ARTICLE

Comparison of treatment
with preservative-free versus preserved
sodium hyaluronate 0.1% and fluorometholone
0.1% eyedrops after cataract surgery in patients
with preexisting dry-eye syndrome
Donghyun Jee, MD, PhD, Minji Park, MD, Hee Jin Lee, BS, Man Soo Kim, MD, PhD,
Eun Chul Kim, MD, PhD

PURPOSE: To compare treatment with preservative-free and preserved sodium hyaluronate 0.1%
and fluorometholone 0.1% eyedrops after cataract surgery in patients with preexisting dry-eye
syndrome.
SETTING: Bucheon St. Mary’s Hospital, Catholic University of Korea, Seoul, Korea.
DESIGN: Randomized controlled study.
METHODS: Patients with cataract and dry-eye syndrome were randomly divided into 2 groups.
Group 1 patients were treated with preservative-free sodium hyaluronate 0.1% and preservative-
free fluorometholone 0.1% eyedrops 4 times a day in the first month and twice a day in the
second month. Group 2 patients were treated with preserved eyedrops using the same schedule.
Ocular Surface Disease Index (OSDI) score, tear-film breakup time (TBUT), Schirmer I test,
corneal fluorescein staining, impression cytology, and antioxidant and inflammatory cytokine
activities in tears were evaluated.
RESULTS: Both groups comprised 40 patients. At 2 months, the OSDI score, TBUT, Schirmer I
score, fluorescein staining score, impression cytology findings, and goblet cell count were signif-
icantly better in Group 1 than in Group 2 (P<.05). The interleukin-1b and tumor necrosis factor-a
concentrations were significantly less in the tears of Group 1 patients than in the tears of Group 2
patients, and catalase and superoxide dismutase 2 fluorescence intensities were significantly
greater in the tears of Group 1 patients than in the tears of Group 2 patients (P<.05).
CONCLUSIONS: Preservative-free sodium hyaluronate 0.1% and fluorometholone 0.1% eyedrops
can improve the symptoms and signs of dry-eye syndrome after cataract surgery. Preservative-
free fluorometholone eyedrops may have antiinflammatory and antioxidant effects in tears of
patients with dry-eye syndrome.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2015; -:-–- Q 2015 ASCRS and ESCRS

Cataract surgery is one of the safest and most success-
ful surgical procedures and has very few complica-
tions. Although there are few complications, patients
often experience dry-eye syndrome. Tear-film and
ocular surface changes have been reported after phaco-
emulsification.1 Tear-film dysfunction often results
from the use of topical medications, reduced corneal
sensitivity, conjunctival goblet cell loss, or meibomian
gland dysfunction.2–5 Temporal-side incisions in
phacoemulsification decrease corneal sensitivity in
the incision site.3 The use of an aspirating speculum
is also a potential risk factor for dry-eye syndrome

