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Journal of Clinical Medicine Review Ocular Surface Changes Associated with Ophthalmic Surgery Lina Mikalauskiene 1, Andrzej Grzybowski 2,3 and Reda Zemaitiene 1,* 1 Department of Ophthalmology, Medical Academy, Lithuanian University of Health Sciences, 44037 Kaunas, Lithuania; [email protected] 2 Department of Ophthalmology, University of Warmia and Mazury, 10719 Olsztyn, Poland; [email protected] 3 Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, 61553 Poznan, Poland * Correspondence: [email protected] Abstract: Dry eye disease causes ocular discomfort and visual disturbances. Older adults are at a higher risk of developing dry eye disease as well as needing for ophthalmic surgery. Anterior segment surgery may induce or worsen existing dry eye symptoms usually for a short-term period. Despite good visual outcomes, ocular surface dysfunction can significantly affect quality of life and, therefore, lower a patient’s satisfaction with ophthalmic surgery. Preoperative dry eye disease, factors during surgery and postoperative treatment may all contribute to ocular surface dysfunction and its severity. We reviewed relevant articles from 2010 through to 2021 using keywords “cataract surgery”, ”phacoemulsification”, ”refractive surgery”, ”trabeculectomy”, ”vitrectomy” in combina- tion with ”ocular surface dysfunction”, “dry eye disease”, and analyzed studies on dry eye disease pathophysiology and the impact of anterior segment surgery on the ocular surface. Keywords: dry eye disease; ocular surface dysfunction; cataract surgery; phacoemulsification; refractive surgery; trabeculectomy; vitrectomy Citation: Mikalauskiene, L.; Grzybowski, A.; Zemaitiene, R. Ocular Surface Changes Associated with Ophthalmic Surgery. J. Clin. 1. Introduction Med. 2021, 10, 1642. https://doi.org/ 10.3390/jcm10081642 Dry eye disease (DED) is a common condition, which usually causes discomfort, but it can also be an origin of ocular pain and visual disturbances. Ocular surface inflammation is Academic Editor: thought to be the main factor in the pathogenesis of DED. It has many overlapping causes, Rodolfo Mastropasqua such as ocular surgery, environmental triggers, medication use and systemic diseases. Ophthalmic surgery may induce or worsen existing DED symptoms usually for a short- Received: 7 March 2021 term period [1]. Ocular surface abnormalities have been reported to develop after surgical Accepted: 7 April 2021 interventions, such as phacoemulsification. Despite good visual gain, DED symptoms Published: 12 April 2021 can significantly affect quality of life and, therefore, lower a patient’s satisfaction with ophthalmic surgery [2]. The transection of corneal nerves during incision, preservatives Publisher’s Note: MDPI stays neutral of medications used during and after surgery, intraoperative irrigation of ocular surface with regard to jurisdictional claims in and light exposure from a microscope may all contribute to ocular surface dysfunction. published maps and institutional affil- Although DED is mostly described after refractive and cataract surgery, other interventions, iations. such as trabeculectomy and vitrectomy, may also alter ocular surface parameters. The prevalence of DED has increased in recent years mostly due to different environmental factors. Moreover, age is a known risk factor for DED, and elderly patients often need ocular surgery. In this review, we aim to analyze the pathogenesis of DED and ocular Copyright: © 2021 by the authors. surface alterations of patients who underwent ophthalmic surgeries: cataract surgery, Licensee MDPI, Basel, Switzerland. refractive surgery, trabeculectomy and vitrectomy. This article is an open access article distributed under the terms and 2. Materials and Methods conditions of the Creative Commons PubMed, BMJ Journals, Clinical Key and the Cochrane Library were searched for Attribution (CC BY) license (https:// entries from 2010 through to 2021 for studies which evaluated ocular surface alterations creativecommons.org/licenses/by/ and DED symptoms after anterior segment surgery, such as cataract surgery, refractive 4.0/). J. Clin. Med. 2021, 10, 1642. https://doi.org/10.3390/jcm10081642 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 1642 2 of 14 J. Clin. Med. 2021, 10, 1642 2 of 14 and DED symptoms after anterior segment surgery, such as cataract surgery, refractive surgery, trabeculectomy and vitrectomy. The search was filtered to include only articles surgery, trabeculectomy and vitrectomy. The search was filtered to include only articles written in English, and nonrelevant studies were excluded. Search terms included “cata- written in English, and nonrelevant studies were excluded. Search terms included “cataract ract surgery”, “phacoemulsification”, “refractive surgery”, “trabeculectomy” and “vitrec- surgery”, “phacoemulsification”, “refractive surgery”, “trabeculectomy” and “vitrectomy” tomy” in combination with “ocular surface dysfunction” and “dry eye disease”. The in combination with “ocular surface dysfunction” and “dry eye disease”. The search of search of the databases resulted in 578 entries. Duplicates (n = 274) were removed using the databases resulted in 578 entries. Duplicates (n = 274) were removed using Endnote Endnote software. In total, 304 records of titles and abstracts were screened, and 79 studies software. In total, 304 records of titles and abstracts were screened, and 79 studies were were included in this review. Studies were excluded when they were not relevant to the included in this review. Studies were excluded when they were not relevant to the topic or topic or focused on the various treatments or management of DED (Figure 1). focused on the various treatments or management of DED (Figure1). FigureFigure 1. 1. FlowchartFlowchart of of study study selection selection process. process. 3.3. Dry Dry Eye Eye Disease Disease TearTear Film and Ocular Surface Society Society (T (TFOS)FOS) Dry Dry Eye Eye WorkShop WorkShop (DEWS) II defines defines DEDDED as as follows follows “Dry “Dry eye eye is is a a multifactorial multifactorial disease disease of of the the ocular ocular surface surface characterized characterized by by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear tear film instability and hyperosmolarity, ocular surface inflammation and damage, and film instability and hyperosmolarity, ocular surface inflammation and damage, and neu- neurosensory abnormalities play etiological roles” [3]. DED can be classified into two cate- rosensory abnormalities play etiological roles” [3]. DED can be classified into two catego- gories: aqueous-deficient and evaporative. Aqueous-deficient DED may be associated with ries: aqueous-deficient and evaporative. Aqueous-deficient DED may be associated with lacrimal gland dysfunction, while the evaporative type occurs with conditions affecting the lacrimal gland dysfunction, while the evaporative type occurs with conditions affecting eyelids or ocular surface. Eye structures and accessory organs of the eye, such as cornea, the eyelids or ocular surface. Eye structures and accessory organs of the eye, such as cor- conjunctiva, eyelids, eyelashes, lacrimal and Meibomian glands, define the ocular surface. nea, conjunctiva, eyelids, eyelashes, lacrimal and Meibomian glands, define the ocular The tear film is a very important structure, as it is the interface of the ocular surface and surface. The tear film is a very important structure, as it is the interface of the ocular sur- the environment. Its function is to protect, lubricate the ocular exterior and form a stable face and the environment. Its function is to protect, lubricate the ocular exterior and form refracting surface [4]. Chen et al. measured precorneal tear film thickness to be approxi- amately stable 1.9refracting± 0.9 µ msurface using [4]. ultrahigh Chen resolutionet al. measured optical precorneal coherent tomographytear film thickness [5]. Tear to film be approximatelyis thought to comprise 1.9 ± 0.9 threeμm using layers: ultrahigh mucin, aqueousresolution and optical lipid. coherent Transmembrane tomography mucins [5]. Tearwhich film are is attached thought toto epithelialcomprise cellsthree extendlayers: tomucin, aqueous aqueous components and lipid. containing Transmembrane various mucinspeptides, which and proteinsare attached protect to epithelial epithelial cell cellss extend [6]. The to tearaqueous film lipidcomponents layer is containing outermost, variousapproximately peptides, 42 and nm proteins thick and protect ensures epithelial resistance cells to [6]. evaporation The tear film [7]. lipid layer is outer- most,Disturbance approximately of the42 nm balance thick ofand the ensures tear film resistance may be to among evaporation the main [7]. factors in the developmentDisturbance of theof the DED balance (Figure of2 ).the Desiccation tear film may of the be ocularamong surface, the main changes factors in in tear the developmentcomposition andof the osmolarity DED (Figure lead 2). to Desiccation the activated of the production ocular surface, of inflammatory changes in mediatorstear com- positionand inflammatory and osmolarity cell recruitment. lead to the Theseactivat processesed production trigger of the inflam dissolutionmatory ofmediators cell junctions, and inflammatorydeath of epithelial cell recruitment. cells and destabilization These processe of thes trigger tear film, the which dissolution
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