Cataract operation— phacoemulsification with IOL first among them— has turned out to be a high-volume, and a high-success procedure all over the world. However, the early postoperative period is still a vulnerable stage during which clear-corneal incisions (CCIs) can briefly demonstrate structural defects that may to a certain degree compromise the integrity of the wound and even cause to a minimal extent an increase in the risk of infectious endophthalmitis [1-3]. CCIs are being favored by surgeons because they are quick to perform, result in little bleeding, and allow for quick visual rehabilitation, but on the other side their use has been pointed out by multiple clinical and laboratory reports that highlight their drawbacks. Case-control data tie CCIs (as opposed to scleral tunnels) to the higher likelihood of acute postoperative endophthalmitis, and as to experimental models, they reveal that extraocular fluid can be sucked into unsutured CCIs under external forces or pressure fluctuations [4-8]. Anterior-segment OCT (AS-OCT) studies in the immediate postoperative period report temporary defects—epithelial gaping, Descemet membrane detachment (DMD), endothelial gaping/misalignment, and loss of coaptation—that mirror diminished sealing in some eyes [9]. Mechanical forces can aggravate this temporary instability. Classic manometry illustrates that eyelid squeezing can dramatically raise intraocular pressure (IOP), and speculum removal or early blinking may change the shape of a fresh CCI. These motions create a feasible path for micro-suction of tear film polluting substances into the anterior chamber when a wound is not properly sealed [10]. In accordance with this, OCT studies have proved that the condition of the wound and the details of the construction of the wound influence the early CCIs architecture [11]. With this situation, the use of postoperative eye protection has been proposed so as to "quiet" the wound through the first postoperative day(s). Randomized evidence suggests that a postoperative patch (compared to shield/instant vision) application leads to a reduction of epithelial gaping on day 1—an anatomical surrogate for improved wound integrity—without significant varying in other defects by day 7 [12]. A broader clinical literature comparing patching with “instant vision” implies that while final acuity and inflammation are comparable, patched eyes undergo less severe early symptoms (pain/foreign-body sensation) and more stable tear film during the first hours after surgery—factors that may protect the wound from blink-related shear [13]. A recent systematic review of postoperative eye protection methods (patch, shield, bandage, instant vision) came to the conclusion that generally patients prefer some form of protection and report fewer early symptoms with a bandage strategy. Although high-quality data on "hard" endpoints (for example, culture-positive endophthalmitis) are still scarce because of the rarity of the event, the symptomatic and architectural advantages give ground to the reasoning in favor of short-term protection [14]. Of particular importance is the fact that adherent ocular bandages and other protective measures have been considered as practical, low-cost ways to reduce the stress on the wound during the short period when CCIs are the most unstable (1,2). The two-day postoperative patching made it possible to extend this protection beyond the first 18–24 hours which were the duration assessed in previous randomized trials. The potential benefits are clear-cut: (1) protecting the wound from unintentional rubbing and blink shear while the epithelial continuity is being re-established, (2) lessening IOP spikes from lid squeezing during sleep, and (3) minimizing exposure to tear-film contaminants until stromal/coaptation stability is established. Each of these mechanisms is biologically plausible given the recorded IOP surges with eyelid squeeze, the OCT-documented early wound defects, and laboratory demonstrations of fluid ingress through incompletely sealed CCIs under external manipulation [15]. These potential benefits are offset against practical considerations: the eye is patched and hence its early visual function is affected, and some regimens may make immediate drop administration harder. However, randomized data show no deficits in early acuity or inflammation when short-term patching is applied, and patients' feedback often leans towards protection on account of less discomfort. In resource-limited environments— where hygiene, self-care, and follow-up may be inconsistent— it can be a reasonable, low-cost strategy to prioritize wound protection during the most dangerous period [12]. Accordingly, this study measures the safety of two-day postoperative patching without eye drops following cataract surgery, concentrating on endophthalmitis incidence and early anterior-segment stability. By locating two-day patching amidst the continuum of evidence—from OCT-based wound biology to randomized patching trials and patient-reported outcomes—we hope to determine whether extending protection beyond the first postoperative day carries more safety without the recovery being affected. This study was designed to evaluate the safety of two-day postoperative patching without eye drops following cataract surgery and its relationship to endophthalmitis and anterior chamber stability. The analysis was performed retrospectively over an eight-year period in Baghdad, Iraq.

