Prophylactic treatment of intraocular pressure elevation after uncomplicated cataract surgery in nonglaucomatous eyes - a systematic review

Prophylaxis against intraocular pressure spikes following uncomplicated phacoemulsification: a systematic-review and meta-analysis

BACKGROUND

To investigate the effect of perioperative intraocular pressure (IOP) lowering medications on controlling postoperative IOP following uncomplicated phacoemulsification.

METHODS

Ovid MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched up until November 2022. Randomised controlled trials (RCTs) that assessed IOP change via applanation tonometry in medicated and control arms following uncomplicated cataract surgery in healthy eyes were included. The primary outcome was the weighted mean difference (WMD) of IOP at 2-8 h, 12-24 h, and 1-7 days postoperatively within each medication class or common fixed-combination formulations. Risk of bias was assessed using the revised risk of bias in randomised trials (RoB-2). Level of evidence was rated using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) RESULTS: From 702 screened articles, 30 RCTs involving 2986 eyes were included. There was a statistically significant reduction in IOP favouring treatment arms at 2-8 h (WMD = -3.87 mmHg; 95% CI [-4.75, -3.00]; p < 0.001) and 12-24 h (WMD = -2.69 mmHg; 95% CI [-3.36, -2.02]; p < 0.001), with the effect wearing off beyond 1 day (p = 0.18). Between medication classes, the largest effect at both 2-8 h and 12-24 h was observed with intracameral cholinergics or fixed-combination carbonic anhydrase inhibitor-beta-blocker (FCCB) formulations. Conversely, the smallest effect was observed with prostaglandin analogues, alpha-agonists, and topical carbonic anhydrase inhibitors (CAIs).

CONCLUSION

Prophylaxis against acute IOP elevations following uncomplicated cataract surgery is effective. FCCB and intracameral cholinergics are the most effective ocular antihypertensive agents, while alpha-agonists, prostaglandin analogues, and topical CAIs were found to be the least effective. These findings may inform future surgical guidelines.

Post-operative Day Zero Versus Day One Follow-Up for Uncomplicated Cataract Surgery

Purpose

To compare the postoperative outcomes and management of uncomplicated cataract surgery seen on postoperative day 0 (POD0) versus postoperative day one (POD1). 

Methods

A retrospective cohort study of patients who followed up within 0-14 days of their uncomplicated surgery (current procedural terminology code 66984) from December 2018 to March 2020. Those who had perioperative complications, those who had combined glaucoma filtering surgery as well as other minimally invasive glaucoma surgery (MIGS) procedures, and those who did not complete their first two follow-up visits within 14 days of their surgery were excluded. Visual acuity (VA), intraocular pressure (IOP), post-operative interventions, and complications of the first and second postoperative visits were collected.

Results

Of the 665 participants studied, the mean (standard deviation) age was 68 (11) years old and 60% were female (n=304) with a mean (SD) pre-op logarithm of the minimum angle of resolution (logMAR) VA of 0.715 (0.625). About one-third (32%) of patients were seen on POD0. Compared to POD1, a higher percent of patients with glaucoma were seen POD0 (23% vs 14%; p = 0.008). The mean VA on POD0 was 0.840 (0.653), which was significantly worse than the mean VA of 0.539 (0.599) on POD1 (p<0.0001). There was no significant difference in VA by the second post-op visit. IOP did not significantly differ between POD0 and POD1 groups at the first post-operative visit. The most common changes in the post-operative drop regimen were related to IOP and inflammation control. The rate of interventions did not significantly differ between groups (p>0.1). Patients who received intervention on POD0 were not seen significantly sooner at the next follow-up visit compared to those seen on POD0 without undergoing an intervention. The incidence of an IOP spike greater than 30mmHg on POD0 or POD1 was not significantly different between patients with and without underlying glaucoma (overall p = 0.2020; with glaucoma p= 0.1238; without glaucoma p=0.999). Those with a history of glaucoma were not more likely to receive intervention to lower IOP on POD0 versus those seen on POD1 (p = 0.999). 

Conclusion

It can be difficult to evaluate patients the day after their uncomplicated cataract surgery, and it is difficult to predict which patients may have post-operative complications. Our study shows no significant changes in management for patients seen on POD0 compared to POD1. Surgeons can expect significantly better visual acuity on POD1, but otherwise, post-operative outcomes were similar between patients seen on POD0 and those seen on POD1. Surgeons may offer the option of a POD0 visit for patients who underwent uncomplicated cataract surgery.

Cystoid macular edema related to cataract surgery and topical prostaglandin analogs: Mechanism, diagnosis, and management

Cystoid macular edema (CME) is a form of macular retina thickening that is characterized by the appearance of cystic fluid-filled intraretinal spaces. It has classically been diagnosed upon investigation after a decrease in visual acuity; however, improvements in imaging technology make it possible to noninvasively detect CME even before a clinically significant decrease in central vision. Risk factors for the development of CME include diabetic retinopathy, retinal vein occlusion, uveitis, and cataract surgery. It has been proposed that eyes with elevated intraocular pressure after cataract surgery, including those treated with prostaglandin analog eye drops, may be at higher risk for the development of CME. We summarize the current knowledge of the molecular mechanisms underlying CME, the potential role of ocular surgery and topical glaucoma medication in increasing the risk of CME, the newly developed imaging methods for diagnosing CME, and the clinical management of CME.

Cataract surgery and intraocular pressure in glaucoma

PURPOSE OF REVIEW

To review the current literature on the relationship between cataract extraction and intraocular pressure (IOP).

RECENT FINDINGS

Cataract extraction can be an effective IOP lowering treatment for open and closed angle glaucoma as well as ocular hypertension. In comparative trials studying novel micro-invasive glaucoma surgeries in open angle glaucoma, the control group undergoing cataract extraction alone routinely achieved significant reductions in IOP and medication use postoperatively. Data from the Effectiveness in Angle Closure Glaucoma of Lens Extraction (EAGLE) trials have demonstrated that lens extraction is more effective at lowering IOP than peripheral iridotomy in patients with angle closure and should be considered as first line therapy. Additionally, patients in the ocular hypertension treatment study who underwent cataract extraction over the course of follow-up demonstrated significant IOP lowering sustained over 3 years.

SUMMARY

Cataract extraction is an effective method to lower IOP in patients with glaucoma. Pressure lowering is more significant in eyes with narrow angles and those with higher baseline IOP levels. In eyes with angle closure, phacoemulsification alone can lower IOP, but when combined with GSL it may be even more effective. Recent large multicenter randomized trials have further elucidated the benefit of standalone cataract extraction to treat mild to moderate primary open angle glaucoma. Prospective and longitudinal studies that systematically investigate the variables that may influence degree and duration of IOP lowering post cataract extraction are lacking.