ORIGINAL ARTICLE ASIAN JOURNAL OF MEDICAL SCIENCES

Changes in central macular thickness before

and after cataract surgery evaluated by optical
coherence tomography in non-diabetic patient
Nilesh J Paraskar1, Vipul K Prajapati2, Jigna R Patel3, Sipra S Engineer4, Farhad Mansuri5
Senior Resident, 2Assistant Professor, 4Resident Doctor, Department of Ophthalmology, M and J Regional
1,5

Institute of Ophthalmology, B J Medical College and Civil Hospital, Ahmedabad, 3Assistant Professor, Department of
Ophthalmology, Surat Municipal Institute of Medical Education and Research, Surat, Gujarat, India

Submission: 31-01-2023 Revision: 28-05-2023 Publication: 01-07-2023

ABSTRACT
Background: Optical coherence tomography (OCT) has been useful for objectively observing Access this article online
central macular thickness (CMT) changes inpre-operative and post-operative uneventful
Website:
cataract surgery. Aims and Objectives: This study was done to compare changes in CMT in
http://nepjol.info/index.php/AJMS
small incision cataract surgery (SICS) and phacoemulsification surgery and to illuminate the
OCT features of CMT after uneventful cataract surgery. Materials and Methods: A prospective DOI: 10.3126/ajms.v14i7.51980
observational study was done at the tertiary eye care center from December 2019 to E-ISSN: 2091-0576
P-ISSN: 2467-9100
November 2020, a total of 60 patients underwent SICS and Phacoemulsification cataract
surgery, were followed and examined postoperatively at day 1, 1 week, 1 month, and
6 months for whole ocular examination and OCT. Results: Comparison analysis was performed Copyright (c) 2023 Asian Journal of
using Friedman’s analysis of variance test.In SICS and Phacoemulsification group, statistical Medical Sciences
analysis differences between the mean CMT at pre-operative, post-operative 1 week,
1 month, and 6 months were found statistically significant (P > 0.001), subclinical macular
edema (increase CMT without affecting visual acuity) was noted at 1 week and 1 month
reviews. Conclusion: The changes in CMT after cataract surgery are reversible, since the
maximum measured increase in macular thickness at 1 month after surgery then gradually
decreased at 6 months follow-up. This increase remained subclinical, and no evidence of This work is licensed under a Creative
clinical cystoid macular edema was seen on OCT. Commons Attribution-NonCommercial
4.0 International License.
Key words: Optical coherence tomography; Central macular thickness; Cataract; Cystoid
macular edema

INTRODUCTION Gass and Norto in 1966, so it is known as Irvine Gass

syndrome (pseudophakic cystoid macula edema).5-7 Post-
Cataract extraction is one of the most commonly operative CME is recognized as the most common cause
performed ophthalmic surgeries. Recent evolutions in of the diminution of vision in patients following cataract
instrumentation, lens design, and surgical technique surgery with or without the implantation of an intraocular
have enhanced the outcome of cataract surgery.1 An lens (IOL).8 This syndrome is accountable for a greater
efficient procedure and uneventful cataract surgery are and frequent loss of vision than the more commonly
associated with good visual results.2 The development discussed post-operative complications, including retinal
of cystoid macular edema (CME) can lead to suboptimal detachment and endophthalmitis.8 Incidence of clinical
post-operative diminution of vision.3 This can occur in CME with visual loss has been reported to be between
patients with ocular diseases, such as uveitis and diabetic 1% and 6% after cataract surgery.9 It is due to the release
retinopathy, and even after uncomplicated cataract surgery.4 of inflammatory mediators that affect the blood-retinal
CME following cataract surgery was initially reported barrier that leads to results in increased permeability
by Irvine in 1953 and demonstrated angiographically by of the parafoveal and perifoveal capillaries with fluid

Address for Correspondence:

Dr. Nilesh J Paraskar, Senior Resident, Department of Ophthalmology, M and J Regional Institute of Ophthalmology, B J Medical College
and Civil Hospital, Ahmedabad, Gujarat, India. Mobile: +91-9974744846. E-mail: njparaskar@gmail.com