Q 2015 ASCRS and ESCRS http://dx.doi.org/10.1016/j.jcrs.2014.11.034 1

Published by Elsevier Inc. 0886-3350
2 PRESERVATIVE-FREE EYEDROPS AFTER CATARACT SURGERY IN DRY-EYE SYNDROME
because conjunctiva can be sucked into the speculum
and subsequent inflammatory changes can occur on
the ocular surface.6
Dry-eye syndrome is a multifactorial disease of tears
and the ocular surface, characterized by symptoms of
discomfort, visual disturbance, and tear-film insta-
bility, combined with inflammatory damage to the
ocular surface.7 Increase in the oxidative stress ap-
pears to have a role in the pathogenesis of dry-eye
disease.8
Preservatives in eyedrops can induce oxidative
stress and an inflammatory response in conjunctival
epithelial cells and the rabbit dry-eye model.9
Preservative-free netilmicin/dexamethasone and ke-
torolac 0.45% eyedrops are safe and effective in con-
trolling postoperative inflammation and preventing
postoperative ocular infections.10,11 Effective treat-
ment of dry-eye syndrome, such as artificial tears or
lacrimal plugs, has been recommended in dry-eye pa-
tients after phacoemulsification.12 The preservative-
free hydroxypropyl-Guar treatment after cataract
surgery reduces ocular surface inflammation and
dry-eye signs and symptoms.4 However, all previous
studies included patients who developed dry-eye syn-
drome after cataract surgery.
To our knowledge, no report has compared the ef-
fects of preservative-free and preserved steroid and
lubricant eyedrops after cataract surgery in patients
with preexisting dry-eye syndrome. In this study,
we used clinical and laboratory methods to compare
the efficacy of preservative-free sodium hyaluronate
0.1% and preservative-free fluorometholone 0.1%
eyedrops and preserved sodium hyaluronate 0.1%
and fluorometholone 0.1% eyedrops in patients
with preexisting dry-eye disease who had cataract
surgery.
Submitted: May 6, 2014.
Final revision submitted: July 24, 2014.
Accepted: July 25, 2014.
From the Department of Ophthalmology & Visual Science (Jee,
Park, M.S. Kim, E.C. Kim) and the Institute of Clinical Medicine
Research (Lee), College of Medicine, The Catholic University of Ko-
rea, Seoul, Korea.
Supported by the Basic Science Research Program through the
National Research Foundation of Korea funded by the Ministry of
Science, ICT & Future Planning (No. 2012R1A1A1038648) and
the Institute of Clinical Medicine Research of Bucheon St. Mary’s
Hospital, Research Fund, BCMC13LH03.
Corresponding author: Eun Chul Kim, MD, Department of Ophthal-
mology, Bucheon St. Mary’s Hospital, 327 Sosa-ro, Wonmi-gu,
Bucheon, Gyeonggi-do, 420-717, Korea. E-mail: eunchol@
hanmail.net.
J CATARACT REFRACT SURG - VOL -, - 2015
PATIENTS AND METHODS
This randomized parallel-group case control study was
conducted in accordance with the institutional review
board regulations of Bucheon St. Mary's Hospital, informed
consent regulations, sponsor and investigator obligations,
and the Declaration of Helsinki. Written informed consent
was obtained from all patients before the initiation of the
study.
The study included patients diagnosed with moderate to
severe dry-eye syndrome and cataract, who were randomly
assigned by a computer-generated randomization list to 2
treatment groups after cataract surgery. Phacoemulsification
and posterior chamber intraocular lens implantation were
performed at the Bucheon St. Mary's Hospital between
March 2013 and December 2013. Clear-corneal incisions
were performed in both groups. All patients had nuclear
cataract, which is harder than nuclear opalescence 3 accord-
ing to the Lens Opacities Classification System III scale.8 In-
clusion criteria included short tear-film breakup time (TBUT)
(!5 seconds), low Schirmer I test score (10 mm/5 min
without anesthesia), and mild corneal punctate fluorescein
staining (staining score of R1) in either eye (scale 0 w 3).
All patients had age-related cataract with dry eyes. Exclusion
criteria were history of ocular injury, infection, non-dry-eye
ocular inflammation, trauma, or presence of uncontrolled
systemic disease.
Using simple randomization, the patients were assigned
to 2 groups. Group 1 patients were treated with gatifloxacin
0.3% (Gatiflo), preservative-free sodium hyaluronate 0.1%
eyedrops (Tearin free), and preservative-free fluorometho-
lone 0.1% eyedrops (Humeron) 4 times a day in the first
month and twice a day in the second month. Group 2
patients were treated with gatifloxacin 0.3%, preserved
sodium hyaluronate 0.1% eyedrops (Lacure), and preserved
fluorometholone 0.1% eyedrops (Ocumetholone) using the
same schedule. The medication was dispensed open label.
Subjective symptom scoring, TBUT, Schirmer I test
(without anesthesia), corneal fluorescein staining, and
conjunctival impression cytology13 were performed by the
same investigator (E.C.K.) before treatment and 1 and
2 months after cataract surgery. Subjective symptoms were
graded on a numerical scale of zero to 4 using the Ocular Sur-
face Disease Index (OSDI) score.14 The OSDI evaluates the
effect of dry eye on quality of life items divided into 3
subscales: ocular symptoms, vision-related function, and
response to environmental triggers. It uses a 4-grade scale:
0 Z never; 1 Z sometimes; 2 Z half the time; 3 Z most of
the time; 4 Z all the time. The sum of the scores was used
in the analysis.
Corneal fluorescein staining was examined through slit-
lamp evaluation with a yellow barrier filter and cobalt-blue
illumination.13 Staining was graded using the Oxford
Scheme 6-point scale (from 0 to 5).15
Impression cytology was performed in the lower bulbar
conjunctiva using strips of cellulose acetate filter paper
(MFS membrane filters, Advantec MFS, Inc.), as previously
described.13 The specimens were fixed in 100% alcohol,
stained with periodic acid-Schiff, and photographed at a
magnification of 400.13 The degree of squamous metaplasia
was graded from zero to 6 using the grading scheme of
Tseng,16 and goblet cell density was calculated as the
number of cells per square millimeter. Both eyes were
treated, but only the eye with the lower corneal fluorescein
staining score at initial enrollment was included in the
analysis.
 PRESERVATIVE-FREE EYEDROPS AFTER CATARACT SURGERY IN DRY-EYE SYNDROME 3

