ARTICLE

Central corneal thickness changes after phacoemulsification cataract surgery

Sachin M. Salvi, MRCOphth, Terrence K. Soong, MRCOphth, Balakrishna V. Kumar, FRCS Ed, Nicholas R. Hawksworth, FRCOphth

PURPOSE: To evaluate changes occurring in central corneal thickness (CCT) immediately after uneventful cataract surgery. METHODS: Thirteen consecutive patients who had uneventful phacoemulsification surgery by the same experienced surgeon were prospectively evaluated for CCT measurements 1 hour preoperatively and 1 hour, 1 day, and 1 week postoperatively. The unoperated eye also had CCT measurements simultaneously on all occasions and served as a control. All patients provided informed consent. SETTING: Department of Ophthalmology, Royal Glamorgan Hospital, Llantrisant, UK RESULTS: Mean age of the patients was 69 years. Central corneal thickness was 550.34 mm preoperatively, 626.39 mm at 1 hour, 585.80 mm at 1 day, and 553.80 mm at 1 week. In the control group, CCT remained stable, within G2 mm of preoperative readings. CONCLUSIONS: Central corneal thickness increased by approximately 13.81% in the immediate postoperative period (at 1 hour). It remained increased by 6.44% on day 1 compared with preoperative values and gradually reduced to preoperative levels by the 1-week postoperative period (0.57% difference). Intraocular pressure (IOP) measured postoperatively in the first week may be falsely elevated to some extent because of the increased corneal thickness in the immediate postoperative period; thus, not all IOP rises have be treated in this period in healthy uncompromised eyes. J Cataract Refract Surg 2007; 33:14261428 Q 2007 ASCRS and ESCRS

In a recent article, Bolz et al.1 evaluated local corneal thickness changes after small-incision cataract surgery. We present the results in our study of the change in central corneal thickness (CCT) after phacoemulsification cataract surgery and its effect on the postoperative intraocular pressure (IOP).

PATIENTS AND METHODS

Thirteen consecutive patients who had uneventful phacoemulsification surgery by the same experienced surgeon (N.R.H.) (study group) had the CCT measured 1 hour preoperatively and 1 hour, 1 day, and 1 week postoperatively. The unoperated eye also had CCT measurements simultaneously on all occasions and served as a control. All patients provided informed consent. Patients with approximately grade 2 nuclear sclerotic agerelated cataract were included in the study. Patients with corneal pathology, including evidence of endothelial abnormality and glaucoma, and single-eyed patients were excluded. Patients who had an unexpected intraoperative course, including prolonged phacoemulsification time, were also excluded. Precise CCT measurements were performed with the optical low-coherence reflectometerslitlamp pachymeter (Haag-Streit).

Accepted for publication April 10, 2007. From the Departments of Ophthalmology (Salvi, Soong, Kumar), Royal Hallamshire Hospital, Sheffield, and Royal Glamorgan Hospital (Hawksworth), Llantrisant, United Kingdom. No author has a financial or proprietary interest in any material or method mentioned. Presented as a poster at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA, AprilMay 2007. Corresponding author: Mr. Sachin M. Salvi, Department of Ophthalmology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom. E-mail: drsachin@doctors.org.uk.

RESULTS The male:female ratio was 6:7. The mean age of the patients was 69.46 years (range 50 to 86 years). Figure 1 shows the changes in CCT in each patient over time in the study group and control group.
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Q 2007 ASCRS and ESCRS Published by Elsevier Inc.

CCT CHANGES AFTER PHACOEMULSIFICATION

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Mean CCT of operated eye

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Figure 1. Changes in CCT in all the patients over time. Top: Study group (operated eyes). Bottom: Control group (unoperated eyes).

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Figure 2. Mean changes in CCT. Top: Study group (operated eyes). Bottom: Control group (unoperated eyes).

