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

Eye (2024)Cite this article

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Abstract

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.

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Fig. 1: Intraocular pressure across all treatments.
Fig. 2: Intraocular pressure stratified by medication class.
Fig. 3: Intraocular pressure stratified by medication class.
Fig. 4: Intraocular pressure stratified by medication class.
Fig. 5: Comparative effect size for prophylactic antihypertensive medications stratified by class.

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Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

Financial disclosures: MMP, AS, CH: none. RK: Allergan/Abbvie. IIKA: 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. HS: Alcon/Novartis, Allergan/Abbvie, Bausch Health, Glaukos, Labtician Thea, Aerie Pharmaceuticals, Johnson & Johnson, Ivantis, Zeiss.

Author information

Author notes

  1. These authors contributed equally: Raageen Kanjee, Marko M. Popovic.

Authors and Affiliations

  1. Department of Ophthalmology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada

    Raageen Kanjee

  2. Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada

    Marko M. Popovic & Iqbal Ike K. Ahmed

  3. Department of Ophthalmology & Visual Sciences, McGill University, Montreal, QC, Canada

    Ali Salimi & Hady Saheb

  4. Ivey Eye Institute, Western University, London, ON, Canada

    Cindy M. L. Hutnik

  5. John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA

    Iqbal Ike K. Ahmed

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Contributions

Designing/revising the protocol: RK, MMP, AS, CH, IIKA, HS. - Conducting the search and screening the studies: RK, MMP, AS, HS - Extracting and analysing the data: RK, MMP, AS, HS - Interpreting the results: RK, MMP, AS, CH, IIK, HS - Writing the report and creating figures/tables: RK, MMP, AS, HS - Critically revising the paper: RK, MMP, AS, CH, IIKA, HS.

Corresponding author

Correspondence to Hady Saheb.

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Competing interests

The authors declare no competing interests.

Ethics approval

The study protocol was reviewed by the McGill University’s Faculty of Medicine Institutional Review Board and was exempt from ethics review based on article 2.2(b) of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. The study adhered to the tenets of the Declaration of Helsinki.

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Supplementary information

Supplementary Table 1.

Supplementary Table 2. Characteristics of included studies

Supplementary Table 3: Summary of Ophthalmic Viscoelastic Devices

41433_2024_2940_MOESM4_ESM.pdf

Supplementary Table 4: Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Summary of Findings Table

Supplementary Table 5: PRISMA checklist

41433_2024_2940_MOESM6_ESM.pdf

Supplementary Figure 1: Modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Flow Diagram.

Supplementary Figure 2: Risk of Bias Summary Table Stratified by Study.

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Kanjee, R., Popovic, M.M., Salimi, A. et al. Prophylaxis against intraocular pressure spikes following uncomplicated phacoemulsification: a systematic-review and meta-analysis. Eye (2024). https://doi.org/10.1038/s41433-024-02940-6

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