Prevalence and Characteristics of Dry Eye Disease After Cataract Surgery: A Systematic Review and Meta-Analysis

Author: Miura M, Inomata T, Nakamura M, Sung J, Nagino K, Midorikawa-Inomata A, Zhu J, Fujimoto K, Okumura Y, Fujio K, Hirosawa K, Akasaki Y, Kuwahara M, Eguchi A, Shokirova H, Murakami A.

Geographical coverage: Asia, Europe, North America, and the Middle East

Sector: Burden of Disease

Sub-sector: Epidemiology

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis and Meta-analysis

Qualitative synthesis method: Not applicable

Background: Cataract surgery is one of the most performed ophthalmic procedures among the older population. While it typically yields excellent visual outcomes, however, some patients develop postoperative dry eye disease (DED), presenting symptoms like ocular discomfort, fatigue, and decreased vision quality. These symptoms negatively affect work productivity and overall quality of life. The pathogenesis of DED after cataract surgery is not well understood, and standardised treatments are lacking. Furthermore, large-scale systematic studies on DED in patients without preexisting conditions are scarce. Therefore, investigating the prevalence and risk factors is essential to enhance postoperative care and patient satisfaction.

Objective: To determine the prevalence, characteristics, perioperative risk factors, treatment, and preventative measures for DED after cataract surgery.

Main findings: The review included 36 studies, of which 9 were included in the meta-analysis to estimate the prevalence of DED after cataract surgery in patients without preexisting DED. The studies were conducted in Asia (n=27), Europe (n=6), North America (n=2), and Middle East (n=1).

The meta-analysis of 9 studies involving 775 patients revealed that 37.4% (95% confidence interval [CI]: 22.6 to 52.3) of patients without preexisting DED developed the condition after cataract surgery. The severity of DED symptoms typically peaked 1 week postoperatively, with persistence for 1–12 months.

Postoperative dry eye disease (DED) following cataract surgery imposed significant clinical and humanistic burdens, affecting both ocular health and patients’ quality of life. Objective metrics like tear film breakup time (TFBUT), Schirmer’s test, and corneal staining worsened post-surgery, with incomplete recovery observed in many cases. Notably, meibomian gland dysfunction (MGD) was frequently associated with DED, exacerbating tear film instability. Subjective symptoms (e.g., via Ocular Surface Disease Index) often remained elevated beyond the resolution of clinical signs, suggesting lingering neural or inflammatory effects.

Key risk factors included older age, female sex, systemic diseases (e.g., diabetes, autoimmune disorders), and psychiatric conditions (e.g., anxiety, depression). Medications such as antihistamines, antidepressants, and preservative-containing eye drops also increased risk. Surgical factors like prolonged phacoemulsification time, femtosecond laser use, and excessive microscope light exposure were linked to higher DED incidence. Preexisting ocular conditions, particularly MGD and short TFBUT, were strong predictors of postoperative DED.

Effective treatments included preservative-free topical therapies, such as diquafosol tetrasodium 3%, which outperformed hyaluronic acid in improving tear stability. Rebamipide and trehalose-hyaluronate combinations also showed promise in reducing inflammation and promoting epithelial recovery. Oral supplements (e.g., omega-3 fatty acids, lactoferrin) were beneficial adjuncts. For severe cases, preoperative MGD management mitigated postoperative DED severity.

Prophylactic strategies emphasised preservative-free eye drops, minimised surgical trauma, and reduced microscope light exposure. Preoperative screening for DED risk factors (e.g., MGD, conjunctivochalasis) allowed targeted interventions, such as preoperative antioxidant solutions or hydroxypropyl methylcellulose application during surgery. Patients were advised to limit screen use postoperatively to reduce evaporative stress.

Overall, the study underscored DED as a multifactorial complication of cataract surgery, necessitating individualised risk assessment and tailored management.

Methodology:  The searches were conducted in PubMed and Embase to identify retrospective (cross-sectional and case–control studies) and prospective studies conducted on patients who underwent cataract surgery. The studies published in English between January 1, 2011 and June 9, 2020, were included if they reported one or more of the following outcomes: prevalence of DED after cataract surgery, TFBUT, TMH, Schirmer’s I test, CFS, TOV, and MGD presence. The reference lists of included studies and previously published articles were also scanned to identify additional relevant publications.

Two reviewers independently screened the articles and extracted the relevant data. Disagreements between the reviewers were resolved through discussion or by contacting a third reviewer. The findings were synthesised using a random-effects model meta-analysis, and subgroup analyses were performed using studies that reported on each specific outcome.

Applicability/external validity: The review noted that the majority of the studies were conducted in Asia, which may limit the generalisability of its findings. In addition, only a few included studies had a follow-up period of more than 1 year, which limited the analysis of long-term effects. The study emphasised that future research should improve generalisability by including diverse ethnic populations, extending follow-up periods, and standardising DED diagnostics using TFOS or Asia Dry Eye Society criteria.

Geographic focus: The review did not apply any geographical limits. The included studies were conducted in Asia, Europe, North America, and the Middle East.

Summary of quality assessment: Overall, there is low confidence in the review’s conclusions. The searches were conducted in PubMed and Embase. Inclusion and exclusion criteria were clearly defined, and two reviewers independently screened the articles and extracted data, with disagreements resolved through discussion or consultation with a third reviewer. Characteristics of included studies were well-documented, meta-analyses were appropriately performed, and heterogeneity was addressed. However, the search was limited to identifying articles published in the English language only, and the review did not provide a list of excluded studies. Additionally, the review did not mention assessing the risk of bias of the included studies.