ACTA OPHTHALMOLOGICA

THESIS
http://www.actaophthalmologica.com

Thesis

Recovery after cataract surgery

Studies on postoperative recovery and outcome after cataract surgery

Susanna Porela-Tiihonen
Department of Anaesthesiology and Department of Intensive Care Medicine,
Kuopio University Hospital, University of Eastern Finland, Kuopio
ACTA OPHTHALMOLOGICA 2016

Preface

This thesis was first published (in print only) by the University of Eastern Finland as: Dissertations in Health Sciences
number 275; 2015; Kuopio, Finland; ISBN (print): 978-952-61-1726-3; ISBN (pdf): 978-952-61-1727-0;
ISSN (print): 1798-5706; ISSN (pdf): 1798-5714; ISSN-L: 1798-5706.

It was presented by permission of the Faculty of Health Sciences, University of Eastern Finland for
public examination in Auditorium 2, Kuopio University Hospital, Kuopio, on Friday, April 10th 2015, at 12 noon

Author’s address: Department of Anaesthesiology and Department of Intensive Care Medicine

Kuopio University Hospital
University of Eastern Finland
KUOPIO
FINLAND

Supervisors: Professor Hannu Kokki, M.D., Ph.D.

Department of Anaesthesiology and Department of Intensive Care Medicine
University of Eastern Finland
KUOPIO
FINLAND

Professor Kai Kaarniranta, M.D., Ph.D.

Department of Ophthalmology
University of Eastern Finland
KUOPIO
FINLAND

Docent Merja Kokki, M.D., Ph.D.

Department of Anaesthesiology and Department of Intensive Care Medicine
University of Eastern Finland
KUOPIO
FINLAND

Reviewers: Professor Anders Behndig, M.D., Ph.D.

Department of Ophthalmology
Umeå University
UMEÅ
SWEDEN

Docent Annika Takala, M.D., Ph.D.

Department of Anaesthesiology
University of Tampere
TAMPERE
FINLAND

Opponent: Professor Juha Holopainen, M.D., Ph.D.

Department of Ophthalmology
University of Helsinki
HELSINKI
FINLAND

To my family
aos_94_A2_Acknowlegements_Layout 1 02-04-2016 11:32 Page 1

ACTA OPHTHALMOLOGICA 2016

Acknowledgements
This study was carried out in the Department of Anesthesiology, Department of Intensive Care Medicine and Department of
Ophthalmology, School of Medicine, University of Eastern Finland and Department of Ophthalmology, Kuopio University Hospital,
during the years 2009-2015.
I would like to express my gratitude to all of the individuals who have participated in this work. I feel myself privileged to have had you
in my life.
I present my deepest gratitude to my principal supervisor Professor Hannu Kokki. The original idea devised by Professor Kokki was the
foundation for the present study, in addition to his exceptional expertise in the study of pain and recovery. Without the impressive
knowledge and willingness to help of Professor Kokki, this work would never have been started, advanced, or completed.
I am grateful for having been able to undertake my thesis under the supportive guidance of Professor Kai Kaarniranta. The excellent
expertise in the field of ophthalmology and science in general provided by Professor Kaarniranta has been invaluable in this work. I am
truly thankful for all the priceless encouragement and support.
I want to express my gratitude to my third supervisor Docent Merja Kokki for the support and excellent advice, which played such an
essential role in this project. I am thankful and pleased for all the kind help and flexibility during these years.
Through your enthusiasm and impressive experience on research and medical practice, you have all provided this work and my life with
inspiration. You were always there for me when I needed help, and I feel privileged to have enjoyed your trust and faith in me as a young
researcher. In addition, your positive attitude makes it a pleasure to work with you. I could have never hoped for better supervisors.
I want to warmly thank Professor emeritus Harri Sintonen for participating in this study. The exceptional knowledge of Professor
Sintonen on health-related quality of life research was invaluable in coping with our study issues. I send my sincere thanks to Professor
Risto Roine for all the essential help and advice on treatment outcome issues. I am deeply grateful to have had a possibility to include
this much expertise in this work.
I am thankful for the collaboration and advice of Sinikka Purhonen MD, PhD; many thanks for all the support and encouragement.
The reviewers of this thesis work, Professor Anders Behndig and Docent Annika Takala, are warmly acknowledged for their construc-
tive and encouraging comments. Their excellent expertise helped to improve this work further.
Many warm thanks need to be expressed to Helvi Käsnänen RN for the help with the study participants. I am deeply grateful to staff of
the cataract surgery unit in Kuopio University Hospital for the kind help with the study questionnaires. I wish to thank Tommi
Karttunen MD for the practical advice concerning cataract surgery. I send my thanks to statistician Tuomas Selander and to Esa Kokki
PhD for the help with the statistics. I also want to acknowledge Ewen McDonald PhD for the linguistic revision of the thesis.
I wish to thank my dear friends, who are so wonderful. I appreciate and enjoy our time together. There are also many other important
people who have helped and supported me during this work. In addition, I send my most sincere thanks to all the study participants.
Finally, I can never thank enough my nearest and dearest, my parents and my family.
Thank you my mother Laimi and my father Olavi for the neverending support and encouragement. You always have the right words to
say, and without your faith in me, I would not be here. Special thanks go to my lovely little ones, our daughter Veera and our baby boy
Elias. I feel blessed to be your mother.
Jukka, I thank you for sharing life with me, and making me a happy wife and a proud mother to our children. Thank you for your
support and patience during this work. Without your help, I would have never been able to finish this project.
This work was financially supported by governmental EVO funding of the Hospital District of Northern Savo and by the University of
Eastern Finland, Kuopio, Finland and The Finnish Medical Foundation, which are gratefully acknowledged.
aos_94_A2_List of Paper_Layout 1 12-04-2016 11:46 Page 1

ACTA OPHTHALMOLOGICA 2016

List of papers
This dissertation is based on the following original publications:

Paper I

Porela-Tiihonen S, Kaarniranta K, Kokki H. Postoperative pain after cataract surgery. J Cataract Refract Surg. 39(5):789–98, 2013

Paper II

Porela-Tiihonen S, Kaarniranta K, Kokki M, Purhonen S, Kokki H. A prospective study on postoperative pain after cataract surgery. Clin
Ophthalmol. 7:1429–35, 2013

Paper III

Porela-Tiihonen S, Kaarniranta K, Kokki M, Kokki H. Recovery and patient satisfaction after cataract surgery. A one-year prospective
follow-up study. Acta Ophthalmol. 93:e172–3, 2015

Paper IV

Porela-Tiihonen S, Roine RP, Sintonen H, Kaarniranta K, Kokki M, Kokki H. Health-related quality of life after cataract surgery with
phacoemulsification technique and intraocular lens implantation. Acta Ophthalmol. 94:21–25, 2016

The publications have been adapted with the permission of the copyright owners.
aos_94_A2_List of abbreviations_Layout 1 02-04-2016 11:49 Page 1

ACTA OPHTHALMOLOGICA 2016

List of abbreviations
15D 15-Dimensional Instrument of Health-Related Quality of Life

ASCRS American Society of Cataract Refractive Surgery

BAK Benzalkonium chloride

BPI Brief Pain Inventory

BUT Tear-film break-up time

CME Cystoid macular oedema

EQ-5D The EuroQol Group Association Five Domain Quality of Life Questionnaire

ESCRS European Society of Cataract Refractive Surgery

HRQoL Health-related quality of life

HUI The Health Utility Index instrument

IASP International Association for the Study of Pain

IOL Intraocular lens

IOP Intraocular pressure

NEI-VFQ The National Eye Institute Visual Function Questionnaire

NHP The Nottingham Health Profile

NRS Numerical Rating Scale

NSAID Non-steroidal anti-inflammatory drug

QALY Quality-Adjusted Life Year

QWB-SA The Quality of Well-Being Scale-Self Administered Version

RCT Randomized controlled trial

SF The Short Form Health Survey

SIP Sickness Impact Profile

VA Visual acuity

VEGF Vascular endothelial growth factor

VF Visual functioning

VF- Visual Functioning Index- Questionnaire

VAS Visual Analogue Scale

VRS Verbal Rating Scale

YAG Yttrium aluminium garnet

aos_92_A2_contents_Layout 1 07-04-2016 08:07 Page 1

ACTA OPHTHALMOLOGICA 2016

Contents

PREFACE II 4.3.4 Management of pain 14

ACKNOWLEDGEMENTS III 4.3.4.1 Analgesic efficacy of the drugs used in
postoperative care 14
LIST OF PAPERS IV 4.3.4.2 Adverse effects 14
ABBREVIATIONS V 4.3.4.3 Non-steroidal anti-inflammatory agents 14
4.3.4.4 Corticosteroids 15
ABSTRACT 1
4.4 Discussion 15
1 INTRODUCTION 2 4.5 References 15
2 REVIEW OF THE LITERATURE 2 5 A PROSPECTIVE STUDY ON POSTOPERATIVE
2.1 Recovery after cataract surgery 2 PAIN AFTER CATARACT SURGERY 17
2.1.1 Common recovery 2 5.1 Introduction 18
2.1.2 Postoperative care 3
5.2 Materials and methods 18
2.1.3 Possible complaints 4
5.3 Statistic 19
2.2 Ocular symptoms after cataract surgery 5
2.2.1 Pain and other ocular symptoms 5 5.4 Results 19
2.2.2 Symptoms during the first hours after surgery 6 5.4.1 Patient characteristics 19
2.2.3 Symptoms during the first days after surgery 6 5.4.2 Pain 19
2.2.4 Symptoms during the first weeks after surgery 7 5.4.3 Other ocular symptoms 20
5.4.4 Analgesics 20
2.3 Outcome and satisfaction after surgery 7
2.3.1 Measuring vision-related outcome 7 5.5 Discussion 21
2.3.2 Satisfaction with treatment outcome 8 5.6 Conclusions 22
2.4 Cataract surgery and health-related quality of life 8 5.7 Acknowledgements 22
2.4.1 Measuring health-related quality of life 8 5.8 Author contributions 22
2.4.2 Generic instruments of health-related 5.9 Disclosure 22
quality of life 8 5.10 References 22
2.4.3 Health-related quality of life after cataract surgery 9 6 RECOVERY AND PATIENT SATISFACTION
3 AIMS OF THE STUDY 9 AFTER CATARACT SURGERY. A ONE-YEAR
PROSPECTIVE FOLLOW-UP STUDY 22
4 POSTOPERATIVE PAIN AFTER CATARACT 6.1 A letter to the editor 22
SURGERY 9 6.2 References 23
4.1 Introduction 9
4.2 Methods 9 7 HEALTH-RELATED QUALITY OF LIFE
4.2.1 Search strategy 9 AFTER CATARACT SURGERY WITH
4.2.2 Selection criteria, types of studies 10 PHACOEMULSIFICATION TECHNIQUE AND
4.2.3 Types of participants 10 INTRAOCULAR LENS IMPLANTATION 23
4.2.4 Types of interventions 10 7.1 Introduction 24
4.2.5 Selection of studies 10 7.2 Materials and methods 24
4.2.6 Data extraction and analysis 10 7.3 Statistics 25
4.2.7 Risk of bias in included studies 12 7.4 Results 25
4.3 Results 12 7.5 Discussion 26
4.3.1 Study descriptions 12 7.6 Acknowledgements 27
4.3.2 Incidence and prevalence of postoperative 7.7 References 27
pain 13
8 GENERAL DISCUSSION 28
4.3.2.1 Pain in the hospital during the first hours
after surgery 13 8.1 Summary 28
4.3.2.2 Pain after discharge 13 8.2 Limitations of the present study 28
4.3.3 Severity of pain 14 8.3 Future directions 28
4.3.3.1 Severity of postoperative pain during 9 CONCLUSIONS 30
early recovery 14
10 SUMMARY IN FINNISH 30
4.3.3.2 Severity of postoperative pain after
discharge 14 11 REFERENCES 30
 Acta Ophthalmologica 2016

Thesis

Recovery after cataract surgery

Susanna Porela-Tiihonen,1 Hannu Kokki,1 Kai Kaarniranta2 and Merja Kokki1
1
Department of Anaesthesiology and Department of Intensive Care Medicine, Kuopio University Hospital, University of Eastern
Finland, Kuopio, Finland
2
Department of Ophthalmology, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland

ABSTRACT.
Cataract surgery is the most common ophthalmological surgical procedure, and
it is predicted that the number of surgeries will increase significantly in the
future. However, little is known about the recovery after surgery. The first aim of
this study was to evaluate the prevalence, severity and duration of pain and other
ocular discomfort symptoms experienced after cataract surgery. The other
objectives were to identify the factors associated with lower postoperative patient
satisfaction and to measure the effect of cataract surgery on patients’ health-
related quality of life (HRQoL) and visual function in everyday life. The study
design was a prospective follow-up study. The course of the recovery and the
presence of ocular symptoms were evaluated by interviewing the patients via a
questionnaire at 1 day, 1 week, 6 weeks and one year after surgery The visual
functioning in everyday life was measured with Visual Functioning Index VF-7
and Catquest-9SF-questionnaires and furthermore the HRQoL was measured
with the 15D-instrument before surgery and at 12 months after surgery.The
patients returned the questionnaires by mail and were interviewed in the hospital
on the day of the surgery. The same patients filled-in all the questionnaires. The
patient reports were used to collect the data on medical history. A total of 303
patients were approached at Kuopio University Hospital in 2010–2011 and of
these 196 patients were eligible and willing to participate, with postoperative
data being available from 186 (95%) patients. A systematic review article was
included in the study procedure and it revealed the wide range in the reported
incidence of postoperative ocular pain. Some of the identified randomized
controlled studies reported no or only minor pain whereas in some studies
significant pain or pain lasting for several weeks has been described in more than
50% of the study patients. In the present study setting, pain was reported by
34% during the first postoperative hours and by approximately 10% of patients
during the first six weeks after surgery. During the early recovery in the hospital,
only a minority of the patients reporting pain were provided with pain
medication. The ocular discomfort symptoms such as itchiness, burning,
foreign-body sensation and tearing were common both before (54%) and after
surgery (38–52%). These symptoms can also be described as painful symptoms
and are often difficult to distinguish from ocular pain. The symptoms are also
typical of ocular surface disease, and some patients may benefit from the
postoperative administration of tear substitutes. The patients reporting postop-
erative ocular symptoms were less satisfied with the treatment outcome at
12 months after surgery (p = 0.001) compared to the patients who experienced
no symptoms. Those patients reporting less disability in visual functioning before
surgery were more satisfied than patients with more reported disability.The
HRQoL improved significantly after cataract surgery (p = 0.002). However,
when compared to an age-and gender-standardized control population, in

1
Acta Ophthalmologica 2016
cataract subjects the HRQoL remained slightly worse both before and at
12 months after surgery.
Acta Ophthalmol. 2016: 94, thesis 2: 1–34
ª 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
doi: 10.1111/aos.13055
1. Introduction
Cataract is an ocular condition that
causes vision impairment due to the
changes in opacity of the ocular lens.
Metabolic changes occurring in the
formerly clear lens lead to a loss of
optical clarity and blurred vision. The
only cure for cataract is a surgical
procedure; the opaque lens is removed
and replaced with an artificial intraoc-
ular lens (IOL; Asbell et al. 2005).
Cataract surgery is the most common
surgical procedure performed in many
countries including Finland (Brian &
Taylor 2001; Rautiainen & Rasilainen
2011). Cataract is an age-related condi-
tion, but some risk factors for lens
opacification have also been found.
Smoking, ocular trauma, exposure to
ultraviolet light, diabetes and drug-
induced metabolic changes in the lens
are some of the conditions which have
been identified as causing cataract, in
addition to hereditary and prenatal
reasons (West & Valmadrid 1995). It
has been estimated that the number of
cataract surgeries will increase signifi-
cantly in the next decades along with the
rise in life expectancy (Brian & Taylor
2001). In Finland, the median age of
patients undergoing phacoemulsifica-
tion with IOL implantation is 74 years
(Rautiainen & Rasilainen 2011).
In particular in the developing coun-
tries, cataract has formerly been a
major cause of loss of vision due to
the lack of appropriate surgical care.
According to a recent report from the
World Health Organization focussing
on the less developed regions, the
major global causes of visual impair-
ment are uncorrected refractive errors
(43%) followed by cataract (33%). In
global terms, cataract still remains as
the most important single cause of
blindness accounting for 51% of total
cases (Pascolini & Mariotti 2012). In
the past decades, the surgical manage-
ment of cataract has become less inva-
sive. The modern surgical procedure of
choice is phacoemulsification with IOL
implantation (Kelman 1967). The tech-
2
nique which was initially developed in
1967 is based on high-energy ultra-
sound to emulsify the cataractous lens
nucleus, with the fragments being sub-
sequently aspirated with an ultrasound
probe. The corneal incision required
for phacoemulsification probe is much
smaller (3 mm or less) in comparison
with limbal incision, usually a 11 mm
incision between cornea and sclera,
that has been earlier used in removal
of the entire lens (Asbell et al. 2005).
As the surgical procedure has
become less invasive, the recovery after
surgery is now easier and patients
usually no longer require in-patient
hospital care after the operation. The
modern minimally invasive cataract
surgery with phacoemulsification is
considered as a minor procedure with
an uneventful and pain-free recovery
period. However, in the published
studies, little attention has been paid
to pain and other postoperative ocular
irritation symptoms, and the data on
the incidence of these symptoms are
conflicting. In some studies, rather few
patients have reported any complaints
after surgery (Camesasca et al. 2007;
Raizman et al. 2007), whereas in other
studies some postoperative ocular irri-
tation symptoms and pain have been
experienced by the majority and even
as many as 90% of patients (Stifter &
Menapace 2007; Anders et al. 2009;
Ahmed et al. 2010; Heuermann et al.
2010; Pianini et al. 2010).
It is beneficial to conduct a patient-
defined subjective assessment when
evaluating the vision-related improve-
ment after cataract surgery. There is a
long tradition of measuring visual acu-
ity (VA) in ophthalmology and oph-
thalmic surgery, but this may not be
sufficient to assess fully the visual
disabilities caused by cataract (Uusi-
talo et al. 1999). The measurement of
visual functioning (VF) and vision-
related disabilities in daily life give
additional information from the
patient’s perspective. The measurement
of health-related quality of life
(HRQoL) is another tool which can
be used in the assessment of patient-
reported outcomes. The evaluation of
the change in HRQoL is a way to grade
the impact of treatment in the patient’s
general health and functioning.
Although cataract extraction is the
most common surgical procedure,
relatively little is known about postop-
erative recovery after phacoemulsifica-
tion with IOL implantation. However,
it is essential to gather knowledge of the
postoperative complaints associated
with surgery because these complaints
may delay recovery after the procedure
and may significantly influence the
patient’s assessment of treatment out-
come and quality of life (Garc
ıa-Cat-
al
an et al. 2009; Feeny et al. 2012). The
first aim of this study was to evaluate
the prevalence, duration and severity of
the symptoms, and other complaints
that cataract surgery patients might
have after surgery. The second aim
was to identify those factors that influ-
ence patient satisfaction and patient-
reported treatment outcome after cat-
aract surgery. The third aim was to
evaluate the impact of cataract surgery
on patients’ HRQoL and compare the
HRQoL of cataract patients to the
similar of age- and gender-standardized
control population.
2. Review of the
literature
2.1. Recovery after cataract surgery
2.1.1. Common recovery
In most cases, recovery after modern
phacoemulsification cataract surgery is
uncomplicated and straightforward.
However, as with any surgical proce-
dure, there is a possible appearance of
adverse events and other complaints
after surgery. Cataract surgery requires
corneal incision, a procedure that
induces a trauma in the corneal epithe-
lial cells and causes damage to the
corneal nerves (Khanal et al. 2008;
Rosado-Adames & Afshari 2012). The
surgical care of cataract includes also
exposure to the light of the microscope
 Acta Ophthalmologica 2016

