Dry eye disease (DED) is one of the most common – and most underestimated – causes of dissatisfaction after otherwise uncomplicated cataract surgery. Symptoms can compromise quality of vision, delay visual recovery, and complicate postoperative refractive outcomes. Yet while phacoemulsification is often assumed to be kinder to the ocular surface, manual small incision cataract surgery (MSICS) remains widely used in high-volume and low-resource settings.
A new prospective study from the Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER) in India offers a head-to-head comparison of both techniques, combining clinical dry eye measures with inflammatory tear biomarkers.
The JIPMER team enrolled 86 patients aged ≥40 years with uncomplicated cataracts, divided equally between MSICS (n=43) and phacoemulsification (n=43). Dry eye assessment was performed preoperatively and at post-op Day 1, Day 21, and Day 60, using a broad panel of tests. Meibomian gland dysfunction (MGD) was evaluated using lid margin score (LMS) and meibum quality score (MQS), while tear inflammation was quantified using IL-1β and IL-6 levels.
The authors found that both MSICS and phacoemulsification produced an acute deterioration in ocular surface health, most pronounced on post-op Day 1. Across both groups, OSDI scores increased, Schirmer I and tear breakup time (TBUT) decreased, and staining worsened – before gradually improving by Day 60. However, recovery was not complete. By two months, OSDI and Schirmer I remained significantly worse than baseline in both groups, suggesting that postoperative DED may persist beyond the early inflammatory phase.
The clearest differentiator between techniques was tear film stability. TBUT was significantly lower in the MSICS group at every postoperative visit, indicating more sustained tear film instability following the larger incision approach.
This aligns with the proposed mechanism: MSICS typically involves a 6–8 mm incision, compared with 2.2–2.75 mm for phaco, potentially transecting more corneal nerves and disrupting reflex tearing and ocular surface homeostasis.
Both groups demonstrated mild MGD that improved postoperatively – likely influenced by the routine topical steroid/antibiotic regimen. But by Day 60, meibum quality (MQS) was significantly worse in the phacoemulsification group, with more patients continuing to show cloudy secretions.
The study indicates that DED is not simply a minor postoperative inconvenience, but a predictable inflammatory and functional event, regardless of technique. MSICS appears to carry a greater TBUT penalty, while phaco may be associated with more persistent meibomian disturbance. As such, the authors suggest that simple tools – OSDI, fluorescein TBUT, and Schirmer – remain highly effective for screening and monitoring, and should be integrated into routine perioperative care.
A new prospective study from the Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER) in India offers a head-to-head comparison of both techniques, combining clinical dry eye measures with inflammatory tear biomarkers.
The JIPMER team enrolled 86 patients aged ≥40 years with uncomplicated cataracts, divided equally between MSICS (n=43) and phacoemulsification (n=43). Dry eye assessment was performed preoperatively and at post-op Day 1, Day 21, and Day 60, using a broad panel of tests. Meibomian gland dysfunction (MGD) was evaluated using lid margin score (LMS) and meibum quality score (MQS), while tear inflammation was quantified using IL-1β and IL-6 levels.
The authors found that both MSICS and phacoemulsification produced an acute deterioration in ocular surface health, most pronounced on post-op Day 1. Across both groups, OSDI scores increased, Schirmer I and tear breakup time (TBUT) decreased, and staining worsened – before gradually improving by Day 60. However, recovery was not complete. By two months, OSDI and Schirmer I remained significantly worse than baseline in both groups, suggesting that postoperative DED may persist beyond the early inflammatory phase.
The clearest differentiator between techniques was tear film stability. TBUT was significantly lower in the MSICS group at every postoperative visit, indicating more sustained tear film instability following the larger incision approach.
This aligns with the proposed mechanism: MSICS typically involves a 6–8 mm incision, compared with 2.2–2.75 mm for phaco, potentially transecting more corneal nerves and disrupting reflex tearing and ocular surface homeostasis.
Both groups demonstrated mild MGD that improved postoperatively – likely influenced by the routine topical steroid/antibiotic regimen. But by Day 60, meibum quality (MQS) was significantly worse in the phacoemulsification group, with more patients continuing to show cloudy secretions.
The study indicates that DED is not simply a minor postoperative inconvenience, but a predictable inflammatory and functional event, regardless of technique. MSICS appears to carry a greater TBUT penalty, while phaco may be associated with more persistent meibomian disturbance. As such, the authors suggest that simple tools – OSDI, fluorescein TBUT, and Schirmer – remain highly effective for screening and monitoring, and should be integrated into routine perioperative care.
