Prophylaxis Against Intraocular Pressure Spikes Following Uncomplicated Phacoemulsification: A Meta-Analysis

Author Block: Ali Salimi 1, Raageen Kanjee 2, Marko Popovic 3, Cindy Hutnik4, Iqbal Ike Ahmed 3,
Hady Saheb 1. 1McGill University, 2University of Manitoba, 3University of Toronto, 4Ivey Eye
Institute, Western University.

Author Disclosure Block:   A. Salimi:  None.  R. Kanjee:  None.  M. Popovic:  None.  C. Hutnik:  None.  I. Ahmed:   Any direct financial payments including receipt of honoraria; Name of for-profit or not-for-profit organization(s); Alcon, Johnson & Johnson Vision, Bausch Health, Santen, Carl Zeiss AG, Aequus, Akorn, Aquea Health, Inc, ArcScan, Beaver Visitec, Beyeonics, Centricity Vision, Inc, CorNeat Vision, Costum Surgical, ELT Sight, ElutiMed, Equinox, Genentech, Gore, Iantrek, InjectSense, Iridex, iStar, LayerBio, Leica Microsystems, Long Bridge Medical, Inc,, MicroOptx, New World Medical, Ocular Instruments, Ocular Therapeutix, Oculo, Omega Ophthalmics, PolyActiva, Radiance Therapeutics, Ripple Therapeutics, Sanoculis, Shifamed, LLC, Sight Sciences, Smartlens, Inc, Stroma, Thea Pharma, ViaLase, Vizzario.  H. Saheb:   Any direct financial payments including receipt of honoraria; Name of for-profit or not-for-profit organization(s); Alcon/Novartis, Allergan/Abbvie, Bausch Health, Glaukos, Labtician Thea, Aerie Pharmaceuticals, Johnson & Johnson, Ivantis, Zeiss.
 

Abstract Body: 

Purpose: Acute elevation of IOP following phacoemulsification is a common
occurrence. IOP may rise between 10‐20 mmHg in 30‐50% of cases. Most clinically‐relevant spikes
occur within the first 24 hours after surgery. As there is no consensus regarding the optimal ocular
hypotensive agent, the present study was designed to systematically analyse data for prophylaxis
against IOP spikes following phacoemulsification. 

Study Design: Systematic review and Metaanalysis.

Methods: A search of Ovid MEDLINE, EMBASE and Cochrane CENTRAL was performed.
Randomized controlled trials (RCTs) that contained medicated and control arms following
uncomplicated cataract surgery in healthy eyes were included. A risk of bias analysis was performed
using the Cochrane guidelines. The primary outcome was the weighted mean difference (WMD) of
IOP at 2‐8 hours, 12‐24 hours, and 1‐7 days postoperatively, within each medication class. 

Results:
From 701 screened articles, 29 RCTs involving 2,909 eyes were included. A risk of bias analysis
revealed frequent cases of unclear risk in random sequence generation, as well as instances of high
risk masking of patients or study personnel. Other analysed domains generally demonstrated low
risk for bias. Across studies, there was a statistically significant reduction in IOP favouring treatment
arms at 2‐8 hours (WMD = ‐3.86 mmHg; 95% CI = ‐4.81 to ‐2.91; p < 0.001) and 12‐24 hours (WMD
=‐2.57 mmHg; 95% CI = ‐3.21 to ‐1.94; p < 0.001), with the effect wearing off beyond 1 day (WMD = ‐
0.36 mmHg; 95% CI = ‐0.88 to 0.16; p = 0.18). Between medication classes, the largest effect was
seen with intracameral cholinergics or fixed‐combination carbonic anhydrase inhibitor‐β‐blocker
formulations. Conversely, the smallest effect was seen with prostaglandin analogues and α‐agonists.
 

Conclusions: Prophylaxis against acute IOP elevations following uncomplicated cataract surgery is
effective. Fixed‐combination carbonic anhydrase inhibitor‐β‐blocker formulations and intracameral
cholinergics are the most effective topical medications. These data will inform future surgical
guidelines.