therapy. Topical anti-inflammatory

agents and antibiotics are both routinely
provided after cataract surgery. Steroi-
dal agents and non-steroidal anti-
inflammatory drugs (NSAIDs) are used
to prevent and treat the postoperative
inflammation occurring after surgery.
Antibiotics are commonly used to pre-
vent postoperative ocular infections
such as endophthalmitis (DeCroos &
Afshari 2008; Behndig et al. 2013). In
other instructions of care, patients may
also be advised to use an eye shield on
the operated eye for the first 24 hr or
even a couple of days after surgery. In
Fig. 1. Anatomy of eye. Modified from Shutterstock images, www.shutterstock.com. addition, patients should avoid hair
washing for 2 days to keep water out
Table 1. The annual numbers of phacoemulsification cataract surgeries performed in public care of the operated-on eye. The instructions
in Finland. usually advise the patient to avoid any
Year Number of surgical procedures Surgeries per one million people strenuous activity such as heavy lifting,
swimming and taking a sauna for the
1997 30 035 5835 first week after surgery (Shoss & Tsai
2000 33 317 6430 2013).
2003 39 335 7535 Corticosteroids. Steroidal anti-inflam-
2005* 41 867 7966 matory drugs, that is corticosteroids
2006 37 560 7117
inhibit the lipoxygenase pathway lead-
2007 37 902 7150
2008 41 171 7729 ing to the leukotriene production and
2009 39 300 7343 thus reduce tissue swelling and prevent
2010 43 070 8012 oedema (McMahon & Koltzenburg
2011 42 360 7842 2006; DeCroos & Afshari 2008). They
2012 38 978 7182 have been used for decades to prevent
ocular inflammation. Corticosteroids
Data are taken from somatic specialist healthcare tables, National Institute for Health and
Welfare and National Research and Development Centre for Welfare and Health. Available at:
are mainly used with antibiotics in
www.thl.fi. Population data from Population structure, Official Statistics of Finland (OSF 2013). combination therapy. Many oph-
* The Act on the Status and Rights of Patients (available at: http://www.finlex.fi/en/laki/ thalmic surgeons prefer a 1 to 6-week
kaannokset/1992/en19920785.pdf) eligible from year 2005, setting the patient’s right of availability period of topical corticosteroids after
to non-emergency treatment by legislation. cataract surgery. The possible adverse
effects of topical ocular corticosteroid
and perioperative use of ocular drugs Conjunctival hyperaemia, anterior therapy include an increase of intraoc-
that may produce ocular surface stress chamber cells and flare and cystoid ular pressure (IOP), inhibition of cor-
response and irritation (Robciuc et al. macular oedema (CME) are some pos- neal wound healing and increased
2014). In addition, topically applied sible signs of inflammation encoun- likelihood of infection and serious
ocular drugs are used in the postopera- tered after cataract surgery (DeCroos complications, but systemic adverse
tive care, and some patients experience & Afshari 2008). The severity of the effects are rare in topical use (DeCroos
symptoms and adverse effects related to inflammation varies from patient to & Afshari 2008; Gonzales et al. 2013).
the postoperative drug therapy. patient. In most cases, the inflamma- According to the practice pattern
The present review of the literature tion is self-limiting, but drug therapy is studies published by ASCRS (Ameri-
examines studies reporting results from used to hasten resolution and to can Society of Cataract Refractive
trials using the phacoemulsification increase ocular comfort after surgery Surgery 2012, practice pattern study),
technique, as phacoemulsification is (Gonzales et al. 2013). The surgical Canadian Ophthalmological Society
the most commonly used technique ocular trauma triggers the inflamma- members study 2011 (Ong-Tone et al.
and is believed to be less traumatic than tory cascade where the cleavage of 2012) and ESCRS (European Society
conventional intracapsular and extra- arachidonic acid by phospholipase-2 of Cataract Refractive Surgery 2012,
capsular cataract extraction. The surgical produces leukotrienes, prostaglandins practice pattern study), there are vari-
technique and instrumentation used may and thromboxanes, which are media- ations in postoperative drug therapy
significantly affect the extent of corneal tors of inflammation (DeCroos & provided to individual patients and
endothelium trauma during surgery Afshari 2008; Fig. 1; Table 1). between different countries. In the
(Rosado-Adames & Afshari 2012). United States and Canada, postopera-
There is some degree of postopera- 2.1.2. Postoperative care tive topical corticosteroids are used in
tive ocular inflammation which occurs In most cases, the postoperative care 92% and 89% of the surgeries, respec-
after cataract surgery in both the ante- after cataract surgery consists of anti- tively, but no corresponding data seem
rior and posterior segments of the eye. inflammatory and antibacterial drug to be available from Europe. The

3
Acta Ophthalmologica 2016
duration of the topical postoperative
drug therapy was 4 weeks in most cases
(47%), 3 weeks (20%) or 2 weeks
(15%) according to the Canadian prac-
tice pattern study (Ong-Tone et al.
2012). In Europe, dexamethasone was
the most commonly used steroidal anti-
inflammatory drug chosen as the pre-
ferred drug by 71% of ophthalmolog-
ical surgeons, followed by prednisolone
(19% of surgeons) and betamethasone
with the proportion of 7%. In Finland,
the topical antibiotic-corticosteroid
therapy lasting for approximately
1 month is recommended (Cataract:
Current Care Guidelines 2014).
Antibiotics. Topically applied antibi-
otics are routinely used for the prophy-
laxis of postoperative bacterial ocular
infections such as endophthalmitis.
Intraocular, usually intracameral or
subconjunctival, antibiotics are used
during the surgery, and both pre- and/
or postoperative topical applications are
also provided (Behndig et al. 2013).
Cefuroxime is the most widely used
drug in perioperative intraocular injec-
tions in Europe (Gower et al. 2013).
When one considers postoperative
topical antibiotic agents, then it seems
that in North America the fourth-
generation fluoroquinolones were the
most extensively prescribed antibiotics
being chosen by 93% of the American
respondents and by 87% of the Cana-
dians, respectively (ACRS 2012, prac-
tice pattern study, Ong-Tone et al.
2012). The most widely used drugs in
Europe were tobramycin (25%), mox-
ifloxacin (17%) and chloramphenicol
(17%) according to the ESCRS (2012)
study report.
Non-steroidal anti-inflammatory agents.
The non-steroidal anti-inflammatory
drugs act by blocking the synthesis of
prostanoids, which are produced from
arachidonic acid in response to tissue
damage and inflammation. Non-ster-
oidal anti-inflammatory drugs differ in
both potency and elimination time
(McMahon et al. 2006). When dis-
pensed as eye drops, NSAID are gen-
erally safe as only small doses of
NSAIDs are used in topical adminis-
tration. The possible local adverse
effects of topical NSAID therapy
include post-cataract surgery atonic
mydriasis, contact dermatitis, delayed
wound healing, slowed corneal re-
epithelialization and corneal melting
(Guidera et al. 2001; Flach 2002). The
systemic exposure is much less in com-
4
parison with NSAIDs given by other
administration routes (Stewart et al.
2007). When NSAIDs are used topi-
cally, the systemic adverse events such
as gastrointestinal ulceration, renal
failure and cardiac events are rare and
their incidence is similar to placebo
(McMahon & Koltzenburg 2006). Non-
steroidal anti-inflammatory drugs have
been reported to decrease the incidence
of postoperative CME and also to
improve the postoperative VA after
cataract surgery (Gonzales et al. 2013).
In America and Canada, topical
NSAIDs are provided to 71% and
74% of patients undergoing cataract
surgery, respectively (ASCRS 2012,
practice pattern study; Ong-Tone et al.
2012). The proportion of European
ophthalmic surgeons using postopera-
tive NSAIDs in the postoperative care
after cataract surgery was not stated in
the European ESCRS report, but the
most commonly preferred NSAIDs
were diclofenac (36%), nepafenac
(24%) and bromfenac (13%). A total
77% of the surgeons in the ASCRS
study, 61% in the Canadian study and
38% in the ESCRS study preferred
starting the NSAID therapy before the
operation day.
2.1.3. Possible complaints
Cataract surgery carries a risk of <2%
for serious or vision-threatening com-
plications such as severe inflammation,
retinal detachment or suprachoroidal
haemorrhage, and is, thus, considered
as a low-risk procedure (Shoss & Tsai
2013; de Silva et al. 2014). However,
some less severe complications and
complaints have been reported to occur
more commonly after uncomplicated
cataract surgery.
Cataract surgery can cause ocular
dryness, and it may make worse previ-
ously present dry eye symptoms (Stifter
& Menapace 2007; Kasetsuwan et al.
2013). The symptoms of postoperative
ocular dryness have been reported to
occur immediately after surgery in some
patients (Li et al. 2007, Stifter & Mena-
pace 2007, Sipos et al. 2011, Kaset-
suwan et al. 2013). Symptoms and
postoperative changes in tear film
parameters were present at 2 months
after surgery in the studies of Li et al.
(2007) and Cho & Kim (2009). In a study
published by Venincasa et al. (2013), no
difference in tear film parameters was
detected between the operated and unop-
erated eye at 3 months after surgery.
Severe sterile or infectious inflamma-
tion of the anterior and/or posterior
chamber of the eye, endophthalmitis, is
a rare yet severe condition that occurs in
0.03–0.3% of patients undergoing cat-
aract surgery (Behndig et al. 2013;
Gower et al. 2013). Endophthalmitis is
a possible vision-threatening complica-
tion of cataract surgery. Swollen eyelids,
ocular pain, conjunctival hyperaemia,
decreased VA, anterior chamber cells
and an opaque vitreous are signs of
endophthalmitis. This condition usually
appears during the first days after
surgery, and in 80% of cases, the
endophthalmitis will have developed
during the first 6 weeks after surgery
(Barry et al. 2009; Gower et al. 2013).
Cystoid macular oedema is the most
common cause of poor visual outcome
following cataract surgery. The exact
cause of the condition is unclear, but
surgical complications and postopera-
tive inflammatory processes have been
proposed being the causative factors.
Patients with diabetes mellitus carry a
higher risk for postoperative CME.
The dilated capillaries cause leakage
and accumulation of intraretinal fluid
in the central retina, macula. The
incidence of clinically significant CME
after modern cataract surgery is esti-
mated to be between 0.1% and 3.3%
(Dieleman et al. 2011; Greenberg et al.
2011; Zur et al. 2011). In contrast, the
incidence of a clinically not important
CME, which nonetheless can be
detected on optical coherence tomog-
raphy, is reported to be as high as 25%
and greater than the condition causing
poor visual outcome (Dieleman et al.
2011). The peak incidence of CME
occurs between 4 and 6 weeks after
surgery; if the duration of CME is
<4 months, it often resolves sponta-
neously. Cystoid macular oedema per-
sisting for 4 months or more is termed
chronic CME. Steroidal and non-ster-
oidal anti-inflammatory agents are
used in the treatment of CME with
topical and/or systemic applications
(Sivaprasad et al. 2012; Shoss & Tsai
2013). Recently, an intravitreal implant
of dexamethasone has been developed
for the treatment of macular oedema
(Haller et al. 2010; Querques et al.
2014). In addition, in recent years,
intravitreal anti-angiogenic drug ther-
apy with vascular endothelial growth
factor (VEGF) inhibitors has been used
in the treatment of CME (Pielen et al.
2013).

An elevation in IOP of more than
30 mmHg immediately or during the
first days after cataract surgery has
been reported in 0.1–14% of patients in
the examined studies (Lane et al. 2007;
Mohammadpour et al. 2007; Shingle-
ton et al. 2007; Pianini et al. 2010;
Smith et al. 2010; Dell et al. 2011;
Dieleman et al. 2011; Donnenfeld et al.
2011; Fan et al. 2014). Patients with a
history of glaucoma surgery, high
myopia and diabetes mellitus carry a
higher risk for early IOP elevation after
surgery. The IOP elevation is also a
possible adverse effect of topical corti-
costeroid therapy (Mohammadpour
et al. 2007; Fan et al. 2014). In some
patients with preoperatively existing
primary open-angle glaucoma and ocu-
lar hypertension, there may be also a
modest and long-lasting decrease in
IOP occurring after cataract surgery
(Hayashi et al. 2001; Shingleton et al.
2007; Shrivastava & Singh 2010).
There are also some more rare
major complications such as an incor-
rect position of the IOL, retained lens
fragments after complicated surgery,
toxic anterior chamber inflammation,
leakage of the wound, bullous ker-
atopathy, suprachoroidal haemorrhage
and retinal detachment which may
also be detected during the early
recovery (Tilleul et al. 2010; Taravati
et al. 2012; Shoss & Tsai 2013). The
underlying condition of uveitis may
also be exacerbated after cataract
surgery (Mohammadpour et al. 2007).
The intraoperative complications that
may lead to combined surgeries
increase also the risk for other post-
operative complications, as in the case
of posterior capsule rupture or vitre-
ous prolapse during the cataract sur-
gery (Jakobsson et al. 2009; Ti et al.
2014).
As a reaction to cataract surgery
occurring in some patients, the poste-
Fig. 2. Cataract surgery using the phacoemulsification technique. Modified from: www.vision-and-eye-health.com.
rior capsular cells may undergo hyper-
plasia and cellular migration,
appearing as a thickening, opacifica-
tion and clouding of the posterior lens
capsule, posterior capsule opacifica-
tion. Posterior capsule opacification is
the most commonly reported late com-
plication of phacoemulsification catar-
act surgery, and the reported incidence
seems to vary between 2% and over
50% (Asbell et al. 2005). Posterior
capsule opacification that compromises
vision can be treated with capsulotomy
performed with a yttrium aluminium
garnet (YAG) laser (Fig. 2).
2.2. Ocular symptoms after cataract
surgery
2.2.1. Pain and other ocular symptoms
The cornea is one of the most densely
innervated tissues in the human body
and thus highly pain-sensitive (M€ uller
et al. 2003). Cataract surgery causes
corneal endothelium trauma, ocular
inflammation and ocular dryness that
can result in ocular irritation during the
recovery period (Li et al. 2007;
Rosado-Adames & Afshari 2012;
Kasetsuwan et al. 2013). These condi-
tions may cause different types of ocu-
lar discomfort symptoms such as pain,
burning, stinging, foreign body sensa-
tion, itchiness and glare in the operated
eye. Ocular irritation symptoms are
often considered also as symptoms of
ocular dryness and ocular surface dis-
ease, or symptoms of superficial ocular
pain (McMahon & Koltzenburg 2006;
Dry Eye WorksShop 2007).
Severe postoperative ocular pain is
assumed to be a sign of postoperative
elevation of intraocular pressure,
inflammation or infection, all condi-
tions requiring immediate care. This
type of intense ocular pain can be also
classified as deep ocular pain, distin-
guishing it from superficial ocular pain
Acta Ophthalmologica 2016
symptoms (McMahon & Koltzenburg
2006).
According to the definition devised
by the International Association for
the Study of Pain (IASP 2011, Classi-
fication of Chronic Pain; Bonica 1979),
pain is ‘an unpleasant sensory and
emotional experience associated with
actual or potential tissue damage, or
described in terms of such damage’.
According to this definition, pain is a
subjective, unpleasant sensorial and
emotional experience. As a third com-
ponent, pain has a cognitive dimension,
that is patients confer meanings on the
postoperative complaints that they
experience (Bonica 1979; IASP 2011
Classification of Chronic Pain). Ocular
irritation symptoms such as itchiness,
stinging, burning and foreign body
sensation are common after oph-
thalmic surgery, and it can be difficult
to distinguish these symptoms from
postoperative pain (Hovanesian et al.
2001; Li et al. 2007; Fong et al. 2012).
Moreover, the elderly may use euphe-
misms in reporting pain conditions that
make pain assessment a challenging
task (Closs & Briggs 2002).
In most of the reviewed randomized
placebo-controlled trials evaluating the
use of topical ocular anti-inflammatory
agents or antibiotics during the first days
and weeks after cataract surgery, the
postoperative ocular irritation symp-
toms have been reported as part of the
safety and tolerability analysis of the
study drug. The ocular irritation symp-
toms were considered as possible drug-
related adverse events, and the routinely
used topical ocular drugs cause transient
discomfort in conjunction with drop
instillation in some patients. Drop-
related discomfort sensations such as
stinging and burning have been reported
by 15–40% of patients in studies that
used topical NSAIDs, corticosteroids or
corticosteroid-antibiotic combinations
5
Acta Ophthalmologica 2016
(Sandoval et al. 2006; Pianini et al.
2010; Fong et al. 2012; Rajpal et al.
2013). In most studies, the ocular symp-
toms were more common in patients
treated with placebo and less common in
the study groups of different NSAIDs
(Price & Price 2004; Maxwell et al. 2008;
Donnenfeld et al. 2011; Silverstein et al.
2011; Fong et al. 2012; Rajpal et al.
2013; Walters et al. 2014). Although
topical ophthalmic solutions of vehicle
do not include any medication, in most
cases the formulation contains the same
preservatives as present in the study
drug. Consequently, these compounds
may cause preservative-induced ocular
irritation in the vehicle-treated patients,
in addition to failing to provide any
symptom-reducing anti-inflammatory
effects. The most commonly used
preservative is benzalkonium chloride
(BAK; Cho & Kim 2009), but the other
preservatives also have cytotoxic and
inflammatory effects (Paimela et al.
2012). Typical adverse effects of eye
drops containing BAK include superfi-
cial punctuate keratopathy, epithelial
erosions, conjunctival hyperaemia, tear-
ing and subjective painful sensations
such as foreign body sensations, itchi-
ness, burning, stinging and ocular irri-
tation (Pisella et al. 2002; Jaenen et al.
2007; Uusitalo et al. 2008, 2010).
2.2.2. Symptoms during the first hours
after surgery
2.2.2.1. Pain. Several randomized
controlled studies report the incidence
or severity of pain during the first
postoperative hours after cataract sur-
gery. However, the reported incidences
of early-onset postoperative ocular
pain vary significantly in the published
literature.
During the first postoperative hours,
pain was reported by 6–95% of patients
in studies by Price & Price (2004),
Kongsap & Wiriyaluppa (2006), Russo
et al. (2007), Anders et al. (2009),
Heuermann et al. (2010), Kaluzny et al.
(2010) and Dell et al. (2011). The inci-
dence of moderate or severe pain ranged
from 1% up to 35% in the reports
published by Stifter & Menapace (2007),
Kaluzny et al. (2010) and Dell et al.
(2011). In the studies conducted by
Anders et al. (1999) and Heuermann
et al. (2010), the patients received an
intraoperative intracameral injection of
lidocaine in the intervention group and a
peribulbar injection of prilocaine in the
control group. The incidence of moder-
6
ate or severe pain was 71–85% at 2 hr
after surgery, and at 6 hr after surgery,
30–36% of the patients still reported
significant pain in both groups.
In most studies evaluating the sever-
ity of postoperative pain after cataract
surgery, the severity was mild. In
most studies, pain was assessed using
a Visual Analogue Scale (VAS) or a
Numerical Rating Scale (NRS) with a
range from 0 = no pain to 10 = most
pain. The mean pain scores during the
first hours after surgery varied between
0.5 and 1.7/10 (Kongsap et al. 2006;
Stifter & Menapace 2007; Dell et al.
2011; Kaluzny et al. 2010). Although
the mean pain severity was mild, some
patients did experience significant post-
operative pain.
In the Stifter & Menapace (2007)
study those patients wearing a postop-
erative eye patch were compared to
unpatched patients after bilateral cat-
aract surgery. One out of every eight
patients (12%) in the unpatched group
reported moderate to severe postoper-
ative pain. In that study, a negative
correlation (r = 0.75 to 0.91) was
noted between tear film break-up time
(BUT) and ocular pain score during the
first hours after surgery. No moderate
or severe pain was reported in the
patched eye group. Another study
detected pain in 55–82% of patients
with either artificial tears or ocular
bandage at 1 hr after surgery. The
prevalence of pain decreased to 0–
11% during the first 24 hr after surgery
(Sipos et al. 2011). Recently, the effect
of a subconjunctival injection of corti-
costeroid-antibiotic solution was com-
pared with iodine eye drops (Ahmed
et al. 2010). Postoperative pain was
significantly higher in patients treated
with subconjunctival injection of dex-
amethasone–gentamycin, 5.7/10, as
compared to patients receiving iodine
eye drops, 2.7/10.
2.2.2.2. Other symptoms. Other ocular
irritation symptoms are commonly
reported during the first hours after
cataract surgery. The incidence of ocu-
lar irritation symptoms experienced
during the first postoperative hours
may be as high as 98% according to
the study of Dell et al. (2011). There is a
report that minimal or mild photopho-
bia is present in 75–100% of patients
immediately after surgery (Pang et al.
2001). Sipos et al. (2011) showed that
artificial tear therapy reduced signifi-
cantly early painful ocular irritation
symptoms at 1 hr after surgery, but no
longer at 6 or 24 hr after surgery.
2.2.3. Symptoms during the first days
after surgery
2.2.3.1. Pain. During the last decade,
the incidence of postoperative pain
during the first 72 postoperative hours
has been evaluated in several random-
ized controlled studies. After discharge,
circa half of the patients have reported
postoperative pain in the placebo-
treated control groups (Lane et al.
2007; Nardi et al. 2007; Maxwell et al.
2008; Donnenfeld et al. 2011; Fong
et al. 2012; Rajpal et al. 2013; Walters
et al. 2014). In the active intervention
groups, pain was generally less fre-
quent; 3–52% of patients in these
groups experienced postoperative pain
after discharge (Bainbridge et al. 1998;
Camesasca et al. 2007; Lane et al.
2007; Nardi et al. 2007; Raizman et al.
2007; Maxwell et al. 2008; Baiza-
Duran et al. 2009; Dell et al. 2011;
Donnenfeld et al. 2011; Silverstein
et al. 2011; Fong et al. 2012; Walters
et al. 2014). By contrast, in the Mohan
et al. (2001) study, 53–90% of the
patients reported pain. However, most
patients in the latter study reported
only slight pain. A total 26% of
patients in the intervention group,
treated with ciprofloxacin–dexametha-
sone ophthalmic suspension, experi-
enced significant pain, versus none in
the active control group treated with an
ophthalmic suspension of betametha-
sone–neomycin (Mohan et al. 2001). In
a study that combined two randomized
phase three trials, 51% of patients in
the placebo group reported pain during
the first postoperative day, versus 21%
in the group treated with bromfenac
0.07% ophthalmic solution. At 3 days
after surgery, the prevalence of pain in
the two groups was 47% and 14%,
respectively (Walters et al. 2014).
There are studies that have evalu-
ated the efficacy of anti-inflammatory
agents in patients with postoperative
inflammation. In these reports, more
pain has been reported in comparison
with studies with less selected patient
groups. In a recent multicentre study, a
total of 407 patients with an anterior
chamber cell count of more than 6
(grade ≥1) in the operated eye were
randomized to receive either lotepred-
nol etabonate 0.5% gel or vehicle after
cataract surgery. At 18–34 hr postop-
eratively, ocular pain was experienced

