REVIEW

CURRENT
OPINION The effect of cataract extraction on intraocular
pressure
Mark A. Slabaugh and Philip P. Chen

Purpose of review
To examine the current literature covering the long-term effect of cataract extraction on intraocular pressure
(IOP).
Recent findings
As a result of the high rate of cataract surgery, the impact on IOP continues to be the subject of multiple
studies in different populations. Recent publications include those that distinguish patients with open angles
from those with more narrow angles, as well as prospective analyses that address the impact of regression
to the mean and other types of bias on the effect of postoperative IOP lowering.
Summary
There are sufficient data to suggest that cataract surgery provides a lowering effect on IOP in the long
term. This effect appears to be proportional to preoperative IOP. Eyes with higher preoperative IOP
have the greatest average lowering, whereas eyes with IOP in the lower range of statistically normal tend
to have an IOP that is unchanged from baseline or even higher following cataract surgery. In patients with
narrow angles, the IOP-lowering effect appears to also be proportional to the degree of anterior chamber
deepening induced by cataract surgery.
Keywords
cataract surgery, glaucoma, intraocular pressure, narrow angles

INTRODUCTION CATARACT SURGERY IN EYES WITH

Intraocular pressure (IOP) remains the only known OPEN ANGLES
modifiable risk factor in the management of glau- The evolution from intracapsular cataract extrac-
coma and is well recognized as a primary risk factor tion (ICCE) to extracapsular cataract extraction
for the development and progression of glaucoma. (ECCE) and later to scleral tunnel and clear corneal
Long-term beneficial effects of cataract surgery on phacoemulsification makes it difficult to pinpoint
IOP have been reported for many years, and this when the long-term effect of surgery on IOP was first
subject has particular relevance for patients who noted. Bigger and Becker [2] reported lower IOP after
have glaucoma or are considered to be at risk for uncomplicated cataract extraction in glaucoma
developing glaucoma. Cataract surgery remains one patients using ICCE in the early 1970s. Hansen
of the most common surgical procedures performed, et al. [3] later published the effects of ECCE with
with approximately 3 million per year in the USA posterior chamber intraocular lens (PCIOL), a pro-
alone [1]. Even a small effect on IOP from cataract cedure with postoperative anatomic resemblance to
surgery could potentially modify the population current cataract surgery, and noted a significant
glaucoma risk in a significant way. decrease in IOP 4 months after surgery. In 1992,
At the individual patient level, the effect of
cataract extraction or lensectomy on IOP might Department of Ophthalmology, University of Washington, Seattle,
result from a number of factors, as recent publi- Washington, USA
cations have attempted to identify. Preoperative Correspondence to Mark Slabaugh, MD, Box 359608, 325 Ninth Ave,
IOP, ocular biometry, angle configuration, lens posi- Seattle, WA 98104 2499, USA. Tel: +1 206 744 2020; fax: +1 206 685
tion and anterior segment pathologies such as pseu- 7055; e-mail: [email protected]
doexfoliation or pigment dispersion should guide Curr Opin Ophthalmol 2014, 25:122–126
patient counseling and surgical planning. DOI:10.1097/ICU.0000000000000033

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 Cataract extraction effect on intraocular pressure Slabaugh and Chen

