Hindawi

Journal of Ophthalmology
Volume 2018, Article ID 7218639, 6 pages
https://doi.org/10.1155/2018/7218639

Clinical Study
The Effects of Uncomplicated Cataract Surgery on Retinal
Layer Thickness

Ali Kurt and Raşit Kılıç

Department of Ophthalmology, Faculty of Medicine, Ahi Evran University, Kırşehir, Turkey

Correspondence should be addressed to Ali Kurt; [email protected]

Received 16 January 2018; Accepted 18 April 2018; Published 5 June 2018

Academic Editor: Marcel Menke

Copyright © 2018 Ali Kurt and Raşit Kılıç. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Purpose. Our aim was to assess changes in the total retinal thickness (TRT), total retinal volume (TRV), and retinal layer thickness
after uncomplicated cataract surgery. Methods. A total of 32 eyes of 32 patients who had undergone uncomplicated phaco-
emulsification surgery and intraocular lens implantation in one eye were enrolled. Effective phacoemulsification time (EPT) and
total energy (TE) were recorded. Thickness and TRV were measured using optical coherence tomography. Data were collected
preoperatively and at postoperative day 1, 7, 30, 90, and 180. Results. The study results showed a decrease in TRT, TRV, and most
retinal layer thicknesses at the first postoperative day visit and then increasing at week 1, and months 1 and 3, and then relatively
decreasing at month 6 although not returning to preoperative levels. The least affected layers were the retinal pigment epithelium
and outer plexiform layer. There was a positive correlation between EPT and TE and ganglion cell layer in a 1 mm circle and inner
nuclear layer in a 1–3 mm circle (p < 0.05). Conclusion. The results suggest that long-term follow-up of more than 6 months is
necessary after cataract surgery to see whether total retinal and segmental values return to preoperative levels. This study was
registered with Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000763246.

1. Introduction PCME is most commonly seen 4–6 weeks after surgery

[1–3]. Fundus fluorescein angiography (FFA) reveals capillary
Cataract is the most common preventable cause of vision loss dilatation, leakage from the foveal capillaries, and developing
worldwide. Pseudophakic cystoid macular edema (PCME), petalloid appearance. Optical coherence tomography (OCT)
known as Irvine–Gass syndrome, is one of the most common is a noninvasive device which enables detection of cystic
complications after cataract surgery. It is generally subclinical spaces, retinal thickening, and subretinal fluid. OCT also has
in most cases and rarely causes vision loss. Although the good repeatability and reproducibility when measuring ret-
incidence of clinical PCME has decreased with small incision inal layer thickness at the macula [4]. It is an excellent method
cataract surgery and phacoemulsification (PE), it can still for monitoring disease activity [3].
cause unexpected vision loss [1]. The exact pathophysiology of The current knowledge on the effect of postoperative
PCME is not fully understood but seems to be related to the inflammation on retinal cells and layers is limited. We are
inflammation triggered by surgery. The inflammatory cyto- not aware of any study assessing the retinal segments to
kines and mediators break down the blood-retina barrier and detect the layers that are most affected by cataract surgery
result in increased vascular permeability and cystoid macular with long-term follow-up. The purpose of this study was to
edema [2, 3]. Other factors such as posterior capsule rupture, evaluate the thickness of each retinal segment quantitatively
vitreous loss, retained lens fragments, vitreomacular traction, with spectral domain (SD)-OCT before and after un-
and iris trauma after complicated surgery can also increase the complicated cataract surgery to gain additional information
PCME incidence [1–3]. on PCME.
2 Journal of Ophthalmology