by 50% of patients in both groups, and
45% of patients required rescue med-
ication (NSAIDs or corticosteroids)
during the study period which lasted
until 18 days after surgery (Fong et al.
2012). In a study on patients with
anterior chamber cells of grade 2,
58% of placebo-treated patients and
27% of patients receiving loteprednol
etabonate still reported pain at 8 days
after surgery (Rajpal et al. 2013).
2.2.3.2. Other symptoms. In most of
the study reports, the presence of
ocular irritation symptoms such as
foreign body sensation, itching, sting-
ing, burning and photophobia are
reported as part of the safety analysis
of the study drug. Ocular irritation
symptoms were reported by 40–70% of
patients during the first day after
surgery in the publication of Sandoval
et al. (2006), by 45–56% of patients in
that of Bainbridge et al. (1998) and by
13–55% in the work of Silverstein et al.
(2011). In contrast, in some studies
ocular irritation symptoms have been
reported by fewer than 5% of patients
(Maxwell et al. 2008; Donnenfeld et al.
2011). Dry eye symptoms were
reported by 16–32% of patients in the
Camesasca et al. (2007) study. Ocular
photophobia and tearing were reported
at 18–34 hr after surgery by 57% and
42% of patients in Fong et al. (2012)
and continual tearing by 53–65% in
Mohan et al. (2001).
2.2.4. Symptoms during the first weeks
after surgery
2.2.4.1. Pain. The prevalence of ocu-
lar pain declines during the first weeks
after surgery and is at its most intense
during the first days after surgery. In
the studies evaluating the postoperative
pain during the first few days after
cataract surgery, the prevalence of pain
varies in the intervention groups
between 2% and 26%, whereas in the
placebo groups it is higher, ranging
between 29% and up to 58% (Mohan
et al. 2001; Lane et al. 2007; Nardi
et al. 2007; Maxwell et al. 2008; Baiza-
Duran et al. 2009; Dell et al. 2011;
Silverstein et al. 2011; Fong et al. 2012;
Rajpal et al. 2013; Modi et al. 2014;
Walters et al. 2014). Raizman et al.
(2007) reported less pain compared to
other studies in a study comparing two
topical prednisolone formulas. In that
study, pain was reported only by 3–6%
of patients during the first weeks after
surgery.
The resolution of early-onset post-
operative pain occurs during the first
days and weeks after surgery as the
prevalence of pain generally decreases
along with the course of the recovery.
In three recent studies, the median time
to resolution of pain was 1–4 days
(Dell et al. 2011; Donnenfeld et al.
2011; Silverstein et al. 2011).
The severity of pain during the first
weeks after surgery is reported to be
mild in general. After discharge and up
to 4 weeks after surgery, the mean pain
score assessed with VAS or NRS has
ranged between 0.6 and 2.5/10 (Ahmed
et al. 2010; Dieleman et al. 2011). In
studies where postoperative pain after
cataract surgery has been measured with
a verbal rating scale (VRS), most
patients have reported either no pain
or only mild pain (Paganelli et al. 2004;
Donnenfeld et al. 2006; Camesasca
et al. 2007, Duong et al. 2007; Raizman
et al. 2007).
One study has described more severe
pain in comparison with other studies,
and this being experienced at 7 days
after surgery. One-third (33%) of
patients who received preservative-free
dexamethasone–netilmicin eye drops,
and 45% of patients who received
preservative-containing dexametha-
sone–tobramycin eye drops, reported
moderate or severe pain (Pianini et al.
2010). Similarly, in the work of Walters
et al. (2014), at 15 days after surgery, a
third of patients in the placebo group
and 8% of patients treated with brom-
fenac 0.07% ophthalmic suspension
reported pain.
2.2.4.2. Other symptoms. In the litera-
ture, there are substantial variations in
the reported prevalence of ocular irri-
tation symptoms during the first weeks
after surgery. Ocular irritation symp-
toms were described by 27%–84% of
patients treated with a topical NSAID,
a corticosteroid or placebo (Smith
et al. 2010; Silverstein et al. 2011).
The duration of the symptoms may
last several weeks in some patients; 29–
50% of patients reported ocular dis-
comfort at 28–30 days after surgery in
two studies (Smith et al. 2010; Dell
et al. 2011). Photophobia was experi-
enced by 40–65% of patients and
tearing by 16–35% of patients at 3–
15 days after surgery in the Comstock
et al. (2011) study. Less frequent symp-
toms were reported in some studies,
with <10% of patients reporting some
symptoms of ocular irritation (Solo-
Acta Ophthalmologica 2016
mon et al. 2001; Lane et al. 2007). The
severity of the reported symptoms is
generally mild and <4/10 on the VAS
(Solomon et al. 2001; Donnenfeld
et al. 2006; Russo et al. 2007).
Bright visual artefact defects such as
glare, halos and starburst symptoms,
that is positive dysphotopsia, are com-
mon after cataract surgery and may
occur in as many as every second
patient. Positive dysphotopsia is con-
sidered as a lens-related deficit phe-
nomenon, whereas the aetiology of
negative dysphotopsia, the presence
shadows and dark spots in the visual
field, remains unknown (Schwiegerling
2006; Visser et al. 2011).
2.3. Outcome and satisfaction after
surgery
2.3.1. Measuring vision-related outcome
The significant improvement of VA
and VF after cataract surgery has been
documented well in numerous study
assessments, and the benefits of catar-
act surgery as a highly effective surgery
with minimal complications are beyond
doubt. Measurement of VA has long
traditions in ophthalmology in the
assessment of visual ability. Although
the vision-related ability to perform
everyday tasks is the most important
outcome for the patient, VA is one of
the most important clinical outcomes
for the cataract surgeon.
Measurement of VA was developed
at the 1840–1850s to standardize vision
tests (Tasman & Jaeger 1992). However,
the use of VA alone neither assesses the
full impact of cataract nor estimates the
full benefit of cataract surgery to the
patient (McAlinden et al. 2011). A
number of cataract surgery outcome
questionnaires have been developed
attempting to estimate the difficulty that
people experience when performing
daily activities. This trait is known as
VF, visual disability or vision-related
activity limitation (McAlinden et al.
2011). When evaluating the outcome
after cataract surgery, many previous
studies have preferred to measure VF
instead of VA (Steinberg et al. 1994a,b;
Cassard et al. 1995; Uusitalo & Tarkka-
nen 1998; Uusitalo et al. 1999; Fried-
man et al. 2002; Mamidipudi et al.
2003; Rosen et al. 2005; McAlinden
et al. 2011).
There are multiple questionnaires
available which have been developed to
measure VF. The Catquest questionnaire
7
Acta Ophthalmologica 2016
was developed in Sweden and initially
consisted of 17 items (Lundstr€om et al.
1997). This questionnaire was short-
ened to a 9-item short form version
Catquest-9SF, and this is considered as
the most responsive VF questionnaire
in a study which compared 16 ques-
tionnaires (Lundstr€ om & Pesudovs
2009; McAlinden et al. 2011). Visual
functioning index (VF) questionnaires
are popular, and they too have been
abridged from the original 14-item
version VF-14 (Steinberg et al. 1994a,
b). The Cataract Symptoms Score,
CSS, has been revised from initial 14-
item questionnaire and consists of two
subscales, mobility and VF (Gothwal
et al. 2009). The National Eye Institute
Visual Function Questionnaires (NEI-
VFQ) were originally 51-, 39- and 25-
item questionnaires, but these also now
have many abbreviated versions (Man-
gione et al. 1998). There are several
other questionnaires being also used by
ophthalmologists.
2.3.2. Satisfaction with treatment out-
come
In addition to measurement of VA and
VF, it has been proposed that a change
in patient satisfaction after cataract
surgery could be used as a quantitative
reference measure for other outcomes
(Uusitalo et al. 1999). Many previous
studies have described a apparent cor-
relation between visual functioning and
patient satisfaction after cataract sur-
gery (Steinberg et al. 1994a,b; Lund-
str€
om et al. 1997; Uusitalo &
Tarkkanen 1998; Uusitalo et al. 1999;
Friedman et al. 2002; Mamidipudi
et al. 2003; Lundstr€
om & Stenevi 2013).
The reasons for dissatisfaction in
some of those patients experiencing
good clinical and functional outcome
are not fully understood. In a recent
study of 4335 patients, the patient
factors that were found to correlate
with better postoperative satisfaction
were good preoperative physical and
mental health and higher education
(Garcia-Gutierrez et al. 2014). The
ocular complaints and symptoms asso-
ciated with surgery may delay recovery
after the procedure and may also
influence the patient’s assessment of
the overall treatment outcome and
quality of life (Garc
ıa-Catal
an et al.
2009; Feeny et al. 2012). Chang-God-
inich et al. (1999) reported that those
patients who were dissatisfied with
postoperative visual improvement
8
1 month after cataract surgery were
significantly older and were also dis-
satisfied with their medical care and life
in general. In that study, those patients
tended to claim that they felt no
functional improvement even though
there was an improvement in their
VA.
In two studies, the presence of ocu-
lar complications after cataract extrac-
tion has been related to less satisfaction
with the outcome (Schein et al. 1995;
Garcia-Gutierrez et al. 2014). In the
study of Kinard et al. (2013), the pres-
ence of pseudophakic dysphotopsia
was associated with postoperative dis-
satisfaction.
2.4. Cataract surgery and health-related
quality of life
2.4.1. Measuring health-related quality
of life
Disease-specific instruments are widely
used to measure the vision-related qual-
ity of life (McAlinden et al. 2011). These
instruments, however, do not allow any
comparison in between ophthalmologi-
cal procedures and other interventions
from other medical specialities in terms
of HRQoL or cost-effectiveness. The
generic HRQoL instruments include
both profile and single index score
instruments. The measurement of
HRQoL with the latter produces an
utility index score, usually between 0
(equivalent to being death) and 1 (equiv-
alent to full, symptom-free functioning).
The EuroQol Group Association five
domain questionnaire (EQ-5D), the
Short Form Health Survey (SF-6D),
the Health Utility Index instruments
(HUI) and the 15-dimensional health
state descriptive questionnaire 15D are
examples of single index score instru-
ments (R€ as€
anen et al. 2006b).
The index score is necessary if one
wishes to conduct a cost-utility analysis
using Quality-Adjusted Life Years
(QALY) gained as a measure of the
effectiveness of care (Fanshel & Bush
1970; Torrance et al. 1972; Weinstein &
Stason 1977; Gold et al. 1996; Wein-
stein et al. 2009). The HRQoL and
QALY analysis allows comparison of
the value of the treatment of different
diseases from the patient perspective.
Accordingly, it is possible to estimate
and compare the patient-assessed sub-
jective effects of different procedures on
quality of life by analysing the changes
of HRQoL (Gold et al. 1996; Ramsey
et al. 2005; Nord et al. 2009; Wisløff
et al. 2014).
2.4.2. Generic instruments of health-
related quality of life
Several generic instruments of HRQoL
have been developed. A 5-domain
instrument, the EQ-5D, is used widely,
and in combination with a VAS, it
forms the EuroQol questionnaire
(EuroQol Group 1990). The Sickness
Impact Profile (SIP) consists of physi-
cal, psychosocial and five other dimen-
sions concerning daily activities. The
original 136-item version has been
shortened to a 68-item questionnaire
(de Bruin et al. 1994). Both the SF-36
and SF-12 questionnaires include eight
health domains: physical functioning,
role physical, bodily pain, general
health, vitality, social functioning, role
emotional and mental health
(Hawthorne et al. 2007). The SF-6D
is a shortened version of these ques-
tionnaires (Brazier et al. 2002). The
Nottingham Health Profile (NHP) was
developed in the 1970s and consists of
two parts, one addressing the health
status with the other estimating the
impact of health on daily living (Hunt
et al. 1981). The Health Utility Index
instruments have two systems, HUI2
and HUI3. The initial HUI1 was
developed to be used in evaluating the
outcomes of very low-birthweight
infants (Horsman et al. 2003). The
Quality of Well-Being Scale–Self-
Administered version (QWB-SA) con-
sists of five parts and 74 items including
a symptom checklist and function sec-
tions (Andresen et al. 1998).
The 15D is an 15-item instrument
developed in Finland that can be used
both as a profile instrument and a
single index utility score measure. As
a profile instrument, the result reflects
the health status of an individual or
patient group in all of the different
dimensions, and a value component is
needed to aggregate the measurements
on the dimensions into a single index
score (Sintonen 1995, 2001). The 15D
instrument has 15 dimensions; mov-
ing, seeing, hearing, breathing, sleep-
ing, eating, speech, excretion, usual
activities, mental function, discomfort
and symptoms, depression, distress,
vitality and sexual activity. All these
produce an individual value between 1
and 5 that is converted to a single
index number of 0 to 1 (15D-score)
with a valuation system based on the

multi-attribute utility theory (Sinto-
nen 1995).
2.4.3. Health-related quality of life after
cataract surgery
Cataract surgery is considered as one
of the most cost-effective surgical pro-
cedures (Busbee et al. 2002; Riaz et al.
2006). However, some previous multi-
attribute utility analyses using generic
instruments of the HRQoL have
yielded inconsistent results with catar-
act patients. Steinberg et al. (1994a,b)
stated that 67% of patients experi-
enced significant improvement in the
SIP at 4 months after cataract surgery,
even though the VA had improved in
almost all (96%) and VF-14 in 89% of
patients. Rosen et al. (2005) reported a
significant improvement in both the
generic instrument QWB-SA and dis-
ease-specific VF-14-instrument after
cataract surgery. However, in patients
with preoperative VA better than 20 of
40 in the operated eye or 20 of 50 in
the unoperated eye, there was no
significant improvement in QWB-SA.
R€as€anen et al. (2006a,b) reported an
insignificant improvement in the over-
all utility score with the 15D instru-
ment, as none of the other dimensions
improved significantly despite the
improvement in vision.
Brown et al. (2013) detected a 21%
gain in quality of life after first-eye
cataract surgery compared to an
untreated cohort, and 1.6 QALYs gain
in utility after cataract surgery. Busbee
et al. (2002) used the same methodol-
ogy, calculating the utility score from
VA; the improvement was rather sim-
ilar, 1.5 QALYs to that reported by
Brown et al. (2013). The EQ-5D-ques-
tionnaire and VAS were used by Dan-
quah et al. (2014); they observed a
significant improvement in many
dimensions of the EQ-5D at 1 year
after surgery. At baseline, the scores of
cataract patients were significantly
worse than those of control patients
with no vision difficulties, but after
surgery there were no statistically sig-
nificant differences between the groups.
The recent review of Agarwal &
Kumar (2011) highlighted the varia-
tions in the values of cost-utility. The
cost per QALYs gained of cataract
surgery for first eye has varied between
245 and 22 000 USD/QALY in Wes-
tern countries and between 9 and 1600
USD/QALY in the developing coun-
tries.
3. Aims of the study
The general aim of the study was to
evaluate the recovery up to 12 months
after phacoemulsification cataract sur-
gery with IOL implantation.
The specific aims were as follows:
I To review the current literature on
postoperative pain after cataract
surgery (Publication I).
II To evaluate early (Publication II)
and late recovery (Publication III)
after cataract surgery.
III To evaluate patient satisfaction with
the treatment outcome and to iden-
tify the factors that may contribute
to dissatisfaction with the cataract
surgery procedure (Publication III).
IV To assess the effect of cataract
surgery on HRQoL (Publication IV).
4. Publication I.
Postoperative pain after
cataract surgery
Abstract
Cataract extraction surgery is the most
common surgical procedure, but
knowledge of postoperative pain
related to cataract surgery is sparse.
In this systematic review, the incidence,
prevalence and management of pain
after phacoemulsification surgery were
identified using PubMed and Scopus.
Selected studies were restricted to
randomized controlled trials with inter-
ventions on postoperative inflamma-
tion and pain. Data from 105 articles
were extracted, and 21 studies met the
final inclusion criteria. Most studies
reported no or only mild postoperative
pain, but some studies reported mod-
erate and severe pain and pain lasting
several weeks. The interventions con-
sisted of drug therapy including topical
non-steroidal anti-inflammatory drugs,
corticosteroids, paracetamol, perioper-
ative intraocular injections, eye pads
used after surgery and different surgical
techniques. The reviewed literature
indicates that cataract surgery is asso-
ciated with significant postoperative
pain in some patients that should be
provided with appropriate counselling
and pain treatment.
4.1. Introduction
Cataract surgery is the most common
surgical procedure. Phacoemulsifica-
Acta Ophthalmologica 2016
tion was introduced in the treatment
of cataract in 1967 and gained accep-
tance in the early 1990s when safety
and efficacy had improved (Emery
et al. 1978). The efficacy of the pha-
coemulsification technique and the
increase in life expectancy are the
reasons for the rising number of pro-
cedures performed. As the number of
elderly people increases, the need for
procedures will rise because cataract is
an age-related condition and surgery is
the only effective treatment for the loss
of lens transparency. In Finland, the
median age of patients having pha-
coemulsification with intraocular lens
(IOL) implantation is 74 years (Rauti-
ainen & Rasilainen 2011).
Although cataract extraction is that
common, little is known about postop-
erative recovery and pain
after phacoemulsification with IOL
implantation. However, knowledge of
the postoperative complaints associated
with ophthalmic surgery is necessary
because these complaints may delay
recovery and may significantly influence
quality of life after the procedure. Pain
after ophthalmic surgery is often con-
sidered to be a sign of a possible com-
plication. Severe pain is assumed to be a
sign of postoperative inflammation or
infection, making it a concern for both
the patient and the physician (V€ alim€
aki
et al. 2012). However, a surgery without
any perioperative complications may
also be associated with significant post-
operative pain during the early recovery.
Thus, appropriate counselling and pain
management should be provided to
improve quality of life.
To understand current knowledge
about recovery after cataract surgery
and the complaints that patients may
have after discharge, we performed a
systematic review of the literature. Our
aims were (1) to evaluate the incidence
and amount of postoperative oph-
thalmic pain and (2) to identify meth-
ods of pain management used after
cataract extraction surgery.
4.2. Methods
4.2.1. Search strategy
A systematic search for relevant studies
was performed according to the
Cochrane Handbook for Systematic
Reviews of Interventions (Higgins &
Green 2011) in the PubMed database,
including the MEDLINE and Scopus
databases. The search was performed
9
Acta Ophthalmologica 2016