Patients and Methods

Methods

Study Design and Setting: This retrospective, descriptive clinical study was conducted over 18 months at two tertiary ophthalmic centers in Baghdad, Iraq: Al-Kindy Teaching Hospital and Imam Ali Teaching Hospital. All procedures adhered to the Declaration of Helsinki and were approved by the local institutional review boards of both centers.

Participants

We reviewed 120 consecutive patients (120 eyes) who underwent cataract extraction with posterior chamber intraocular lens (PCIOL) implantation using one of the following standard techniques: phacoemulsification with clear-corneal incision (CCI), manual small-incision cataract surgery (MSICS), or extracapsular cataract extraction (ECCE).

Inclusion Criteria

• Age 30–80 years

• Uneventful cataract extraction via CCI or scleral tunnel

• Availability of complete postoperative follow-up for at least two weeks (with scheduled follow-up detailed below)

Exclusion Criteria

• Immunocompromised status (e.g., poorly controlled diabetes mellitus, autoimmune disease, chronic systemic corticosteroid use)

• Intraoperative scenarios necessitating anterior chamber intraocular lens (AC-IOL) implantation

• Note: The previously drafted exclusion related to “mycotic intraocular procedures (e.g., trabeculectomy, vitrectomy) within the last 6 months” was removed per the updated protocol

Surgical Technique

All surgeries were performed by experienced ophthalmic surgeons under local peribulbar anesthesia with strict aseptic technique. Preoperative preparation included periocular scrubbing with 10% povidone-iodine and 5% povidone-iodine instilled into the conjunctival sac for ≥3 minutes before incision.

• Phacoemulsification: self-sealing CCI 2.8–3.0 mm, continuous curvilinear capsulorhexis, nucleus emulsification, and implantation of a foldable acrylic PCIOL in the capsular bag.

• MSICS/ECCE: scleral tunnel incision, manual nucleus extraction, and PMMA PCIOL implantation.

• Wound closure: hydration of the stromal lips to achieve watertight self-sealing; no sutures used in CCI cases

Perioperative Prophylaxis

At the end of surgery, all eyes received subconjunctival gentamicin 20 mg/mL (0.5 mL) and dexamethasone 4 mg/mL (0.5 mL).

Immediate Postoperative Protection and Medications

The operated eye was covered with sterile gauze and a rigid protective shield for a continuous 48 hours, with no topical drops or ointments during this period to avoid contamination and to support epithelial healing. After patch removal under sterile conditions, a comprehensive slit-lamp examination was performed. Subsequently, tobramycin–dexamethasone eye drops were prescribed QID for two weeks, tapered according to clinical response.

Follow-up schedule (updated)

Patients were examined at Day 1, Week 1, Week 3, and Week 6. Each visit included:

• Uncorrected and best-corrected distance visual acuity (UDVA/CDVA)

• Corneal clarity and edema

• Anterior chamber (AC) reaction (cells/flare/fibrin)

• Wound stability/leak assessment and intraocular pressure (IOP)

• Clinical signs suggestive of infection (pain, redness, photophobia, vitreous haze)
  Eyes with suspected endophthalmitis underwent aqueous/vitreous sampling for microbiological culture and sensitivity

Outcomes

• Primary outcome: Safety, defined as the incidence of culture-positive endophthalmitis

• Secondary outcomes: Early anterior segment stability (corneal edema, shallow AC, wound leak) and trajectory of visual recovery (BCVA) through Week 6

Data Management and Statistical Analysis

Demographic, surgical, and postoperative data were tabulated in Microsoft Excel and analyzed using SPSS v25.0. Variables are summarized as counts and percentages; complication rates and visual outcomes were reported descriptively in line with the study’s retrospective design.

Table 1 illustrates the demographic characteristics of the 120 patients who underwent cataract surgery in this study. The sample included 72 males (60.00%) and 48 females (40.00%), indicating a male predominance among the operated cases. This finding aligns with other regional studies suggesting that men are more likely to seek or access surgical care for visual impairment compared to women, possibly due to social, occupational, or cultural factors. The majority of patients (91.66%) were older than 40 years, with the highest proportions in the 40–60 years and above 60 years groups (45.83% each). This distribution reflects the well-established association between cataract formation and aging, as lens opacification increases progressively with age due to cumulative oxidative stress and metabolic changes in lens proteins. The relatively small proportion of patients under 40 years (8.33%) likely represents cases of secondary or congenital cataract.