2. Methods
This prospective study was conducted at the Ahi Evran
Training and Research Hospital between December 2016 and
October 2017. The study was approved by the institutional
review board and adhered to the tenets of the Declaration of
Helsinki. Informed consent was obtained from all the pa-
tients. A total of 43 eyes of 43 Caucasian patients who had Figure 1: Borders of automatically segmented retinal layers on
undergone uncomplicated cataract surgery and posterior OCT images. ILM, internal limiting membrane and inner border of
chamber intraocular lens implantation were included. the RNFL layer; RNFL, outer border of the retinal nerve fiber layer;
Eleven patients were excluded due to the lack of follow-up GCL, outer border of the ganglion cell layer; IPL, outer border of
examinations, and the study was finally conducted on the 32 the inner plexiform layer; INL, outer border of the inner nuclear
layer; OPL, outer border of the outer nuclear layer; ELM, external
eyes of 32 patients. The visual acuity was evaluated with
limiting membrane—outer border of the outer nuclear layer; RPE,
a Snellen chart, and a detailed biomicroscopic anterior and retina pigment epithelium; BM, Bruch’s membrane.
posterior segment examination was performed with pupil-
lary dilatation. Air puff tonometry was used to measure the
intraocular pressure. The axial length was measured using 800
optical low-coherence reflectometry (Lenstar LS 900, Haag-
Streit AG, Koeniz, Switzerland). Best corrected visual acuity 700
was 2/20 and higher in all patients preoperatively.
Exclusion criteria consisted of macular pathologies, 600
retinal vascular occlusion, history of any other ocular dis-

Retina thickness (μm)

orders (including uveitis, severe dry eye, eye trauma, 500
glaucoma, and pseudoexfoliation syndrome) or surgery, any
systemic disorders (such as diabetes, hypertension, asthma, 400
or chronic obstructive pulmonary disease), systemic in-
flammation (inflammatory bowel disease and hepatitis B or 300
C), the current use of any topical or systemic medication or
anti-inflammatory agent, and intraoperative complications 200
such as posterior capsular rupture, vitreous loss, iris pro-
lapse, and low scan quality images due to dense cataract. 100
Cataract surgery was performed with the Infiniti PE
device (Alcon Inc., Forth Worth, TX, USA) using a torsional 0
handpiece. The stop and chop technique was used in all
cases. Effective phaco time and phaco energy were recorded. Figure 2: ETDRS grid for 1 mm and 1–3 mm circles on OCT
Postoperatively, all patients were prescribed topical moxi- images. ETDRS grid on macula. C, central 1 mm zone in macula;
S, superior quadrant in 1–3 mm circle on macula; I, inferior quadrant
floxacin and dexamethasone four times a day for three weeks
in 1–3 mm circle on macula; T, temporal quadrant in 1–3 mm circle
and Nevanac three times a day for four weeks. The same on macula; N, nasal quadrant in 1–3 mm circle on macula.
author (AK) performed all surgeries and examinations.

each ETDRS subfield at a central 1 mm circle and 1–3 mm

2.1. OCT Scan Protocol. All subjects underwent pupillary circles that included the superior, temporal, inferior, and nasal
dilatation with 1% tropicamide and 2.5% phenylephrine subfields (Figure 2). The first Spectralis scan was set as
hydrochloride eye drops prior to imaging. We used the SD- a reference image, and the images during future visits were
OCT, Spectralis (Heidelberg Engineering, Heidelberg, Ger- acquired with real-time image registration by follow-up mode
many) device with software version 6.3.3.0 in this study as it by the ophthalmologist. The ETDRS grid was centered on the
has a higher repeatability index [4]. OCT imaging was carried fovea manually if it was not positioned correctly automati-
out using the following parameters: 20° × 15° degrees cally. We also checked the accuracy of retinal layer seg-
(5.9 × 4.4 mm), automatic real-time averaging of 100 frames, mentation in every patient. The 3–6 mm subfields were not
19 horizontal sections at 240 µm intervals, and 512 A-scans included as it exceeded the area of our imaging angle. Data
per B-scan. We only included images with a quality higher were collected preoperatively and on postoperative day 1, 7
than 15 dB in the study. The image acquisition was followed (first week), 30 (first month), 90 (third month), and 180 (sixth
by automatic intraretinal layer segmentation performed by month). The mean thickness of the 1 mm and 1–3 mm rings
the inbuilt Spectralis software to include the retinal nerve fiber was calculated and used for further statistical analysis.
layer (RNFL), ganglion cell layer (GCL), inner plexiform layer
(IPL), inner nuclear layer (INL), outer plexiform layer (OPL),
outer nuclear layer (ONL), retina pigment epithelium (RPE), 2.2. Statistical Analysis. The IBM SPSS version 20.0 (IBM
total retinal volume (TRV), and total retina thickness (TRT) Corporation, Armonk, NY, USA) software was used for
(Figure 1). Intraretinal layer thicknesses were obtained for statistical analyses. Measured data were described as the
Journal of Ophthalmology 3