PUBM ED: 825 citations SCOPUS: 869 citations

Total: 1694 citations
Excluded: 1345 citations

Studies not related to ophthalmology

349 citations: Animal studies and basic research studies
Reviewed by two authors
using titles and abstracts
Excluded: 244 citations

Studies with other ophthalmological interventions than

cataract extraction
Trials of interventions only on anaesthesia strategies and
studies discussing only perioperative conditions
105 citations:
Included in the full-text analysis
made by two authors Excluded: 83 citations
Did not concern postoperative pain: 15
Included only patients with an adverse event or
complication: 12
Surgeries performed were not limited to cataract
extractions: 4
Surgical techique used was other than phacoemulsification
or not described: 9
Could not be reached via KUH/UEF information service:8
Language used other than English, Germany, Spanish, or
French: 3
Was not original article:17
Prospective or retrospective survey, a cohort or case series,
letter to the editor or a commentary: 15
Only RCTs included in the final analysis:
21 trials, 22 reports

Fig. 3. Flow diagram of the included and excluded articles. RCT = Randomized controlled trial, KUH = Kuopio University Hospital,
UEF = University of Eastern Finland.

in July 2011. The following search
terms were used: cataract extraction*
AND pain, cataract* AND pain, cat-
aract* AND pain, postoperative.
Search filters and language restrictions
were not used in the initial search.
4.2.2. Selection criteria, types of studies
Randomized controlled trials with
active- or placebo-controlled treat-
ment groups were included. Both
blinded and open-label studies were
eligible for the review. The language
of publication of eligible studies was
restricted to English, German, French
or Spanish.
4.2.3. Types of participants
Included studies were limited to adult
patients with senile/presenile cataract
who had cataract extraction surgery.
Studies presenting data only on paedi-
atric patients or animals were excluded.
4.2.4. Types of interventions
We included data from studies using
the phacoemulsification technique for
cataract extraction. Studies using all
analgesics, antiinflammatory agents
and other postoperative interventions
were considered eligible.
4.2.5. Selection of studies
The articles to be included in this
review were first selected individually
on the basis of their titles by two of the
authors. Then, the abstracts of the
available articles were examined. Our
searches yielded 825 study reports
from the PubMed database and 869
reports from the Scopus database.
Articles with no ophthalmological
intervention were excluded by one
author (SP-T). The remaining 349
titles and abstracts were then evalu-
ated by two authors (SP-T and HK).
Reports that did not address postop-
erative intervention, such as those
discussing only perioperative condi-
tions and anaesthesia, were excluded.
Finally, 105 reports were considered
eligible by both authors and were
retrieved for data extraction. At this
stage, all remaining studies were
included in the review.
4.2.6. Data extraction and analysis
Data from 104 studies were extracted
from the 105 original papers using a
standardized form. The following data
were collected: (1) study design and
number of participants, (2) study drugs
or other study intervention evaluated,
(3) pain assessment methods and
instruments and schedule of pain
assessment and (4) the primary out-
come parameter concerning postoper-
ative pain.
All 105 original reports were read to
assess eligibility. At this stage, only
randomized controlled trials (RCTs)
were included in the final analysis. The
number of eligible RCTs was 21 [22
publications; the results of one study
were reported in two papers: Anders
et al. (1999) and Heuermann et al.
(2000)]. The other reports were
excluded for the following reasons:
the study did not concern intraopera-
tive or postoperative pain (n = 9); the
study discussed only intraoperative and
no postoperative pain (n = 6); the
study included only patients with
endophthalmitis, other postoperative
inflammation or other complications
(n = 12); the surgical technique used
was not phacoemulsification (n = 6);
the surgical technique was not
described (n = 3); the study was not
limited to cataract extractions; that is,
various ophthalmic surgeries were
included (n = 4); the study report could
not be obtained from the hospital/
university information service (n = 8);
the study report was published only in
a language other than English, Ger-
man, Spanish or French (n = 3); the
study was not an original article
(n = 17); the study design was a
prospective or retrospective survey, or
a cohort or case series, and not a RCT
(n = 11); or the article was a letter to
the editor or a commentary (n = 4).
Figure 3 summarizes the article selec-
tion process.

10
 Table 2. Randomized studies included in the analysis.

Study* Study design and participants Study intervention Pain measurement Main results concerning postoperative pain Quality†

Anders (1999) Open study Infiltration + intraocular VRS 0–1 No pain: 5% versus 15% 3
n = 200 lidocaine versus peribulbar POH: 2, 4, 6 Severe pain: 30–85% versus 28–73%
lidocaine Intraocular more pain POH 2, p = 0.0017
Heuermann (2000) Open study Infiltration + intraocular VRS 0–4 No pain: 5% versus 15% 3
n = 186 lidocaine versus peribulbar POH: 2, 4, 6 Severe pain: 32–81% versus 38–71%
lidocaine
Mohan (2001)‡ Double-blinded Topical VRS 0–2 POD 1 No pain: 10% versus 47% 5
n = 61 ciprofloxacin–dexamethasone POD: 1, 7 Severe pain: 25% versus 0%
versus POD 7 No pain: 74% versus 83%
betamethasone–neomycin Severe pain 0% versus 0%
Paganelli (2004) Double-blinded Topical prednisolone versus sc VRS 0–4 Mean pain: POD 1–7: 0.2–0.6 versus 0.1–0.7 3
n = 100 triamcinolone POD: 1, 3, 7, 14, 28 POD 14–28: 0 versus 0
Russo (2007) Double-blinded Topical dexamethasone with VRS 0–3 Pain: POD 7 p = 0.21; POD 14 p = 0.0033 5
n = 233 netilmycin versus tobramycin POD: 1, 7, 14 Pain values not presented
Donnenfeld (2006) Double-blinded, placebo-controlled Topical ketorolac 3 days versus VRS 1–5 Mean pain: 1.1 versus 1.2 versus 2.0 versus 2.3 5
n = 100 1 day versus 1 hr versus POD: 1 p < 0.001 3 days versus 1 hr and placebo
placebo
Raizman (2007) Double-blinded Two topical prednisolone VRS 0–3 No pain: 94–100% versus 97–100% 4
n = 73 formulations POD: 1, 14, 28 Severe pain: 0% versus 0%
Duong (2007) Double-blinded Topical nepafenac versus VRS 1–5 Mean pain: 1.2 versus 1.5; p < 0.025 4
n = 183 ketorolac POD: 1
Nardi (2007) Randomized, double-blinded, Topical nepafenac versus VRS 0–5 Nepafenac superior to placebo POD 3–28, p < 0.05 4
placebo- and active-controlled ketorolac versus placebo
n = 227 POD: 1, 3, 7, 14, 21, 28 Nepafenac superior to ketorolac POD 3, p = 0.04
Maxwell (2008) Double-blinded Topical nepafenac versus VRS 0–5 No pain: 76–98% versus 52–62%; p < 0.02 4
n = 212 placebo POD: 1, 3, 7, 14
Baiza-Duran (2009) Double-blinded Topical meloxicam versus VRS 0–3 No pain: POD 2: 80% versus 80% 4
n = 146 diclofenac POD: 2, 4, 7, 15, 30 POD 4–15 75–95% versus 70–97%
POD 30: 100% versus 100%
Kaluzny (2010) Double-blinded, active-controlled Preop paracetamol 1 g versus VAS 0–10 Mean pain: 0.6 versus 1.5 4
n = 160 vitamin C 400 mg by mouth VRS 0–4 Severe pain: 1% versus 13%; p < 0.1
POH: 8–12
Donnenfeld (2011) Double-blinded, placebo-controlled Topical ketorolac versus VRS 0–4 No pain: 72% versus 60%; p < 0.001
n = 511 placebo POD: 1–14 daily Rescue analgesia needed: 19% versus 43%; p = 0.001
Resolution of pain: 1 day versus 2 days; p < 0.001
Silverstein (2011) Double-blinded, placebo-controlled Topical bromfenac versus OCGA, 0–3 No pain: 87–95% versus 65–71%; p < 0.0001 4
n = 455 placebo POD 1, 3, 8, 15 Resolution of pain: 2 days versus 4 days§
Bainbridge (1998) Single-blinded Postoperative paraffin-gauze VAS 0–10 POD 1: Severe pain: 19% versus 9% 2
n = 83 pad versus clear plastic shield VRS 0–3
Kongsap (2006) Single-blinded Prechop manual fragmentation NRS 0–10 No pain: 84% versus 94% 3
n = 100 versus phacoemulsification POH: 2 Mean pain: 0.6 (1.1) versus 0.5 (1.3)
Pianini (2010) Randomized, single-blinded Topical dexamethasone with VRS 0–3 No pain: 23% versus 8% 2
n = 80 netilmycin versus tobramycin POD: 7 Severe pain: 45% versus 33%
Dell (2011) Single-blinded Hydrogel ocular bandage NRS 0–10 Mean pain: 1.3 (1.8) versus 1.1 (1.6) 4
n = 420 versus collagen corneal shield POH: 1, 4
Acta Ophthalmologica 2016

11
Acta Ophthalmologica 2016

4.2.7. Risk of bias in included studies

inj = injection, IOL = intraocular lens, NRS = numerical rating scale, NS = no significant difference, OCGA = ocular comfort grading assessment score, POD = postoperative day, POH = postoperative
Quality†
To determine whether there was a need
to exclude any studies from the anal-
3

2
ysis to reduce the study bias, the
instrument developed by Jadad et al.
(1996) to measure the likelihood of
Mean pain at: POH 12.7 versus 5.7; p < 0.005 bias in pain research reports was used.
The instrument includes three ques-
Main results concerning postoperative pain

tions: (1) randomization: yes (1 point)/

Mean pain: 1.4 (1.1) versus 1.4 (1.3) no (0 point), described and appropriate
Most pain: 0.6 versus 1.7; p < 0.001

No pain: 91–100% versus 87–100%

(+1 point)/inappropriate ( 1 point);
Mean pain: 0.0–0.4 versus 0.0–0.4
(2) double blinding: yes (1 point)/no
Severe pain: 0% versus 17%

(0 point), described and appropriate

No pain: 75% versus 43%

(+1 point)/inappropriate ( 1 point);

POD 7: 0.6 versus 0.7

(3) description of withdrawals and

PODl: 2.2 versus 2.5

dropouts: withdrawals stated (+1

point)/no statement on withdrawals (0
points). The evaluation of the selected
studies with these three questions could
yield a score between zero and five
points.
None of the selected studies was
NRS 0–10 Binominal: yes/no

excluded from the analysis, as all stud-

ies obtained evaluation scores of two to
POH: 1, 2, 4, 8, 12, 24

five points (mean 3.5, median 4).

Pain measurement

POD: 1, 3, 7, 15

4.3. Results
hour, sc = subconjunctival, SD = standard deviation, VAS = visual analogue scale, VRS = verbal rating scale.
POD: 1, 7
VAS 0–10

VAS 0–10

VRS 1–10

4.3.1. Study descriptions

POH <1

POD: l

The characteristics of the 21 included

studies are presented in Table 2. Of the
21 RCTs included, 12 trials were dou-
ble-blinded (Mohan et al. 2001; Paga-
Postoperative eye patch versus

Topical dexamethasone versus

Both phacoemulsification and extracapsular cataract extraction techniques used in the study.

nelli et al. 2004; Donnenfeld et al.

tobramycin-dexamethadone
dexamethasone-gentamycin

2006, 2011; Duong et al. 2007; Raiz-

Topical chloramphenicol-

Quality assessment; the result of the use of instrument described by Jadad et al. (1996).
Topical iodine versus sc

betamethasone versus

man et al. 2007; Nardi et al. 2007;

Russo et al. 2007; Maxwell et al.
sc betamethasone
Study intervention

2008; Baiza-Duran et al. 2009;

no patching

Kaluzny et al. 2010; Silverstein et al.

Median time of pain resolution among patients reporting pain at POD 1.

2011), four were single-blinded (Bain-

bridge et al. 1998; Kongsap & Wiriya-
luppa 2006; Pianini et al. 2010; Dell
et al. 2011), four were open-label
(Anders et al. 1999; Heuermann et al.
2000; Stifter & Menapace 2007; Ahmed
et al. 2010; Dieleman et al. 2011), and
Study design and participants

in one RCT, the blinding was not

described (Camesasca et al. 2007). Six-
Blinding not described

teen studies compared the analgesic

efficacy of anti-inflammatory agents,
specifically non-steroidal anti-inflam-
Open study

Open study

Open study

matory agents (NSAIDs; n = 7), corti-

* First author (publication year).

costeroids (n = 8) or paracetamol
n = 400

n = 142
n = 60

n = 60

(n = 1).
Five of the NSAIDs studies were
placebo-controlled (Donnenfeld et al.
Table 2. (Continued)

2006, 2011; Nardi et al. 2007; Maxwell

Camesasca (2007)
Dieleman (2011)

et al. 2008; Silverstein et al. 2011), and

Ahmed (2010)
Stifter (2007)

three were active-controlled (Duong

et al. 2007; Nardi et al. 2007; Baiza-
Study*

Duran et al. 2009). The corticosteroid

studies were active-controlled (Mohan
†
‡
§

12

et al. 2001; Camesasca et al. 2007;
Raizman et al. 2007; Russo et al.
2007; Ahmed et al. 2010; Pianini et al.
2010; Dieleman et al. 2011), as was the
paracetamol study (Kaluzny et al.
2010).
Intraocular injections of lidocaine
were compared with peribulbar block-
ade in one study (Anders et al. 1999;
Heuermann et al. 2000). Three studies
evaluated the eye shields used in post-
operative care (Bainbridge et al. 1998;
Stifter & Menapace 2007; Dell et al.
2011). Two surgical techniques, pha-
coemulsification and prechop manual
phacofragmentation (Prechop MPF),
were compared in one study (Kongsap
& Wiriyaluppa 2006).
Five different NSAIDs were evalu-
ated: ketorolac (n = 4; Donnenfeld
et al. 2006, 2011; Duong et al. 2007;
Nardi et al. 2007), nepafenac (n = 3;
Duong et al. 2007; Nardi et al. 2007,
Maxwell et al. 2008), diclofenac (n = 1;
Baiza-Duran et al. 2009), meloxicam
(n = 1; Baiza-Duran et al. 2009) and
bromfenac (n = 1; Silverstein et al.
2011). Of the four corticosteroid agents
evaluated, dexamethasone was used in
six studies (Bainbridge et al. 1998;
Mohan et al. 2001; Camesasca et al.
2007; Russo et al. 2007; Pianini et al.
2010; Dieleman et al. 2011);
betamethasone in three (Mohan et al.
2001; Camesasca et al. 2007; Dieleman
et al. 2011); prednisolone in two (Paga-
nelli et al. 2004; Raizman et al. 2007);
and triamcinolone in one study (Paga-
nelli et al. 2004).
Perioperative pain was the primary
outcome measure only in one study
(Kaluzny et al. 2010), and the pres-
ence of postoperative pain was used as
one of the outcome measures in 10
studies (Anders et al. 1999; Mohan
et al. 2001; Nardi et al. 2007; Stifter &
Menapace 2007; Maxwell et al. 2008;
Baiza-Duran et al. 2009; Ahmed et al.
2010; Pianini et al. 2010; Dell et al.
2011; Silverstein et al. 2011). In these
studies, pain after surgery was used to
evaluate the efficacy, safety and
patient comfort or satisfaction of the
study interventions. In 10 studies,
perioperative pain was measured
and/or analgesic consumption was
reported, although this measure was
not listed as an outcome measure
(Bainbridge et al. 1998; Paganelli
et al. 2004; Donnenfeld et al. 2006,
2011; Kongsap & Wiriyaluppa 2006;
Camesasca et al. 2007; Duong et al.
2007; Raizman et al. 2007, Russo
et al. 2007; Dieleman et al. 2011).
For pain assessment, a verbal rating
scale (VRS; n = 16) was the most
commonly used tool, followed by a
numerical rating scale (NRS; n = 3),
visual analogue scale (VAS; n = 4) and
ocular comfort grading scale (n = 1).
4.3.2. Incidence and prevalence of post-
operative pain
4.3.2.1. Pain in the hospital during the
first hours after surgery. The incidence
of ophthalmic pain during the first
postoperative hours was evaluated in
five studies (Anders et al. 1999; Heuer-
mann et al. 2000; Kongsap & Wiriya-
luppa 2006; Russo et al. 2007; Kaluzny
et al. 2010; Dell et al. 2011).
The reported incidence of early-
onset postoperative ocular pain varied
significantly between 6% and 95%
(Anders et al. 1999; Heuermann et al.
2000; Kongsap & Wiriyaluppa 2006),
and the incidence of moderate or severe
pain was 1–35% across the studies
(Stifter & Menapace 2007; Kaluzny
et al. 2010; Dell et al. 2011). Higher
frequencies of significant pain were
reported in one study evaluating early
recovery after surgery. In that study,
the patients had an intraoperative
intracameral injection of lidocaine in
the intervention group and a peribul-
bar injection of prilocaine in the con-
trol group. The incidence of moderate
or severe pain was 71–85% at 2 hr
after surgery, and 30–36% of the
patients still reported significant pain
at 6 hr (Anders et al. 1999; Heuermann
et al. 2000).
4.3.2.2. Pain after discharge. First
72 hr—The incidence of postoperative
pain during the first 72 postoperative
hours after discharge was evaluated in
10 studies (Bainbridge et al. 1998;
Mohan et al. 2001; Camesasca et al.
2007; Nardi et al. 2007; Raizman et al.
2007; Maxwell et al. 2008; Baiza-
Duran et al. 2009; Dell et al. 2011;
Donnenfeld et al. 2011; Silverstein
et al. 2011). After discharge, 40–48%
of the patients in the placebo-treated
control groups reported postoperative
pain (Nardi et al. 2007; Maxwell et al.
2008; Donnenfeld et al. 2011). In the
active intervention groups, pain was
less frequent; 3–42% of patients in
these groups had postoperative pain
after discharge (Bainbridge et al. 1998;
Camesasca et al. 2007; Nardi et al.
2007; Raizman et al. 2007; Maxwell
Acta Ophthalmologica 2016
et al. 2008; Baiza-Duran et al. 2009;
Dell et al. 2011; Donnenfeld et al.
2011; Silverstein et al. 2011). There
was one outlier; 53–90% of patients
in the Mohan et al. (2001) study
reported pain. However, most patients
in that study reported only slight pain,
and only, 26% of patients in the
intervention group, who were treated
with ciprofloxacin–dexamethasone
ophthalmic suspension, reported sig-
nificant pain versus none in the active
control group, who were treated with
an ophthalmic suspension of
betamethasone–neomycin.
First weeks after surgery—The preva-
lence of postoperative pain was eval-
uated 4–15 days after surgery in eight
studies (Mohan et al. 2001; Came-
sasca et al. 2007; Nardi et al. 2007;
Raizman et al. 2007; Maxwell et al.
2008; Baiza-Duran et al. 2009; Pianini
et al. 2010; Silverstein et al. 2011).
Postoperative pain was relatively com-
mon in the placebo groups and in the
intervention groups. In five studies,
the prevalence of pain in the interven-
tion groups was between 2% and 26%
and in the placebo groups, between
29% and 47% (Mohan et al. 2001;
Nardi et al. 2007; Maxwell et al. 2008;
Baiza-Duran et al. 2009; Silverstein
et al. 2011). In two studies, pain was
reported significantly less frequently,
with rates of 0–3% at 7–15 days after
surgery (Nardi et al. 2007; Raizman
et al. 2007). The highest prevalence of
pain was reported in Pianini et al.’s
(2010) study evaluating the use of
local ointments containing 1 of 2
antibiotics, netilmicin or tobramycin,
and dexamethasone in postoperative
care. In that study, 77–92% of
patients had pain at 7 days after
surgery and moderate or severe pain
was reported by 33–45%.
The rate decreased during the course
of recovery in all studies. After the first
2 postoperative weeks, the pain was
measured in three studies, and it
ranged between 0% and 24% (Nardi
et al. 2007; Raizman et al. 2007; Baiza-
Duran et al. 2009). In Nardi et al.’s
study, the proportions of patients
reporting pain at 21 and 28 days after
surgery were 4–10% in two interven-
tion groups; however, 24–26% of the
placebo-treated patients reported pain.
Two studies reported significantly less
postoperative pain as only 0–3% of
patients had pain at 4 weeks (Raizman
et al. 2007; Baiza-Duran et al. 2009).
13
Acta Ophthalmologica 2016
None of the included studies evaluated
pain more than 30 days after surgery.
The resolution of pain after surgery
was evaluated in three studies, all
reporting a median time of pain reso-
lution of 1 day in the active groups,
whereas the time of pain resolution in
the placebo group was 1 day in one
study and 2 days in another (Dell et al.
2011; Donnenfeld et al. 2011; Silver-
stein et al. 2011). Silverstein et al. eval-
uated pain resolution among patients
reporting pain during the first 24 hr. In
that study, 35% of patients in the
placebo group and 13% in the active
group reported pain during the first
24 hr. Among the patients reporting
pain at 24 hr, the median time to pain
resolution was 4 days in the placebo
group and 2 days in patients treated
with ophthalmic suspension of brom-
fenac once daily.
4.3.3. Severity of pain
4.3.3.1. Severity of postoperative pain
during early recovery. The severity of
postoperative pain during the first
hours after surgery was evaluated in
six studies (Anders et al. 1999; Heuer-
mann et al. 2000; Stifter & Menapace
2007; Ahmed et al. 2010; Kaluzny
et al. 2010; Dell et al. 2011).
Most patients had only mild or no
pain. In four studies, pain was reported
using a VAS or NRS ranging from
0 = no pain to 10 = most pain, and the
mean pain scores during the first hours
after surgery ranged between 0.5 and
1.7/10 (Stifter & Menapace 2007;
Kaluzny et al. 2010; Dell et al. 2011).
Although the median pain severity was
slight, some patients experienced signif-
icant postoperative pain. In the Stifter &
Menapace (2007) study, one of eight
patients (12%) in the unpatched group
had moderate or severe postoperative
pain. In the patched eye group, no
moderate or severe pain was reported.
Severe pain was also reported in the
Anders et al. (1999) and Heuermann
et al. (2000) studies, in which the mean
pain score was moderate in the peribul-
bar group and severe in the intracameral
applications. Moreover, severe postop-
erative pain was reported by half the
patients who received an intracameral
lidocaine injection and by one-third of
those who received peribulbar anaes-
thesia. In that study, pain was reported
on a 5-point VRS, where 0 = no pain
and 4 = most pain (Anders et al. 1999;
Heuermann et al. 2000).
14
Recently, Ahmed et al. (2010) com-
pared subconjunctival injection of cor-
ticosteroid-antibiotic solution with
iodine eye drops. Postoperative pain
grading was significantly higher in
patients with subconjunctival injection
of dexamethasone–gentamycin, 5.7/10,
than in patients receiving iodine eye
drops, 2.7/10.
4.3.3.2. Severity of postoperative pain
after discharge. The severity of postop-
erative pain after discharge was evalu-
ated in eight studies (Paganelli et al.
2004; Donnenfeld et al. 2006; Came-
sasca et al. 2007; Duong et al. 2007;
Raizman et al. 2007; Ahmed et al.
2010; Pianini et al. 2010; Dieleman
et al. 2011). After discharge and up to
4 weeks after surgery, the mean pain
score measured with VAS or NRS
ranged between 0.6 and 2.5 of 10
(Ahmed et al. 2010; Dieleman et al.
2011). In five studies, postoperative
pain was measured with VRS, and
most patients in all studies reported
no pain or only mild pain (Paganelli
et al. 2004; Donnenfeld et al. 2006;
Camesasca et al. 2007; Duong et al.
2007; Raizman et al. 2007).
In one study, more severe pain was
reported at 7 days. One-third (33%) of
patients who received preservative-free
dexamethasone–netilmicin eye drops,
and 45% of patients who received
preserved dexamethasone–tobramycin
eye drops reported moderate or severe
pain (Pianini et al. 2010).
4.3.4. Management of postoperative pain
All study compounds, NSAIDs, corti-
costeroids, antibiotics and iodine were
administered topically in ophthalmic
drugs, except in one study where
paracetamol was administered by
mouth 1 hr before surgery (Kaluzny
et al. 2010).
4.3.4.1. Analgesic efficacy of the drugs
used in postoperative care. In all five
studies where NSAIDs were compared
with placebo, NSAIDs were superior to
placebo (Donnenfeld et al. 2006, 2011;
Nardi et al. 2007; Maxwell et al. 2008;
Silverstein et al. 2011). Patients in the
active groups reported pain signifi-
cantly less frequently, 5–42% in the
NSAID groups versus 24–48% in the
placebo groups (Nardi et al. 2007;
Maxwell et al. 2008; Silverstein et al.
2011). The use of rescue analgesics was
evaluated in two studies, and in both
studies, the need for rescue analgesia
was less in patients treated with ketoro-
lac, at 8% and 20%, compared to the
patients treated with placebo, at 40%
and 49%, respectively (Donnenfeld
et al. 2006, 2011).
In one study where 1 g of paraceta-
mol taken by mouth before surgery was
compared with 400 mg of vitamin C,
paracetamol appeared to be more
effective. At 8–12 hr after surgery, only
one of 80 patients treated with parac-
etamol reported moderate or severe
pain, while 10 of 80 patients showed
moderate or severe pain after vitamin
C administration (Kaluzny et al. 2010).
Three studies compared the anal-
gesic efficacy of different NSAIDs
(Duong et al. 2007; Nardi et al. 2007;
Baiza-Duran et al. 2009). In the Baiza-
Duran et al. (2009) study, the analgesic
efficacies of meloxicam and diclofenac
were similar. In the two studies evalu-
ating ketorolac and nepafenac eye
drops (Duong et al. 2007; Nardi et al.
2007), the analgesic efficacy of both
compounds was relatively similar dur-
ing the first 24 hr after surgery, but
later nepafenac performed better.
Seven studies compared the use of
different corticosteroid agents or differ-
ent combinations of corticosteroid and
antibiotic agents after surgery. The
drugs performed equally well at pain
prevention and management in all stud-
ies, with no significant differences
reported (Mohan et al. 2001; Paganelli
et al. 2004; Camesasca et al. 2007; Raiz-
man et al. 2007; Russo et al. 2007;
Pianini et al. 2010; Dieleman et al.
2011). One study compared postopera-
tive usage of iodine eye drops with
intraoperative subconjunctival injection
of dexamethasone–gentamycin, and
there was no significant difference in
analgesic efficacy after surgery (Ahmed
et al. 2010).
Discontinuation rates of the study
medications due to a lack of sufficient
analgesic efficacy were not reported in
any study.
4.3.4.2. Adverse effects. Safety of the
medicines or other interventions was
evaluated in all studies except one
(Ahmed et al. 2010). Neither serious
nor severe adverse events or cases of
endophthalmitis were reported in any
study.
4.3.4.3. Non-steroidal anti-inflammatory
agents. Adverse effects related to
NSAID therapy were evaluated in all
seven studies (Donnenfeld et al. 2006,
2011; Duong et al. 2007; Nardi et al.
2007; Maxwell et al. 2008; Baiza-

