332 Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013

Original Article
Department of Ophthalmology, Regional Institute of Ophthalmology, Sitapur Eye Hospital, Sitapur, Uttar Pradesh, India
Corresponding Author: Dr. Virendra K. Pal, Regional Institute of Ophthalmology, Sitapur Eye Hospital, Sitapur, Uttar Pradesh, India.
E-mail: vkpalophp@gmail.com
INTRODUCTION
V
arious studies have found that cataract surgery alone
is frequently sufficient for controlling mildly elevated
intraocular pressure (IOP).
1
Many studies have demonstrated
a reduction in IOP after cataract surgery.
2
However, most
recent data indicates that IOP reduction after cataract surgery
is more significant and sustained than previously presumed.
3

The method of cataract extraction may influence the reduction
of IOP. For example, there is a greater reduction in IOP after
phacoemulsification compared to manual extracapsular cataract
extraction (ECCE).
4-7
The reduction in IOP lasts for at least
ABSTRACT
Purpose: The purpose of the study is to evaluate the long-term changes in intraocular
pressure (IOP) after extracapsular cataract extraction (ECCE) with posterior chamber
intraocular lens (PCIOL) implantation versus phacoemulsifcation with PCIOL implantation
in otherwise normal cataract patients in India.
Materials and Methods: The study was conducted in the Department of Ophthalmology,
King Georges Medical College, Lucknow between August 2000 and August 2001. One
hundred and seventeen eyes of 115 patients were included in the study. 84 patients were
randomly selected for ECCE with PCIOL implantation (ECCE group) and 31 patients were
selected for phacoemulsifcation with PCIOL implantation (Phaco group). IOP was measured
pre-operatively and post-operatively, from the 1
st
month to the 12
th
month. Statistical
signifcance was indicated by P < 0.05.
Results: There was a mean fall in IOP of 2.70 mm Hg (19.74%) in the ECCE group and
2.74 mm Hg (20.57%) in the phaco group. The decrease in the mean post-operative IOP
from baseline was statistically signifcant (P < 0.01) at the end of 2 months in both groups.
There was no statistically signifcant difference in postoperative IOP at any visit between
groups (P > 0.05, all post-operative visits). After 4
th
monthpost-operatively, the IOP was
mostly stable, but it was signifcantly lower than the preoperative IOP.
Conclusion: Signifcant IOP reduction may be expected after cataract surgery with either
ECCE or phacoemulsifcation with IOL implantation. The lowering of IOP became statistically
signifcant at about 2 months postoperatively, but became almost stable after the 4
th
month.
Key words: Extracapsular Cataract Extraction, Intraocular Pressure, Phacoemulsifcation,
Posterior Chamber Intraocular Lens
Long-Term Change in Intraocular Pressure after
Extracapsular Cataract Extraction with Posterior
Chamber Intraocular Lens Implantation Versus
Phacoemulsification with Posterior Chamber
Intraocular Lens Implantation in Indians
Virendra K. Pal, Ajai Agrawal, Suwarna Suman, V. B. Pratap
Access this article online
Website:
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DOI:
10.4103/0974-9233.120021
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Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013 333
Pal, et al.: Intra Ocular Pressure- Post Cataract Surgery
12 months after phacoemulsification in non-glaucomatous
eyes.
5,8
The behavior of IOP after cataract surgery in Indians
remains unknown. In the current study, we evaluate the
changes in IOP after ECCE with posterior chamber intraocular
lens (PCIOL) implantation and phacoemulsification with PCIOL
implantation in otherwise normal cataract patients in India. In
addition, we compared the differences in IOP between these
surgeries in Indian patients. Post-operative follow-up was for
1 year to determine the long-term change in IOP.
