The Effects of Povidone-Iodine and Chlorhexidine Gluconate on the Ocular Surface in Phacoemulsification

The Effects of Povidone-Iodine and Chlorhexidine Gluconate on the Ocular Surface in Phacoemulsification | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effects of Povidone-Iodine and Chlorhexidine Gluconate on the Ocular Surface in Phacoemulsification Osman Parca, Ugur Yılmaz, Tunahan Akyol This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7716182/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Nov, 2025 Read the published version in International Ophthalmology → Version 1 posted 12 You are reading this latest preprint version Abstract Purpose: To compare the effects of 5% povidone-iodine (PI) and 0.1% chlorhexidine gluconate (CHG) on ocular surface parameters and patient comfort following phacoemulsification cataract surgery. The study aimed to determine whether CHG offers advantages over PI in terms of ocular surface recovery and postoperative comfort. Methods: This prospective, randomized controlled trial included 61 patients undergoing phacoemulsification for senile cataract. Participants were randomly assigned to conjunctival irrigation with either 5% PI or 0.1% CHG for 3 minutes before surgery. Ocular surface assessments included Schirmer test, tear break-up time (TBUT), tear meniscus height (TMH), and the Ocular Surface Disease Index (OSDI). Evaluations were performed preoperatively and postoperatively at Week 1, Month 1, and Month 3. Pain scores were recorded using a numerical rating scale within the first 24 hours. Results: Baseline parameters were comparable between groups. At Week 1, OSDI scores were significantly higher in the PI group than in the CHG group (p = 0.029). Both groups showed significant early postoperative deterioration of ocular surface parameters, but recovery was faster in the CHG group. TBUT remained significantly reduced in the PI group at Month 3, whereas CHG eyes normalized. Schirmer values returned to baseline by Month 1 in both groups. Postoperative pain scores were significantly higher in the PI group (p < 0.001). Conclusion: Both PI and CHG caused transient ocular surface changes after cataract surgery. However, CHG demonstrated faster recovery of tear film parameters and improved early postoperative comfort, suggesting it may be a preferable antiseptic in patients with ocular surface sensitivity. WHAT WAS KNOWN Povidone-iodine (PI) is considered the gold standard for preoperative antisepsis in cataract surgery but is associated with ocular surface toxicity and postoperative discomfort. Chlorhexidine gluconate (CHG) is an alternative with comparable antimicrobial efficacy, yet limited data exist regarding its long-term impact on ocular surface integrity. In addition to surgical trauma, the choice of antiseptic may significantly influence the development of dry eye symptoms after cataract surgery. WHAT THIS PAPER ADDS This randomized controlled trial is the first to compare the effects of PI and CHG on ocular surface parameters following phacoemulsification cataract surgery. Both groups exhibited transient postoperative ocular surface deterioration; however, the CHG group showed faster recovery and significantly lower pain scores within the first 24 hours. The lower ocular surface toxicity and improved early postoperative comfort associated with CHG suggest that it may be a preferable antiseptic agent in patients with ocular surface sensitivity. INTRODUCTION Cataract surgery is among the most commonly performed procedures worldwide, primarily due to an aging global population and continuous improvements in surgical techniques. As with many surgical interventions, preoperative antisepsis in cataract surgery plays a critical role in preventing postoperative endophthalmitis. In this context, 5% povidone–iodine (PI) is universally accepted as the standard recommended antiseptic owing to its broad-spectrum antimicrobial efficacy and proven ability to reduce rates of postoperative endophthalmitis. 1 However, chlorhexidine gluconate (CHG) has emerged as a safe and effective alternative—particularly in patients with a history of PI allergy—and is widely used. 2 Comparative studies involving large patient cohorts undergoing cataract surgery and intravitreal injections have demonstrated that PI and CHG exhibit similar antimicrobial effectiveness and safety profiles. 2 , 3 In addition to antimicrobial efficacy, the ocular surface toxicity of antiseptics and their association with postoperative dry eye syndrome (DES) warrant careful evaluation. Postoperative DES is a multifactorial condition influenced by corneal incisions, mechanical trauma, prolonged exposure to microscope illumination, cumulative phacoemulsification energy, and postoperative topical medications. 4 , 5 Although PI is an effective antiseptic, it can disrupt the tear film and induce damage to both the corneal epithelium and endothelium. 2 In contrast, data on the effects of CHG on ocular surface integrity and its long-term relationship with DES are limited, highlighting a significant gap in perioperative safety assessments. The aim of this study was to compare the ocular surface toxicity, long-term impact on DES, and patient comfort associated with 5% PI versus 0.1% CHG—while accounting for other intraoperative risk factors (phacoemulsification energy, surgical duration, exposure to irrigation solutions, etc.)—in patients undergoing phacoemulsification cataract surgery. METHODS This prospective, randomized controlled study was conducted between May 2021 and January 2023 following approval by the Pamukkale University Ethics Committee (April 13, 2021; No. 08). The study was conducted in accordance with the principles of the Declaration of Helsinki, and written informed consent was obtained from all participants. Participant Selection and Exclusion Criteria Patients scheduled for phacoemulsification due to senile cataract were enrolled. A detailed medical history was taken, and comprehensive ophthalmic examination was performed. Patients with chronic use of topical ocular medications, history of prior ocular surgery, eyelid pathologies, contact lens wear, allergic or chronic conjunctivitis, and exposure keratopathy were excluded. Patients with systemic diseases contributing to dry eye (thyroid dysfunction, lupus, rheumatoid arthritis, scleroderma, Sjögren’s syndrome, vitamin A deficiency) and inability to comply with follow-up visits were also excluded. Preoperative Evaluation All patients underwent measurement of best-corrected visual acuity (BCVA) using the Snellen chart, intraocular pressure (IOP) by Goldmann applanation tonometry, and detailed anterior and posterior segment examinations using a slit-lamp biomicroscope. Cataract type and nuclear sclerosis grade were assessed according to the Lens Opacities Classification System III (LOCS III). 6 The following tests were performed to evaluate the ocular surface parameters: 1. Schirmer Test: Without topical anesthesia, a Schirmer strip (Chauvin Laboratory, France) was placed in the lateral one-third of the lower fornix. After 5 min, the length of wetting (mm) was recorded. 7,8 2. Tear Break-Up Time (TBUT): A fluorescein strip (Haag-Streit AG, Switzerland) was applied to the lower fornix. After 1 min, the interval between the last blink and the appearance of the first dry spot on the cornea was measured in seconds under cobalt-blue illumination. 7,8 3. Tear Meniscus Height (TMH): The vertical height (mm) of the tear meniscus at the junction of the tear film with the corneal surface and eyelid margin was measured. 7,8 4. Ocular Surface Disease Index (OSDI): A 12-item questionnaire assessing dry eye symptoms over the previous two weeks and their impact on daily activities was administered. 