138 Asian Journal of Medical Sciences | Jul 2023 | Vol 14 | Issue 7

 Paraskar, et al.: Changes in CMT before and after cataract Surgery evaluated by OCT in non-diabetic patient

accumulation in the retina that leads to CME.10 The tropicamide and 5%phenylephrine hydrochloride before
CME can be detected by clinically, angiographically, recording the image. During OCT examinations, six
and optical coherence tomography (OCT). OCT is an radial-line scans, 6.00 mm each in length and raster scan
objective, noninvasive, comfortable, noncontact method with the length of 5 mm in the horizontal and vertical
for quantitative measurements, with a high degree of axis, centered on the foveola, were performed and a
reproducibility and repeatability, and with 10 mm resolution topographical map of the macula was produced and
that helps to detect subtle changes in retinal thickness that CMT was measured.
cannot be seen at clinical examination.11 OCT is the most
sensitive way to detect CME, followed by angiography and Surgical steps
then clinical examination. All the patients were randomly divided into two groups and
operated by the same surgeon using a standard technique.
Aims and objectives In phacoemulsification, 2.8 to 3.2 mm clear corneal
1. To compare changes in central macular thickness incision, anterior capsulorrhexis, nuclear fragmentation
(CMT) in small incision cataract surgery (SICS) and using low to high ultrasound power and implantation of
phacoemulsification surgery
foldable acrylic hydrophobic IOL in the bag. In SICS,
2. To illuminate the OCT features of CMT after
5.5 to 6.5 mm superior sclerocorneal tunnel, anterior
uneventful cataract surgery.
capsulorrhexis, the nucleus was delivered out of the
anterior chamber. A 6.0 mm non-foldable polymethyl
MATERIALS AND METHODS methacrylate single-piece rigid IOL was implanted in the
bag at the end of surgery. The post-operative regimen
A prospective and observational study was done at the included moxifloxacine (0.5%) and dexamethasone (0.1%)
tertiary eye care center from December 2019 to November eye drops 6 times a day for the 1st week, followed by a
2020, with prior approval from the institutional ethics tapering dose of it for weekly over 6 weeks. All patients
committee. There were a total of 60 patients included in were followed and examined postoperatively at day 1, week,
the study after taking an informed and written consent. 1 month, and 6 months for BCVA, slit-lamp examination
of the anterior segment and retinal biomicroscopy using
Inclusion criteria
Senile immature cataract underwent uneventful cataract +90D, +20D, and OCT.
surgery without any retinal, macular and other ocular
pathology. RESULTS
Exclusion criteria This study was conducted at a tertiary eye care center
Mature cataract, traumatic cataract, complicated cataract, from December 2019 to November 2020. Based on the
amblyopia, and squint. Intraoperative surgical complications defined inclusion and exclusion criteria, 60 individuals
such as vitreous loss, iris trauma, and posterior capsule were enrolled in the study. The age of the patients ranged
rupture. Systemic diseases such as diabetes, hypertension, from 35 to 75 years (mean age 59.63±8.256 years). Of
or cardiovascular disease. Patients using topical medication these, 31 (51% of the total) underwent SICS, 29 (49% of
such as prostaglandins, pilocarpine, steroid, or systemic
the total) underwent phacoemulsification. The mean age
steroid.
of SICS group was 58.71±9.648 (95% C.I.=45–75) years
Study technique and phacoemulsification group was 60.39±6.477 (95%
A detailed history and ocular examination was made C.I.=35–74) years. In our study out of the total 60 patients,
in all patients, which included pre- and post-operative 28 (46%) patients were male and 32 patients (54%) were
visual acuity, which was recorded with the Snellen visual female. In SICS group, 12 (20%) were male and 19 (32%)
acuity chart and converted into LogMAR visual acuity, were female, while in Phacoemulsification group, 16 (26%)
slit-lamp biomicroscopy of the anterior segment, and were male and 13 (54%) female.
retinal biomicroscopy using +90D, +20D and OCT. The
macular status of each eye was evaluated by Spectral The mean pre-operative BCVA was 0.59±0.25 (95%
Domain OCT (Topcon 3 DOCT–2000). All patients C.I.=0.50–0.68) in Phacoemulsification and 0.67±0.32 (95%
were followed and examined postoperatively at day 1, C.I.=0.55–0.79) in SICS; this difference was statistically
week, 1 month, and 6 months for best-corrected visual significant (P<0.001). The mean post- operative BCVA was
acuity (BCVA), tonometry, slit-lamp biomicroscopy of 0.05±0.10 (95% C.I.= 0.01-0.09) in phacoemulsification
the anterior segment, and retinal biomicroscopy using and 0.06±0.11 (95% C.I.=0.02-0.10) in SICS, this difference
+90D,+20D and OCT. Each eye was dilated with 1% was not statistically significant.