Duran et al. 2009; Silverstein et al.
2011).
In the three placebo-controlled stud-
ies, patients in the placebo groups
reported more adverse effects than
patients treated with topical NSAIDs
(Maxwell et al. 2008; Donnenfeld et al.
2011; Silverstein et al. 2011). In the
placebo groups, the incidence of adverse
effects was 14% in one study, and 41%
and 60% in the two other studies com-
pared to 6%, 25% and 47% in the
groups treated with ketorolac, nepafe-
nac or bromfenac, respectively (Max-
well et al. 2008; Donnenfeld et al. 2011;
Silverstein et al. 2011). In the two recent
studies, the proportion of patients who
discontinued the study compound
because of adverse events was 3–4 times
higher in the placebo groups, 16–18%,
than in the active groups, 4% and 6%
(Donnenfeld et al. 2011; Silverstein
et al. 2011).
The most commonly reported drug-
related adverse events in patients tak-
ing NSAIDs were intraocular pressure
(IOP) elevation (Donnenfeld et al.
2011), eye discomfort, choroidal effu-
sion, eye pain and eyelid margin crust-
ing (Nardi et al. 2007; Maxwell et al.
2008). Duong et al. (2007) suggest that
there could be some differences
between NSAIDs in the occurrence of
adverse effects. In that study, posterior
capsule opacification was reported in
5% of patients treated with ketorolac
and in 14% of patients treated with
nepafenac. In the Baiza-Duran et al.
(2009) study, meloxicam and diclofe-
nac eye drops were associated with
similar incidences of adverse effects.
About half of the patients in both
groups reported a burning sensation
after NSAID instillation, and even
greater proportions of patients exhib-
ited conjunctival hyperaemia. The rate
and severity of these complaints
decreased with time.
Contrary to most studies, in one
evaluating local NSAID eye drops,
adverse effects were reported neither
in patients treated with NSAIDs nor in
patients treated with placebo (Donnen-
feld et al. 2006). Moreover, in the
Kaluzny et al. (2010) study, no adverse
effects related to the usage of paracetamol
or vitamin C by mouth were reported.
4.3.4.4. Corticosteroids. Adverse
events related to corticosteroid eye
drops were evaluated in seven studies
(Mohan et al. 2001; Paganelli et al.
2004; Camesasca et al. 2007; Raizman
et al. 2007; Russo et al. 2007; Stifter &
Menapace 2007; Pianini et al. 2010).
The most common adverse effects
associated with corticosteroid eye drops
were subconjunctival haemorrhage
(Camesasca et al. 2007), IOP elevation
(Raizman et al. 2007; Pianini et al.
2001), iritis (Raizman et al. 2007), and
the occurrence of white deposits around
the eye (Mohan et al. 2001).
In three studies, no cases of adverse
events were reported in patients treated
with topical corticosteroids (Paganelli
et al. 2004; Camesasca et al. 2007;
Russo et al. 2007).
4.4. Discussion
To our knowledge, this is the first
systematic review evaluating clinical
trials of postoperative pain and pain
management after cataract surgery. An
extensive search of the current litera-
ture identified 21 studies of pain epi-
demiology and pain management after
cataract surgery, but postoperative
pain or postoperative pain manage-
ment was not a primary aim of any of
the identified publications. Moreover,
the studies reporting postoperative
pain yielded inconsistent findings;
most studies reported no or minimal
pain after surgery, whereas other stud-
ies reported severe pain and pain
lasting a few weeks. Reason for that
is unclear, but even only studies using
phacoemulsification technique were
included in this review, differences in
surgical technique and incision types
may affect the surgical trauma and
postoperative recovery. However, the
most likely reason for inconsistent
findings is the perioperative and post-
operative care of the patients. More
pain was reported in patients who did
not have eye patch after the surgery
(Stifter & Menapace 2007). Also, intra-
cameral (Anders et al. 1999; Heuer-
mann et al. 2000) and subconjunctival
injections (Ahmed et al. 2010) were
associated with significant postopera-
tive pain. In one study, the preserva-
tive benzalkonium chloride induced an
increase on IOP that could be one
reason for higher pain incidence and
severity in that study (Kongsap &
Wiriyaluppa 2006).
The incidence of reported pain var-
ied between few and over 90% in the
first postoperative hours, and a similar
variation remained also during the first
week after surgery. In two studies, the
Acta Ophthalmologica 2016
possible correlations between pain and
other ophthalmological findings were
analysed. In one study, there was a
high correlation between impaired tear
film break-up time (BUT) and pain
sensations during the first 4 hr, but no
later on. That indicates the role of
postoperative dry eye sensations and
tear film pathologies in pain during the
early recovery. In comparing patients
with and without postoperative pain,
no significant differences were found in
IOP, anterior chamber flare, corneal
epithelium defects or corneal injections
(Stifter & Menapace 2007). In another
study, there was no correlation
between IOP and postoperative pain
(Bainbridge et al. 1998). Topical and
intracameral anaesthetics have differ-
ent efficacy profile to prevent ocular
pain (Masket & Gokmen 1998; Fer-
nandez et al. 2009). In addition, it has
been documented that some of the
local anaesthetics may induce interim
cytotoxic effects on cornea cells (Chang
et al. 2006; Borazan et al. 2009; Tap-
peiner et al. 2012). Thus, topical and
intracameral local anaesthetics and
theirs toxic effects may reflect to indi-
vidual dependent pain sense that dis-
turbs interpretation of the results
between different studies.
Only one study evaluated the use of
systemic analgesics. Paracetamol (1 g)
was compared with vitamin C
(400 mg), both given by mouth 1 hr
before surgery (Kaluzny et al. 2010).
Unfortunately, the dose of vitamin C
was relatively small, preventing any
meaningful comparison of these two
compounds for this indication (Kanazi
et al. 2012). Moreover, during the
perioperative period, the absorption
of swallowed drugs is erratic and
delayed, so parenteral dosing is pre-
ferred in perioperative settings (Kemp-
painen et al. 2006).
Most studies evaluated topical
NSAIDs and corticosteroids, which is
rational because all surgical incisions
are associated with secondary inflam-
matory pain. Five different topical
NSAIDs were used, with no clinically
meaningful difference in outcome, indi-
cating that the selection of a NSAID is
not a critical factor in postoperative
pain management after cataract sur-
gery (Donnenfeld et al. 2006, 2011;
Duong et al. 2007; Nardi et al. 2007;
Maxwell et al. 2008; Baiza-Duran
et al. 2009; Silverstein et al. 2011). In
all placebo-controlled studies, topical
15
Acta Ophthalmologica 2016
NSAIDs were superior to placebo,
indicating high analgesic efficacy (Don-
nenfeld et al. 2006, 2011; Nardi et al.
2007; Maxwell et al. 2008; Silverstein
et al. 2011). The prevalence of cataract
increases in old age, and most patients
who have the surgery are elderly.
Advanced age is a concern in using
NSAIDs because elderly patients often
experience adverse effects, such as gas-
trointestinal irritation and cardiovas-
cular complications. Moreover, many
elderly patients have absolute con-
traindications for systemic NSAIDs,
such as compromised renal function,
history of gastric ulcers, arterial hyper-
tension or heart failure (Gislason et al.
2009). However, small doses of
NSAIDs are used in topical adminis-
tration; thus, the systemic exposure is
low, and this approach should be safer
than NSAIDs given by other adminis-
tration routes (Stewart et al. 2007).
Although topical NSAID eye drops
are generally safe, local eye irritation,
hypersensitivity and other allergic reac-
tions may be observed, but only rare
cases of systemic adverse events have
been reported.
Topical corticosteroids and antibi-
otics are commonly used in postoper-
ative care after cataract surgery.
However, most of the postoperatively
used ocular drops contain preserva-
tives, such as benzalkonium chloride
(BAK), that has been documented to
induce cytotoxicity and inflammatory
reactions in corneal and conjunctival
cells in numerous in vitro and in vivo
models (Rolando et al. 1991; De Saint
Jean et al. 1999; Debbasch et al. 2001;
Noecker et al. 2004; Pisella et al. 2004;
Baudouin et al. 2008; Kahook &
Noecker 2008; Leung et al. 2008; Uusi-
talo et al. 2008; Martone et al. 2009;
Uusitalo et al. 2010). Typical adverse
effects of eye drops containing BAK
include superficial punctuate keratopa-
thy, epithelial erosions, conjunctival
hyperaemia, tearing and subjective
painful sensations such as foreign body
sensations, itching, burning, stinging
and ocular irritation (Pisella et al.
2002; Jaenen et al. 2007). All of these
findings reveal that postoperative pain
after cataract surgery not only is asso-
ciated with surgical trauma, operative
complications or postoperative inflam-
mation but also might be related to the
use of ocular drops containing preser-
vatives. Thus, pharmaceutical compa-
nies should develop better-tolerated
16
ocular drops, and preservative-free for-
mulas are recommended when possible.
In conclusion, this systematic review
evaluating clinical trials of postopera-
tive pain and pain management after
cataract surgery indicates that recovery
after phacoemulsification cataract sur-
gery is uneventful in most patients.
However, in some patients, surgery is
associated with significant postopera-
tive pain. These patients should be
provided with appropriate pain man-
agement and follow-up instructions.
Moreover, postoperative pain and pain
management after cataract surgery
have not been evaluated systematically
in clinical trials; hence, more clinical
data are needed to understand the
implications of postoperative pain for
recovery.
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solution 0.09%. J Ocul Pharmacol Ther 23:
601–612.
Stifter E & Menapace R (2007): ‘Instant
vision’ compared with postoperative patch-
ing: clinical evaluation and patient satisfac-
tion after bilateral cataract surgery. Am J
Ophthalmol 143: 441–448.
Tappeiner C, Flueckiger F, Boehnke M,
Goldblum D & Garweg JG (2012): Effect
of topical anesthetic agents and ethanol on
corneoepithelial wound healing in an ex vivo
whole-globe porcine model. J Cataract
Refract Surg 38: 519–524.
Uusitalo H, Kaarniranta K & Ropo A (2008):
Pharmacokinetics, efficacy and safety pro-
files of preserved and preservative-free taflu-
prost in healthy volunteers. Acta
Ophthalmol Suppl 242: 7–13.
Uusitalo H, Chen E, Pfeiffer N et al. (2010):
Switching from a preserved to a preserva-
tive-free prostaglandin preparation in topi-
cal glaucoma medication. Acta Ophthalmol
88: 329–336.
V€alim€aki J, Tuisku I, Linnola R, Suomalainen
V-P, Virtanen P & Vuorio A; Working
Group appointed by the Finnish Medical
Society Duodecim, Finnish Ophthalmologi-
cal Society and Finnish Society of Cataract
and Refractive Surgeons (2012): Cataracts.
Current Care Guideline 2010. The Finnish
Medical Society Duodecim. Available at:
http://www.kaypahoito.fi/web/kh/suosituk-
set/naytaartikkeli/tunnus/hoi50035.
(Accessed on 8 Dec 2012).
5. Publication II. A
Prospective study on
postoperative pain after
cataract surgery
Abstract
Purpose: To evaluate postoperative
pain and early recovery in cataract
patients.
Patients and methods: A total of 201
patients who underwent elective first-
eye cataract extraction surgery were
enrolled, and 196 were included in the
final analysis. The study design was a
single-centre, prospective, follow-up
17
Acta Ophthalmologica 2016
study in a tertiary hospital in eastern
Finland. Postoperative pain was eval-
uated with the brief pain inventory at
four time points: at baseline, and at
24 hr, 1 week and 6 weeks post-
surgery.
Results: Postoperative pain was rel-
atively common during the first hours
after surgery, as it was reported by 67
(34%) patients. After hospital dis-
charge, the prevalence decreased; at
24 hr, 1 week and 6 weeks, 18 (10%),
15 (9%) and 12 (7%) patients reported
having ocular pain, respectively. Most
patients with eye pain reported signif-
icant pain, with a score of ≥4 on a pain
scale of 0–10, but few had taken
analgesics for eye pain. Those who
had used analgesics rated the analgesic
efficacy of paracetamol and ibuprofen
as good or excellent. Other ocular
irritation symptoms were common
after surgery; as a new postoperative
symptom, foreign body sensation was
reported by 40 patients (22%), light
sensitivity by 29 (16%), burning by 15
(8%) and itching by 15 (8%).
Conclusion: Moderate or severe
postoperative pain was relatively com-
mon after cataract surgery. Thus, all
patients undergoing cataract surgery
should be provided appropriate coun-
selling on pain and pain management
after surgery.
5.1. Introduction
Cataract surgery is the most common
surgical procedure in ophthalmology
practice, and the number of surgeries is
assumed to increase in the future
because cataracts are an age-related
condition and life expectancy is
increasing in most countries (Salomon
et al. 2012). The high number of surg-
eries performed is also due to good
outcomes for the surgical treatment of
cataracts.
The modern minimally invasive cat-
aract surgery technique with pha-
coemulsification is considered to be a
minor procedure with an uneventful
and pain-free recovery period. How-
ever, in the published studies, little
attention has been paid to pain and
other postoperative ocular irritation
symptoms, and the data on the inci-
dence of these symptoms are conflict-
ing. For example, in two studies
(Camesasca et al. 2007; Raizman et al.
2007), few patients reported any com-
plaints after surgery, whereas in other
18
studies (Mohan et al. 2001; Pianini
et al. 2010), postoperative ocular irri-
tation symptoms were reported by up
to 90% of patients. In those studies
that found postoperative pain, in some
cases, an uneventful surgery was asso-
ciated with significant postoperative
pain or other ocular symptoms requir-
ing immediate pain control (Anders
et al. 1999; Heuermann et al. 2000;
Stifter & Menapace 2007; Mohan et al.
2001; Pianini et al. 2010).
The current evidence indicates that
postoperative pain, when it occurs, can
be slight and have duration of only a
few hours, but more severe or consis-
tent pain with duration of several days
has also been reported (Pianini et al.
2010). A recent systematic review did
not identify any studies with postoper-
ative pain after cataract surgery as a
primary outcome measure (Porela-Tii-
honen et al. 2013). To fill this gap, we
performed a prospective study in which
the primary aim was to evaluate the
incidence and severity of pain and
other ocular irritation symptoms after
cataract surgery with the phacoemulsi-
fication technique and intraocular lens
implantation (IOL).
5.2. Materials and methods
The study design was a prospective
follow-up clinical trial. The protocol
was approved by the Research Ethics
Committee of the Hospital District of
Northern Savo, Kuopio, Finland
(Protocol No 40/2010), and it was
conducted in accordance with the
principles presented in the Declara-
tion of Helsinki. After receiving oral
and written information, the patients
gave written consent. Patients under-
went surgery between October 2009
and September 2011 at the Kuopio
University Hospital, Kuopio, Fin-
land.
We enrolled adult patients who pre-
sented to the hospital for elective first-
eye unilateral cataract surgery per-
formed under local anaesthesia. We
did not enrol patients who planned to
have the surgery under general anaes-
thesia or those who had dementia or
other diseases that could have impaired
their memory or cognitive function. In
addition, we excluded patients who had
any major psychiatric disease that
could have affected their ability to
complete the study questionnaires. A
total of 303 consecutive patients were
asked to participate, and 244 patients
agreed. However, for 39 patients, the
scheduled operation was cancelled or
delayed with an unknown rescheduled
time for surgery. Because of complica-
tions during the phacoemulsification
surgery, four patients had combined
eye surgery, phacoemulsification with
vitrectomy, and were thus excluded
from the analysis. No pre- and post-
operative data were available for five
patients. As a result, 196 patients who
underwent first-eye unilateral cataract
surgery with the phacoemulsification
technique and intraocular lens implan-
tation (with IOL) were included in the
analysis.
The surgical technique used was
phacoemulsification with IOL per-
formed under local anaesthesia. Eight
surgeons with an extensive experience
performed the operations using the
same surgical technique, clear cornea
cataract extraction. No premedication
was used, but the patients were allowed
to take their normal medications.
Perioperative medication was as
follows:
Prior to surgery
• Tropicamide 5 mg/ml-pheny-
lephrine hydrochloride 100 mg/
ml drops (prepared by the Kuopio
University Hospital Pharmacy)
○ twice to each eye.
• Cyclopentolate hydrochloride
10 mg/ml drops (Oftan Syklo;
Santen Oy, Tampere, Finland)
○ twice to the operated-on eye.
• Levofloxacin 5 mg drops (Ofta-
quix; Santen Oy)
○ four times to each eye.
• 1–2 drops of tetracaine gel 40 mg/
ml (Ametop; Smith and Nephew,
Hull, UK).
• Washing with povidone-iodine
50 mg/ml (Betadine; Alcon Labo-
ratories Inc., Fort Worth, TX,
USA).
Intracameral
• Sodium hyaluronate 7000 14 mg/
ml (Healon GV OVD; Abbott
Medical Optics Inc., Santa An,
CA, USA).
• 1.5 mg of cefuroxime 10 mg/ml
(prepared by the Kuopio Univer-
sity Hospital Pharmacy).