MATERIALS AND METHODS
This prospective study was conducted in the Department of
Ophthalmology, King Georges Medical College, Lucknow,
India between August 2000 and August 2001. The subjects
were randomly selected from patients admitted for cataract
surgery either for ECCE with PCIOL implantation (ECCE
group) or phacoemulsification with PCIOL implantation (phaco
group). The choice of surgery (ECCE or phaco) was based on
two criteria: (1) Patients choice, as phaco surgery is costlier than
ECCE; (2) The decision of the surgeon, as phacoemulsification
is difficult in advanced cataract. This study adhered to the tenets
of the Declarations of Helsinki. All patients selected for this
study were adults willing to undergo surgery under local/topical
anesthesia (inclusion criteria). Patients were excluded if they
had traumatic, congenital or developmental and/or complicated
cataract, an elevated IOP above 22 mm Hg, glaucoma or suspected
glaucoma or any other ocular diseases, to avoid any known or
unknown cause of change in IOP. All patients underwent a
detailed baseline ophthalmic evaluation preoperatively, including
fundus examination and IOP measurement with the Goldmann
applanation tonometer. The post-operative follow-up visits were
performed after the 1
st
, 2
nd
, 4
th
, 8
th
, 10
th
and 12
th
months with
Goldmann applanation tonometer.
A written consent was required pre-operatively. Topical
ciprofloxacin was administered the preceding night. The pupil was
dilated with tropicamide 0.8% and 2.5% phenylephrine 30 min
before cataract surgery along with flurbiprofen 0.3% eye drops.
All surgeries were performed by a single surgeon. All patients
underwent surgery with peribulbar anesthesia (lignocaine 2% +
bupivacaine 0.5%). For ECCE, a fornix based conjunctival (10
Oclock to 2 Oclock) flap was made with an incision (10 Oclock
to 2 Oclock) at the corneo-scleral junction. After PCIOL (poly
methyl methacrylate) implantation, the incision was closed
with 5 interrupted radial sutures with 10-0 monofilament
non-absorbable nylon sutures. Phacoemulsification surgery was
similar to the above technique, but a clear corneal incision was
performed and a foldable PCIOL (hydrophobic acrylic) was
implanted. After both surgeries, subconjunctival injections of
dexamethasone and gentamycin were delivered. Post-operatively,
both groups received ciprofloxacin eye drops prednisolone eye
drops 6 times/day (on a tapering regime) and flurbiprofen eye
drops qid up to 1 month. No post-operative complications
were noted.
The differences between pre-operative and post-operative IOP
were analyzed using the Student t-test for paired comparison,
with a significance level of P < 0.05. This was one tailed test
as we are testing the superiority of one method over another.
Data were analyzed with MS-Excel (Microsoft Corp., Redmond,
WA, USA) and Statistical Package for the Social Sciences
version 14 (IBM Corp., New York, NY, USA). The sample
size was calculated using G*Power software
17
with a minimum
power of 80% likely to be achieved at a confidence level 95%.
The normality of the study population was verified by the
Kolmogorov-Smirnov test.
RESULTS
A total number of 185 patients were screened out of which
115 were included in the study. Seventy patients were excluded
based on inclusion and exclusion criteria. One hundred and
seventeen eyes of 115 patients (54 males [46.96%] and
61 females [53.04%]) were selected for this study. There were
84 patients (73.04%) in the ECCE group (39 [46.43%] males
and 45 [53.57%] females). There were 31 (26.96%) patients
in the phaco group (15 [48.39%] males and 16 [51.61%]
females). The mean age of patients for both groups was
58.34 10.05 years. (The mean age was 57.33 10.83 years
for the ECCE group and 61.06 7.05 years for the phaco
group). There were no significant differences in age or sex
between groups (P > 0.05, both comparisons).
Changes in IOP with time intervals in both groups were
compared [Table 1]. The preoperative mean IOP in the ECCE
group was 13.68 2.34 mm Hg and 13.32 2.27 mm Hg
in the phaco group (P < 0.46). Both groups were comparable
with each other. Pre-operative and post-operative mean
IOP and the statistical analyses after 1
st
, 2
nd
, 4
th
, 8
th
, 10
th
and
12
th
months of both groups are presented in Table 2. The
reductions in IOP in both groups up to the 1
st
month were
not significant (P > 0.05). There were statistically significant
reductions in IOP at the end of the 2
nd
month that continued to
the 4
th
month post-operatively (P < 0.05, both post-operative
visits). After the 4
th
month post-operatively, the IOP became
almost stable in both groups.
DISCUSSION
Surgical management of a patient with coexisting cataract and
glaucoma has been a subject of debate for decades (Greve,
1987).
9
It has been shown that cataract surgery alone lowers
IOP
10
and glaucoma medication can be discontinued after
cataract surgery alone.