9 All measurements were repeated three times at 10-min intervals in a standardized environment between 09:00 and 12:00, and the mean of the three recordings was used in analyses. Surgical Protocol and Randomization All surgeries were performed by a single surgeon in the same operating room using a Leica F40 operating microscope (Leica Microsystems, Heerbrugg, Switzerland) and an Alcon Centurion phacoemulsification system (Alcon Surgical, Fort Worth, TX, USA). A standardized preoperative and postoperative protocol was used for all participants. For preanesthesia , both groups received 0.5% proparacaine hydrochloride drops (Alcaine ® , Alcon) instilled three times at 5-min intervals. A 2.2-mm 90° superior incision was made via the clear corneal incision technique . Postoperative medications were prescribed as follows: topical moxifloxacin 0.5% (Vigamox®, Alcon) four times daily for four weeks; dexamethasone 0.1% (Maxidex®, Alcon) six times daily during week 1, four times daily during week 2, and twice daily during weeks 3–4; and nepafenac 0.1% (Nevanac®, Alcon) three times daily for four weeks . Patients were randomly divided into two groups in a 1:1 ratio using Research Randomizer software. The PI group consisted of patients who received conjunctival irrigation with 5% PI for 3 minutes, while the CHG group consisted of patients who received conjunctival irrigation with 0.1% CHG for 3 minutes. 10 Intraoperative parameters—including microscope light exposure time, cumulative dissipated energy (CDE), and total ultrasound (U/S) time—were recorded for each case. Postoperative Evaluation Pain levels were assessed twice: during the intraoperative period, which spans the entire duration of the surgery, and in the early postoperative period to quantify the maximum pain intensity reported within the first 24 hours following surgery. Both assessments were made using a Numerical Rating Scale (NRS) ranging between 0 and 10. 11 On this scale, 0 represents “no pain” and 10 represents “the most severe pain imaginable”. At postoperative Week 1, Month 1, and Month 3, Schirmer test, TBUT, and TMH measurements were repeated, and the OSDI questionnaire was re-administered. Statistical Analysis Data normality was evaluated using the Kolmogorov–Smirnov test. Parametric tests (Student’s t-test, ANOVA) were used for normally distributed data, and non-parametric tests (Mann–Whitney U and Kruskal–Wallis) were used for non-normally distributed data. Statistical analyses were performed using SPSS 25.0 (IBM Corp., USA), and p < 0.05 was considered statistically significant in all analyses. RESULTS In this prospective, randomized controlled trial, 82 patients with senile cataract were evaluated between May 2021 and January 2023. Sixteen patients with chronic topical medication use, history of ocular pathology, or systemic comorbidities and five patients who did not attend follow-up visits were excluded, leaving 61 patients (PI group, 29 eyes; CHG group, 32 eyes) for analysis. No statistically significant differences were found between the groups in demographic or baseline ocular parameters (Table 1 ). Table 1 Demographic and ocular characteristics of the patients. Povidone iodine Chlorhexidine gluconate P value n % n % Gender Female 14 48,3 17 51,5 0,799 Male 15 51,7 16 48,5 Age (years) 62,72 ± 7.38 63,97 ± 7.18 0,504 Laterality Right eye 16 55,2 22 66,7 0,354 Left eye 13 44,8 11 33,3 Types of cataracts Nuclear 18 62,1 19 57,6 0,977 Cortical 0 0,0 0 0,0 Posterior subcapsular 5 17,2 8 24,2 Corticonuclear 6 20,7 6 18,2 Cataract grade a 2 9 31,0 7 21,2 0,531 3 15 51,7 17 51,5 4 5 17,2 9 27,3 a According to the Lens Opacities Classification System III. There were no significant differences in preoperative and postoperative BCVA in either of the groups. Postoperative day 1 IOP values increased significantly compared to preoperative levels in both groups, but the intergroup difference was not significant (p = 0.41). Intraoperative parameters (microscope light exposure time, CDE, and U/S time) were similar between the groups. Intraoperative pain scores were comparable (PI, 1.72; CHG, 1.55; p = 0.518), whereas pain scores in the first 24 h postoperatively were significantly higher in the PI group (PI, 2.52; CHG, 1.55; p < 0.001; Table 2 ). Table 2 Intraoperative parameters and pain scores. Povidone iodine Chlorhexidine gluconate P value Microscope light exposure time (minutes) 14.10 ± 2.64 14.55 ± 3.63 0.688 CDE a (j oule) 13.96 ± 8.16 12.95 ± 8.51 0.635 U/S time b (seconds) 1.33 ± 0.85 1.32 ± 1.08 0.962 Intraoperative Pain Score 1.72 ± 1.13 1.55 ± 1.03 0.518 Postoperative 24-Hour Pain Score 2.52 ± 1.09 1.52 ± 0.97 < 0.001 a CDE: Cumulative dissipated energy. b U/S time: Ultrasound time. Preoperative and postoperative ocular surface parameters are summarized in Table 3 . Among all cross-sectional comparisons between the two antiseptic groups, the only statistically significant intergroup difference was observed in OSDI scores at postoperative Week 1, with higher scores in the PI group compared to the CHG group (p = 0.029). No other parameter at any postoperative time point showed a statistically significant difference between the groups. Table 3 Preoperative and postoperative ocular surface parameters. Preoprerative Postoperative 1st Week Postoperative 1st Month Postoperative 3rd Month Schirmer Test (mm) Povidone iodine 16.79 ± 3.35 14.10 ± 3.09 15.52 ± 2.8 16.07 ± 3.07 Chlorhexidine gluconate 16.91 ± 3.58 14.52 ± 3.08 15.97 ± 2.64 16.48 ± 3.27 P value 0.896 0.602 0.515 0.610 Tear Break-Up Time (second) Povidone iodine 11.66 ± 2 8.97 ± 2.03 10.55 ± 1.9 10.97 ± 1.57 Chlorhexidine gluconate 11.73 ± 2.10 9.21 ± 1.45 10.67 ± 1.83 11.42 ± 1.62 P value 0.891 0.581 0.809 0.264 Tear Meniscus Height (mm) Povidone iodine 0.25 ± 0.07 0.20 ± 0.03 0.22 ± 0.05 0.24 ± 0.07 Chlorhexidine gluconate 0.24 ± 0.06 0.20 ± 0.04 0.23 ± 0.06 0.23 ± 0.05 P value 0.710 0.626 0.591 0.753 OSDI a Score Povidone iodine 16.48 ± 3.89 22.11 ± 5.05 18.77 ± 3.52 17.16 ± 3.78 Chlorhexidine gluconate 16.34 ± 3.79 19.35 ± 4.67 20.65 ± 4.78 16.25 ± 3.89 P value 0.892 0.029 0.087 0.357 a OSDI: Ocular Surface Disease Index In intragroup comparisons, both antiseptic groups (PI and CHG) exhibited marked alterations in ocular surface parameters during the early postoperative period, with differences in the timing of recovery. Schirmer test values showed a significant decrease at Week 1 in both groups (PI: p < 0.001; CHG: p = 0.004), while no statistically significant change was observed at Month 1 compared to baseline (PI: p = 0.105; CHG: p = 0.098). Tear break-up time significantly decreased at all postoperative time points in the PI group (Week 1: p < 0.001; Month 1: p = 0.019; Month 3: p = 0.023). In the CHG group, a significant decrease in tear break-up time was observed at Week 1 ( p < 0.001) and Month 1 ( p = 0.016), but not at Month 3 ( p = 0.506). Ocular Surface Disease Index (OSDI) scores increased significantly in both groups during the early postoperative period. In both groups, scores remained elevated until Month 1 (PI: p = 0.002; CHG: p = 0.000) and returned to baseline by Month 3 without statistically significant difference (PI: p = 0.349; CHG: p = 0.927). No complications, such as infectious endophthalmitis, retinal detachment, glaucoma, or severe corneal–conjunctival infections, were observed in either group during the study period. DISCUSSION While large-scale studies comparing the efficacy of antiseptics used in cataract surgery exist, no previous research has evaluated the long-term effects of antiseptics on the ocular surface and dry eye, accounting for preoperative and intraoperative risk factors. In this context, this is the first study in the literature comparing the effects of PI and CHG on postoperative dry eye symptoms in patients undergoing cataract surgery with phacoemulsification. In our cohort, OSDI scores demonstrated significant changes in both antiseptic groups at postoperative Week 1 and Month 1. Other ocular surface parameters also declined significantly at Week 1. By Month 1, partial recovery was observed in most variables, although TBUT remained impaired, particularly in the PI group. However, there was no marked difference between the PI and CHG groups in the magnitude of these changes. Notably, PI-treated patients reported significantly higher pain scores in the first 24 h postoperatively, indicating greater discomfort compared to the CHG group. No serious complications occurred in either group throughout follow-up. In addition to surgical success, patient comfort is an important factor in the postoperative period. In a prospective randomized trial, CHG provided lower ocular pain scores, less corneal epithelial damage, and comparable asepsis relative to PI. 12 These results were supported by a recent meta-analysis, highlighting minimal patient intolerance to CHG, greater pain reduction with CHG, and a higher incidence of corneal epithelial defects with PI, while finding no statistically significant difference between the two antiseptics in reducing ocular surface microbial isolates. 