Eye Protection Following Cataract Surgery: A Systematic Review

Author: Dhoot AS, Popovic MM, Lee S, El-Defrawy S, Schlenker MB. 

Geographical coverage: China, Austria, America, the Philippines, and Malaysia

Sector: Cataract surgery

Sub-sector: Treatment, eye protection

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background: Cataracts are a one of the major causes of global blindness and visual impairment which affects an estimated 94 million people globally. Postoperative eye protection is a long-established practice among ophthalmologists, yet there remains considerable variability in the prescribed methods. These include plastic eye shields, eye patches, ocular bandages, and the omission of protection altogether which is known as instant vision. Each method offers distinct benefits such as protection from trauma, support for wound healing, or immediate visual recovery. Despite its widespread usage, there is no consensus or guideline on the ideal postoperative eye protection regimen. This highlights the increasing interest of scientists to evaluate the effectiveness and patient comfort associated with each modality.

Objective: To evaluate the quality of evidence in this setting, specifically with respect to patient-reported symptoms.

Main findings: The review included 8 studies, involving 598 eyes. Of the included studies, 7 were randomised controlled trials (RCTs) and one was an observational cohort study. Studies were conducted in China (n=3), Austria (n=2), America (n=1), Philippines (n=1), and Malaysia (n=1). Cataract surgery with phacoemulsification was performed in all included eyes and was performed either unilaterally (n=6), or bilaterally (n=2). Methodological quality of the included studies was rated as high for the observational study. None of the included RCTs demonstrated a high or unclear risk of bias in all categories; however, 6 RCTs demonstrated a high risk in the masking of outcome assessment, 3 in masking of participants and personnel, while one declared a conflict of interest.

The results revealed that ocular bandages generally provide superior patient comfort compared to other modalities. In five studies, ocular bandage users reported either reduced or equivalent symptoms of discomfort, and three studies found an associated improvement in tear breakup time (TBUT), indicating better ocular surface health. Additionally, one study reported enhanced corneal wound healing in the ocular bandage group. When compared directly with eye patches or instant vision, ocular bandages consistently showed better outcomes in terms of patient-reported comfort and tear stability.

Studies comparing eye patches to instant vision showed that patches were preferred by most patients and were associated with fewer symptoms. Notably, in a head-to-head comparison, patients significantly preferred eye patches (65%) over instant vision (8%), with better TBUT values and reduced reports of pain. However, a different study found more epithelial gaping in patients with eye shields compared to eye patches, suggesting possible limitations of shield use regarding wound healing.

Instant vision, which avoids any form of postoperative eye covering, was linked to the highest frequency of discomfort and lowest TBUT across several studies. Despite offering immediate visual function, instant vision led to increased reports of pain and dry eye symptoms shortly after surgery. Some improvements were noted when tear supplements were added, but instant vision without adjunctive therapy was the least favoured.

Methodology:  The searches were conducted in Medline, Embase, and Cochrane CENTRAL to original research articles reporting pain, foreign body sensation (FBS), tearing, photophobia, subjective symptom scores, ocular surface disease index (OSDI) scores, corneal wound architecture, best-corrected visual acuity (BCVA), or TBUT after the use of an eye protection modality following phacoemulsification cataract surgery. The studies published in English from January 2000 to April 2021 were included in this review.

Two reviewers independently screened the articles. The quality of the included studies was appraised using the Cochrane’s risk of bias tool for randomised controlled trials and the Newcastle-Ottawa Scale for non-randomised studies. Relevant data were extracted, and findings were synthesised narratively.

Applicability/external validity: The review acknowledged limitations affecting applicability, including heterogeneity in study designs, variability in postoperative medications, and lack of standardised follow-up protocols. The authors cautioned against the broad application of findings and emphasised to interpret the findings should be interpreted with limitations in mind. They also emphasised the need for more standardised, head-to-head studies to better understand the efficacy of these treatment modalities following cataract surgery.

Geographic focus: The review did not apply any geographical limits. The included studies were conducted in China, Austria, America, the Philippines, and Malaysia.

Summary of quality assessment: Overall, there is medium confidence in the review’s conclusions. The searches were comprehensive. Inclusion and exclusion criteria were clearly defined, and two reviewers independently screened the articles. The study quality was assessed using established tools. Characteristics of included studies were well-documented, and the findings were synthesised narratively. However, the search was limited to identifying articles published in the English language only, the review did not provide a list of excluded studies, did not report checking the reference lists or contacting authors/experts, and did not specify the number of reviewers independently involved in the data extraction.