Postoperative
• Chloramphenicol 2 mg/ml–hy-
drocortisone 5 mg/ml drops
(Oftan C–C; Santen Oy)
○ three times per day for 3 weeks.
Additional anaesthesia was used in
two patients, topical tetracaine gel in
one patient and lidocaine gel topical
and intracameral in one patient. Four
patients had a parabulbar blockade,
and one regional anaesthesia was con-
verted to general anaesthesia; this
patient was included into the intent to
treat analysis.
No routine postoperative pain med-
ication was prescribed, but patients
who were in pain while in the recovery
area were allowed to have ibuprofen, if
not contraindicated, and paracetamol
by mouth, as needed.
Postoperative aftercare instructions
were given according to the normal
protocol of the hospital. For the first
24 hr after cataract surgery, an eye
shield was placed over the operated-on
eye. Patients were informed to avoid
hair washing for 2 days to keep water
out of the operated-on eye. They were
instructed to avoid any strenuous activ-
ity, heavy lifting, swimming or sauna use
for the first week after surgery. A post-
operative visit was scheduled for
1 month after surgery, and the patients
were provided contact information to
use if ocular complaints appeared ear-
lier. At the time of hospital discharge,
patients were not prescribed pain med-
ication.
The data were collected using a
structured study form and a question-
naire at baseline, during the periopera-
tive period in hospital, and at 24 hr,
1 week and 6 weeks after surgery. The
structured study questionnaire was
developed to gather data on patients’
preoperative medical history and med-
ications in use, bodily and ocular pain,
and other eye symptoms at baseline. The
questionnaire was pretested in ten pilot
patients to ensure that the patients were
able to understand the questions and
complete the questionnaire accurately.
The short form of the Brief Pain Inven-
tory (BPI; Daut et al. 1983) was used to
evaluate the severity of pain, the impact
of pain on daily function, the location of
pain, the pain medications used and the
amount of pain relief in the previous
24 hr. Answers were given using
an eleven-point numeric rating scale
(NRS) scored 0–10, where 0 = best out-
come/does not interfere/no pain/com-
plete pain relief and 10 = worst
outcome/completely interferes/most
pain/no pain relief. Ten additional ques-
tions concerned ocular irritation symp-
toms, and some yes/no and open-ended
questions were also used to evaluate the
presence and severity of eye pain and
other ocular symptoms, including itch-
ing, foreign body sensation and burning.
Patients were asked about their use and
the efficacy of analgesics and whether
analgesics were used for ophthalmic
pain, for other eye symptoms or for
other bodily pain.
The preoperative questionnaires
were sent to patients with an invitation
letter, and patients were asked to bring
the completed questionnaires with
them when they travelled to the hospi-
tal for the surgery. In hospital, the
completed questionnaires were checked
by a study nurse to ensure the com-
pleteness of the data.
The perioperative data, recovery in
hospital, and pain and other symptoms
at hospital discharge were collected
prospectively with a structured study
form, and missing data were searched
for and recorded from the patients’
medical records.
At hospital discharge, patients were
given three sets of questionnaires and
prepaid postal envelopes in which to
return the completed questionnaires.
Patients were asked to fill out the BPI
at 24 hr, 1 week and 6 weeks after the
surgery. After the questionnaires had
been completed, the patients were to
return all questionnaires at same time
with the prepaid envelope. Non-respon-
ders were contacted by phone at 8–
10 weeks after surgery, and they were
asked to return the completed question-
naires or were interviewed over the
phone. Due to the prospective nature
of the study, only data from 6 weeks
after surgery were available for patients
who did not complete the questionnaires
at 24 hr or at 1 week (n = 4).
The primary outcome measure was
the presence and severity of pain and
other ocular irritation symptoms after
cataract surgery. The secondary out-
come measures were the use and effi-
cacy of analgesics.
5.3. Statistics
The data were entered, and descriptive
and statistical analysis was performed,
Acta Ophthalmologica 2016
using statistical software (IBM SPSS
Statistics 19; IBM, Armonk, NY,
USA). For binary dependent variables,
we used McNemar’s chi-square test,
and for nominal variables, we used the
Wilcoxon signed-rank test. A two-sided
p-value of <0.05 was considered statis-
tically significant.
5.4. Results
5.4.1. Patient characteristics
In total, 196 patients, 68 men and 168
women, aged between 40 and 91 years
(median 74) were included in the final
analysis. Not all patients completed
all postoperative questionnaires, but
some postoperative data were avail-
able for 186 patients, giving a
response rate of 95%. All three post-
operative questionnaires were com-
pleted by 164 patients. The study
questionnaires were completed by
179 patients at 24 hr, 174 patients at
1 week and 170 patients at 6 weeks.
One patient died before the end of the
6-week follow-up period, and the
autopsy indicated that he had coro-
nary thrombosis.
In total, 93% (183/196) of patients
had one or more concomitant medical
conditions, with circulatory system dis-
eases being the most common, reported
by 76% (149/196) of patients; 50/196
(26%) had arthritis or other diseases of
the musculoskeletal system or connec-
tive tissue. In addition to cataracts,
other ophthalmological conditions/dis-
eases were observed in 28 of the 196
patients (14%), including glaucoma
(n = 16), retinopathy or maculopathy
(n = 5), retinitis pigmentosa (n = 2),
cornea dystrophy (n = 2), chronic con-
junctivitis (n = 1), chronic iritis (n = 1)
and retinal detachment (n = 1). Regular
medications were used by 93% (182/
196) of patients, 43% (85/196) used
analgesics and 3% (5/196) used tear
substitutes.
A postoperative rise of intraocular
pressure requiring medication was
noted in four patients. One patient
had iris prolapse, and one patient had
subconjunctival haemorrhage. Iris
retractors were used in two patients to
enforce mydriasis. These patients were
all included in the analysis.
5.4.2. Pain
The prevalence and severity of postop-
erative ocular pain are presented in
Fig. 4 and Table 3.
19
Acta Ophthalmologica 2016

any analgesics for ocular symptoms,

but three had taken analgesics for other
bodily pain.
At 6 weeks after surgery, 12 of 170
patients (7%) reported pain, and the
median pain score was 3–4 of 10. Five
patients had used analgesics for ocular
pain.

5.4.3. Other ocular symptoms

Fig. 4. Prevalence of ocular pain.
At baseline before the surgery, eight
patients (4%) reported ocular pain,
and one of them had ocular pain at
every follow-up; the other seven
patients did not report any postopera-
tive pain.
At the hospital during the first post-
operative hours, 34% (67/196) of
patients reported ocular pain. Most
had mild pain, but 18 patients had
moderate or severe pain, corresponding
to a pain score of 4 or more on the
eleven-point NRS. However, only five
patients were given analgesics, includ-
ing paracetamol by mouth (n = 4) and
diclofenac eye drops (n = 1). At the
time of hospital discharge, 27% (53/
194) had ocular pain, and nine of them
reported significant pain (NRS ≥ 4/
10).
After hospital discharge, less ocular
pain was reported (p = 0.001), but the
number of patients with significant
pain remained relatively constant dur-
ing the 6-week study period.
At 24 hr after surgery, 18 of 179
patients (10%) reported ocular pain,
and most of them had moderate pain,
with a median of pain score 4–5/10.
However, only eight of these 18
patients in pain had taken any anal-
gesics.
At 1 week after surgery, 15 of 174
patients (9%) reported pain, and the
median pain score was 4 of 10. None of
the patients with ocular pain had taken
Ocular symptoms, such as itching,
burning, light sensitivity and foreign
body sensation, were common both
before and after surgery (Table 4).
Approximately half of the patients,
56% (110/196), reported ocular symp-
toms before surgery, with itching
(n = 43) and foreign body sensation
(n = 43) being the most common symp-
toms at baseline. At 24 hr after sur-
gery, the prevalence of ocular irritation
symptoms was similar to that at base-
line, but at 24 hr, foreign body sensa-
tion (n = 47) was more common, as
was burning (n = 31), than at baseline.
Thereafter, there was a slight decline in
the prevalence of ocular symptoms, but
even at 6 weeks, one-third (65/170) had
irritation symptoms. Most patients had
mild symptoms, but moderate or severe
symptoms (NRS ≥ 4/10) were reported
by 33/179 patients (18%) at 24 hr, by
16/174 (9%) at 1 week and by 19/170
(11%) at 6 weeks after surgery.
When the patients were asked which
of the ocular symptoms had developed
after surgery, 45% (84/186) reported
new symptoms. Foreign body sensa-
tion was reported as a new symptom by
22% (40/186) of patients, light sensi-
tivity by 16% (29/186), burning by 8%
(15/186) and itching by 8% (15/186).
5.4.4. Analgesics
At baseline, analgesics were used by 85
patients (43%) for different indica-
tions. After surgery, 46 patients (25%)

Table 3. Postoperative pain after surgery.

In hospital At discharge At 24 hr At 1 week At 6 weeks

Variable (n = 196) (n = 194) (n = 179) (n = 174) (n = 170)

Patients with ocular pain* 67 (34) 53 (27) 18 (10) 15 (9) 12 (7)

NRS pain score >4/10* 18 (9) 9 (5) 13 (7) 8 (5) 6 (4)
Current pain, for those in pain (NRS 0–10)† 2.8 (1.9) 2.1 (1–4) 3.9 (1.5) 3.1 (1.7) 3.5 (1.8)
2 [1–7] 2 [1–6] 4 [2–6] 4 [1–6] 4 [1–6]
Average pain during the last 24 hr (NRS 0–10)† 4.3 (1.7) 3.5 (2.2) 3.3 (1.6)
4 [2–7] 3 [1–8] 3 [1–6]
Most pain during the last 24 hr (NRS 0–10)† 4.9 (1.5) 4.1 (2.6) 4.3 (2.1)
5 [2–7] 4 [1–10] 4 [2–8]

The numeric rating scale (NRS) was scored 0–10, where 0 = no pain and 10 = most pain.
Data are expressed as *number of patients (%), †mean (SD) and median [range].

20

Table 4. Ocular symptoms before and after surgery.
At baseline
Variable (n = 196)
Patients with any ocular 105 (54)
irritation symptoms
Ocular symptoms
Foreign-body sensation 43 (22)
Itching 43 (22)
Burning 23 (12)
Photosensitivity 3 (2)
Tearing 19 (10)
Data are number of patients (%).
used analgesics for postoperative ocu-
lar pain or other painful ocular symp-
toms. The most frequently used
analgesics were paracetamol (n = 33)
and ibuprofen (n = 10). The analgesic
efficacy of the compounds was rated as
good or excellent; on an eleven-point
NRS, where 0 = no pain relief and
10 = complete pain relief, the analgesic
efficacy was rated to be between 5 of 10
and 10 of 10, with no difference
between the two drugs.
The analgesics were well tolerated,
and no serious or unexpected adverse
events were reported. Four patients
reported five mild adverse effects:
naproxen was associated with dry
mouth, sweating and constipation,
and ibuprofen was associated with
sweating and headache.
5.5. Discussion
This was one of the first studies with
postoperative pain as a primary out-
come measure after cataract surgery.
The data indicate that pain and other
ocular symptoms are common after
cataract surgery with the phacoemulsi-
fication technique. Some patients (9%)
reported significant pain, and moderate
or severe irritation symptoms were
common (18%) during the early hours
of recovery at the hospital, but only
few patients were provided analgesics.
These data are consistent with recent
data reported in a cohort study under-
taken as a part of quality improvement
registry, from Germany. In that study,
the median of worst pain during the
first 24 hr after eye surgery was 2/10,
and the 25th and 75th percentiles were
0/10 and 5/10, respectively (Gerbersha-
gen et al. 2013). However, in that
study, different types of eye surgery
were included, and the number of
cataract surgeries was not reported. In
At 24 hr At 1 week At 6 weeks
(n = 179) (n = 174) (n = 170)
93 (52) 79 (45) 65 (38)
47 (26) 33 (19) 26 (15)
21 (12) 25 (14) 21 (12)
31 (17) 19 (11) 20 (12)
9 (5) 7 (4) 19 (11)
8 (4) 2 (1) 4 (2)
contrast to the current study, less pain
was reported in a study by Kaluzny
et al. (2010). They compared paraceta-
mol and vitamin C for pain prevention
in cataract surgery, and less than 10%
of patients were reported to have any
pain. In our study, one-third of
patients reported some pain during
the early hours, and the majority of
these patients (79%) left the hospital
with a pain symptom remaining. To
prevent unnecessary suffering, patients
with significant postoperative pain or
other ocular symptoms must be identi-
fied, and appropriate counselling and
clear instructions on analgesic use
should be provided.
In this study, we showed that post-
operative ocular irritation symptoms
and pain after cataract surgery vary
between individuals and vary in dura-
tion. Some patients had severe pain and
other irritation symptoms lasting up to
6 weeks, whereas most patients recov-
ered with no or only minor and short-
lasting postoperative complaints. Ocu-
lar irritation symptoms are common
after cataract surgery. In the present
study, half of the patients reported
different ocular symptoms. These local
symptoms, such as foreign body sensa-
tion, pruritus, irritation, itching, light
sensitivity and blurred vision, are usu-
ally considered as ocular symptoms
rather than pain by the ophthalmologist
(Dell et al. 2011). Therefore, mild or
moderate pain may be misdiagnosed
and interpreted to be involved with
ocular symptoms and thus may not be
treated with analgesics.
Individuals undergoing cataract sur-
gery are usually elderly individuals who
have different severity levels of dry eye
syndrome and various other ocular
symptoms (Erb et al. 2008). These
ocular irritation symptoms may be
associated with concomitant diseases,
Acta Ophthalmologica 2016
such as diabetes mellitus, hypertension,
rheumatoid disease, thyroid dysfunc-
tion, psychiatric disease and cancer and
with the drugs used to treat these
diseases. All these conditions increase
the severity of dry eye and its associ-
ated symptoms. In the present study,
the prevalence of concomitant disease
was high, as expected; 76% of patients
had cardiovascular disease, and 36%
had endocrine, nutritional or metabolic
disease.
The elderly population presents
challenges for pain assessment and
management due to the subjective
nature of pain and the limitations of
ascertaining pain severity. Ageing may
affect pain perception and expression.
Thus, different approaches are needed
for pain assessment, and this is also the
case for cataract surgery, for which
tools based on visual function are not
optimal. Ocular irritation symptoms
are common after eye surgery, and it
can be difficult to distinguish these
symptoms from postoperative pain. In
the present study, half of the patients
reported some new ocular irritation
symptoms after surgery, and one-fifth
had moderate or severe symptoms.
Unfortunately, we asked the patients
only the severity of the symptoms and
not the level of unpleasantness.
According to the definition of the
International Association for the Study
of Pain, pain is ‘an unpleasant sensory
and emotional experience associated
with actual or potential tissue damage,
or described in terms of such damage’
(Bonica 1979). According to this defi-
nition, pain is a subjective, unpleasant
sensorial and emotional experience. As
a third component, in addition to
sensory and affective dimensions, pain
has a cognitive dimension, that is
patients give meanings to the postop-
erative complaints they have. Elderly
surgical patients may consider some
ocular irritation symptoms to be
related to surgery, and even though
the symptoms may be unpleasant and
severe, as was the case in the present
study, these symptoms are not called
pain. Therefore, each individual has a
different use of the word pain, and
elderly individuals may use euphe-
misms when reporting pain conditions,
making pain assessment a challenging
task in clinical work.
The selection of an appropriate
analgesic is also an issue for elderly
individuals. Most elderly patients
21
Acta Ophthalmologica 2016
have concomitant diseases and use
medications, as observed for 93% of
patients in the present study. Both
age- and disease-related changes in
physiology and drug interactions
should be taken into account when
prescribing analgesics to elderly
patients. However, most cataract sur-
gery patients had only mild or mod-
erate pain, and thus, commonly used
non-opioid analgesics, such as parac-
etamol and traditional non-steroidal
anti-inflammatory drugs (NSAIDs),
are appropriate choices for short-term
use. However, care should be taken to
ensure that the patients understand
they should use the lowest effective
dose for the shortest time needed. It
has been shown that there is a high
risk that analgesics intended for short-
term use will be used for prolonged
periods. In a recent study, there was a
four- to fivefold higher risk of becom-
ing a long-term NSAID user if
NSAIDs were prescribed for postop-
erative pain after cataract surgery
than if there was no NSAID prescrip-
tion (Alam et al. 2012).
5.6. Conclusion
In conclusion, at least one out of ten
patients can have significant pain after
cataract surgery, and one-fifth can have
other moderate or severe ocular irrita-
tion symptoms, which may last up to
6 weeks in some patients. Thus, patients
should be provided appropriate coun-
selling on pain and pain management as
part of routine postoperative care, and
they should be given information on
who to contact if problems arise after
hospital discharge.
5.7. Acknowledgements
The study was financially supported by
the governmental EVO-fund, Kuopio
University Hospital, Kuopio, Finland,
and by the University of Eastern Fin-
land, Kuopio, Finland.
5.8. Author contributions
All authors participated in the concep-
tion and design of the study, acquisition
of data, analysis and interpretation of
data; and approved the final version to
be published. SP-T and HK drafted the
first version of the article. KK partici-
pated in drafting the article. MK and
SP-T participated in reviewing the
22
article critically for important intellec-
tual content.
5.9. Disclosure
The authors report no conflict of
interests in this work.
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AJ, Peelen LM, Kalkman CJ & Meissner W
(2013): Pain intensity on the first day after
surgery: a prospective cohort study compar-
ing 179 surgical procedures. Anesthesiology
118: 934–944.
Heuermann T, Anders N, Rieck P & Hart-
mann C (2000): Peribulbar anesthesia versus
topical anesthesia in cataract surgery: com-
parison of the postoperative course. Oph-
thalmologe 97: 189–193. German.
Kaluzny BJ, Kazmierczak K, Laudencka A,
Eliks I & Kaluzny JJ (2010): Oral acetami-
nophen (paracetamol) for additional anal-
gesia in phacoemulsification cataract surgery
performed using topical anesthesia Ran-
domized double-masked placebo-controlled
trial. J Cataract Refract Surg 36: 402–406.
Mohan N, Gupta V, Tandon R, Gupta SK &
Vajpayee RB (2001): Topical ciprofloxacin-
dexamethasone combination therapy after
cataract surgery: randomized controlled
clinical trial. J Cataract Refract Surg 27:
1975–1978.
Pianini V, Passani A, Rossi GC & Passani F
(2010): Efficacy and safety of netilmycin/
dexamethasone preservative-free and tobra-
mycin/dexamethasone-preserved fixed com-
bination in patients after cataract surgery. J
Ocul Pharmacol Ther 26: 617–621.
Porela-Tiihonen S, Kaarniranta K & Kokki H
(2013): Postoperative pain after cataract
surgery. J Cataract Refract Surg 39: 789–798.
Raizman MB, Donnenfeld ED & Weinstein
AJ (2007): Clinical comparison of two topi-
cal prednisolone acetate 1% formulations in
reducing inflammation after cataract sur-
gery. Curr Med Res Opin 23: 2325–2331.
Salomon JA, Wang H, Freeman MK et al.
(2012): Healthy life expectancy for 187
countries, 1990–2010: a systematic analysis
for the Global Burden Disease Study 2010.
Lancet 380: 2144–2162.
Stifter E & Menapace R (2007): ‘Instant
vision’ compared with postoperative patch-
ing: clinical evaluation and patient satisfac-
tion after bilateral cataract surgery. Am J
Ophthalmol 143: 441–448.
6. Publication III.
Recovery and patient
satisfaction after
cataract surgery: A
1-year prospective
follow-up study
6.1. A letter to the editor
Editor,
Recovery after modern phacoemul-
sification cataract surgery is often con-
sidered to be straightforward.
However, the type and frequency of
postoperative complaints and the
effects of these on patients’ satisfaction
with cataract surgery have not been
fully established (Porela-Tiihonen
et al. 2013). On a prospective longitu-
dinal clinical trial, we have evaluated
the patient-reported visual outcome
and satisfaction at 12 months after
cataract surgery and surveyed the com-
plaints that patients might have after
cataract surgery, and tried to identify
the factors that affect the patient-
reported treatment outcome.
The protocol was approved by the
Local Research Ethics Committee, and
a written consent was obtained from all
participants. A total of 196 consecutive
patients who underwent phacoemulsi-
fication and intraocular lens implanta-
tion under topical anaesthesia were
included, and the follow-up data at
12 months were available for 164

