dry-eye-after-clear-cornea-phacoemulsification/ 9. Liu Z, Luo L, Zhang Z, Cheng B, Zheng D, Chen W, et al. Tear film changes after phacoemulsification. Zhonghua Yan Ke Za Zhi. 2002;38(5):274–277. 10. Wilson WS, Duncan AJ, Jay JL. Effect of benzalkonium chloride on the stability of the precorneal tear film in rabbit and man. Br J Ophthalmol. 1975;59(11):667–669. 11. Aljarousha M, Alghamdi WM, Attaallah S, Alhoot MA. Ocular Surface Disease Index questionnaire in different languages. Med Hypothesis Discov Innov Ophthalmol. 2025;13(4):190–200. doi:10.51329/mehdiophthal1510. 12. Brott NR, Zeppieri M, Ronquillo Y. Schirmer test. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2026. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559159/ 13. McCarty CA, Bansal AK, Livingston PM, Stanislavsky YL, Taylor HR. The epidemiology of dry eye in Melbourne, Australia. Ophthalmology. 1998;105(6):1114–1119. 14. Schein OD, Muñoz B, Tielsch JM, Bandeen-Roche K, West S. Prevalence of dry eye among the elderly. Am J Ophthalmol. 1997;124(6):723–728. 15. Prevalence and risk factors associated with dry eye symptoms: a population based study in Indonesia. Available from: https://pubmed.ncbi.nlm.nih.gov/12446361/ 16. Brewitt H, Sistani F. Dry eye disease: the scale of the problem. Surv Ophthalmol. 2001;45 Suppl 2:S199–S202. 17. Mathers WD, Lane JA, Zimmerman MB. Tear film changes associated with normal aging. Cornea. 1996;15(3):229–234. 18. Hom MM, Martinson JR, Knapp LL, Paugh JR. Prevalence of meibomian gland dysfunction. Optom Vis Sci. 1990;67(9):710–712. 19. Sullivan BD, Evans JE, Dana MR, Sullivan DA. Influence of aging on the polar and neutral lipid profiles in human meibomian gland secretions. Arch Ophthalmol. 2006;124(9):1286–1292.