1
In the current study, 117 eyes of 115
normal Indian patients with a mean age of 58.34 10.05 years
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334 Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013
Pal, et al.: Intra Ocular Pressure- Post Cataract Surgery
underwent cataract surgery. ECCE with PCIOL implantation
was performed in 84 (73.04%) cases and phacoemulsification
with PCIOL implantation was performed in 31 (26.96%) cases.
In both groups, the IOP was significantly reduced at the end
of the 2
nd
month and it almost stabilized after the 4
th
month.
In this study, both types of surgeries reduced IOP statistically
significantly after the end of 2
nd
month and the trends were similar
between groups. Persalo
11
conducted a retrospective analysis of
226 eyes of 182 glaucoma patients (mean age 81.6 years) who
had undergone phacoemulsification with PCIOL implantation
with a follow-up of 1 year. Persalo
11
reported a statistically
significant increase in IOP from the mean pre-operative value
of 17.1 3.9 mm Hg to 20.7 9.0 mm Hg by the first
post-operative morning (P < 0.01). One week post-operatively,
the average IOP was 17.4 5.3 mm Hg and 1 year post-operatively
the mean IOP was 15.3 3.1 mm Hg.
11
223 eyes were available
for follow-up at the 7
th
day, 125 eyes at 1 month and 127 eyes
were available after 1 year.
11
The reduction of IOP of 1.8 mm Hg
was statistically significant (P < 0.01) within 1 year.
11
Persalo
11

reported a final reduction of 3.1 mm Hg.
Shingleton et al.
12
conducted a retrospective analysis of patients
who underwent clear corneal phacoemulsification with PCIOL
with a minimum of 12 months follow-up. The patients were
divided into three groups - no glaucoma, glaucoma suspect
and glaucoma.
12
IOP changes occurred in all groups.
12
In the
non-glaucoma group, the pre-operative IOP was 16.42 2.77
mm Hg and post-operative IOP on 1
st
day, 6
th
week, 6
th
month
and 1 year was 16.75 4.82 m Hg, 15.30 3.15 mm Hg,
14.38 2.47 mm Hg and 14.37 2.97 mm Hg respectively.
There were statistically significant changes in IOP at 6 months and
1 year post-operatively in Shingleton et al.s study (P < 0.01).
12

In the current study, the statistically significant reduction in IOP
was greater compared with Shingleton et al.s study.
12
A randomized prospective study
13
evaluated IOP changes
after ECCE or phacoemulsification with PCIOL implantation
in otherwise normal cataract patients. IOP was measured
pre-operatively and post-operatively out to 6 months. There
was a mean decrease in IOP of 1.1 mm Hg (5.72%) in the
ECCE group (15 eyes) and 0.6 mm Hg (4.16%) in the phaco
group (24 eyes) after 6 months.
13
The decrease in the mean
IOP was significant at 2 months in the phaco group and at
4-6 months in the ECCE group (P < 0.05).
13
However, there
was no statistically significant difference between groups during
the follow-up period (P > 0.05).
13
The current study shows that
there was a statistically significant (maximum) post-operative
IOP reduction in both the ECCE (19.74% reduction) and
phaco (20.57% reduction) groups (P < 0.01). However, the
magnitude of reduction was not significantly different between
groups at any time (P > 0.05). The results of this study are
comparable with the published literature.
A possible explanation for the decrease in IOP after cataract
surgery with PCIOL implantation is increased anterior chamber
depth (reduction in lens volume) resulting in decreased
resistance to aqueous outflow.
14
Additionally, higher levels of
prostaglandins (F2) in aqueous humor
15
may also reduce the
IOP. Reduced IOP may also be associated with a hyposecretion
of aqueous humor resulting from traction on the ciliary body
due to fibrosis and contraction of the posterior lens capsule.
16

After 4 months, these processes likely ceased and IOP stabilized.
This study is one of the first studies to observe the long-term
changes in IOP after cataract surgery in an Indian cohort. We
also compared the long-term changes in IOP in ECCE versus
phacoemulsification with PCIOL implantation.
The study has some limitations. The patients were randomly
assigned to the ECCE/phaco group, which may lead to selection
bias. Evaluation of long term changes in IOP may require
follow-up greater than 1 year. The study was performed on
normal subjects. Patients with glaucoma should be included in
future studies.