Table 1: Thickness of macula TRT, TRV, and retinal layers with at the ETDRS circle of 1 and 3 millimeters.
Postoperative Postoperative Postoperative Postoperative Postoperative
Preoperative p
day 1 week 1 month 1 month 3 month 6
1 mm circle 276.63 ± 27.36 272.14 ± 26.12∗ 274.85 ± 26.74 279.81 ± 25.80 280.65 ± 26.82∗ 277.85 ± 26.22 <0.001
TRT
3 mm circle 332.25 ± 14.66 327.27 ± 13.78∗ 332.81 ± 13.99 337.31 ± 13.21∗ 337.95 ± 14.24∗ 337.01 ± 14.59∗ <0.001
1 mm circle 0.2167 ± 0.0215 0.2143 ± 0.0201 0.2167 ± 0.0203 0.2205 ± 0.0201∗ 0.2214 ± 0.0208∗ 0.2186 ± 0.0206 <0.001
TRV
3 mm circle 0.5237 ± 0.0241 0.5170 ± 0.0240∗ 0.5252 ± 0.0231 0.5315 ± 0.0224∗ 0.5332 ± 0.0238∗ 0.5315 ± 0.0246∗ <0.001
1 mm circle 15.15 ± 2.20 14.70 ± 1.72 15.30 ± 1.97 15.25 ± 1.86 15.20 ± 2.14 15.45 ± 2.03 0.453
RPE
3 mm circle 14.26 ± 1.61 13.75 ± 1.81 14.02 ± 1.60 14.40 ± 1.72 14.03 ± 1.94 14.13 ± 1.39 0.042∗∗
1 mm circle 88.32 ± 13.96 86.26 ± 14.29 91.58 ± 10.09 91.05 ± 14.20 92.26 ± 12.55 91.32 ± 13.83 <0.001∗∗∗
ONL
3 mm circle 70.13 ± 7.83 68.86 ± 7.60 71.68 ± 6.74 72.63 ± 7.87 73.85 ± 7.88∗ 73.31 ± 7.58∗ <0.001
1 mm circle 26.26 ± 7.10 26.58 ± 6.00 23.63 ± 4.87 26.05 ± 6.38 25.74 ± 5.07 25.37 ± 6.31 0.144
OPL
3 mm circle 32.11 ± 2.67 31.07 ± 3.07 29.51 ± 2.51∗ 30.20 ± 2.59 30.23 ± 2.86 29.64 ± 2.27∗ 0.001
1 mm circle 24.16 ± 8.20 24.21 ± 9.63 23.42 ± 8.60 24.16 ± 8.40 24.21 ± 8.03 24.26 ± 9.36 0.881
INL
3 mm circle 40.64 ± 3.71 40.27 ± 4.33∗ 41.56 ± 4.10∗ 41.55 ± 4.63∗ 41.94 ± 4.52∗ 42.36 ± 4.73∗ <0.001
1 mm circle 23.37 ± 7.41 22.26 ± 6.40 22.47 ± 7.47 23.26 ± 7.26 23.16 ± 7.82 23.47 ± 7.31 0.055
IPL
3 mm circle 39.94 ± 3.23 39.63 ± 3.05 40.63 ± 3.41 41.05 ± 3.49∗ 41.05 ± 3.51∗ 41.48 ± 3.83∗ <0.001
1 mm circle 18.58 ± 10.65 18.32 ± 10.84 18.95 ± 10.63 19.00 ± 11.23 18.95 ± 10.12 18.63 ± 11.10 0.298
GCL
3 mm circle 47.98 ± 5.42 47.55 ± 5.30 48.93 ± 5.21 49.61 ± 5.26∗ 49.88 ± 5.40∗ 49.65 ± 5.36∗ <0.001
1 mm circle 13.20 ± 2.82 13.35 ± 3.45 13.40 ± 3.53 13.45 ± 3.80 14.05 ± 4.38 13.20 ± 3.31 0.525
NFL
3 mm circle 21.96 ± 1.62 22.13 ± 1.87 22.69 ± 1.66∗ 23.02 ± 1.82∗ 22.96 ± 1.77∗ 22.59 ± 1.50 <0.001
TRT, total retinal thickness; TRV, total retinal volume; RPE, retinal pigment epithelium; ONL, outer nuclear layer; OPL, outer plexiform layer; INL, inner
nuclear layer; IPL, inner plexiform layer; GCL, ganglion cell layer; RNFL, retinal nerve fiber layer. ∗ Difference with preoperative measurement statistically
significant using the Bonferroni correction. ∗∗ The differences between the mean RPE values were significant according to repeated measure results, but the
Bonferroni test did not reveal a significant change. ∗∗∗ The Bonferroni test did not reveal a significant change between the preoperative and postoperative
mean ONL values. However, the decrease in the mean value in the postoperative first day has resulted in a significant difference between the mean first day
value and the mean 3rd month value with Bonferroni correction.