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 Paraskar, et al.: Changes in CMT before and after cataract Surgery evaluated by OCT in non-diabetic patient

CMT
The 60 patients who underwent cataract surgery, mean
preoperatively CMT was 255.30±15.757 µ (95% C.I.=251.313–
259.287 µ). Postoperatively, at the 1st week, the mean CMT
was 262.50±17.083 µ (95% C.I.=258.17–266.823 µ); at the
1-month review, the mean CMT was 265.15±17.219 µ (95%
C.I.=260.793–269.507 µ); at the 6 months review, the mean
CMT was 255.50±15.655 µ (95% C.I.=251.53–259.461 µ);
Statistical analysis of the differences between the four mean
values of pre-operative, post-operative 1 week, 1 month, and
6 months) was done using Freidman’s analysis of variance Figure 1: Pre- and post-operative mean central macular thickness (µ)
(ANOVA) test, the differences were found to be statistically in 31 patients underwent small incision cataract surgery
significant (P<0.001). In the 60 patients who underwent
cataract surgery, subclinical macular edema was noted at the
1st week and 1 month reviews; the peak subclinical macular
edema was noted at the 1 month review. However, at the
6 months review, the CMT had reduced the baseline (pre-
operative values).

In SICS g roup, preoperatively, the mean CMT

was 253.81±18.48 µ (95% C.I.=247.03–260.59 µ).
Postoperatively, the following readings were noted: at
the 1st week, the mean CMT was 261.71±19.104 µ (95%
Figure 2: Pre and post operative mean central macular thickness (µ)
C.I.=254.77–268.78 µ); at 1-month review, the mean CMT in 29 patients underwent phacoemulsification surgery
was 265.61±18.72 µ (95% C.I.=258.74–272.48 µ); at the
6 months review, mean CMT was 254.55±18.01 µ (95%
C.I.=247.99–261.16 µ); statistical analysis differences
between the four mean values of CMT Pre-operative,
Postoperative 1 week, 1 month and 6 months and was done
using Friedman’s ANOVA test; the differences were found
statistically significant (P<0.001). In SICS group, subclinical
macular edema was noted at the 1st week and 1 month
reviews without visual acuity being affected (Figure 1).

In phacoemulsification group, preoperatively, the mean CMT Figure 3: Comparison of pre and post-operative mean central macular
value was 256.90±12.32 µ (95% C.I.=252.21–261.58 µ). thickness (µ) in patients underwent small incision cataract surgery and
Postoperatively, the following readings were noted: At the Phacoemulsification surgeries
1st-week review, the mean CMT was 263.28±14.921 µ (95%
C.I.=257.60–268.95 µ); At the1 month review, the mean CMT DISCUSSION
was 264.66±15.767 µ (95% C.I.=258.66–270.65 µ); at the
6 months review the mean CMT was 256.52±12.911 µ (95% OCT is a method for high-resolution cross-sectional
C.I.=251.61–261.43 µ); statistical analysis differences between imaging of the retina that directly measures changes
the four mean values of CMT Pre-operative, Post-operative in the z-plane (depth of the retina). 11-13 There were
1 week, 1 month, and 6 months was made using Friedman’s total 60 patients divided into two group SICS and
ANOVA test; the differences were found to be statistically Phacoemulsification. The mean age of patients in this
significant (P<0.001) In Phacoemulsification group, there study was 58.71±9.64 in SICS group and 60.39±6.4 in the
was a significant subclinical change in the macula, subclinical phacoemulsification group and this is similar to Ghosh
macular edema at the 1st week and 1 month follow-up without, et al.,14 Where the mean age of patients was 62±6 in and
the visual acuity being affected (Figure 2). 61±6 in SICS and Phacoemulsification group, respectively
and is less compared to findings Biroetal15 where average
When both the group SICS and phacoemulsification was 68.8±8.8 years. In the present study, female patients
cataract surgeries were compared, a subclinical macular (54%) were more than males (46%) in contrast to Perente
edema was noted up to the 1 month review (Figure 3). CME et al.,16 and Agarwal et al.,17 where male patients were
was not noted in any of the patients in the current study. frequently seen.

