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
modifiable risk factor in the management of glau-
coma and is well recognized as a primary risk factor
for the development and progression of glaucoma.
Long-term beneficial effects of cataract surgery on
IOP have been reported for many years, and this
subject has particular relevance for patients who
have glaucoma or are considered to be at risk for
developing glaucoma. Cataract surgery remains one
of the most common surgical procedures performed,
with approximately 3 million per year in the USA
alone [1]. Even a small effect on IOP from cataract
surgery could potentially modify the population
glaucoma risk in a significant way.
At the individual patient level, the effect of
cataract extraction or lensectomy on IOP might
result from a number of factors, as recent publi-
cations have attempted to identify. Preoperative
IOP, ocular biometry, angle configuration, lens posi-
tion and anterior segment pathologies such as pseu-
doexfoliation or pigment dispersion should guide
patient counseling and surgical planning.
OPEN ANGLES
The evolution from intracapsular cataract extrac-
tion (ICCE) to extracapsular cataract extraction
(ECCE) and later to scleral tunnel and clear corneal
phacoemulsification makes it difficult to pinpoint
when the long-term effect of surgery on IOP was first
noted. Bigger and Becker [2] reported lower IOP after
uncomplicated cataract extraction in glaucoma
patients using ICCE in the early 1970s. Hansen
et al. [3] later published the effects of ECCE with
posterior chamber intraocular lens (PCIOL), a pro-
cedure with postoperative anatomic resemblance to
current cataract surgery, and noted a significant
decrease in IOP 4 months after surgery. In 1992,
Department of Ophthalmology, University of Washington, Seattle,
Washington, USA
Correspondence to Mark Slabaugh, MD, Box 359608, 325 Ninth Ave,
Seattle, WA 98104 2499, USA. Tel: +1 206 744 2020; fax: +1 206 685
7055; e-mail: mas12@uw.edu
Curr Opin Ophthalmol 2014, 25:122–126
DOI:10.1097/ICU.0000000000000033

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 Cataract extraction effect on intraocular pressure Slabaugh and Chen
KEY POINTS
 IOP prior to cataract surgery is the strongest predictor
of postoperative IOP-lowering.
 In patients with narrow angles, cataract surgery is likely
to lower IOP in proportion to the change in anterior
chamber volume and depth.
 In patients with low IOP prior to cataract surgery,
additional lowering should not be expected and some
of these patients may have a higher IOP after
cataract surgery.
Steuhl et al. [4] noted a similar outcome in patients
with and without glaucoma undergoing ECCE/
PCIOL and hypothesized that this effect was due
to a widening of the angle, which they measured
using laser tomography. Suzuki et al. [5] described
the effects of cataract extraction by phacoemulsifi-
cation with PCIOL on IOP in 1994 and also noted
that this effect appeared to be proportional to the
level of preoperative IOP. A later publication by
the same authors described the 10-year IOP results
of the same procedure and noted that there was a
proportional effect on IOP: those having the highest
preoperative IOP experienced the most postopera-
tive lowering, whereas those with a low preoperative
IOP frequently had a higher postoperative IOP [6].
These early studies recognized several key find-
ings that have been reproduced in more recent
studies. First, the effect on IOP in patients with open
angles appears to be proportional to the level of
preoperative IOP. This proportional effect on IOP
has led to some confusion as to whether this finding
might in fact be due to regression to the mean [7].
However, several recent studies suggest that the IOP
effect is a true finding and not due to statistical error.
A report derived from a post-hoc analysis of patients
in the Ocular Hypertension Treatment Study (OHTS)
demonstrated that the patients who underwent
cataract extraction had proportional IOP-lowering
&&
[8 ]. The OHTS had several measures in place to
prevent regression to the mean such as multiple
preoperative and postoperative IOP measurements
performed according to strict guidelines using
calibrated equipment.
A recent randomized prospective trial designed
to evaluate the effect of a trabecular bypass stent
placed at the time of phacoemulsification versus
phacoemulsification alone provides additional evi-
dence for this finding [9,10]. Enrolled patients
underwent medication washout prior to surgery,
and the subsequent mean preoperative IOP of
25 mmHg was similar in both groups. At 1-year
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postoperatively, the cataract extraction-alone group
had a mean IOP reduction of 8.5 mmHg, with 35%
of patients having restarted ocular hypotensive
medications. At 2 years postoperatively, the cataract
extraction-alone arm had a sustained mean IOP
reduction of 7.4 mmHg, whereas the mean number
of medications increased slightly [10]. The absolute
IOP reduction in this study was somewhat greater
than that seen by other authors, but was con-
founded by the fact that patients were allowed to
restart medications to maintain an IOP less than
21 mmHg.