13 Another study reported that CHG use led to a lower rate (0.002%) of post-injection ocular surface irritation or hypersensitivity symptoms—symptoms that occurred in over 5% of PI-treated patients. 3 Consistent with these findings, the present study observed significantly lower 24-h postoperative pain scores in the CHG group compared to the PI group. This PI-associated discomfort, likely secondary to corneal epithelial toxicity, may adversely affect patients’ daily activities and supports literature suggesting superior tolerability and lower chemical irritation potential of CHG. 12,13 It is well-established that cataract surgery adversely affects the tear film in the postoperative period and contributes to the development of DES, as demonstrated in several studies. 5,14,15 In terms of etiopathogenesis, it has been proposed that the toxic effects of eye drops containing topical anesthetics and preservatives, such as benzalkonium chloride, on the corneal epithelium, together with corneal nerve disorganization induced by phacoemulsification and other corneal surgeries result in decreased tear production, increased corneal epithelial permeability, reduced epithelial metabolic activity, and delayed wound healing. Conversely, an experimental study on rabbits showed that CHG at concentrations of ≤1% did not impair the rate of epithelial defect healing. 16 Moreover, inflammatory mediators released following corneal incisions can alter corneal nerve function and reduce corneal sensitivity, thereby contributing to tear film instability. 17,18 During healing, neural growth factors regenerate subepithelial corneal axons, a process typically completed within one month. The regeneration of corneal nerves in this manner may explain why dry eye signs and symptoms are most pronounced immediately after surgery and why they subsequently ameliorate. Khanal et al. 19 reported impaired corneal sensitivity and tear physiology immediately following phacoemulsification. Corneal sensitivity did not return to preoperative levels until 3 months post-surgery, although tear function recovered within 1 month. Kasetsuwan et al. 20 observed that dry eye signs and symptoms emerged 7 days after phacoemulsification and worsened over time. This was consistent with findings by Sahu et al., 5 who noted postoperative deterioration in Schirmer test I, TBUT, TMH, and lissamine green staining of the cornea and conjunctiva, with amelioration beginning by 1 month. In the present study, dry eye parameters in both groups approached preoperative values by 1 month post-surgery and reached levels closest to baseline at 3 months. These findings indicate that the long-term ocular surface effects of antiseptics are minimal, yet suggest that more tolerable agents—such as CHG—should be preferred in the early postoperative period to optimize patient comfort. In addition to these general trends, intragroup analyses revealed distinct differences in the recovery timeline between the two antiseptic agents. Although both groups exhibited early postoperative impairment in tear production, tear film stability, and symptom scores, most parameters in the CHG group approached baseline levels by the first month, whereas recovery was more prolonged in the PI group. In particular, tear break-up time and OSDI scores improved more rapidly and noticeably in patients treated with CHG. These findings suggest that CHG may exert less toxic effects on the ocular surface and may be better tolerated in the postoperative period compared to PI. Similarly, Kasetsuwan et al. 20 reported that dry eye severity peaked 7 days post cataract surgery when measured via OSDI and clinical tests, followed by rapid and gradual amelioration at 1 and 3 months postoperatively. Xue et al. reported higher OSDI scores at 1 and 3 months postoperatively compared to preoperative values. 21 The primary limitations of the present study include its relatively small sample size, short follow-up period (3 months), and the exclusion of systemic or ocular conditions (e.g., Sjögren’s syndrome, chronic blepharitis, rheumatoid arthritis) that could influence dry eye parameters. These exclusion criteria may limit the generalizability of the results, particularly for patient groups with comorbidities. Additionally, the single-center design and lack of demographic diversity pose potential challenges in extrapolating findings to broader populations. In conclusion, although both PI and CHG resulted in transient postoperative ocular surface alterations in patients undergoing cataract surgery, CHG was associated with earlier restoration of tear film parameters and markedly lower early postoperative discomfort. These findings highlight CHG as a promising alternative to PI, particularly in patients at risk of ocular surface intolerance. Nevertheless, given the single-center design, limited sample size, and short follow-up period, these results should be regarded as preliminary. Validation through large-scale, multicenter trials will be essential before CHG can be recommended as a routine first-line antiseptic in cataract surgery. Declarations Disclosure: The authors have no conflict of interest. Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. AI Usage Statement: No generative artificial intelligence tools were used in the writing or data analysis of this manuscript. References Halachimi-Eyal, O., Lang, Y., Keness, Y., & Miron, D. Preoperative topical moxifloxacin 0.5% and povidone–iodine 5.0% versus povidone–iodine 5.0% alone to reduce bacterial colonization in the conjunctival sac. Journal of Cataract & Refractive Surgery, 2009; 35(12): 2109-14. Kanclerz, P., & Myers, W. G. Chlorhexidine and other alternatives for povidone–iodine in ophthalmic surgery: review of comparative studies. Journal of Cataract & Refractive Surgery, 2022;48(3):363-369. Merani, R., McPherson, Z. E., Luckie, A. P., Gilhotra, J. S., Runciman, J., Durkin, S., ... & Davies, P. E. Aqueous chlorhexidine for intravitreal injection antisepsis: a case series and review of the literature. Ophthalmology, 2016;123(12):2588-94. Mencucci, R., Ambrosini, S., Ponchietti, C., Marini, M., Vannelli, G. B., & Menchini, U. Ultrasound thermal damage to rabbit corneas after simulated phacoemulsification. Journal of Cataract & Refractive Surgery, 2005;31(11):2180-86. Sahu, P. K., Das, G. K., Malik, A., & Biakthangi, L. Dry eye following phacoemulsification surgery and its relation to associated intraoperative risk factors. Middle East African Journal of Ophthalmology, 2015:22(4):472-77. Chylack LT jr., Wolfe JK, Singer DM et al. The Lens Opacities Classification System III. Arch Ophthalmol 1993;111:831–36. doi:10.1001/ archopht.1993.01090060119035 Wolffsohn, J. S., Arita, R., Chalmers, R., Djalilian, A., Dogru, M., Dumbleton, K., et al. TFOS DEWS II diagnostic methodology report. The ocular surface, 2017;15(3):539-74. Palas, C. Ç., Öztürk, H., & Özen, B. Katarakt Cerrahisinin Oküler Yüzey Parametrelerine ve Kuru Göz Gelişimine Etkileri: Prospektif Klinik Çalışma. Turkiye Klinikleri Journal of Ophthalmology, 2024;33(1):46-55. Grubbs Jr, J. R., Tolleson-Rinehart, S., Huynh, K., & Davis, R. M. A review of quality of life measures in dry eye questionnaires. Cornea, 2014;33(2):215-18. Research randomizer: Free random sampling and random assignment. Available from: http://www.randomizer.org/index.htm. Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. Br J Anaesth 2008;101(1):17–24. Ali, F. S., Jenkins, T. L., Boparai, R. S., Obeid, A., Ryan, M. E., Wibblesman, T. D., ... & Regillo, C. D. Aqueous chlorhexidine compared with povidone-iodine as ocular antisepsis before intravitreal injection: a randomized clinical trial. Ophthalmology Retina, 2021;5(8):788-96. Mihalache, A., Tao, B. K., Huang, R. S., Dhivagaran, T., Popovic, M. M., Kertes, P. J., et al. Chlorhexidine Versus Povidone-Iodine for Intravitreal Injection Antisepsis: A Systematic Review and Meta-Analysis. American Journal of Ophthalmology. 2025: https://doi.org/10.1016/j.ajo.2025.03.031 Kohli, P., Arya, S. K., Raj, A., et al. Changes in ocular surface status after phacoemulsification in patients with senile cataract. International ophthalmology, 2019;39:1345-53. Garg, P., Gupta, A., Tandon, N., et al. Dry eye disease after cataract surgery: study of its determinants and risk factors. Turkish journal of ophthalmology, 2020;50(3): 133. Hamill MB, Osato MS, Wilhelmus KR. Experimental evaluation of chlorhexidine gluconate for ocular antisepsis. Antimicrob Agents Chemother. 1984;26(6):793-796. doi:10.1128/AAC.26.6.793 Cetinkaya, S., Mestan, E., Acir, N. O., Cetinkaya, Y. F., Dadaci, Z., et al. The course of dry eye after phacoemulsification surgery. BMC ophthalmology, 2015;15:1-5. Cho, Y. K., Kim, M. S. Dry eye after cataract surgery and associated intraoperative risk factors. Korean Journal of Ophthalmology, 2009;23(2):65-73. Khanal, S., Tomlinson, A., Esakowitz, L., Bhatt, P., Jones, D., Nabili, S., & Mukerji, S. Changes in corneal sensitivity and tear physiology after phacoemulsification. Ophthalmic and Physiological Optics, 2008;28(2):127-134. Kasetsuwan, N., Satitpitakul, V., Changul, T., Jariyakosol, S. Incidence and pattern of dry eye after cataract surgery. PloS one, 2013;8(11):e78657. Xue, W., Zhu, M. M., Zhu, B. J., Huang, J. N., Sun, Q., Miao, Y. Y., Zou, H. D. Long-term impact of dry eye symptoms on vision-related quality of life after phacoemulsification surgery. International Ophthalmology, 2019;39:419-29 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Nov, 2025 Read the published version in International Ophthalmology → Version 1 posted Editorial decision: Revision requested 09 Oct, 2025 Reviews received at journal 08 Oct, 2025 Reviews received at journal 07 Oct, 2025 Reviewers agreed at journal 29 Sep, 2025 Reviews received at journal 28 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviewers agreed at journal 27 Sep, 2025 Reviewers invited by journal 27 Sep, 2025 Editor assigned by journal 26 Sep, 2025 Submission checks completed at journal 26 Sep, 2025 First submitted to journal 25 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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04:22:24","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77305,"visible":true,"origin":"","legend":"","description":"","filename":"c574fa0dfed14d37ad18fbc7369f443a1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7716182/v1/41cc84b3ae57d927c2a2f56e.xml"},{"id":93098535,"identity":"d3f17147-f6ab-40c4-ae64-f5841081f092","added_by":"auto","created_at":"2025-10-09 04:22:24","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74674,"visible":true,"origin":"","legend":"","description":"","filename":"c574fa0dfed14d37ad18fbc7369f443a1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7716182/v1/de07c5e653aeb5258b7edecf.xml"},{"id":93098536,"identity":"8cec45bf-eac6-4c05-9483-6377dfcf7fa0","added_by":"auto","created_at":"2025-10-09 04:22:24","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81829,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7716182/v1/c800f50b343f2c0bcc7fd162.html"},{"id":96105108,"identity":"65f04913-707a-4990-afd4-e9bbeac65d69","added_by":"auto","created_at":"2025-11-17 16:08:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":803634,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7716182/v1/c7fb6669-8943-41c5-b5ba-2fdf42826569.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Effects of Povidone-Iodine and Chlorhexidine Gluconate on the Ocular Surface in Phacoemulsification \u003c/p\u003e","fulltext":[{"header":"WHAT WAS KNOWN","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003ePovidone-iodine (PI) is considered the gold standard for preoperative antisepsis in cataract surgery but is associated with ocular surface toxicity and postoperative discomfort.\u003c/li\u003e\n \u003cli\u003eChlorhexidine gluconate (CHG) is an alternative with comparable antimicrobial efficacy, yet limited data exist regarding its long-term impact on ocular surface integrity.\u003c/li\u003e\n \u003cli\u003eIn addition to surgical trauma, the choice of antiseptic may significantly influence the development of dry eye symptoms after cataract surgery.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWHAT THIS PAPER ADDS\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eThis randomized controlled trial is the first to compare the effects of PI and CHG on ocular surface parameters following phacoemulsification cataract surgery.\u003c/li\u003e\n \u003cli\u003eBoth groups exhibited transient postoperative ocular surface deterioration; however, the CHG group showed faster recovery and significantly lower pain scores within the first 24 hours.\u003c/li\u003e\n \u003cli\u003eThe lower ocular surface toxicity and improved early postoperative comfort associated with CHG suggest that it may be a preferable antiseptic agent in patients with ocular surface sensitivity.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eCataract surgery is among the most commonly performed procedures worldwide, primarily due to an aging global population and continuous improvements in surgical techniques. As with many surgical interventions, preoperative antisepsis in cataract surgery plays a critical role in preventing postoperative endophthalmitis. In this context, 5% povidone\u0026ndash;iodine (PI) is universally accepted as the standard recommended antiseptic owing to its broad-spectrum antimicrobial efficacy and proven ability to reduce rates of postoperative endophthalmitis.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e However, chlorhexidine gluconate (CHG) has emerged as a safe and effective alternative\u0026mdash;particularly in patients with a history of PI allergy\u0026mdash;and is widely used.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Comparative studies involving large patient cohorts undergoing cataract surgery and intravitreal injections have demonstrated that PI and CHG exhibit similar antimicrobial effectiveness and safety profiles.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn addition to antimicrobial efficacy, the ocular surface toxicity of antiseptics and their association with postoperative dry eye syndrome (DES) warrant careful evaluation. Postoperative DES is a multifactorial condition influenced by corneal incisions, mechanical trauma, prolonged exposure to microscope illumination, cumulative phacoemulsification energy, and postoperative topical medications.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Although PI is an effective antiseptic, it can disrupt the tear film and induce damage to both the corneal epithelium and endothelium.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In contrast, data on the effects of CHG on ocular surface integrity and its long-term relationship with DES are limited, highlighting a significant gap in perioperative safety assessments.\u003c/p\u003e\u003cp\u003eThe aim of this study was to compare the ocular surface toxicity, long-term impact on DES, and patient comfort associated with 5% PI versus 0.1% CHG\u0026mdash;while accounting for other intraoperative risk factors (phacoemulsification energy, surgical duration, exposure to irrigation solutions, etc.)\u0026mdash;in patients undergoing phacoemulsification cataract surgery.