patients; five patients had died, and 27
were lost to follow-up. Thirty-three
patients had ocular comorbidities:
glaucoma (n = 15), diabetic retinopa-
thy or maculopathy (n = 6), or other
(n = 12), and were excluded from the
analysis. A total of 131 patients were
included in the final analysis.
Vision-related disability in everyday
life was evaluated with the visual func-
tioning index VF-7 (Uusitalo et al.
1999) and Catquest-9SF (Lundstr€ om
& Pesudovs 2009). For background
data, we recorded the patient’s demo-
graphics data, medical history, medi-
cations, ocular symptoms and other
bodily pain symptoms. Patient’s satis-
faction with health and life in general
was tested on a five-point Likert scale.
Patients, 87 females and 44 males,
median of 73 years (40–91), were oper-
ated between October 2010 and August
2011. The second-eye cataract surgery
was performed in 87 of 131 (66%)
patients during the first postoperative
year. During the follow-up period, 21
patients underwent 24 additional oph-
thalmological procedures: a YAG-laser
capsulotomy (n = 6), argon laser pho-
tocoagulation (n = 5), vitrectomy
(n = 5) or other (n = 8).
In the Catquest-9SF-questionnaire,
the gain in visual function was signif-
icant in all nine dimensions (p < 0.001,
t-test) and the mean item score
improved from 0.54 (SD 1.5) at
baseline to 3.1 (1.2; p < 0.001) at
12 months. In the VF-7, patients
reported significantly less (p < 0.01,
McNemar test) difficulty in performing
daily activities 12 months after surgery
for all except one, that is driving a car.
Most patients were satisfied with the
treatment. Nineteen patients (15%)
who were dissatisfied reported signifi-
cantly more ocular symptoms (15/19,
Table 5. Ocular symptoms before and after surgery.
At baseline
Variable (n = 131)
Patients with any 73 (56)
symptoms (%)
Ocular symptoms (%)
Itching 25 (19)
Foreign-body sensation 9 (7)
Burning sensation 23 (18)
Tearing 16 (12)
Ocular pain 5 (4)
Photophobia 2 (2)
Data are presented as the number of patients (%).
79%) than those who were satisfied
(44/112, 39%, p = 0.001). Postopera-
tive ocular symptoms are presented at
Table 5. Patients who reported better
visual function at baseline with Cat-
quest-9SF were more likely to be sat-
isfied with treatment outcome at
12 months than those with greater
baseline visual function impairment
[p = 0.012, logistic regression analysis,
OR 1.5 (95% CI 1.1, 2.1)]. Life satis-
faction was reported as good or very
good by 87% at baseline and by 85%
at 12 months. Patients who underwent
cataract surgery in the second eye
within the 12 month follow-up period
reported greater life satisfaction
(p < 0.001). At baseline 15 (11%)
patients and at 12 months, three (2%)
patients reported ocular condition- or
vision-related distress (p = 0.02).
The main findings were that patients
with better visual function at baseline
were more satisfied with the outcome,
whereas the presence of postoperative
ocular symptoms was related to lower
patient satisfaction at 12 months after
the first-eye cataract surgery. In our
study, 85% of patients were satisfied
with the treatment outcome, which is
similar to previous findings (Uusitalo &
Tarkkanen 1998). Patients who under-
went cataract surgery also in the sec-
ond eye were more satisfied than
patients with first-eye surgery only.
The main limitations of the present
study were the exclusion on complex
cases and a relatively small sample size.
Thus, further studies are needed to
confirm these findings.
6.2 References
Lundstr€
om M & Pesudovs K (2009): Catquest-
9SF patient outcomes questionnaire: nine-
At 12 months p-Value
after surgery (n = 131) (McNemar test)
59 (45) 0.009
29 (22) 1.000
15 (11) 0.286
17 (13) 0.169
11 (8) 0.210
6 (5) 1.000
5 (4) 0.453
Acta Ophthalmologica 2016
item short-form Rasch-scaled revision of the
Catquest questionnaire. J Cataract Refract
Surg 35: 504–513.
Porela-Tiihonen S, Kaarniranta K & Kokki H
(2013): Postoperative pain after cataract
surgery. J Cataract Refract Surg 39: 789–
798.
Uusitalo RJ & Tarkkanen A (1998): Outcomes
of small incision cataract surgery. J Cataract
Refract Surg 24: 212–221.
Uusitalo RJ, Brans T, Pessi T & Tarkkanen A
(1999): Evaluating cataract surgery gains by
assessing patients’ quality of life using the
VF-7. J Cataract Refract Surg 25: 989–994.
7. Publication IV.
Health-related quality of
life after cataract surgery
with phacoemulsification
technique and intraocular
lens implantation
Abstract
Purpose: Disease-specific instruments
have shown significant gains in mea-
suring health-related quality of life
(HRQoL) in subjects having cataract
surgery. However, the usage of generic
instruments has resulted in conflicting
evidence.
Methods: In this prospective study,
we have evaluated the impact of
cataract surgery on subjects’ HRQoL
measured with a 15-dimension generic
instrument, the 15D. The HRQoL of
cataract subjects was compared with
that of an age- and gender-standar-
dized sample of the general population
in Finland. A total of 152 subjects
(mean age 74 years, 66% females) with
a first-eye cataract surgery completed
the 15D questionnaire both before and
12 months after cataract surgery.
Results: When compared with the
general population, cataract subjects
had much lower HRQoL at baseline
[mean difference 0.037 (95% CI: 0.020,
0.054), p < 0.001]. At 12 months after
cataract surgery, the overall utility
index improved from the mean of
0.837 to 0.855 [mean difference 0.018
(95% CI: 0.007, 0.029), p = 0.002].
Significant improvement was observed
on the following five dimensions: see-
ing, moving, hearing, usual activities
and discomfort/symptoms in the 15D
questionnaire.
Conclusion: Our data indicate that at
12 months after first-eye cataract sur-
gery, patients’ HRQoL is slightly better
23
Acta Ophthalmologica 2016
than that before surgery. However,
patients’ postoperative HRQoL may
remain lower than that of an age- and
gender-standardized control population.
Keywords: Cataract – Cataract sur-
gery – Quality of life – Quality-adjusted
life years
7.1. Introduction
Cataract surgery is highly effective at
reversing visual impairment. A signifi-
cant improvement in cataract patients’
daily activities and in vision-related
quality of life (QoL) has been shown
with disease-specific instruments
(Steinberg et al. 1994a,b; Lundstr€ om
& Pesudovs 2009; McAlinden et al.
2011). However, the usage of generic
instruments for health-related quality
of life (HRQoL) assessment is neces-
sary to be able to compare outcomes
after cataract surgery with other pro-
cedures and health conditions from
other medical specialties (Damiano
et al. 1995; Gold et al. 1996; Ramsey
et al. 2005; Nord et al. 2009; Wisløff
et al. 2014). Previous analyses using
generic instruments for HRQoL assess-
ment have yielded inconsistent results
in cataract subjects (Steinberg et al.
1994a,b; R€as€anen et al. 2006; Brown
et al. 2013; Danquah et al. 2014).
Due to conflicting evidence, we per-
formed a prospective follow-up study
in subjects having cataract surgery with
a phacoemulsification technique in a
tertiary hospital in Finland. The pri-
mary aim of this study was to evaluate
the impact of cataract surgery on
patients’ HRQoL measured with a 15-
dimension generic instrument, the 15D
(Sintonen 1995). The second aim was
to compare HRQoL of patients under-
going cataract surgery with that in an
age- and gender-standardized sample
of the general population in Finland.
7.2. Materials and methods
The study design was a prospective
follow-up study. The protocol was
approved by the Research Ethics Com-
mittee of the Hospital District of
Northern Savo, Kuopio, Finland (No.
40/2010), and the study was conducted
in accordance with the principles pre-
sented in the Declaration of Helsinki.
After providing verbal and written
information about the study, written
consent was obtained from all partici-
pants. The data were collected prospec-
24
tively between 2010 and 2012 in the
Kuopio University Hospital (KUH).
The study is part of a large study
setting, and some results have been
previously published (Porela-Tiihonen
et al. 2013, 2015).
Initially, 303 consecutive patients
who presented for cataract surgery
were asked to participate. Of these,
196 (65%) agreed to participate and
had an elective first-eye cataract sur-
gery in the year 2010 or 2011. The
follow-up questionnaire was mailed to
subjects 12 months after surgery and
included a prepaid envelope for return-
ing the questionnaire. Cataract subjects
who did not return the questionnaire
within 2 weeks were contacted and
interviewed by phone. Preoperative
data were available for 182 (93%)
subjects, and 152 returned the follow-
up questionnaire at 12 months and
were included in the final analysis,
ending up to a response rate of 84%.
The trial profile is presented as a
flowchart in Fig. 5.
For background information, we
collected age and sex data. Further-
more, the patient records were searched
for information on whether the sub-
jects had a second-eye cataract surgery
or other ophthalmological surgical pro-
cedures during the 12-month follow-up
time. The HRQoL was measured at
baseline before surgery and at
12 months after surgery with a self-
administered standardized instrument,
the 15D (Sintonen 1994, 1995, 2001).
Fig. 5. Flow-chart.
The 15D includes the following 15
dimensions, which have five levels each:
moving, seeing, hearing, breathing,
sleeping, eating, speech, excretion,
usual activities, mental function, dis-
comfort and symptoms, depression,
distress, vitality and sexual activity.
The valuation system is based on an
application of the multi-attribute utility
theory. The single index score (15D
score), representing the overall
HRQoL on a 0–1 scale (1 = full health,
0 = being dead), and the dimension
level values, reflecting the subject’s
reported level relative to no problems
on the dimension (=1) and to being
dead (=0), are calculated from the
health state descriptive system using a
set of population-based preference or
utility weights (Sintonen 1995).
The minimally important change of
the 15D score is 0.015, and the distri-
bution of changes of the 15D scores
(postoperative score – baseline score) is
divided into the following five cate-
gories: >0.035 for ‘much better’, 0.015–
0.035 for ‘slightly better’, greater than
0.015 and <0.015 for ‘much the same
(no change)’, 0.035 to 0.015 for
‘slightly worse’ and less than 0.035
for ‘much worse’. These values are
based on data of altogether 4903 hos-
pital patients representing 16 disease
entities and having the 15D score at
baseline repeated the HRQoL assess-
ment at 6 months after treatment and
answered the question: compared to
the situation before treatment, my
 Acta Ophthalmologica 2016

overall health status is now (1) much
better, (2) slightly better, (3) much the
same, (4) slightly worse, (5) much
worse. Based on that data, a generic
minimally important change (slightly
better/worse) of 0.015 of 15D scored
was found (Alanne et al. 2015).
The improvement of HRQoL was
assumed to last till the end of life, and
quality-adjusted life years (QALY’s)
were calculated by multiplying the
utility index (e.g. the HRQoL score
between 0 and 1) by the remaining
statistical life expectancy of each sub-
ject based on the Life Tables 2012 from
the Official Statistics of Finland (2014).
A discount rate of 5% was used in the
QALY calculation (Busbee et al. 2002;
R€as€anen et al. 2006).
We compared the HRQoL of the
study subjects with that of an age- and
gender-standardized representative
sample of the general population from
the Health 2011 survey. The data were
collected by the National Institute for
Health and Welfare (THL) in 2011
using self-administered questionnaires,
including the 15D questionnaire, per-
sonal interviews and clinical examina-
tions (Koskinen et al. 2012). For the
comparison those individuals were
selected, who were in the age range of
the patients (n = 4307), and this sample
was weighted to reflect the age and
gender distribution of the patients.
7.3. Statistics
The data were entered into SPSS sta-
tistical software (IBM SPSS Statistics
19; Armonk, NY, USA). The statistical
tests used were t-tests of the paired
samples to compare pre- and postop-
erative data, chi-squared test to com-
pare proportions and t-tests of
independent samples were used to
compare the data with an age- and
gender-standardized sample. Data are
presented as number of cases (%),
mean (SD) and mean difference (95%
confidence interval for the difference)
as appropriate. A p-value of <0.05 was
considered to be statistically signifi-
cant.
7.4. Results
Data at baseline were available for 182
(93%) subjects, mean age 73 years (SD
9.6), 65% females and at 12 months
after surgery for 152 (84%) subjects
with a mean age 74 years (9.7) and
66% female. During the 12-month
follow-up, 100 of the 152 subjects
(66%) also had cataract surgery in the
second eye. Of the 152 patients, 30
(20%) had ocular comorbidities at
baseline; 15 (10%) patients had glau-
coma, 4 (3%) had diabetic retinopathy
or maculopathy, and 11 (7%) had
other ocular diseases. The best-cor-
rected visual acuity at baseline is pre-
sented at Table 6.
No prior sample size calculation was
performed, but a two-sided post hoc
power analysis indicated that the study
had a power of 0.86 to show an
improvement of at least of 0.015 in
the mean 15D score at 12 months after
surgery compared to that before sur-
gery at a desired significance level of
0.05.
The improvement of HRQoL after
cataract surgery was slight. In subjects
with both the baseline and postopera-
tive data (n = 152), the 15D score
improved from a mean of 0.837
(0.093) to 0.855 (0.097) with a mean
difference of 0.018 [95% CI: 0.007,
0.029, p = 0.002 (t-test of paired sam-
ples)] at 12 months after the first-eye
cataract surgery. This change was also
clinically important. The postoperative
HRQoL was much better (>0.035) in
64 (42%) subjects, slightly better
(0.015–0.035) in 12 (8%) subjects and
much the same in 30 (20%) subjects.
The postoperative HRQoL at
12 months was slightly worse ( 0.035
to 0.015) in 16 (11%) subjects and
much worse (less than 0.035) in 30
(20%) subjects. The 15D instrument
showed significant improvement on five
dimensions as follows: moving, seeing,
hearing, usual activities and discom-
fort/symptoms (Fig. 6).
For subjects with only the first eye
operated during the 12-month follow-
up [n = 52 (34%)], the mean 15D score
was clinically and statistically signifi-
cantly higher at 12 months [0.858
(0.112)] compared with the baseline
[0.828 (0.103), p = 0.003]. The postop-
erative HRQoL was much better in 25
(48%) subjects, slightly better in 5
(10%) and much the same in 10
(19%) subjects. The postoperative
HRQoL at 12 months was slightly
worse in 6 (12%) subjects and much
worse in 6 (12%) subjects, respectively.
For subjects with an operation in
their second eye during the 12-month
follow-up period [n = 100 (66%)], the

Table 6. The best-corrected visual acuity at baseline and change in the 15D score.

Change in 15D score (n)

Much better Slightly better Much the same Slightly worse Much worse
Visual acuity* (>0.035) (0.015 to 0.035) (0.015 to 0.015) ( 0.015 to 0.035) (< 0.035) Total (n)
**
Worse eye
≤0.10 7 2 – – 4 13
0.125–0.25 10 1 7 6 6 30
0.30–0.63 43 8 20 9 20 100
≥0.80 3 – 2 1 – 6
Total 63 11 29 16 30 149
Better eye***
≤0.10 2 – – – – 2
0.125–0.25 2 2 1 – 3 8
0.30–0.63 46 7 22 12 22 109
≥0.80 13 2 7 4 5 31
Total 63 11 30 16 30 150

Data are number of cases.

*Best-corrected visual acuity (Snellen equivalents); **p = 0.373; ***p = 0.644, chi-squared test.

