Conjunctival Goblet Cell Density Following Cataract Surgery With Diclofenac Versus Diclofenac and Rebamipide: A Randomized Trial  Kumiko Kato, Kensaku Miyake, Nagako Kondo, Sayaka Asano, Junko Takeda, Akiko Takahashi, Yuko Takashima, Mineo Kondo  American Journal of Ophthalmology  Volume 181, Pages 26-36 (September 2017) DOI: 10.1016/j.ajo.2017.06.016 Copyright © 2017 The Author(s) Terms and Conditions

Figure 1 Study design, examinations, randomization, and dropouts. Before the surgery, 80 patients were randomized into 4 groups based on the postoperative topical drops to be used. After the surgery, 1 patient (Group A) received an unplanned anti–dry eye medication because of severe dry eye symptoms. Two patients (Groups B and D) could not visit the hospital as scheduled. In addition, 12 eyes were excluded because the quality of the impression cytology specimens was not sufficient for the measurements of goblet cell density. Thus, a total of 65 eyes were analyzed. American Journal of Ophthalmology 2017 181, 26-36DOI: (10.1016/j.ajo.2017.06.016) Copyright © 2017 The Author(s) Terms and Conditions

Figure 2 Photomicrographs of impression cytology with periodic acid–Schiff staining of specimens obtained from the eyes of representative patients in the 4 groups (A-D). Impression cytology images before and 1 month after cataract surgery in the same subjects are shown. Group A: eyes that had received topical diclofenac without rebamipide. Group B: eyes that received topical diclofenac with rebamipide. Group C: eyes that received topical betamethasone without rebamipide. Group D: eyes that received betamethasone with rebamipide. Scale bars, 50 μm. American Journal of Ophthalmology 2017 181, 26-36DOI: (10.1016/j.ajo.2017.06.016) Copyright © 2017 The Author(s) Terms and Conditions

Figure 3 Means and standard errors of the means of goblet cell densities before and at 1 month after cataract surgery in Groups A and B. (Left and Middle) Goblet cell density before cataract surgery and at 1 month after surgery in Groups A (diclofenac without rebamipide) and B (diclofenac with rebamipide). The decrease of goblet cell density at 1 month after surgery was statistically significant in Group A but not significant in Group B. (Right) Decrease of goblet cell density at 1 month after surgery in Groups A and B. The decrease of goblet cell density at 1 month after surgery was significantly greater in Group A than in Group B. American Journal of Ophthalmology 2017 181, 26-36DOI: (10.1016/j.ajo.2017.06.016) Copyright © 2017 The Author(s) Terms and Conditions

Figure 4 Means and standard errors of the means of goblet cell densities before and at 1 month after cataract surgery in Groups C (betamethasone without rebamipide) and D (betamethasone with rebamipide). (Left and Middle) The mean goblet cell density was slightly lower at 1 month after the surgery in both Groups C and D, but these differences were not statistically significant. (Right) The decrease in the mean goblet cell density was not significantly different between Groups C and D. American Journal of Ophthalmology 2017 181, 26-36DOI: (10.1016/j.ajo.2017.06.016) Copyright © 2017 The Author(s) Terms and Conditions

Figure 5 Means and standard errors of the means of the tear film breakup time (BUT) before and at 1 and 2 months after cataract surgery for the 4 groups. (Top left) Eyes that received postoperative topical diclofenac without rebamipide. (Top right) Eyes that received postoperative topical diclofenac with rebamipide. (Bottom left) Eyes that received postoperative topical betamethasone without rebamipide. (Bottom right) Eyes that received postoperative topical betamethasone with rebamipide. The tear film BUT was decreased after the surgery for all 4 groups. The reduction of the mean tear film BUT was significant at 1 and 2 months after surgery in Group A, and at 1 month after surgery in Group B. American Journal of Ophthalmology 2017 181, 26-36DOI: (10.1016/j.ajo.2017.06.016) Copyright © 2017 The Author(s) Terms and Conditions

Figure 6 Means and standard errors of the means of the aqueous flare value before and at 1 and 2 months after cataract surgery for the 4 groups. (Top left) Eyes that received postoperative topical diclofenac without rebamipide. (Top right) Eyes that received postoperative topical diclofenac with rebamipide. (Bottom left) Eyes that received postoperative topical betamethasone without rebamipide. (Bottom right) Eyes that received postoperative topical betamethasone with rebamipide. The flare values tended to increase at 1 month after surgery and then decreased slightly at 2 months after surgery for all groups. Significant increase of aqueous flare value after surgery was seen only at 1 month in Group C. American Journal of Ophthalmology 2017 181, 26-36DOI: (10.1016/j.ajo.2017.06.016) Copyright © 2017 The Author(s) Terms and Conditions

Dr Kumiko Kato is an Assistant Professor of Ophthalmology at the Mie University Graduate School of Medicine of Japan. Her research has focused on the mechanism and treatment of the postoperative dry eye syndrome. She is studying the effect of eye surgeries and topical drugs on the goblet cell density in the conjunctiva using impression cytology. Her other research interest is the physiology of the visual system determined electrophysiologically. American Journal of Ophthalmology 2017 181, 26-36DOI: (10.1016/j.ajo.2017.06.016) Copyright © 2017 The Author(s) Terms and Conditions