Table 1: Demographic Distribution of Patients

Table 2 demonstrates the distribution of patients according to the surgical technique used. The majority of cases (79.17%) were managed by phacoemulsification with sutureless clear corneal incision, reflecting the widespread adoption of modern, minimally invasive cataract surgery techniques that promote faster recovery, reduced postoperative inflammation, and minimal induced astigmatism. Manual small-incision cataract surgery (MSICS) accounted for 15.00% of cases, typically employed in patients with advanced lens opacities, hard nuclei, or in situations where phacoemulsification resources or equipment may be limited. Extracapsular cataract extraction (ECCE) was performed in only 5.83% of cases, reserved for complicated cataracts, dense lenses, or when posterior capsule integrity was at risk.

Table 2: Distribution by Surgical Technique

Table 3 summarizes the systemic and ocular risk factors observed among the study population. Diabetes mellitus was the most prevalent comorbidity, affecting 35.00% of patients, which is consistent with the known high incidence of cataract formation among diabetic individuals due to chronic hyperglycemia and oxidative stress leading to lens protein glycation. Hypertension was identified in 25.83% of cases, a common systemic condition in the elderly that may indirectly influence ocular health by affecting microvascular circulation. Treated adnexal infections, such as blepharitis, conjunctivitis, or dacryocystitis, were reported in 7.50% of patients, all of whom underwent adequate preoperative management to minimize postoperative complications, particularly the risk of endophthalmitis. Notably, 31.67% of patients had no identifiable systemic or ocular risk factors, representing otherwise healthy individuals undergoing surgery for age-related cataract.

Table 3: Systemic and Ocular Predisposing Factors

Table 4 presents the intraoperative findings observed during cataract surgeries. The vast majority of cases (89.17%) were uneventful, reflecting a high level of surgical proficiency and adherence to standard aseptic and operative protocols. Posterior capsule rupture with or without vitreous loss occurred in 6.67% of patients, representing the most frequent intraoperative complication. This rate is within the acceptable international range for cataract surgery and typically results from hard or dense nuclei, poor pupillary dilation, or inadvertent stress during phacoemulsification. Iris prolapse or wound leakage was observed in 2.50% of cases, usually associated with high intraocular pressure during surgery or inadequate wound construction, both of which were managed successfully without long-term consequences. Prolonged operative time exceeding 30 minutes was recorded in only 1.67% of cases, indicating efficient surgical performance.

Table 4: Intraoperative Observations

Table 5 illustrates the early postoperative clinical findings observed within the first 48 hours after cataract surgery, prior to the removal of the protective eye patch. The majority of patients (93.33%) exhibited normal healing with clear corneas and stable anterior chambers, reflecting effective wound protection and infection control during the initial recovery period. Mild corneal edema was noted in 4.17% of cases, a common transient finding following phacoemulsification due to endothelial stress or intraoperative fluid turbulence, which typically resolves spontaneously within a few days. Shallow anterior chamber was observed in 1.67% of patients and was attributed to early postoperative wound instability or minor leakage, both of which improved after patch removal and topical therapy initiation. Only 0.83% of cases demonstrated mild subconjunctival hemorrhage, a benign and self-limiting condition associated with subconjunctival injection or minor trauma.

Table 5: Early Postoperative Findings (First 48 h before Patch Removal)

Table 6 highlights the incidence of postoperative endophthalmitis, the most serious complication following cataract surgery. Among the 120 operated eyes, no confirmed cases of endophthalmitis (00.00%) were detected, demonstrating excellent infection control and the safety of the two-day postoperative patching protocol. Only one case (00.83%) showed mild postoperative inflammation that clinically mimicked early infection; however, microbiological cultures were negative, confirming a sterile reaction rather than a true infective process. The complete absence of endophthalmitis underscores the effectiveness of the intraoperative prophylactic measures, including meticulous aseptic technique, periocular preparation with povidone-iodine, and subconjunctival antibiotic–steroid injection at the end of surgery. Furthermore, maintaining the eye under a two-day protective patch likely minimized the entry of pathogens during the vulnerable early postoperative phase.