&&
A publication by Yang et al. [11 ] reported on a
trial which prospectively evaluated 999 patients
who underwent uncomplicated phacoemulsifica-
tion and had statistically normal preoperative IOP
with postoperative IOP measured at 3 months. They
found a proportional effect to the IOP-lowering after
cataract surgery when they stratified into five groups
based on preoperative IOP. They also reported on
the IOP of the fellow nonoperative eyes and showed
that the IOP in those eyes was unchanged after
surgery, which suggests that the IOP-lowering
detected was not due to a statistical phenomenon.
The biological basis for a proportional IOP-low-
ering effect from cataract surgery in patients with
open angles is not clear. Poley et al. [12] proposed
‘phacomorphic ocular hypertension’ as a new term
to describe a continuum of lens-induced elevated
IOP which may be reversed by lensectomy. A
possible mechanism for this phenomenon, as pro-
posed by Johnstone [13], is that the anterior lens
zonules are unable to maintain posterior traction on
the scleral spur as the lens increases in antero-
posterior dimensions throughout life, thus resulting
in decreased outflow facility. The strength of this
hypothesis is that it does not require iris interference
with the trabecular meshwork in these patients
with open angles. Rather, it suggests a mechanical
effect modulated through scleral spur position and
zonular tension: small anatomic changes that may
go undetected even with sophisticated anterior seg-
ment imaging.
The relationship between cataract surgery and
IOP appears complex when preoperative IOP is in
the statistically normal range. Poley et al. demon-
strated that whereas approximately 55% of patients
with preoperative IOP between 15 and 17 mmHg
had a lower IOP after cataract surgery, 30% had a
higher postoperative IOP, and the remainder were
unchanged. In the group with preoperative IOP
below 15 mmHg, this proportion switched, with
approximately 55% of patients having a higher post-
&&
operative IOP and 35% having a lower IOP [11 ].
This finding was replicated in the study by Yang
&&
et al. [11 ], although the point of reversal at which
www.co-ophthalmology.com 123
 Glaucoma
IOP became higher after phacoemulsification
occurred at a lower IOP [10]. One might expect that
if the IOP-lowering effect of cataract surgery was due
solely to an anatomical and mechanical change,
patients with low IOP preoperatively would be
expected to have a less robust IOP effect or no
change rather than an elevation.
An alternatively proposed mechanism for the
IOP-lowering after cataract extraction in patients
with open angles is that trabecular endothelium is
remodeled in response to stress from ultrasonic
vibrations during phacoemulsification [14]. A
related hypothesis that has not been investigated
is that the trabecular endothelium undergoes stress-
induced remodeling in response to the supra-
physiologic IOP that is experienced by the anterior
segment during routine phacoemulsification [15,16].
These hypotheses are inadequate as a comprehensive
explanation, given that the first studies to report IOP-
lowering after cataract surgery were on patients
undergoing ICCE or ECCE rather than phacoemulsi-
fication [2–4]. More work is required to elucidate the
pathophysiology of this frequently observed pheno-
menon.
The patients who arguably stand to benefit the
most from lensectomy as an IOP-lowering procedure
are also those who are most difficult to study,
namely those with known glaucomatous optic
neuropathy. As previously mentioned, most of
these patients are already taking IOP-lowering medi-
cations. In the trabecular micro-bypass stent
studies, patients underwent medication washout
and showed a large subsequent decrease in IOP after
phacoemulsification alone. However, applying this
methodology clinically to obtain the maximum
IOP-lowering effect of cataract surgery in glaucoma
patient would be inadvisable. A recent study evalu-
ating open angle glaucoma patients considered to be
medically controlled prior to cataract extraction
found that the preoperative IOP was the strongest
predictor of postoperative IOP change [17]. Notably,
38% of patients had worsened IOP control after
phacoemulsification, which is in line with the
findings of Poley et al. in untreated patients with
statistically normal preoperative IOP. Interestingly,
patients with increased preoperative anterior
chamber depth received the greatest benefit in
IOP reduction from phacoemulsification.
CATARACT SURGERY IN EYES WITH
NARROW ANGLES
The IOP effect of cataract surgery in patients
with narrow angles is a subject of recent clinical
research and interest. Early reports have suggested
that in patients with narrow angles with or without
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elevated IOP, the level of IOP-lowering after cataract
surgery is proportional both to the preoperative IOP
and to the resultant angle widening [18–20]. Thus,
patients with the narrowest angles preoperatively
might be expected to benefit the most from cataract
extraction as a single procedure, provided the angle
has not become permanently closed with peripheral
anterior synechiae.