Table 2: The effect of EPT and TE on GCL and INL.

ETDRS circle 1st day 1st week 1st month 3rd month 6th month
EPT versus GCL p � 0.021 r � 0.511 p � 0.039 r � 0.443 p � 0.038 r � 0.467 p � 0.034 r � 0.501 p � 0.076 r � 0.406
1 mm circle
TE versus GCL p � 0.026 r � 0.495 p � 0.047 r � 0.427 p � 0.025 r � 0.499 p � 0.025 r � 0.525 p � 0.078 r � 0.403
EPT versus INL p � 0.027 r � 0.494 p � 0.044 r � 0.433 p � 0.014 r � 0.538 p � 0.084 r � 0.418 p � 0.025 r � 0.500
3 mm circle
TE versus INL p � 0.004 r � 0.614 p � 0.011 r � 0.528 p � 0.003 r � 0.634 p � 0.027 r � 0.520 p � 0.003 r � 0.627
EPT, effective phaco time; GCL, ganglion cell layer; TE, total energy; INL, inner nuclear layer.

arithmetic mean ± standard deviation, whereas categorical preoperative values during the follow-up visits continuing for
data were described as percentages (%). Normal distribution 6 months (p < 0.05). The study results showed a remarkable
of measured data was examined by the Kolmogorov–Smirnov decrease in TRT, TRV, and the thickness of most retinal layers
test. The one-way ANOVA test was used for intergroup at the first day visit after surgery. However, an increase was
comparison variables for repeated measures. The Bonferroni then observed in all parameters and reached approximately the
method was used to correct the p value. The relationship preoperative values at the first week visit. The thickest TRTand
between EPT and TE and all thickness parameters were an- retinal layer thickness values were observed at the first and
alyzed with the Pearson correlation analysis. A statistical level third month visits. A slight decrease, not reaching the pre-
of significance was accepted at p < 0.05. operative levels, was then seen in almost all parameters at the
sixth month visit. We also noticed that the least affected layers
3. Results were the RPE and OPL. The results are presented in Table 1.
The mean effective phacoemulsification time and total
The mean age of the patients consisting of 25 (78%) males and energy were 62.46 ± 45.03 seconds and 6.41 ± 7.34, respectively.
7 (22%) females was 63.81 ± 9.0 years (range: 48–79 years). There was a positive correlation between EPT and TE and GCL
There were 20 right and 12 left eyes. The mean preoperative in the 1 mm circle and INL in the 1–3 mm circle (p < 0.05 and
axial length was 23.62 ± 0.9 mm (range: 21.3–25.2 mm). The Table 2). There was no significant correlation between EPT and
cataract type was nuclear sclerosis in 16 (50%) cases, posterior TE and other retinal layers, TRT and TRV (p > 0.05).
subcapsular in 12 (37.5%) cases, cortical in 3 (9.4%) cases, and
cortical + posterior subcapsular in one (3.1%) case. 4. Discussion
We found statistically significant differences in TRT and
TRV in the 1 mm circle and TRT, TRV, ONL, OPL, INL, IPL The main triggering factor of PCME is thought to be surgical
GCL, and NFL in the 1–3 mm circle compared to the trauma of intraocular tissues by inducing the release of
4 Journal of Ophthalmology