Table 6: Incidence of postoperative endophthalmitis

Table 7 presents the best-corrected visual acuity (BCVA) of patients two weeks following cataract surgery. The results show that 97 patients (80.83%) achieved excellent postoperative vision between 6/6 and 6/12, indicating successful restoration of visual function in the majority of cases. This high proportion reflects effective surgical technique, stable wound healing, and the absence of major postoperative complications such as infection or significant corneal edema. Eighteen patients (15.00%) attained moderate visual improvement (6/18–6/36), mainly due to preexisting ocular conditions such as diabetic retinopathy, age-related macular changes, or mild residual corneal edema that typically improve with further follow-up. Only five patients (04.17%) recorded poor visual outcomes (<6/60), primarily related to preexisting retinal pathology or intraoperative complications like posterior capsule rupture.

Table 7: Visual Outcomes at two Weeks

Table 8 compares the outcomes of the current study’s two-day patching protocol with data reported in the literature for one-day patching following cataract surgery.

The findings clearly demonstrate that two-day patching offers comparable or superior safety and comfort profiles. The incidence of endophthalmitis was 00.00%, notably lower than the 00.10–00.30% reported in most published series using single-day patching, suggesting that prolonged wound protection during the early healing phase may further minimize infection risk. The occurrence of shallow anterior chamber (01.67%) and wound leakage (00.00%) was also lower compared to the one-day patching reports (04.00–06.00% and 01.00–02.00%, respectively), emphasizing the mechanical stability achieved by extended patching. Patients also reported a higher level of comfort and reduced postoperative inflammation, likely due to minimized ocular exposure and disturbance during the first 48 hours. Overall, these comparative outcomes support that two-day postoperative patching is a safe, effective, and patient-friendly strategy that enhances early wound healing and provides additional protection against postoperative complications without compromising visual recovery.

Table 8: Comparison of Outcomes with Literature (Two-Day vs. One-Day Patching)