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 Paraskar, et al.: Changes in CMT before and after cataract Surgery evaluated by OCT in non-diabetic patient

In the present study, we compared pre-operative and post- are required to confirm the initial results of the present
operative CMT in OCT scans at 1 week, 1 months and investigation. In these future studies, a larger number of
6 months, similar to Perente et al.,16 and Vukicevic et al.,18 patients should be enrolled, and the study period should
We had taken pre-operative CMT value as a control group be extended.
increases the accuracy of our study as it overcomes the
variability present in the normal population. In contrast
to Ghosh et al.,14 Biro et al.,15 have taken the first post-
CONCLUSION
operative day as the baseline value. While in another study
OCT is rapid, non-invasive and beneficial in detecting
done by Vonjagowetal19 found that retina thickness was
and monitoring CME in post-cataract surgery patients.
significantly increased on the first post-operative day may
There is an increase in CMT with respect to pre-operative
due to surgery-induced inflammation, so in the present
values after uncomplicated cataract surgery on OCT. The
study, we have considered pre-operative OCT scan as the
changes in CMT after cataract surgery are reversible since
baseline value.
the maximum measured increase in macular thickness
In this study, CMT continued to increase on the first at 1 month after surgery. The measured values of CMT
post-operative week in SICS and in phacoemulsification then gradually decreased over the 6-month follow-up.
group, with a significance P<0.001. At the 1 month of The Subclinical macular edema after uncomplicated
post-operative CMT in SICS and in phacoemulsification cataract surgery from 1 week after surgery and can last
group at the 1-month review, the CMT was a significance up to 1 month. This increase remained subclinical and no
P<0.001 and returned to Pre-operative value in SICS and evidence of clinical CME was seen on OCT. There was no
phacoemulsification group, at the 6 month review. The effect of increased macular thickness found on the final
present study is supported by Ghosh et al.,14 Cagini et al.,20 visual outcome with any of the surgeries. Hence, both the
and Vukicevic et al.18 SICS and phacoemulsification surgeries are comparable
to each other.
The study done by Lobo et al.,21 showed increase in
macular thickness maximum at post-op 6 week, which ACKNOWLEDGMENT
was conducted only in 32 patients; post-op examination
was done at 3, 6, 12 and 30 week by OCT, while present We would like to acknowledge the department of
study conducted in 60 patients and OCT was done at Pre- ophthalmology of B.J. medical college Ahmedabad, and
op, 1 week, 1 month and 6 months post-op examination. all the patients and staff included in this study.
They noted at 30 weeks, all eyes had good visual acuity,
but 7 (22%) eyes still had macular edema while in our
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Authors’ Contributions:
NJP- Literature survey, prepared first draft of manuscript, data collection, data analysis, manuscript preparation and submission of article; VKP- Concept,
design, clinical protocol, manuscript preparation, editing and manuscript revision; JRP- Design of study, statistical analysis, interpretation, manuscript
preparation and editing; SSE- Review manuscript, literature survey; FM- Preparation of figures, coordination and manuscript revision.

Work Attributed to
M and J Regional Institute of Ophthalmology, B J Medical College and Civil Hospital, Ahmedabad, Gujarat, India.

Orcid ID:
Nilesh J Paraskar - https://orcid.org/0009-0001-2601-2902
Vipul K Prajapati - https://orcid.org/0009-0008-6141-1301
Jigna R Patel - https://orcid.org/0009-0003-3628-8261
Sipra S Engineer - https://orcid.org/0009-0005-6526-6939

Source of Support: Nil, Conflict of Interest: None declared.

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