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis prospective,\u0026nbsp;randomized controlled study was conducted between May 2021 and January 2023 following approval by the Pamukkale University Ethics Committee (April 13, 2021; No. 08). The study was conducted in accordance with the principles of the Declaration of Helsinki, and written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant Selection and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients scheduled for phacoemulsification due to senile cataract were enrolled. A detailed medical history was taken, and comprehensive ophthalmic examination was performed. Patients with chronic use of topical ocular medications, history of prior ocular surgery, eyelid pathologies, contact lens wear, allergic or chronic conjunctivitis, and exposure keratopathy were excluded. Patients with systemic diseases contributing to dry eye (thyroid dysfunction, lupus, rheumatoid arthritis, scleroderma, Sjögren’s syndrome, vitamin A deficiency) and inability to comply with follow-up visits were also excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent measurement of best-corrected visual acuity (BCVA) using the Snellen chart, intraocular pressure (IOP) by Goldmann applanation tonometry, and detailed anterior and posterior segment examinations using a slit-lamp biomicroscope. Cataract type and nuclear sclerosis grade were assessed according to the Lens Opacities Classification System III (LOCS III).\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe following tests were performed to evaluate the ocular surface parameters:\u003c/p\u003e\n\u003cp\u003e1. Schirmer Test: Without topical anesthesia, a Schirmer strip (Chauvin Laboratory, France) was placed in the lateral one-third of the lower fornix. After 5 min, the length of wetting (mm) was recorded.\u003csup\u003e7,8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e2. Tear Break-Up Time (TBUT): A fluorescein strip (Haag-Streit AG, Switzerland) was applied to the lower fornix. After 1 min, the interval between the last blink and the appearance of the first dry spot on the cornea was measured in seconds under cobalt-blue illumination.\u003csup\u003e7,8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e3. Tear Meniscus Height (TMH): The vertical height (mm) of the tear meniscus at the junction of the tear film with the corneal surface and eyelid margin was measured.\u003csup\u003e7,8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e4. Ocular Surface Disease Index (OSDI): A 12-item questionnaire assessing dry eye symptoms over the previous two weeks and their impact on daily activities was administered.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAll measurements were repeated three times at 10-min intervals in a standardized environment between 09:00 and 12:00, and the mean of the three recordings was used in analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Protocol and Randomization\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed by a single surgeon in the same operating room using a Leica F40 operating microscope (Leica Microsystems, Heerbrugg, Switzerland) and an Alcon Centurion phacoemulsification system (Alcon Surgical, Fort Worth, TX, USA). A standardized preoperative and postoperative protocol was used for all participants. For \u003cstrong\u003epreanesthesia\u003c/strong\u003e, both groups received 0.5% proparacaine hydrochloride drops (Alcaine\u003csup\u003e®\u003c/sup\u003e, Alcon) instilled three times at 5-min intervals. A 2.2-mm 90° superior incision was made via the clear \u003cstrong\u003ecorneal incision\u003c/strong\u003e \u003cstrong\u003etechnique\u003c/strong\u003e. \u003cstrong\u003ePostoperative medications were prescribed as follows: topical moxifloxacin 0.5% (Vigamox®, Alcon) four times daily for four weeks; dexamethasone 0.1% (Maxidex®, Alcon) six times daily during week 1, four times daily during week 2, and twice daily during weeks 3–4; and nepafenac 0.1% (Nevanac®, Alcon) three times daily for four weeks\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003ePatients were randomly divided into two groups in a 1:1 ratio using Research Randomizer software. The PI group consisted of patients who received conjunctival irrigation with 5% PI for 3 minutes, while the CHG group consisted of patients who received conjunctival irrigation with 0.1%\u0026nbsp;CHG for 3 minutes.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIntraoperative parameters—including microscope light exposure time, cumulative dissipated energy (CDE), and total ultrasound (U/S) time—were recorded for each case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePain levels were assessed twice: during the intraoperative period, which spans the entire duration of the surgery, and in the early postoperative period to quantify the maximum pain intensity reported within the first 24 hours following surgery. Both assessments were made using a Numerical Rating Scale (NRS) ranging between 0 and 10.\u003csup\u003e11\u003c/sup\u003e On this scale, 0 represents “no pain” and 10 represents “the most severe pain imaginable”.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt postoperative Week 1, Month 1, and Month 3, Schirmer test, TBUT, and TMH measurements were repeated, and the OSDI questionnaire was re-administered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData normality was evaluated using the Kolmogorov–Smirnov test. Parametric tests (Student’s t-test, ANOVA) were used for normally distributed data, and non-parametric tests (Mann–Whitney U and Kruskal–Wallis) were used for non-normally distributed data. Statistical analyses were performed using SPSS 25.0 (IBM Corp., USA), and p \u0026lt; 0.05 was considered statistically significant in all analyses.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eIn this prospective, randomized controlled trial, 82 patients with senile cataract were evaluated between May 2021 and January 2023. Sixteen patients with chronic topical medication use, history of ocular pathology, or systemic comorbidities and five patients who did not attend follow-up visits were excluded, leaving 61 patients (PI group, 29 eyes; CHG group, 32 eyes) for analysis. No statistically significant differences were found between the groups in demographic or baseline ocular parameters (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and ocular characteristics of the patients.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003ePovidone iodine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eChlorhexidine gluconate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48,3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51,5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0,799\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51,7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e48,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e62,72\u0026thinsp;\u0026plusmn;\u0026thinsp;7.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e63,97\u0026thinsp;\u0026plusmn;\u0026thinsp;7.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0,504\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eLaterality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRight eye\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55,2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e66,7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0,354\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLeft eye\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44,8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e33,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eTypes of cataracts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNuclear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62,1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e57,6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0,977\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCortical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0,0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0,0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePosterior subcapsular\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17,2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e24,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCorticonuclear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20,7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18,2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCataract grade\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31,0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21,2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0,531\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51,7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e51,5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17,2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27,3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003ea\u003c/sup\u003e\u003cb\u003eAccording to the Lens Opacities Classification System III.