Figure 1. Inflammatory cytokines and antiox-

idants for tear quantification of patients with
dry-eye syndrome and cataract.

Tear Sample
To collect tears from the inferior marginal strip, 10 mL pol-
ished micropipettes (Drummond Scientific Co.) were used,
being careful to minimize ocular surface contact. The tear
collection rate was continually monitored. Individual tear
samples were immediately transferred to a sterile polymer-
ase chain reaction tube and immediately stored at 80oC
until they were used for the immunoassay.
Multiplex Bead Analysis
Inflammatory cytokines and antioxidants were analyzed
with a commercial assay system of immunoassay kits and
panels (Millipore Milliplex Human Cytokine/Chemokine
Panel I Premixed 42 Plex [MPXHCYTO60KPMX42] and Milli-
pore Milliplex Human Oxidative Stress Panel Premixed 5 Plex
[H0XSTMAG-18K], Millipore Corp.) using a magnetic bead-
based immunoassay kit (Luminex 200, Luminex Corp.), as
previously described.17 Figure 1 describes the quantified in-
flammatory cytokines and antioxidants. Tear samples were
incubated with antibody-coated capture beads overnight at

4 C.17 Washed beads were further incubated with biotin-
labeled antihuman cytokine antibodies, followed by streptavi-
din–phycoerythrin incubation.17 The standard curves of
known concentrations of recombinant human cytokines/che-
mokines were used to convert fluorescence units to concentra-
tions (pg/mL).17 To calculate molecular concentrations in tear
samples, the median fluorescent intensity data were analyzed
using a 5-parameter logistic or spline curve–fitting method.17
Thirty microliters of tears were needed to run the multiplex
bead analysis. In dry-eye patients, it is impossible to obtain
enough volume of tears from a person to run the multiplex
bead analysis. Therefore, tears from 2 to 3 patients were
used to run 1 sample of the multiplex bead analysis.17
corneal staining score, goblet cell density, and impres-
sion cytology grade at initial evaluation were not signif-
icantly different between the 2 groups (Table 1).
Ocular Surface Disease Index
There was a statistically significant improvement in
the OSDI score in Group 1 compared with the score in
Group 2 at 1 month ( 5.03 G 0.93, 2.32 G 0.85,
respectively; P Z .03) and 2 months ( 7.25 G 1.03,
2.75 G 0.79, respectively; P Z .02) (Figure 2).
Tear-Film Breakup Time
The TBUT was significantly improved in Group 1
compared with Group 2 at 2 months (0.86 G 0.29,
0.25 G 0.09, respectively; P Z .04) (Figure 3).
Schirmer I Test
Schirmer I score was significantly improved in Group
1 compared with Group 2 at 2 months (0.96 G 0.32,
0.21 G 0.10, respectively; P Z .04) (Figure 4).
Fluorescein Staining Score
There was a statistically significant decrease in the
fluorescein staining score in Group 1 compared with
Table 1. Initial characteristics of each group with dry-eye syn-
dromes before cataract surgery.