Figure 2 shows the mean changes in CCT over time in the study group and control group. In the study group, the mean preoperative CCT was 550.34 mm (range 521.4 to 584.7 mm). The mean postoperative CCT was 626.39 mm (range 598.1 to 659.5 mm) at 1 hour, 585.82 mm (range 540.4 to 630.3 mm) at 1 day, and 553.49 mm (range 522.4 to 586.6 mm) at 1 week. In the control group, the mean CCT was 547.93 mm (range 515.9 to 585.4 mm) 1 hour before surgery, 546.49 mm (range 515.6 to 585.4 mm) 1 hour postoperatively, 546.3 mm (range 518.4 to 583.1 mm) at 1 day, and 548.33 mm (range 519.8 to 586.6 mm) at 1 week. Thus, the mean postoperative CCT in the control eyes remained within G2 mm of the mean preoperative CCT in these eyes. Compared with preoperatively, there was a mean increase in CCT in the study group of 76.05 mm (13.81% increase) 1 hour postoperatively, 35.48 mm (6.44%) at 1 day, and 3.15 mm (0.57%) at 1 week. DISCUSSION In our study we found the CCT in a healthy, uncompromised cornea increased by approximately 13.81%

in the immediate postoperative period. This decreased to 6.44% on day 1 and gradually to preoperative levels by 1 week postoperatively (0.57% difference). Our findings are similar to those of Bolz et al.,1 and we agree with them that pachymetric changes after phacoemulsification surgery are reversible, almost reaching baseline values 1 week after surgery. Although we measured CCT, we did not evaluate the changes in thickness at other positions on the cornea. As applanation tonometry is done in the central cornea, changes occurring in CCT will alter tonometry readings. An increased CCT will effectively give a false high IOP reading on applanation tonometry. Kohlhaas et al.2 recently showed the association between the IOP reading and CCT, finding an approximately 1 mm Hg correction for every 25 mm deviation from a CCT of 550 mm. Applying this correction factor to our study, we suggest that IOP is overestimated by approximately 3 mm Hg in the immediate postoperative period and by at least 1 mm Hg on the first postoperative day. Studies3,4 have shown that cataract surgery is associated with transient elevated IOP (IOP spikes) in the

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immediate postoperative period. Tranos et al.5 report a 25% incidence of IOP spikes (O30 mm Hg) 4 to 6 hours after uneventful phacoemulsification and intraocular lens implantation. However, 24 hours postoperatively, the incidence of IOP spikes declined significantly, to 10%, and in all cases the IOP was within normal limits (21 mm Hg) 3 weeks later. Ahmed et al.6 report IOP greater than 28 mm Hg in 18% of patients without glaucoma in the early (3 to 7 hours) postoperative period; the IOP decreased to below preoperative levels by 4 days in most cases. These findings correlate with our finding of a reversible increase in the CCT in the immediate postoperative period. Tranos et al.7 recommend not treating postoperative IOP spikes in healthy eyes as there is no compelling evidence to suggest that transient IOP spikes produce significant permanent damage. In conclusion, we believe that changes occur in the CCT in the immediate period after cataract surgery and that the changes are reversible, resolving to near baseline levels within 1 week. The change in the CCT can give a falsely elevated IOP reading during the first postoperative week. This might partially account for the IOP spikes recorded in the first postoperative week. We also believe these IOP spikes need not be treated in patients with healthy nonglaucomatous eyes.

REFERENCES
1. Bolz M, Sacu S, Drexler W, Findl O. Local corneal thickness changes after small-incision cataract surgery. J Cataract Refract Surg 2006; 32:16671671 2. Kohlhass M, Boehm AG, Spoerl E, et al. Effect of central corneal thickness, corneal curvature, and axial length on applanation tonometry. Arch Ophthalmol 2006; 124:471476 3. Podolsky MM, Ritch R. Elevated intraocular pressure in the immediate postoperative period after cataract extraction. Ann Ophthalmol 1981; 13:12391240 4. Galin MA, Lin LL-K, Obstbaum SA. Cataract extraction and intraocular pressure. Trans Ophthalmol Soc UK 1978; 98:124 127 5. Tranos P, Wickremasinghe S, Hildebrand D, et al. Same-day versus first-day review of intraocular pressure after uneventful phacoemulsification. J Cataract Refract Surg 2003; 29:508 512 6. Ahmed IIK, Kranemann C, Chipman M, Malam F. Revisiting early postoperative follow-up after phacoemulsification. J Cataract Refract Surg 2002; 28:100108 7. Tranos P, Bhar G, Little B. Postoperative intraocular pressure spikes: the need to treat. Eye 2004; 18:673679

First author: Sachin M. Salvi, MRCOphth Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, United Kingdom

J CATARACT REFRACT SURG - VOL 33, AUGUST 2007