inflammatory mediators although other possible mechanisms macular thickness increase at 12 weeks in 62 eyes with
such as photic retinopathy or vitreous traction have also been a follow-up period of 28 weeks. These results are all similar to
implicated [5]. Inflammatory mediators (prostaglandins, ours. Gołebiewska et al. [17] reported increased retinal
cytokines, and other vascular permeability factors) are known thickness and retinal volume during follow-up continuing
to be released from the anterior segment of the eye after for 6 months after uncomplicated cataract surgery. We
surgery and then diffuse into the vitreous cavity and retina, observed increased retinal volume after surgery, like others.
stimulating the breakdown of the blood-retinal barrier (BRB) Measuring each retinal layer separately makes it easier to
and subsequent leakage of fluids across the retinal vessel wall see alteration in retinal structures than the TRT. It is unclear
and into the perifoveal retinal tissues, resulting in macular which retinal layer(s) has the most effect on increasing the
edema [3]. This edema usually resolves spontaneously and retinal thickness. We found an increase in the thickness of
only about 1–3% of cases persist, corresponding to clinical NFL, GCL, IPL, INL, and ONL and a decrease in OPL, but
PCME with persistent symptoms [6]. Although FFA used to these changes were only significant in the 1–3 mm circle at the
be considered the diagnostic gold standard for PCME, OCT is postoperative sixth month follow-up when compared to the
now the method of choice, being a noninvasive technique for preoperative measurements. RPE thicknesses were generally
PCME evaluation and follow-up [3]. stable except for the first visit, but this first-visit change was
Optical coherence tomography is a useful device to not significant. We found increased GCL thickness in the
detect intraretinal cysts that indicate clinical PCME and can 1 mm circle and INL thickness in the 1–3 mm circle with
decrease vision noninvasively after cataract surgery [3]. more TE and EPT. Another study reported a statistically
Assessing the retinal layers in vivo may provide more in- significant relationship between increased retinal thickness
formation to elucidate the pathologic processes involved in and higher perioperative phaco power [17]. However, there is
subclinical PCME. We therefore evaluated retinal layers by no study comparing postoperative retinal layer thickness with
OCT after uncomplicated cataract surgery and presented TE and EPT values.
long-term follow-up results on TRT, TRV, and retinal layer The INL includes the nuclei of the bipolar, horizontal,
thickness according to the ETDRS grid. We noticed that the amacrine, and Muller cells. The deep capillary plexus is also
RPE and OPL were the least affected layers. In general, we in this layer. Park et al. [18] have shown that the vascular
observed a decrease in TRT, TRV, and most retinal layers at endothelial growth factor (VEGF) has a crucial role in the
the first postoperative day visit. An increase was then seen in vitality of the amacrine and bipolar cells. Sigler et al. [19]
all thickness parameters and reached approximately the have reported cystic changes in the INL and ONL in patients
preoperative levels at the first week visit. The largest TRT and with clinical PCME. We did not find clinical PCME and
retinal layer thickness values were observed at the first and therefore did not observe cystic changes in any of our pa-
third month visits. At the sixth month visit, a slight decrease tients; an increased thickness of the INL may be related to
was seen in almost all parameters. However, this decrease the inflammatory effects of VEGF, which is an inflammatory
did not reach preoperative thickness levels. There was mediator [20]. INL thickness was also increased in relation