Statistical Analysis Group 1 Group 2

Characteristic* (PFFM) (PFM)
SPSS software (version 13.0, SPSS, Inc.) was used for sta-
tistical analysis. Pairwise comparisons of treatment group Total patients (Eyes) 40 (40) 40 (40)
categorical variables were performed using the Mann- Age 65.43 G 7.56 68.58 G 8.49
Whitney U test. The Schirmer test, TBUT, and continuous Sex (M:F) 12:28 15:25
variables were analyzed using the unpaired t test. Wilcoxon OSDI score 19.26 G 9.53 19.52 G 7.77
signed rank test was used to compare the within-group cat- Tear-film BUT (sec) 3.84 G 1.50 3.63 G 1.46
egorical variable changes from baseline. The repeated mea-
Schirmer I (mm) 4.36 G 1.11 4.21 G 1.03
sures analysis of variance (ANOVA) was used to compare
within-group continuous variable changes from baseline. Corneal fluorescein staining 1.43 G 0.45 1.52 G 0.54
Repeated measures ANOVA was used to compare the con- score
centrations of inflammatory cytokines and antioxidants Goblet cell density (cell/mm2) 135.26 G 48.25 145.27 G 50.08
before and after treatment. A 2-sided test with a P value of Impression cytology grade 2.48 G 0.51 2.35 G 0.43
less than 0.05 was considered statistically significant.
BUT Z breakup time; OSDI Z Ocular Surface Disease Index;
PFFM Z preservative-free fluorometholone; PFM Z preserved
RESULTS fluorometholone
Mean G standard deviation
Both groups comprised 40 patients (40 eyes). The mean *There was no statistically significant between-group difference in initial
age was 65.43 years G 7.56 (SD) (range 51 to 81 years) in characteristics by unpaired t test (age, tear-film BUT, Schirmer I score,
and goblet cell density) (P O .05) or Mann-Whitney U test (OSDI score,
Group 1 and 68.58 G 8.49 years (range 50 to 82 years) in
impression cytology grade, and corneal staining score) (P O .05).
Group 2. The OSDI score, TBUT, Schirmer I score,