&
A recent publication by Huang et al. [21 ]
showed that preoperative lens vault as measured
by anterior segment optical coherence tomography
(AS-OCT) was correlated with IOP reduction,
although lens thickness was not evaluated. The
&&
previously noted publication by Yang et al. [11 ]
showed that in addition to preoperative IOP, change
in IOP after cataract surgery was proportional to lens
thickness as well as changes in anterior chamber
area and in degree of angle opening as evaluated by
AS-OCT. Although that study did not specifically
evaluate or stratify patients by angle anatomy, other
researchers have shown in an Asian cohort that the
increase in anterior chamber depth following cata-
ract surgery is inversely proportional to preoperative
anterior chamber depth in patients with occludable
angles prior to surgery [22]. Investigators’ use of
anterior segment imaging to describe several pro-
perties of the iris, angle anatomy and lens charac-
teristics (vault and thickness) could assist in
predicting which patients are the most likely to
benefit from cataract surgery in terms of IOP-low-
&&
ering [11 ,20,23].
It is important to note that although these
studies evaluated patients with narrow angles, they
did not include patients with primary angle closure
or angle closure glaucoma. Gonioscopy remains
indispensable in successfully identifying these
patients, whereas AS-OCT may provide additional
objective data about angle morphology.
Two recently published randomized trials com-
paring surgical approaches in patients with chronic
angle closure have clarified treatment guidelines for
eyes that do have synechial closure of the angle or
eyes with appositional closure in the presence of a
&
patent laser iridotomy [24 ,25]. In the first group,
patients whose IOP was controlled to 21 mmHg
or less with medical therapy were randomized to
phacoemulsification or combined phacotrabeculec-
tomy. The authors found that patients undergoing
combined surgery had a decreased requirement for
IOP-lowering medication postoperatively, but con-
cluded that the marginal improvement in IOP con-
trol did not warrant the additional surgical risk of a
trabeculectomy. Of note, only 1 out of 35 patients
(2.9%) in the phacoemulsification-alone group
went on to require trabeculectomy during the
follow-up period of 2 years.
Volume 25  Number 2  March 2014
 Cataract extraction effect on intraocular pressure Slabaugh and Chen
In the second trial, patients whose IOP could
not be medically controlled were randomized to
phacoemulsification alone or trabeculectomy alone.
The authors demonstrated that there was significant
IOP-lowering after phacoemulsification alone, but
that 73% of patients in that arm of the study
required medications or trabeculectomy by 2 years.
These authors concluded that there was significant
benefit from phacoemulsification alone, but that
trabeculectomy, despite having relatively more sur-
gical complications, was more effective at con-
trolling IOP. Five patients of 26 (19%) in the
phacoemulsification-alone group went on to require
trabeculectomy during the follow-up period of
2 years [25].
As these studies demonstrate, the proportional
effect of IOP-lowering after cataract surgery does
not necessarily extend to patients with closed
angles. A plausible biological explanation for this
is that only a proportion of the trabecular mesh-
work may be functionally available postoperatively
to mediate the potential IOP-lowering effects of
cataract surgery. They also highlight the import-
ance of meticulous static and dynamic gonioscopy
to evaluate what proportion of the angle has
been permanently closed by peripheral anterior
synechiae.
CONCLUSION
There are many reasons to consider cataract extrac-
tion in patients with elevated IOP or glaucoma. First,
glaucoma patients derive an excellent visual benefit
from the increased acuity and improved contrast
sensitivity provided by an artificial lens [26]. The
improved vision also allows more accurate visual
field monitoring, and a clear optical pathway
enhances the quality and reproducibility of any
optic nerve imaging. The effect of cataract extrac-
tion on IOP is more complex and requires additional
preoperative evaluation in order to best predict who
is likely to benefit the most.
Patients with narrow angles and patients with
a high preoperative IOP will often see a lowering of
their IOP after cataract surgery performed as a
single procedure. This lowering effect is likely to
be proportional to the level of preoperative IOP as
well as the increase in anterior chamber depth. If
the preoperative IOP is already low prior to cata-
ract surgery, additional lowering should not be
expected from surgery alone, and patients should
be counseled about the risk of a higher post-
operative IOP.
Acknowledgements
None.
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Conflicts of interest
Financial support: Unrestricted departmental grant from
Research to Prevent Blindness.
No conflicting relationship exists for any author.
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& of special interest
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