The current experiment measured the risk and clinical outcomes of two-day covering after cataract operation and exhibited amazing visual result, low complication rates, and not a single case of culture-proven endophthalmitis. The findings assured that a short time of protective covering won't elevate the risk of postoperative infection and even, might support early wound stability and healing more than shorter or no-patching protocols. The male patient group was 60.00% of the total in this trial, which is consistent with the male-female ratio given in regional ophthalmic surgery cohorts, where men are usually more likely to choose surgical treatment by reason of the factors like occupation or socio-cultural accessibility [1]. The age distribution also indicates a strong correlation between cataracts and older age, as more than 90% of the patients were over 40 years. The reason for this is the oxidative stress that finally results in the cumulative damage of lens proteins and cataract formation over time [2]. The majority of surgeries were carried out by sutureless phacoemulsification (79.17%) correlating to the worldwide trend towards micro-incision cataract surgery which not only quickens rehabilitation but also changes astigmatism to a negligible extent ⁿ⁵⁾. In fact, nearly 90% of surgeries went without any remarkable occurrences, while the few incidents like posterior capsule rupture (6.67%), which were regarded as minor surgical complications, were within the internationally acceptable limits (4–8%)[4]. The very low rates of both wound leakage (2.50%) and prolonged surgery time (1.67%) are indicative of very careful surgical practice and strict adherence to hygiene protocols such as using periocular povidone-iodine, intraoperative sterilization, and administering subconjunctival gentamicin–dexamethasone [5]. It has been demonstrated that the combination of these infection-prevention measures can effectively cut the risk of endophthalmitis by half if they are properly applied [6]. The early evaluation of the postoperative period revealed normal healing in 93.33% of the patients with just corneal edema (4.17%) or anterior chamber depth reduction (1.67%) which mostly is routed to light effects from phaco fluidics or temporary wound hydration. These non-callow changes usually disappear within days following the normalization of corneal pump function [8] uras. On the other hand, no leaking of the incisions or hypotony were seen, thus supporting the claim that the two-day patching time offered sufficient mechanical protection during the most critical period of incision healing. In one way, our results confirm those of Ho et al., who in randomized trials, proved that postoperative patching for about 18 hours significantly lowered the amount of epithelial gaping at day one compared to eyes that were under clear shields [9]. The authors mentioned that better coaptation of the wound and less trauma of the epithelium were seen in eyes that had a patch on them. Likewise, Calladine and Packard showed that the early postoperative instability of the clear corneal incisions is a common phenomenon and pointed out that this is due to the fact that the first 24-48 hours are critical and require mechanical protection, which can also reduce the ingress of tear-borne contaminants [10]. OCT-based research has also backed this up showing that clear corneal incisions do have epithelial and endothelial gaping, DMD, and misalignment right after surgery, with most of it being resolved by the start of the first postoperative week [11-12]. These temporary defects in structure act as potential pathways not only for pathogens but also for fluctuations in intraocular pressure (IOP). Keeping the eyelids off and preventing blinking-induced stress during this early phase could thus reduce the anterior chamber contamination risk [13]. The present work did not detect any of the cases of endophthalmitis following the operation (0.00%), revealing a very different situation from published incidence rates of 0.05-0.3% in extensive cataract series studies [14-15]. It has been established in multiple studies that by using povidone-iodine for antisepsis together with intracameral or subconjunctival antibiotics, the microbial colonization of ocular surface and conjunctival sac is reduced dramatically [16-17]. By ensuring that the incision is kept closed for the first two days, we have most likely reduced the chances of the self-sealing clear cornea incision getting exposed to environmental flora. Advocates for the “No Stitch No Patch” method, claim that the skipping of occlusion will hasten the visual recovery, and dropping the eye drops will be easier; nonetheless, meta-analyses show that there is not a significant difference in the infection rates of the shielded and the patched eyes [18]. On the contrary, Honda et al. and Stifter et al. proved that the use of temporary patching is associated with fewer early pain scores, less discomfort due to light, and overall better patient comfort, without delaying the visual rehabilitation process [19-20]. Our clinical observations are in line with these results; none of our patients complained of discomfort or experienced delayed healing during the occlusion period of 48 hours. Histological and biomechanical studies have shown that the healing of the epithelium is very important in order for the wound to be impermeable to pathogens [21]. The occlusive patch most probably acts as a temporary ocular bandage, preventing eyelid friction and microtrauma, and on top of that, keeping a humid microenvironment conducive to epithelial regeneration [22]. Furthermore, the patch may have reduced lid squeezing during sleep which is known to cause transient IOP spikes of more than 60 mmHg, and hence the patch may have also prevented wound deformation and leakage during this time [23]. Wound healing has been great, since no leaks have been reported which corresponds with the conclusion of Calladine and Tanner that stromal hydration allows for more cooperation of the wound lips as it increases tunnel thickness [24]. Our protocol was such that it contained both—stromal hydration and early occlusion, which could have led to a synergistic effect. Among the patients, there were diabetic individuals that comprised 35% of the group but no delayed healing or poor wound condition was observed. The above finding corroborates Ho et al. report that diabetes status has no effect on CCI healing provided blood sugar control is proper [9]. The reason is that although hyperglycemia is associated with poor adhesion of corneal epithelium as a result of accumulation of advanced glycation end-products [25], taking short term protective measures like patching might help cover the subtle healing deficits in diabetic eyes. At the two weeks’ time, 80.83% of the people reached BCVA which was between 6/6 and 6/12 thus confirming that the two-day patching regime doesn't prohibit visual rehabilitation. Studies with shield-only regimens reported similar visual recovery rates [18,26]. The good results seen in this study point out that a limited, controlled occlusion is adequate for wound protection and still keep the benefits provided by modern cataract surgery. The comparison with literature (Table 8) also intimates about the possibility of two-day patching to diminuate the incidence of shallow anterior chamber (1.67% vs. 4–6%) and to enhance patient comfort as compared to one-day patching. Though additional randomized studies are required to substantiate these benefits, our findings advocate the view that a 48-hour patching period is both safe and effective, especially for sutureless corneal incisions and eyes at a higher risk of mechanical stress and contamination.

To sum up, this investigation endorses the safety and potential benefits of the two-day postoperative patching after cataract surgery. It brings about a better wound protection during the critical early healing phase, without the risk of infection nor postponed recovery. In settings with low resources or this is the case with high-volume surgical procedures where patient compliance and postpartum hygiene might be poor, extending the patching period to 48 hours can be a practical and inexpensive adjunct to the existing prophylactic measures. Prospective trials using AS-OCT analysis and microbial surveillance are recommended to further characterize the patching duration and its role in modern cataract surgery care.

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