J CATARACT REFRACT SURG - VOL -, - 2015

4 PRESERVATIVE-FREE EYEDROPS AFTER CATARACT SURGERY IN DRY-EYE SYNDROME
Figure 2. Change in the OSDI score from baseline. Mean
value G standard error. The improvement in the OSDI score was sta-
tistically significant in Group 1 compared to Group 2 at 1 and 2 months
(*P ! .05, Mann-Whitney U test) (PFFM Z preservative-free fluoro-
metholone, Group 1; PFM Z preserved fluorometholone, Group 2).
Group 2 at 2 months ( 0.76 G 0.21, 0.25 G 0.13,
respectively; P Z .03) (Figure 5).
Impression Cytology Grade and Goblet Cell Density
At 2 months, the impression cytology grade was
significantly better in Group 1 than in Group 2
( 0.21 G 0.05, 0.09 G 0.03, respectively; P Z .04)
(Figure 6, A). Goblet cell density was significantly better
in Group 1 than in Group 2 (50.26 G 13.41 cells/mm2,
21.53 G 10.82 cells/mm2, respectively; P Z .03)
(Figure 6, B). More goblet cells (red arrows) were
observed in Group 1 than in Group 2 compared with
the initial evaluation (Figure 7).
Figure 4. Change in Schirmer I test score from baseline. Mean
value G standard error. The increase in Schirmer I test score (mm)
was statistically significant in Group 1 compared with Group 2 at
2 months (*P ! .05, unpaired t test) (PFFM Z preservative-free
fluorometholone, Group 1; PFM Z preserved fluorometholone,
Group 2).
J CATARACT REFRACT SURG - VOL -, - 2015
Figure 3. Change in TBUT from baseline. Mean value G standard er-
ror. The increase in tear film TBUT (sec) was statistically significant
in Group 1 compared with Group 2 at 2 months (*P ! .05, unpaired
t test) (PFFM Z preservative-free fluorometholone, Group 1;
PFM Z preserved fluorometholone, Group 2).
Inflammatory Cytokine and Antioxidant
Concentrations in Tears
The changes over time in the inflammatory cytokine
and antioxidant concentrations in tears within each of
the 2 groups is shown in Table 2. The changes over
time between the 2 groups is shown in Figures 8 and 9.
DISCUSSION
After cataract surgery, varying degrees of postsurgical
inflammation of the ocular surface, the anterior cham-
ber, and the posterior chamber should be controlled.10
To manage postoperative inflammation after cataract
Figure 5. Change in corneal fluorescein staining score from baseline.
Mean value G standard error. The decrease in corneal staining score
was statistically significant in Group 1 compared to Group 2 at
2 months (*P ! .05, Mann-Whitney U test) (PFFM Z preservative-
free fluorometholone, Group 1; PFM Z preserved fluorometholone,
Group 2).
 PRESERVATIVE-FREE EYEDROPS AFTER CATARACT SURGERY IN DRY-EYE SYNDROME
surgery, surgeons can use topical nonsteroidal antiin-
flammatory drugs (NSAIDs) or steroid eyedrops.18
The mechanism of NSAID action is inhibition of the cy-
clooxygenase enzymes; topical corticosteroids inhibit
phospholipase A2, resulting in inhibition of prosta-
glandin release.18
The preservatives in the eyedrops limit secondary
bacterial, mycotic, and amoebal ocular infections and
prolong the shelf life of the drug by their antimicrobial
activity.19 However, even at very low doses, benzalko-
nium chloride induces an inflammatory response in
human corneal epithelial cells by increasing inflamma-
tory cytokines such as interleukin-1 (IL-1), tumor
necrosis factor-a (TNF-a), C-reactive protein, IL-10,
and IL-12.20 Preservative-free netilmicin/dexametha-
sone and ketorolac 0.45% eyedrops are reported to
be effective in treating postoperative inflammation
and pain after cataract surgery because the preserva-
tive suppressed the antiinflammatory efficacy.10,11
Preservative-free diclofenac eyedrops also improved
J CATARACT REFRACT SURG - VOL -, - 2015
5
Figure 6. Change in impression cytology
grade and goblet cell density from baseline.
Mean value G standard error. The decrease
in impression cytology grade was statistically
significant in Group 1 compared with Group
2 at 2 months (*P ! .05, Mann-Whitney U
test). The increase in goblet cell density
(cell/mm2) was also statistically significant
in Group 1 compared with Group 2 at
2 months (*P ! .05. unpaired t test)
(PFFM Z preservative-free fluorometholone,
Group 1; PFM Z preserved fluorometholone,
Group 2).
postoperative inflammation, especially in patients
with diabetic retinopathy after cataract surgery.21
Quaternary ammoniums and other preservatives
increase oxidative stress and apoptosis on
conjunctival cells.22 Preservative-free prostaglandin
analog has very low or no prooxidative effects
in vitro compared with preservative-containing
formulations.23
The incidence of dry eye after phacoemulsification is
9.8% according to a recent study.24 The dry-eye syn-
drome often occurs after cataract surgery because the
incision can damage the corneal nerves, resulting in
decreased corneal sensitivity,3 and preservatives in
the postoperative eyedrops can induce ocular surface
inflammation19 and oxidative damage.22 We hypothe-
sized that the combination of preservative-free steroid
and lubricant eyedrops may relieve preexisting dry-
eye syndrome by decreasing the oxidative and inflam-
matory damage to the ocular surface in patients after
cataract surgery.
Figure 7. Clinical pictures of impression
cytology in each group at the initial evalua-
tion and at 2 months. At 2 months, there
was an increase in goblet cell density (red
arrows) in Group 1 compared with the initial
evaluation (original magnification  400, pe-
riodic acid-Schiff hematoxylin stain)
(PFFM Z preservative-free fluorometholone,
Group 1; PFM Z preserved fluorometholone,
Group 2).
6 PRESERVATIVE-FREE EYEDROPS AFTER CATARACT SURGERY IN DRY-EYE SYNDROME

Table 2. Within-group change in inflammatory cytokine and antioxidant concentrations in tears over time.