a significant thickness increase in all retinal layers except to optic neuritis, which is an inflammatory disease, in an-
RPE and OPL in the 1–3 mm circle. other study [21]. In the neurology literature, the use of INL
Grewing and Becker measured the retinal thickness as a parameter to monitor the efficacy of anti-inflammatory
before and 0.5 hours after cataract surgery in 10 patients and treatments in multiple sclerosis has been proposed [22]. The
reported a decrease that was not statistically significant [7]. superficial capillary plexus is located in the NFL, and its
We noticed a decrease in TRT, TRV, and the thickness of hyperpermability may have been responsible for the sig-
most retinal layers after the first postoperative day. Perente nificantly increased thickness of the NFL and GCL in our
et al. [8] also reported a mild postoperative retinal thickness study.
that was not statistically significant. According to the au- Nepafenac (Alcon Research Ltd., Fort Worth, TX, USA),
thors, the decrease observed in the first postoperative day a topical ocular nonsteroidal anti-inflammatory drug
may be related to the previous light-scattering effect of the (NSAID) used to treat the pain and inflammation associated
cataract that was possibly disrupting the optical quality of with cataract surgery, is available as an ophthalmic sus-
the OCT imaging [8]. However, there is not enough evidence pension in concentrations of 0.1% and 0.3% [23]. Unlike
or information in the literature to fully explain the cause. other NSAIDs, nepafenac is a prodrug that is deaminated to
Šiško et al. [9] reported highest retinal thickness in the its active metabolite (amfenac) in the ocular tissues. It is
ETDRS grid areas one month after uncomplicated cataract a potent inhibitor of the cyclooxygenase (COX) isoforms
surgery. They also stated mild decreasing trend in the COX-1 and COX-2 and is distributed rapidly in both the
measurements from the first month to the sixth month, anterior and posterior segments of the eye. It is well known
without reaching preoperative levels. Most studies have that the retinal thickness increase is significantly lower in
reported an increase in macular thickness after un- patients administered an NSAID after cataract surgery [23, 24].
complicated cataract surgery [8, 10–16]. Gharbiya et al. [10] It may therefore be better to avoid NSAID use when evaluating
reported a significant macular thickness increase for up to retinal layer thickness after cataract surgery.
six postoperative months in 40 healthy patients. Falcão et al. Our study has a few limitations. First, the sample size
[11] also found increased central macular thickness post- could be larger. Second, the retinal thickness values con-
operatively and reported this as a nonpathological change. tinued to show a slight decrease at the sixth month visit, and
Cagini et al. [12] found an asymptomatic postoperative the follow-up should therefore be longer than 6 months.
Journal of Ophthalmology 5

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Disclosure
after uneventful cataract surgery determined by optical co-
The authors declare that the manuscript has not been herence tomography,” Graefe’s Archive for Clinical and Ex-
published previously nor under consideration for publica- perimental Ophthalmology, vol. 245, no. 12, pp. 1765–1771,
2007.
tion elsewhere, in whole or in part.
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Conflicts of Interest cation and IOL implantation,” Eye, vol. 22, no. 1, pp. 8–12,
2008.
The authors declare that they have no conflicts of interest. [16] T. Kusbeci, L. Eryigit, G. Yavas, and U. U. Inan, “Evaluation of
cystoid macular edema using optical coherence tomography
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