\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere were no significant differences in preoperative and postoperative BCVA in either of the groups. Postoperative day 1 IOP values increased significantly compared to preoperative levels in both groups, but the intergroup difference was not significant (p\u0026thinsp;=\u0026thinsp;0.41). Intraoperative parameters (microscope light exposure time, CDE, and U/S time) were similar between the groups. Intraoperative pain scores were comparable (PI, 1.72; CHG, 1.55; p\u0026thinsp;=\u0026thinsp;0.518), whereas pain scores in the first 24 h postoperatively were significantly higher in the PI group (PI, 2.52; CHG, 1.55; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIntraoperative parameters and pain scores.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePovidone iodine\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChlorhexidine gluconate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMicroscope light exposure time (minutes)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e14.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e14.55\u0026thinsp;\u0026plusmn;\u0026thinsp;3.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.688\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCDE\u003csup\u003ea\u003c/sup\u003e (j\u003cb\u003eoule)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e13.96\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e12.95\u0026thinsp;\u0026plusmn;\u0026thinsp;8.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.635\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eU/S time\u003csup\u003eb\u003c/sup\u003e (seconds)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.962\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntraoperative Pain Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.518\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePostoperative 24-Hour Pain Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.52\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e CDE: Cumulative dissipated energy.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e U/S time: \u003cem\u003eUltrasound time.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePreoperative and postoperative ocular surface parameters are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Among all cross-sectional comparisons between the two antiseptic groups, the only statistically significant intergroup difference was observed in OSDI scores at postoperative Week 1, with higher scores in the PI group compared to the CHG group (p\u0026thinsp;=\u0026thinsp;0.029). No other parameter at any postoperative time point showed a statistically significant difference between the groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePreoperative and postoperative ocular surface parameters.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePreoprerative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePostoperative 1st Week\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePostoperative 1st Month\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePostoperative 3rd Month\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSchirmer Test (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePovidone iodine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.79\u0026thinsp;\u0026plusmn;\u0026thinsp;3.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.10\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.52\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16.07\u0026thinsp;\u0026plusmn;\u0026thinsp;3.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChlorhexidine gluconate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.91\u0026thinsp;\u0026plusmn;\u0026thinsp;3.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.52\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.97\u0026thinsp;\u0026plusmn;\u0026thinsp;2.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16.48\u0026thinsp;\u0026plusmn;\u0026thinsp;3.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.896\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.602\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.515\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.610\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eTear Break-Up Time (second)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePovidone iodine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.66\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.97\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChlorhexidine gluconate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.21\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.891\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.581\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.809\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.264\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eTear Meniscus Height (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePovidone iodine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChlorhexidine gluconate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.710\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.626\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.591\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.753\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eOSDI\u003csup\u003ea\u003c/sup\u003e Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePovidone iodine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.48\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.11\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.77\u0026thinsp;\u0026plusmn;\u0026thinsp;3.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17.16\u0026thinsp;\u0026plusmn;\u0026thinsp;3.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChlorhexidine gluconate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19.35\u0026thinsp;\u0026plusmn;\u0026thinsp;4.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.65\u0026thinsp;\u0026plusmn;\u0026thinsp;4.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.892\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.087\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.357\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e OSDI: Ocular Surface Disease Index\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn intragroup comparisons, both antiseptic groups (PI and CHG) exhibited marked alterations in ocular surface parameters during the early postoperative period, with differences in the timing of recovery. Schirmer test values showed a significant decrease at Week 1 in both groups (PI: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; CHG: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004), while no statistically significant change was observed at Month 1 compared to baseline (PI: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.105; CHG: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.098). Tear break-up time significantly decreased at all postoperative time points in the PI group (Week 1: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Month 1: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019; Month 3: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023). In the CHG group, a significant decrease in tear break-up time was observed at Week 1 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Month 1 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.016), but not at Month 3 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.506). Ocular Surface Disease Index (OSDI) scores increased significantly in both groups during the early postoperative period. In both groups, scores remained elevated until Month 1 (PI: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002; CHG: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000) and returned to baseline by Month 3 without statistically significant difference (PI: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.349; CHG: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.927).