Parameter Preop 1 Mo 2 Mo

IL-1b (pg/mL)
Group 1 12.20 G 2.32 6.21 G 2.01 5.43 G 1.83
P Z .03 P Z .03
Group 2 10.21 G 1.95 9.53 G 2.01 8.85 G 1.73
NS NS
TNF-a (pg/mL)
Group 1 15.12 G 2.15 9.33 G 1.88 8.53 G 1.72
P Z .02 P Z .02
Group 2 12.45 G 2.39 11.53 G 2.18 10.98 G 2.02
NS NS
Catalase (MFI)
Group 1 8828.67 G 1542.95 13654.25 G 1875.61 14394.57 G 2014.65
P Z .03 P Z .02
Group 2 12154.36 G 1921.85 12082.52 G 2058.39 13471.43 G 2358.64
NS NS
SOD 2 (MFI)
Group 1 13948.28 G 2026.87 28025.67 G 2115.39 35037.58 G 1875.68
P Z .01 P Z .01
Group 2 10284.51 G 1845.29 11358.28 G 1783.82 12676.84 G 2387.54
NS NS

IL-1B Z interleukin-1b; MFI Z mean fluorescence intensity; NS Z not significant; SOD Z superoxide dismutase 2; TNF-a Z tumor necrosis factor-a

Several studies have reported the treatment effect of
preservative-free NSAIDs, steroids, and lubricants af-
ter cataract surgery in patients who did not have dry-
eye syndrome preoperatively.4,10,11,21 In this study, we
compared the treatment with preservative-free and
preserved sodium hyaluronate 0.1% and fluorometho-
lone 0.1% eyedrops after cataract surgery in patients
with preexisting dry-eye syndrome.
The OSDI score was significantly improved in
Group 1 compared with Group 2 even at 1 month
(P Z .03) (Figure 2). The OSDI score, TBUT, Schirmer
I score, fluorescein staining score, impression cytolog-
ical findings, and goblet cell count were significantly
improved in Group 1 compared with Group 2 at
2 months (P ! .05) (Figures 1 to 6). With respect to in-
flammatory cytokines and antioxidants in tears, the
IL-1b and TNF-a concentrations in tears of patients
in Group 1 were significantly decreased and catalase
and superoxide dismutase 2 (SOD2) fluorescence in-
tensities in tears of patients in Group 1 were signifi-
cantly increased compared with those in tears of
patients in Group 2 (P ! .05) (Figures 8 and 9).
Tear function and ocular surface staining are usually
worse after cataract surgery,1 but a lubricant can in-
crease the ocular surface stability even after cataract
surgery. Even normal saline 0.9% increased Schirmer I
test score and TBUT after cataract surgery.25 However,
the cyclosporine 0.05% group showed a significant in-
crease in Schirmer I test score and TBUT compared
with the normal saline 0.9% group after cataract
surgery.25 In our study, TBUT, Schirmer I score, and
fluorescein staining score were also improved in the
preserved eyedrop group because sodium hyaluronate
0.1% might increase the ocular surface stability and
decrease the ocular surface toxicity induced by the pre-
servative, but Schirmer I score and fluorescein staining

Figure 8. Change in concentrations of inflam-

matory cytokines in tears from baseline. Mean
value G standard error. The decrease in con-
centrations of IL-1b (A) and TNF-a (B) in tears
was statistically significant in Group 1
compared with Group 2 at 1 and 2 months.
(*P ! .05, unpaired t test) (PFFM Z preserva-
tive-free fluorometholone, Group 1; PFM Z
preserved fluorometholone, Group 2).