postoperatively, the cataract extraction-alone group

KEY POINTS had a mean IOP reduction of 8.5 mmHg, with 35%
 IOP prior to cataract surgery is the strongest predictor of patients having restarted ocular hypotensive
of postoperative IOP-lowering. medications. At 2 years postoperatively, the cataract
extraction-alone arm had a sustained mean IOP
 In patients with narrow angles, cataract surgery is likely reduction of 7.4 mmHg, whereas the mean number
to lower IOP in proportion to the change in anterior
of medications increased slightly [10]. The absolute
chamber volume and depth.
IOP reduction in this study was somewhat greater
 In patients with low IOP prior to cataract surgery, than that seen by other authors, but was con-
additional lowering should not be expected and some founded by the fact that patients were allowed to
of these patients may have a higher IOP after restart medications to maintain an IOP less than
cataract surgery.
21 mmHg.
&&
A publication by Yang et al. [11 ] reported on a
trial which prospectively evaluated 999 patients
who underwent uncomplicated phacoemulsifica-
Steuhl et al. [4] noted a similar outcome in patients tion and had statistically normal preoperative IOP
with and without glaucoma undergoing ECCE/ with postoperative IOP measured at 3 months. They
PCIOL and hypothesized that this effect was due found a proportional effect to the IOP-lowering after
to a widening of the angle, which they measured cataract surgery when they stratified into five groups
using laser tomography. Suzuki et al. [5] described based on preoperative IOP. They also reported on
the effects of cataract extraction by phacoemulsifi- the IOP of the fellow nonoperative eyes and showed
cation with PCIOL on IOP in 1994 and also noted that the IOP in those eyes was unchanged after
that this effect appeared to be proportional to the surgery, which suggests that the IOP-lowering
level of preoperative IOP. A later publication by detected was not due to a statistical phenomenon.
the same authors described the 10-year IOP results The biological basis for a proportional IOP-low-
of the same procedure and noted that there was a ering effect from cataract surgery in patients with
proportional effect on IOP: those having the highest open angles is not clear. Poley et al. [12] proposed
preoperative IOP experienced the most postopera- ‘phacomorphic ocular hypertension’ as a new term
tive lowering, whereas those with a low preoperative to describe a continuum of lens-induced elevated
IOP frequently had a higher postoperative IOP [6]. IOP which may be reversed by lensectomy. A
These early studies recognized several key find- possible mechanism for this phenomenon, as pro-
ings that have been reproduced in more recent posed by Johnstone [13], is that the anterior lens
studies. First, the effect on IOP in patients with open zonules are unable to maintain posterior traction on
angles appears to be proportional to the level of the scleral spur as the lens increases in antero-
preoperative IOP. This proportional effect on IOP posterior dimensions throughout life, thus resulting
has led to some confusion as to whether this finding in decreased outflow facility. The strength of this
might in fact be due to regression to the mean [7]. hypothesis is that it does not require iris interference
However, several recent studies suggest that the IOP with the trabecular meshwork in these patients
effect is a true finding and not due to statistical error. with open angles. Rather, it suggests a mechanical
A report derived from a post-hoc analysis of patients effect modulated through scleral spur position and
in the Ocular Hypertension Treatment Study (OHTS) zonular tension: small anatomic changes that may
demonstrated that the patients who underwent go undetected even with sophisticated anterior seg-
cataract extraction had proportional IOP-lowering ment imaging.
&&
[8 ]. The OHTS had several measures in place to The relationship between cataract surgery and
prevent regression to the mean such as multiple IOP appears complex when preoperative IOP is in
preoperative and postoperative IOP measurements the statistically normal range. Poley et al. demon-
performed according to strict guidelines using strated that whereas approximately 55% of patients
calibrated equipment. with preoperative IOP between 15 and 17 mmHg
A recent randomized prospective trial designed had a lower IOP after cataract surgery, 30% had a
to evaluate the effect of a trabecular bypass stent higher postoperative IOP, and the remainder were
placed at the time of phacoemulsification versus unchanged. In the group with preoperative IOP
phacoemulsification alone provides additional evi- below 15 mmHg, this proportion switched, with
dence for this finding [9,10]. Enrolled patients approximately 55% of patients having a higher post-
&&
underwent medication washout prior to surgery, operative IOP and 35% having a lower IOP [11 ].
and the subsequent mean preoperative IOP of This finding was replicated in the study by Yang
&&
25 mmHg was similar in both groups. At 1-year et al. [11 ], although the point of reversal at which