\u003c/p\u003e\u003cp\u003eNo complications, such as infectious endophthalmitis, retinal detachment, glaucoma, or severe corneal\u0026ndash;conjunctival infections, were observed in either group during the study period.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWhile large-scale studies comparing the efficacy of antiseptics used in cataract surgery exist, no previous research has evaluated the long-term effects of antiseptics on the ocular surface and dry eye, accounting for preoperative and intraoperative risk factors. In this context, this is the first study in the literature comparing the effects of PI and CHG on postoperative dry eye symptoms in patients undergoing cataract surgery with phacoemulsification. In our cohort, OSDI scores demonstrated significant changes in both antiseptic groups at postoperative Week 1 and Month 1. Other ocular surface parameters also declined significantly at Week 1. By Month 1, partial recovery was observed in most variables, although TBUT remained impaired, particularly in the PI group. However, there was no marked difference between the PI and CHG groups in the magnitude of these changes. Notably, PI-treated patients reported significantly higher pain scores in the first 24 h postoperatively, indicating greater discomfort compared to the CHG group. No serious complications occurred in either group throughout follow-up.\u003c/p\u003e\n\u003cp\u003eIn addition to surgical success, patient comfort is an important factor in the postoperative period. In a prospective randomized trial, CHG provided lower ocular pain scores, less corneal epithelial damage, and comparable asepsis relative to PI.\u003csup\u003e12\u003c/sup\u003e These results were supported by a recent meta-analysis, highlighting minimal patient intolerance to CHG, greater pain reduction with CHG, and a higher incidence of corneal epithelial defects with PI,\u0026nbsp;while finding no statistically significant difference between the two antiseptics in reducing ocular surface microbial isolates.\u003csup\u003e13\u003c/sup\u003e\u0026nbsp;Another study reported that CHG use led to a lower rate (0.002%) of post-injection ocular surface irritation or hypersensitivity symptoms\u0026mdash;symptoms that occurred in over 5% of PI-treated patients.\u003csup\u003e3\u003c/sup\u003e Consistent with these findings, the present study observed significantly lower 24-h postoperative pain scores in the CHG group compared to the PI group. This PI-associated discomfort, likely secondary to corneal epithelial toxicity, may adversely affect patients\u0026rsquo; daily activities and supports literature suggesting superior tolerability and lower chemical irritation potential of CHG.\u003csup\u003e12,13\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIt is well-established that cataract surgery adversely affects the tear film in the postoperative period and contributes to the development of DES, as demonstrated in several studies.\u003csup\u003e5,14,15\u003c/sup\u003e In terms of etiopathogenesis, it has been proposed that the toxic effects of eye drops containing topical anesthetics and preservatives, such as benzalkonium chloride, on the corneal epithelium, together with corneal nerve disorganization induced by phacoemulsification and other corneal surgeries result in decreased tear production, increased corneal epithelial permeability, reduced epithelial metabolic activity, and delayed wound healing. Conversely, an experimental study on rabbits showed that CHG at concentrations of \u0026le;1% did not impair the rate of epithelial defect healing.\u003csup\u003e16\u003c/sup\u003e Moreover, inflammatory mediators released following corneal incisions can alter corneal nerve function and reduce corneal sensitivity, thereby contributing to tear film instability.\u003csup\u003e17,18\u003c/sup\u003e During healing, neural growth factors regenerate subepithelial corneal axons, a process typically completed within one month. The regeneration of corneal nerves in this manner may explain why dry eye signs and symptoms are most pronounced immediately after surgery and why they subsequently ameliorate.\u003c/p\u003e\n\u003cp\u003eKhanal et al.\u003csup\u003e19\u003c/sup\u003e reported impaired corneal sensitivity and tear physiology immediately following phacoemulsification. Corneal sensitivity did not return to preoperative levels until 3 months post-surgery, although tear function recovered within 1 month. Kasetsuwan et al.\u003csup\u003e20\u003c/sup\u003e observed that dry eye signs and symptoms emerged 7 days after phacoemulsification and worsened over time. This was consistent with findings by Sahu et al.,\u003csup\u003e5\u003c/sup\u003e who noted postoperative deterioration in Schirmer test I, TBUT, TMH, and lissamine green staining of the cornea and conjunctiva, with amelioration beginning by 1 month. In the present study, dry eye parameters in both groups approached preoperative values by 1 month post-surgery and reached levels closest to baseline at 3 months. These findings indicate that the long-term ocular surface effects of antiseptics are minimal, yet suggest that more tolerable agents\u0026mdash;such as CHG\u0026mdash;should be preferred in the early postoperative period to optimize patient comfort.\u003c/p\u003e\n\u003cp\u003eIn addition to these general trends, intragroup analyses revealed distinct differences in the recovery timeline between the two antiseptic agents. Although both groups exhibited early postoperative impairment in tear production, tear film stability, and symptom scores, most parameters in the CHG group approached baseline levels by the first month, whereas recovery was more prolonged in the PI group. In particular, tear break-up time and OSDI scores improved more rapidly and noticeably in patients treated with CHG. These findings suggest that CHG may exert less toxic effects on the ocular surface and may be better tolerated in the postoperative period compared to PI.\u003c/p\u003e\n\u003cp\u003eSimilarly, Kasetsuwan et al.\u003csup\u003e20\u0026nbsp;\u003c/sup\u003ereported that dry eye severity peaked 7 days post cataract surgery when measured via OSDI and clinical tests, followed by rapid and gradual amelioration at 1 and 3 months postoperatively. Xue et al. reported higher OSDI scores at 1 and 3 months postoperatively compared to preoperative values.