25
Acta Ophthalmologica 2016
Fig. 6. The comparison of cataract patients and control population in the 15 dimensions of 15D Instrument: Move = moving, See = Seeing,
Hear = Hearing, Breath = breathing, Sleep = sleeping, Eat = eating, Speech = speech, Excret = eliminating, Uact = usual activities, Mental = men-
tal function, Disco = discomfort and symptoms, Depr = depression, Distr = distress, Vital = vitality and sex = sexual activity, Popul = Age- and
gender-matched control population.
mean 15D score was similar at baseline
[0.842 (0.088)] and at 12 months [0.853
(0.087), p = 0.118]. The postoperative
HRQoL was much better in 38 (38%)
subjects, slightly better in 7 (7%) sub-
jects and much the same in 20 (20%)
subjects. The postoperative HRQoL at
12 months was slightly worse in 10
(10%) subjects and much worse in 25
(25%) subjects, respectively.
The mean QALY gain in the whole
study population was modest. A mean
life expectancy of 13.9 remaining years
in the whole study population, multi-
plied by the net utility gain, resulted in
0.14 (95% CI: 0.03, 0.25) discounted
QALYs gained by cataract surgery.
For subjects with only the first eye
operated, the mean QALY gain was
0.27 (95% CI: 0.10, 0.45) compared
with 0.068 (95% CI: 0.06, 0.20) for
subjects with an operation in their
second eye during the 12 months fol-
low-up.
When compared with the age- and
gender-standardized sample of the
general population, cataract subjects
had much worse HRQoL at baseline
with a mean difference of 0.037 (95%
CI: 0.020, 0.054), p < 0.001 (t-test of
independent samples). The difference
was clinically important. At baseline,
cataract subjects reported significantly
more difficulties on nine out of the 15
dimensions as follows: moving, seeing,
hearing, breathing, excretion, usual
activities, discomfort and symptoms,
distress and vitality (p < 0.05). At
12 months after surgery, five dimen-
sions had improved, but the HRQoL
26
remained slightly lower in the cataract
group than in the control population
with a mean difference of 0.019 (95%
CI: 0.002, 0.037, p = 0.029). The dif-
ference was still clinically important.
At 12 months, four dimensions, see-
ing, breathing, excretion and vitality,
were lower in cataract subjects than in
the control population (p < 0.05;
Fig. 6).
7.5. Discussion
Our data indicate that people with
cataract have low HRQoL, not only
on seeing but also on several other
dimensions. In the present study, we
have shown a mean improvement of
the HRQoL after cataract surgery as
measured by a generic instrument, the
15D. Five of the fifteen dimensions
improved significantly, that is after
cataract surgery with a phacoemulsifi-
cation technique, subjects reported
fewer problems with seeing and also
with moving, hearing, usual activities
and discomfort/symptoms than at
baseline before surgery. However, in
general, the gain was modest.
In our comparison of cataract sub-
jects with an age- and gender-standar-
dized control population, the overall
HRQoL score was worse both at
baseline and at 12 months after sur-
gery in cataract subjects. Before sur-
gery, cataract subjects reported more
difficulties on nine out of fifteen
dimensions. As the population 15D
data were collected at the same time as
those of the cataract subjects, this is
likely to decrease the bias associated
with the use of historical controls
(Koskinen et al. 2012). However,
beyond the improvement of vision-
related difficulties after surgery in
cataract subjects, previously reported
difficulties in moving, usual activities,
discomfort and symptoms, and distress
had improved and were similar to the
control population at 12 months after
surgery.
When compared our results to a
sample collected from a rural area of
Finland and 10 years earlier, the study
subjects reported much better HRQoL
(a mean 15D score of 0.84) than those
who were on a waiting list for cataract
surgery 10 years ago (a mean 15D
score of 0.79). In that study, the
quality of life of patients waiting for
cataract surgery was equal to the
population-based sample. 15D scores
indicated better HRQoL in those
patients with less cataract and better
visual acuity (Falck et al. 2008). Our
study indicates no significant differ-
ences in the improvement of HRQoL
in between patients with different
visual acuity measured at baseline.
There are two likely reasons for the
reported difference in the HRQoL
between the two studies. The differ-
ence could be related to the better
visual acuity on the study subjects
compared to those in the Falck et al.
(2008) study. Moreover, the perception
of life among Finns has improved
during the last decade, and this may
be the case also among people with
cataract (Koskinen et al. 2012).

When evaluated with disease-specific
outcome measures, cataract surgery is
highly effective and considered to be
one of the most cost-effective surgical
procedures (Busbee et al. 2002; Riaz
et al. 2006; Brown et al. 2013). How-
ever, analyses using generic HRQoL
instruments have yielded inconsistent
results. R€as€anen et al. (2006) used the
15D instrument and reported an
insignificant improvement in the mean
15D score, as only seeing of the 15
dimensions of the HRQoL instrument
improved compared with baseline.
Using the same generic instrument,
15D, we found slightly more improve-
ment in the mean 15D score at
12 months with 0.018 in the present
study versus 0.010 at 6 months after
cataract surgery as found in the
R€as€anen et al. (2006) study.
Another generic instrument, the EQ-
5D questionnaire (EuroQoL Group
1990), was used in the Danquah et al.
(2014) study that reported a significant
improvement in most of the five
domains at 12 months after cataract
surgery. At baseline, the self-rated
health score in cataract subjects was
worse than that in age- and gender-
matched controls without seeing diffi-
culties, but after surgery, the self-rated
health score of cataract subjects was
reported to be similar to the controls,
as were most of the five dimensions of
the EQ-5D. Unfortunately, Danquah
et al. (2014) did not report the overall
EQ-5D score in their paper.
In a study by Steinberg et al.
(1994a), 67% of patients showed a
significant gain in HRQoL measured
with a generic instrument, the Sick-
ness Impact Profile (de Bruin et al.
1994), at 4 months after cataract
surgery. The visual acuity and visual
functioning improved in 96% and
89% of patients measured with the
Visual Functioning Index VF-14
(Steinberg et al. 1994b), respectively.
Our findings, based on measurements
with the disease-specific visual func-
tioning questionnaires Catquest-9SF
(Lundstr€ om & Pesudovs 2009) and
Visual Functioning Index VF-7 (Uusi-
talo et al. 1999), have shown a similar
significant gain in visual functioning
and vision-specific HRQoL after cat-
aract surgery (Porela-Tiihonen et al.
2014).
In our study population, the QALY
gain was modest, 0.14. A recent report
by Brown et al. (2013) reported a
significantly higher mean gain of 1.6
QALYs after cataract surgery based on
hypothetical time trade-off (TTO)
vision utilities. Therefore, these gains
are not comparable. The usage of
generic instruments is necessary to
compare procedures from different
medical specialties, as disease-specific
instruments may overestimate the gain
of QALYs.
There are some limitations in the
present study. Our sample size was
relatively small as we had pre- and
postoperative data on 152 subjects. We
assess 303 patients for eligibility but 59
(19%) decline to participate, 92 (30%)
were excluded because surgery was
cancelled or delayed, or because the
patients were lost to follow-up. This
may have caused a selection bias on
the study population. However, with
this sample size the study had a two-
sided power of 0.86 to detect an
improvement of 0.015 on 15D score,
and thus, the sample size could be
considered sufficient. Moreover, we did
not collect postoperative data either on
visual acuity or ophthalmic status in
our study procedure, both of whom
might have provided further interesting
information concerning the HRQoL.
Other ocular conditions such as dia-
betic retinopathy and presbyopia have
been reported also to have a negative
impact on HRQoL (Goertz et al. 2014;
Hannula et al. 2014). However, only
few patients in our study sample suf-
fered from severe macular degenera-
tion or diabetic retinopathy. During
the follow-up of 12 months, an YAG-
capsulotomy was made for four
patients, and two patients having age-
related macular degeneration were
treated with intraocular VEGF-inhibi-
tor therapy. We enrolled patients hav-
ing first-eye surgery, but we also
included subjects with the second eye
operated during the follow-up period
in the analysis. The HRQoL improve-
ment was more significant in subjects
with only the first-eye surgery per-
formed. This finding was not expected,
because second-eye surgery has been
previously shown to further improve
the HRQoL in cataract patients based
on hypothetical TTO vision utilities
(Brown et al. 2013). However, the
previous studies have found that the
second-eye surgery may be less cost-
effective and provides less improve-
ment compared with the first-eye sur-
gery, which may be related to a good
Acta Ophthalmologica 2016
baseline visual function after the first-
eye cataract surgery (Sach et al. 2010).
However, due to methodological dif-
ferences, these results may not be
comparable.
The previous literature has shown
that the reliability and repeatability of
the 15D Instrument are good (Sintonen
1994; Stavem 1999). However, previous
literature has also shown limitations in
the usage of patient-reported outcome
measurements of HRQoL in the area
of cataract surgery and other sensory-
related interventions (Kobelt et al.
2006; Sach et al. 2010). The utility
scores may be driven more by the
function of the better-seeing eye rather
than its poorer counterpart (Kobelt
et al. 2006).
In conclusion, cataract subjects had
a low HRQoL on several dimensions
measured with a generic instrument.
Our data indicate that cataract surgery
improves the HRQoL at 12 months
after a first-eye cataract surgery, but
the postoperative HRQoL may remain
lower than that of an age- and gender-
standardized control population. At
12 months after cataract surgery, see-
ing improved significantly, and the
preoperatively reported difficulties in
moving, usual activities, discomfort
and symptoms, and distress reached
the levels of the control population.
7.6. Acknowledgements
There was no conflict of interests that
could be perceived as prejudicing the
impartiality of the research reported.
No external sources of funding were
used to prepare this manuscript.
7.7 References
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BG, Lieske HB & Lieske PA (2013):
Cataract surgery cost utility revisited in
2012: a new economic paradigm. Ophthal-
mology 120: 2367–2376.
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Stevens FC & Philipsen H (1994): The
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Busbee BG, Brown MM, Brown GC &
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27
Acta Ophthalmologica 2016
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8. General discussion
8.1. Summary
Postoperative ocular surface irritation
may result from both the surgical
trauma and the topical ocular drug
therapy used as a part of perioperative
and postoperative care. The present
literature search revealed a wide range
in the occurrence of postoperative pain
and painful ocular symptoms after
cataract surgery (Publication I). The
present study indicates that postopera-
tive pain was relatively common during
the first hours after cataract surgery;
one out of three patients reported some
pain and one out of every ten patients
experienced moderate to severe pain
after surgery (Publication II). The
presence of postoperative ocular symp-
toms was related to lower patient
satisfaction at 12 months after the
first-eye cataract surgery. Thus, the
patients should be provided with
instructions for pain management and
contact information; in case, they
should experience significant postoper-
ative ocular pain. Itchiness, burning
sensation and foreign body sensation
were the most common symptoms
reported after surgery (Publication II).
These symptoms are also considered to
be manifestations of ocular surface
disease (Dry Eye WorkShop 2007),
and some patients may benefit from
tear substitutes as a way to improve
postoperative ocular comfort and
enhance patient satisfaction after cat-
aract surgery. Some of the symptoms
such as burning and foreign body
sensation are also difficult to distin-
guish from ocular pain.
The present study indicates that
patients who report postoperative ocu-
lar discomfort are less satisfied with
their treatment outcome (Publication
III). There do not appear to be any
previous studies which have evaluated
the relationship between postoperative
symptoms and patient satisfaction after
cataract surgery. Here, 85% of patients
were satisfied with the treatment out-
come, which is similar to previous
findings (61–91%; Steinberg et al.
1994a,b; Schein et al. 1995; Tielsch
et al. 1995; Uusitalo & Tarkkanen
1998; Nijkamp et al. 2000; Mamidi-
pudi et al. 2003; Garcia-Gutierrez
et al. 2014). No correlation was
detected between increasing age or
ocular comorbidity and satisfaction

with treatment outcome or satisfaction
with life in general. Of the 24 patients
reporting dissatisfaction with the treat-
ment outcome, ten also expressed feel-
ings of distress and dissatisfaction
related to other health issues. Those
patients who underwent cataract sur-
gery in the second eye within the 12-
month follow-up period were more
satisfied compared to patients with
the first-eye surgery only, similar to
the findings of R€ onbeck et al. (2011).
Patients who underwent additional
ocular surgical procedures during the
12-month follow-up period were less
satisfied with the cataract surgery out-
come. This was expected and is in
agreement with two previous studies in
which the presence of ocular complica-
tions after cataract extraction surgery
was related to lower satisfaction with
the outcome (Schein et al. 1995; Gar-
cia-Gutierrez et al. 2014).
Patients with less VF impairment at
baseline were more satisfied with the
outcome thus supporting the benefits of
early surgical intervention in patients
with cataract (Publication III). Several
previous studies have presented a posi-
tive correlation between better postop-
erative VF and greater patient
satisfaction after cataract surgery
(Steinberg et al. 1994a,b; Lundstr€ om
et al. 1997; Uusitalo & Tarkkanen
1998; Uusitalo et al. 1999; Friedman
et al. 2002; Mamidipudi et al. 2003;
Lundstr€ om & Stenevi 2013). In the
present study, patients who reported
greater preoperative difficulties in the
Catquest questionnaire reported less
satisfaction with the postsurgical out-
come. This agrees with the results from
Garcia-Gutierrez et al. (2014) who used
the VF-14 as a VF measurement but
contradict the results reported by
R€onbeck et al. (2011) in which patients
with lower preoperative best-corrected
VA reported greater postoperative sat-
isfaction. In the studies of Uusitalo et al.
(1999), Mamidipudi et al. (2003) and
Garcia-Gutierrez et al. (2014), the
change in the VF score was a strong
predictor of the change in the patients’
satisfaction with their vision.
The improvement in VF measured
with the Catquest, and the VF-7 was as
good as expected (Publication III).
When this improvement was analysed
with respect to the level of visual
disability after surgery in VF-7-index,
only two items achieved statistical
significance (p < 0.05): reading small
text and doing fine handwork. The
numbers of patients eligible to analyse
the level of disability, using the Wil-
coxon signed-rank test, were too small
in most questions, which may be the
reason for the statistically non-signifi-
cant improvement in these items.
The cataract patients reported some
difficulties in several dimensions mea-
sured with a 15-dimensional generic
HRQoL instrument, the 15D (Publica-
tion IV). The data indicate that cataract
surgery improves the HRQoL at
12 months after first-eye cataract sur-
gery, but the postoperative HRQoL
may still remain lower than that of an
age- and gender-standardized control
population. Five of the fifteen dimen-
sions of the 15D instrument improved
after cataract surgery, as fewer difficul-
ties were reported with seeing, moving,
hearing, usual activities and discom-
fort/symptoms at 12 months after sur-
gery than had been present at baseline.
However, in general, the gain was
modest. When compared to an age-
and gender-standardized control popu-
lation at 12 months after cataract sur-
gery, the dimension of seeing had
improved significantly, and the preop-
eratively reported difficulties in moving,
usual activities, discomfort and symp-
toms, and distress reached the level of
the control population.
8.2. Limitations of the present study
There were some limitations in the
study design, as it was a prospective
observational longitudinal clinical
study. The sample size was relatively
small as the study patients were col-
lected over a limited time period, and
the follow-up time was also relatively
short, 12 months. Moreover, as the
observation period was pre-deter-
mined, two-thirds of the subjects had
a second eye operated before the last
questionnaire. Thus, there was com-
plete data only for 52 patients with a
single eye operated. The same patients
filled in all the study questionnaires
that may have affected the answers. It
is possible that over a time respondents
may have unknowingly changed their
qualitative responses to better fit what
they consider to be the observer’s
intended goal. Moreover, the presence
of outliers in such a small cohort can
exert a major influence on the results
(Kobelt et al. 2006). Approximately
one-fifth of the recruited 303 patients
Acta Ophthalmologica 2016
declined to participate or were not able
to participate due health-related con-
ditions. However, this is a common
problem in studies performed with
elderly people (Provencher et al.
2014). Some of the study questions
may also not have been fully under-
stood by all of the subjects, as some of
their answers were inconsistent. Five
patients died during the 1-year follow-
up. Moreover, most of the outcome
measurements were assessed subjec-
tively by the patients, and the subjects
had no follow-up visits that could have
provided some objective data on VA,
for example.
The patients with severe intraopera-
tive complications were excluded, as the
aim was to study the results of routine,
uncomplicated cataract surgery. The
inclusion of these patients might have
provided further information. As the
study was performed in an educational
university hospital, eight different sur-
geons with different histories of surgical
and educational experience performed
the surgeries. Moreover, the patients’
satisfaction with the treatment outcome
is assumed to be affected of the surgeon’s
communication with the patient.
The previous literature has also
shown limitations in the usage of
patient-reported outcome measure-
ments of HRQoL in the area of cataract
surgery and other sensory-related inter-
ventions (Kobelt et al. 2006; Sach et al.
2010). The utility scores may be driven
more by the function of the better-seeing
eye rather than its poorer counterpart
(Brown 2000; Kobelt et al. 2006). In
unilateral cataract surgery, the good VA
in the better-seeing eye may result in less
gain in HRQoL despite the improved
vision in the operated eye (Kobelt et al.
2006). Furthermore, it is possible that
the patients may also have adapted to
the disabilities they have (Sach et al.
2010).
8.3. Future directions
To elucidate more the value of the
treatment of different diseases and
performing different procedures includ-
ing cataract surgery, more data of
HRQoL should be collected with gen-
eric instruments. Guidelines of safe and
effective pain treatments after cataract
surgery are needed. As the symptoms
of ocular irritation resemble those of
dry eye syndrome, the efficacy of ocular
lubricant therapy should be evaluated
29
Acta Ophthalmologica 2016
in studies with a sufficient sample size
and prospective follow-up.
Future studies with larger sample
sizes will be needed to evaluate the
management of postoperative pain and
other painful ocular irritation symp-
toms with analgesic drug therapy after
cataract surgery. A conclusion emerg-
ing from this study was that postoper-
ative ocular pain and other painful
ocular symptoms after cataract surgery
do affect the patients’ experience of
care and satisfaction with the treatment
and the treatment outcome. Thus, all
patients should be provided with suffi-
cient counselling about the possible
symptoms they may experience after
surgery as one way to improve patient
satisfaction and the quality of life after
cataract surgery.
9. Conclusions
I The literature review indicated that
for a minority of patients, the catar-
act surgery is associated with signif-
icant postoperative pain and other
painful ocular irritation symptoms.
II Recovery after phacoemulsification
cataract surgery is uneventful in most
patients. However, at least one out of
every ten patients may experience
significant pain after cataract sur-
gery, and one in every five may suffer
from other moderate or severe ocular
irritation symptoms, which may last
up to 6 weeks.
III The presence of postoperative ocu-
lar symptoms is related to lower
patient satisfaction at 1 year after
cataract surgery. Less impairment
in daily VF at baseline is associated
with greater patient satisfaction
with the outcome of the procedure.
IV Health-related quality of life
improved significantly after catar-
act surgery, but remained lower
than that in an age- and gender-
standardized control population.
In addition to the improvement of
seeing, after cataract surgery there
were also fewer difficulties reported
in other fields of HRQoL when
compared to those at baseline.
10. Tiivistelm€
a nen olivat yleisi€ a sek€ a ennen leikkausta
Kaihileikkaus on yleisin silm€ a€
an
teht€av€a kirurginen toimenpide ja leik-
kausten m€a€ar€an arvioidaan kasvavan
merkitt€av€asti tulevina vuosina. Kai-
hileikkauksen yleisyydest€a huolimatta
30
leikkauksen j€ alkeist€a toipumista on kuivasilm€ aisyyden oireita, ja osa poti-
tutkittu vain v€ ah€an. T€ am€an tutkimuk- laista hy€ otyisi mahdollisesti kuiv-
sen tavoitteena on selvitt€ a€
a kai- asilm€ aisyyden hoitoon k€ aytett€
avist€
a
hileikkauksen j€ alkeisen silm€ akivun ja paikallisvalmisteista.
silm€an €arsytysoireiden esiintyvyytt€ a, Tutkimuksessa osoitettiin silm€ aoire-
voimakkuutta ja kestoa. Tutkimuksen ita ilmoittavien potilaiden olevan
toisena tavoitteena on selvitt€ a€a poti- merkitt€ av€
asti tyytym€att€om€ampi€a
laiden leikkauksen j€ alkeiseen tyy- leikkaustulokseen vuosi leikkauksen
tyv€aisyyteen vaikuttavia tekij€ oit€
a, ja alkeen (p = 0.001). Potilaiden ennen
j€
kaihileikkauksen vaikutusta potilaiden leikkausta ilmoittama parempi
terveyteen liittyv€ a€an el€ am€ anlaatuun p€aivitt€
ainen n€ ak€okyky oli yhteydess€ a
sek€a p€aivitt€aiseen el€ am€ a€
an liittyv€ a€
an my€ os parempaan tyytyv€ aisyyteen vuosi
n€ak€okykyyn. leikkauksen j€ alkeen. Terveyteen liittyv€a
Tutkimus oli seurantatutkimus, jossa el€
am€ anlaatu parani merkitt€av€asti
toipumista ja silm€ aoireita mitattiin (p = 0.002) 15D-mittarilla mitattuna.
kyselyll€a 1 p€aiv€a, 1 viikko, 6 viikkoa ja I€ a€
alt€ an ja sukupuoleltaan vastaavaan
1 vuosi leikkauksen j€ alkeen. Kai- verrokkiv€ aest€ €n verrattuna kaihipoti-
oo
hileikkauksen vaikutusta p€ aivitt€
aiseen laiden terveyteen liittyv€ a el€am€anlaatu
n€ak€okykyyn liittyv€ a€
an haittaan mitat- oli huonompi sek€ a ennen leikkausta
tiin Visual Functioning Index VF-7 ja ett€
a vuosi leikkauksen j€ alkeen.
Catquest-9SF-mittarein ennen leik-
kausta ja vuosi leikkauksen j€ alkeen.
Terveyteen liittyv€ a€a el€ am€ anlaatua
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Correspondence:
Department of Anaesthesiology and
Department of Intensive Care Medicine
Kuopio University Hospital,
University of Eastern Finland
Kuopio
Tel: +358407761183
Email: susanna.porela-tiihonen@fimnet.fi