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 Glaucoma

IOP became higher after phacoemulsification elevated IOP, the level of IOP-lowering after cataract
occurred at a lower IOP [10]. One might expect that surgery is proportional both to the preoperative IOP
if the IOP-lowering effect of cataract surgery was due and to the resultant angle widening [18–20]. Thus,
solely to an anatomical and mechanical change, patients with the narrowest angles preoperatively
patients with low IOP preoperatively would be might be expected to benefit the most from cataract
expected to have a less robust IOP effect or no extraction as a single procedure, provided the angle
change rather than an elevation. has not become permanently closed with peripheral
An alternatively proposed mechanism for the anterior synechiae.
&
IOP-lowering after cataract extraction in patients A recent publication by Huang et al. [21 ]
with open angles is that trabecular endothelium is showed that preoperative lens vault as measured
remodeled in response to stress from ultrasonic by anterior segment optical coherence tomography
vibrations during phacoemulsification [14]. A (AS-OCT) was correlated with IOP reduction,
related hypothesis that has not been investigated although lens thickness was not evaluated. The
&&
is that the trabecular endothelium undergoes stress- previously noted publication by Yang et al. [11 ]
induced remodeling in response to the supra- showed that in addition to preoperative IOP, change
physiologic IOP that is experienced by the anterior in IOP after cataract surgery was proportional to lens
segment during routine phacoemulsification [15,16]. thickness as well as changes in anterior chamber
These hypotheses are inadequate as a comprehensive area and in degree of angle opening as evaluated by
explanation, given that the first studies to report IOP- AS-OCT. Although that study did not specifically
lowering after cataract surgery were on patients evaluate or stratify patients by angle anatomy, other
undergoing ICCE or ECCE rather than phacoemulsi- researchers have shown in an Asian cohort that the
fication [2–4]. More work is required to elucidate the increase in anterior chamber depth following cata-
pathophysiology of this frequently observed pheno- ract surgery is inversely proportional to preoperative
menon. anterior chamber depth in patients with occludable
The patients who arguably stand to benefit the angles prior to surgery [22]. Investigators’ use of
most from lensectomy as an IOP-lowering procedure anterior segment imaging to describe several pro-
are also those who are most difficult to study, perties of the iris, angle anatomy and lens charac-
namely those with known glaucomatous optic teristics (vault and thickness) could assist in
neuropathy. As previously mentioned, most of predicting which patients are the most likely to
these patients are already taking IOP-lowering medi- benefit from cataract surgery in terms of IOP-low-
&&
cations. In the trabecular micro-bypass stent ering [11 ,20,23].
studies, patients underwent medication washout It is important to note that although these
and showed a large subsequent decrease in IOP after studies evaluated patients with narrow angles, they
phacoemulsification alone. However, applying this did not include patients with primary angle closure
methodology clinically to obtain the maximum or angle closure glaucoma. Gonioscopy remains
IOP-lowering effect of cataract surgery in glaucoma indispensable in successfully identifying these
patient would be inadvisable. A recent study evalu- patients, whereas AS-OCT may provide additional
ating open angle glaucoma patients considered to be objective data about angle morphology.
medically controlled prior to cataract extraction Two recently published randomized trials com-
found that the preoperative IOP was the strongest paring surgical approaches in patients with chronic
predictor of postoperative IOP change [17]. Notably, angle closure have clarified treatment guidelines for
38% of patients had worsened IOP control after eyes that do have synechial closure of the angle or
phacoemulsification, which is in line with the eyes with appositional closure in the presence of a
&
findings of Poley et al. in untreated patients with patent laser iridotomy [24 ,25]. In the first group,
statistically normal preoperative IOP. Interestingly, patients whose IOP was controlled to 21 mmHg
patients with increased preoperative anterior or less with medical therapy were randomized to
chamber depth received the greatest benefit in phacoemulsification or combined phacotrabeculec-
IOP reduction from phacoemulsification. tomy. The authors found that patients undergoing
combined surgery had a decreased requirement for
IOP-lowering medication postoperatively, but con-
CATARACT SURGERY IN EYES WITH cluded that the marginal improvement in IOP con-
NARROW ANGLES trol did not warrant the additional surgical risk of a
The IOP effect of cataract surgery in patients trabeculectomy. Of note, only 1 out of 35 patients
with narrow angles is a subject of recent clinical (2.9%) in the phacoemulsification-alone group
research and interest. Early reports have suggested went on to require trabeculectomy during the
that in patients with narrow angles with or without follow-up period of 2 years.

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 Cataract extraction effect on intraocular pressure Slabaugh and Chen

In the second trial, patients whose IOP could Conflicts of interest

not be medically controlled were randomized to Financial support: Unrestricted departmental grant from
phacoemulsification alone or trabeculectomy alone. Research to Prevent Blindness.
The authors demonstrated that there was significant No conflicting relationship exists for any author.
IOP-lowering after phacoemulsification alone, but
that 73% of patients in that arm of the study
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