\u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe primary limitations of the present study include its relatively small sample size, short follow-up period (3 months), and the exclusion of systemic or ocular conditions (e.g., Sj\u0026ouml;gren\u0026rsquo;s syndrome, chronic blepharitis, rheumatoid arthritis) that could influence dry eye parameters. These exclusion criteria may limit the generalizability of the results, particularly for patient groups with comorbidities. Additionally, the single-center design and lack of demographic diversity pose potential challenges in extrapolating findings to broader populations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn conclusion, although both PI and CHG resulted in transient postoperative ocular surface alterations in patients undergoing cataract surgery, CHG was associated with earlier restoration of tear film parameters and markedly lower early postoperative discomfort. These findings highlight CHG as a promising alternative to PI, particularly in patients at risk of ocular surface intolerance. Nevertheless, given the single-center design, limited sample size, and short follow-up period, these results should be regarded as preliminary. Validation through large-scale, multicenter trials will be essential before CHG can be recommended as a routine first-line antiseptic in cataract surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosure:\u0026nbsp;\u003c/strong\u003eThe authors have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAI Usage Statement:\u0026nbsp;\u003c/strong\u003eNo generative artificial intelligence tools were used in the writing or data analysis of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHalachimi-Eyal, O., Lang, Y., Keness, Y., \u0026amp; Miron, D. 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Available from:\u0026nbsp;http://www.randomizer.org/index.htm.\u003c/li\u003e\n \u003cli\u003eBreivik H, Borchgrevink PC, Allen SM, et al.\u0026nbsp;Assessment of pain.\u0026nbsp;Br J Anaesth\u0026nbsp;2008;101(1):17\u0026ndash;24.\u003c/li\u003e\n \u003cli\u003eAli, F. S., Jenkins, T. L., Boparai, R. S., Obeid, A., Ryan, M. E., Wibblesman, T. D., ... \u0026amp; Regillo, C. D. Aqueous chlorhexidine compared with povidone-iodine as ocular antisepsis before intravitreal injection: a randomized clinical trial.\u0026nbsp;Ophthalmology Retina,\u0026nbsp;2021;5(8):788-96.\u003c/li\u003e\n \u003cli\u003eMihalache, A., Tao, B. K., Huang, R. S., Dhivagaran, T., Popovic, M. M., Kertes, P. J., et al. Chlorhexidine Versus Povidone-Iodine for Intravitreal Injection Antisepsis: A Systematic Review and Meta-Analysis.\u0026nbsp;American Journal of Ophthalmology. 2025: https://doi.org/10.1016/j.ajo.2025.03.031\u003c/li\u003e\n \u003cli\u003eKohli, P., Arya, S. K., Raj, A., et al. Changes in ocular surface status after phacoemulsification in patients with senile cataract.\u0026nbsp;International ophthalmology,\u0026nbsp;2019;39:1345-53.\u003c/li\u003e\n \u003cli\u003eGarg, P., Gupta, A., Tandon, N., et al. Dry eye disease after cataract surgery: study of its determinants and risk factors.\u0026nbsp;Turkish journal of ophthalmology,\u0026nbsp;2020;50(3): 133.\u003c/li\u003e\n \u003cli\u003eHamill MB, Osato MS, Wilhelmus KR. Experimental evaluation of chlorhexidine gluconate for ocular antisepsis. Antimicrob Agents Chemother. 1984;26(6):793-796. doi:10.1128/AAC.26.6.793\u003c/li\u003e\n \u003cli\u003eCetinkaya, S., Mestan, E., Acir, N. O., Cetinkaya, Y. F., Dadaci, Z., et al. The course of dry eye after phacoemulsification surgery.\u0026nbsp;BMC ophthalmology,\u0026nbsp;2015;15:1-5.\u003c/li\u003e\n \u003cli\u003eCho, Y. K., Kim, M. S. Dry eye after cataract surgery and associated intraoperative risk factors.\u0026nbsp;Korean Journal of Ophthalmology,\u0026nbsp;2009;23(2):65-73.\u003c/li\u003e\n \u003cli\u003eKhanal, S., Tomlinson, A., Esakowitz, L., Bhatt, P., Jones, D., Nabili, S., \u0026amp; Mukerji, S. Changes in corneal sensitivity and tear physiology after phacoemulsification.\u0026nbsp;Ophthalmic and Physiological Optics,\u0026nbsp;2008;28(2):127-134.\u003c/li\u003e\n \u003cli\u003eKasetsuwan, N., Satitpitakul, V., Changul, T., Jariyakosol, S. Incidence and pattern of dry eye after cataract surgery.\u0026nbsp;PloS one,\u0026nbsp;2013;8(11):e78657.\u003c/li\u003e\n \u003cli\u003eXue, W., Zhu, M. M., Zhu, B. J., Huang, J. N., Sun, Q., Miao, Y. Y., Zou, H. D. Long-term impact of dry eye symptoms on vision-related quality of life after phacoemulsification surgery.\u0026nbsp;International Ophthalmology,\u0026nbsp;2019;39:419-29\u003cstrong\u003e.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7716182/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7716182/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose:\u003c/h2\u003e\u003cp\u003eTo compare the effects of 5% povidone-iodine (PI) and 0.1% chlorhexidine gluconate (CHG) on ocular surface parameters and patient comfort following phacoemulsification cataract surgery. The study aimed to determine whether CHG offers advantages over PI in terms of ocular surface recovery and postoperative comfort.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eThis prospective, randomized controlled trial included 61 patients undergoing phacoemulsification for senile cataract. Participants were randomly assigned to conjunctival irrigation with either 5% PI or 0.1% CHG for 3 minutes before surgery. Ocular surface assessments included Schirmer test, tear break-up time (TBUT), tear meniscus height (TMH), and the Ocular Surface Disease Index (OSDI). Evaluations were performed preoperatively and postoperatively at Week 1, Month 1, and Month 3. Pain scores were recorded using a numerical rating scale within the first 24 hours.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eBaseline parameters were comparable between groups. At Week 1, OSDI scores were significantly higher in the PI group than in the CHG group (p\u0026thinsp;=\u0026thinsp;0.029). Both groups showed significant early postoperative deterioration of ocular surface parameters, but recovery was faster in the CHG group. TBUT remained significantly reduced in the PI group at Month 3, whereas CHG eyes normalized. Schirmer values returned to baseline by Month 1 in both groups. Postoperative pain scores were significantly higher in the PI group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eBoth PI and CHG caused transient ocular surface changes after cataract surgery. However, CHG demonstrated faster recovery of tear film parameters and improved early postoperative comfort, suggesting it may be a preferable antiseptic in patients with ocular surface sensitivity.\u003c/p\u003e","manuscriptTitle":"The Effects of Povidone-Iodine and Chlorhexidine Gluconate on the Ocular Surface in Phacoemulsification","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-09 04:22:19","doi":"10.21203/rs.3.rs-7716182/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-09T18:45:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-08T21:00:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-07T05:49:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306190545284180727149359444622533235214","date":"2025-09-29T11:28:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T17:27:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273561431803038700967994659859456155114","date":"2025-09-28T02:33:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289483928183833439461223985613541630078","date":"2025-09-27T11:35:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56522888709383926187835672298198179305","date":"2025-09-27T11:19:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-27T10:27:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-26T06:46:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-26T06:45:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Ophthalmology","date":"2025-09-25T21:34:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"199e43bf-dd1c-499e-874a-85eae50522a6","owner":[],"postedDate":"October 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:03:04+00:00","versionOfRecord":{"articleIdentity":"rs-7716182","link":"https://doi.org/10.1007/s10792-025-03857-z","journal":{"identity":"international-ophthalmology","isVorOnly":false,"title":"International Ophthalmology"},"publishedOn":"2025-11-15 15:57:22","publishedOnDateReadable":"November 15th, 2025"},"versionCreatedAt":"2025-10-09 04:22:19","video":"","vorDoi":"10.1007/s10792-025-03857-z","vorDoiUrl":"https://doi.org/10.1007/s10792-025-03857-z","workflowStages":[]},"version":"v1","identity":"rs-7716182","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7716182","identity":"rs-7716182","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}