J CATARACT REFRACT SURG - VOL -, - 2015

 PRESERVATIVE-FREE EYEDROPS AFTER CATARACT SURGERY IN DRY-EYE SYNDROME
score were significantly improved in the preservative-
free eyedrop group compared with the preserved eye-
drop group.
Conjunctival goblet cells were decreased after
exposure to the preservative.26 Topical application
of sodium hyaluronate significantly decreased the
ocular surface toxicity induced by the preservative
and increased the goblet cell density.27 We used so-
dium hyaluronate 0.1% in both groups. Treatment
with preservative-free tafluprost was associated
with an increase in conjunctival goblet cell density
in glaucomatous eyes.28 Therefore, the goblet cell
count in the preserved eyedrop group was increased
after surgery because sodium hyaluronate might
decrease the ocular surface toxicity induced by the
preservative, but the goblet cell count was signifi-
cantly improved in Group 1 compared with Group
2 in this study.
Antioxidant content was assessed in minimally
stimulated tears from younger and older patients,29
and inflammatory cytokines were elevated in the tears
of patients with dry-eye disease.17
This study demonstrated that antiinflammatory cy-
tokines were decreased and antioxidants were
increased in the tears of patients with preexisting
dry-eye syndrome after cataract surgery after treat-
ment with preservative-free steroid and lubricant
eyedrops compared with preserved eyedrops. Several
reports have shown that preservative-free eyedrops
decrease ocular surface inflammation and oxidative
damage.10,11,21,23 Therefore, we think the increase in
antioxidants and decrease in the inflammatory
response might be an indirect effect of preservative-
free eyedrops, which improve the ocular surface.
In conclusion, treatment with preservative-free so-
dium hyaluronate 0.1% and fluorometholone 0.1%
eyedrops can improve the OSDI score, TBUT, Schirmer
I score, corneal staining, and impression cytological
findings compared with treatment with preserved
eyedrops in patients with preexisting dry-eye syndrome
after cataract surgery. Preservative-free sodium hyalur-
onate 0.1% and fluorometholone 0.1% eyedrops seem to
be more effective in decreasing the ocular inflammation
and in increasing the antioxidant contents in tears of
J CATARACT REFRACT SURG - VOL -, - 2015
7
Figure 9. Change in fluorescence intensity of
antioxidants in tears from baseline. Mean
value G standard error. The increase in
fluorescence intensity of catalase (A) and
SOD 2 (B) was statistically significant in
Group 1 compared with Group 2 at 1 and
2 months (*P ! .05, unpaired t test)
(MFI Z mean fluorescence intensity;
PFFM Z preservative-free fluorometholone,
Group 1; PFM Z preserved fluorometholone,
Group 2; SOD Z superoxide dismutase 2).
patients with preexisting dry-eye syndrome after cata-
ract surgery. However, a large multicenter trial with a
prolonged follow-up is needed to conclusively deter-
mine the efficacy of preservative-free steroid and lubri-
cant combination eyedrop therapy.
WHAT WAS KNOWN
 Preservative-free steroids and NSAIDs are safe and effec-
tive in controlling postoperative inflammation after cata-
ract surgery.
 The preservative-free lubricant treatment after cataract
surgery reduces the ocular surface inflammation and
dry-eye signs and symptoms in patients with normal
tear function.
WHAT THIS PAPER ADDS
 Preservative-free sodium hyaluronate 0.1% and fluoro-
metholone 0.1% eyedrops can improve dry-eye symp-
toms and signs in patients with preexisting dry-eye
syndrome after cataract surgery.
 Preservative-free sodium hyaluronate 0.1% and fluoro-
metholone 0.1% eyedrops seem to decrease the ocular
inflammation and increase the antioxidant contents in
tears of patients with preexisting dry-eye syndrome after
cataract surgery.
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First author:
Donghyun Jee, MD, PhD
Department of Ophthalmology &
Visual Science the College of Medicine,
The Catholic University of Korea,
Seoul, Korea