Neurosensory Ocular Surface Symptom–Sign Mismatch After Cataract Surgery: Associations With Dissatisfaction, Photophobia And Confocal Nerve Alterations
Published 2026 - 44th Congress of the ESCRS
Reference: PP23.04 | Type: Free paper | DOI: 10.82333/d4vp-h828
Authors: Dr Alessandra Curci* 1 , Giada Morese 1 , Prof. Giuseppe Giannaccare 2 , Linda Guo 3 , Dr Filippo Lixi 2 , Dr Claudia Corda 2 , Prof. Giulia Coco 4 , Prof. Paolo Nucci 3 , Prof. Edoardo Villani 3
1Università degli Studi di Milano, Milan, Lombardy, Italy. Eye Clinic San Giuseppe Hospital.,Milan,Italy, 2Università degli Studi di Cagliari, Cagliari, Sardinia, Italy. ,Cagliari,Italy, 3Università degli Studi di Milano, Milan, Lombardy, Italy. Eye Clinic San Giuseppe Hospital. ,Milan,Italy, 4Università degli Studi di Roma Tor Vergata, Rome, Lazio, Italy.,Roma,Italy
Purpose
Persistent ocular surface symptoms (OSS) after uncomplicated cataract surgery often occur despite minimal clinical findings, suggesting neurosensory phenotype rather than tear-film dysfunction. This study aimed to investigate associations between satisfaction, symptom–sign mismatch and neuropathic markers at 3, 6 and 12 months.
Setting
Multicenter cross-sectional observational study at the Eye Clinic of San Giuseppe Hospital (Milan) and University Hospital of Cagliari (Cagliari).
Methods
One hundred twenty patients (60 dissatisfied, 60 satisfied; age- and sex-matched) were evaluated after uneventful phacoemulsification using CATquest-9SF, OSDI, DEQ-5, SANDE, best corrected visual acuity (BCVA), ocular surface assessment, light-discomfort testing (Lumiz 100™), and topical anesthetic challenge. Central sub-basal nerve plexus (SNP) was imaged by in vivo confocal microscopy (HRT3/RCM; ACCMetrics). Mismatch was defined as moderate-to-severe symptoms (OSDI ≥23, DEQ-5 ≥12, and SANDE ≥30) with normal-to-mild signs (NIKBUT >5 s, FBUT >5 s, Schirmer >5 mm, and staining <2). Outcomes were compared between groups using parametric or non-parametric tests; effects are reported as OR (95%CI).
Results
Symptoms were higher in dissatisfied than satisfied patients (OSDI 32±18 vs 12±10; DEQ-5 11±6 vs 5±4; SANDE 40±27 vs 18±22; all p<0.0001), with similar BCVA and ocular signs (all p>0.10). Mismatch was more frequent in dissatisfied (64% vs 21%; OR 6.7, 95% CI 3.2-14.0, p<0.0001) and showed higher NPSI-eye (median 6 vs 0, p=0.002), higher OPAS (p=0.01), greater residual pain after anesthetic (18±23 vs 5±14 mm, p=0.004) and lower light-discomfort thresholds (variable-light 3,900±2,400 vs 7,200±3,800 units, p=0.001). At 12 months, mismatch had higher CNFL/CNFD/CNBD (13.1/25.4/24.5 vs 9.4/17.2/11.8; p≤0.006), more neuroma (68% vs 24%; OR 6.4; p=0.001), microneuroma (72% vs 27%; p<0.001) and dendritic-cell density (42±30 vs 18±13 n/mm², p=0.003).
Conclusions
Dissatisfaction after cataract surgery appears driven less by classic tear-film abnormalities than by severe OSS with a symptom–sign mismatch and a neurosensory signature combining neuropathic pain features, photophobia and SNP remodeling. Identifying this post-cataract neurosensory ocular surface phenotype may refine counselling, patient stratification and mechanism-based interventions.