In summary, the outcomes of this study indicate that significant
IOP reduction may be expected after cataract surgery with either
ECCE or phacoemulsification with intraocular lens implantation.
Table 2: Differences in mean intraocular pressure in both groups
over time (follow-up)
Time interval ECCE with
PCIOL
MeanSD
P< Phaco with
PCIOL
MeanSD
P<
Post-operative (months)
1
st
0.352.22 0.18 0.172.49 0.71
2
nd
1.561.82 0.01 1.321.63 0.01
4
th
2.011.84 0.01 2.131.88 0.01
8
th
2.632.01 0.01 2.741.87 0.01
10
th
2.651.96 0.01 2.722.02 0.01
12
th
2.702.05 0.01 2.741.93 0.01
P<0.05 is statistically signicant. ECCE with PCIOL denotes ECCE with PCIOL
implantation. Phaco with PCIOL denotes phacoemulsication with PCIOL
implantation. ECCE: Extracapsular cataract extraction, PCIOL: Posterior chamber
intraocular lens, SD: Standard deviation
Table 1: Changes in intraocular pressure over time
Time interval MeanSD P<
ECCE with
PCIOL
Phaco with
PCIOL
Total
Pre-operative 13.682.34 13.322.27 13.582.31 0.46
Post-operative (months)
1
st
13.242.58 13.172.05 13.222.44 0.74
2
nd
12.162.23 11.961.93 12.112.15 0.54
4
th
11.462.16 11.242.21 11.402.17 0.76
8
th
11.012.05 10.581.94 10.862.01 0.82
10
th
11.242.02 11.011.96 11.102.06 0.78
12
th
10.981.98 11.322.06 11.032.03 0.64
P<0.05 is statistically signicant. ECCE with PCIOL denotes ECCE with PCIOL
implantation. Phaco with PCIOL denotes phacoemulsication with PCIOL
implantation. ECCE: Extracapsular cataract extraction, PCIOL: Posterior chamber
intraocular lens, SD: Standard deviation
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Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013 335
Pal, et al.: Intra Ocular Pressure- Post Cataract Surgery
The reduction in IOP became statically significant at about
2 months post-operatively and stabilized after the 4
th
month.
REFERENCES
1. Knoche M. Cataract plus glaucoma: The usefulness of foldable
IOLs. Ocul Surg News 1996;38.
2. Levkovitch-Verbin H, Habot-Wilner Z, Burla N, Melamed S,
Goldenfeld M, Bar-Sela SM, et al. Intraocular pressure elevation
within the first 24 hours after cataract surgery in patients
with glaucoma or exfoliation syndrome. Ophthalmology
2008;115:104-8.
3. Poley BJ, Lindstrom RL, Samuelson TW. Long-term effects
of phacoemulsification with intraocular lens implantation in
normotensive and ocular hypertensive eyes. J Cataract Refract
Surg 2008;34:735-42.
4. Hansen MH, Gyldenkerne GJ, Otland NW, Corydon L, Naeser K.
Intraocular pressure seven years after extracapsular cataract
extraction and sulcus implantation of a posterior chamber
intraocular lens. J Cataract Refract Surg 1995;21:676-8.
5. Tennen DG, Masket S. Short- and long-term effect of clear
corneal incisions on intraocular pressure. J Cataract Refract
Surg 1996;22:568-70.
6. Suzuki R, Tanaka K, Sagara T, Fujiwara N. Reduction
of intraocular pressure after phacoemulsification and
aspiration with intraocular lens implantation. Ophthalmologica
1994;208:254-8.
7. Sacc S, Marletta A, Pascotto A, Barabino S, Rolando M,
Giannetti R, et al. Daily tonometric curves after cataract surgery.
Br J Ophthalmol 2001;85:24-9.
8. Hayashi K, Hayashi H, Nakao F, Hayashi F. Changes in
anterior chamber angle width and depth after intraocular
lens implantation in eyes with glaucoma. Ophthalmology
2000;107:698-703.
9. Greve EF, editor. Surgical Management of Coexisting Glaucoma
and Cataract. Amsterdam: Kugler Publications, Ghedini Editore;
1987.
10. Tomey KF, Traverso CE. The glaucomas in aphakia and
pseudophakia. Surv Ophthalmol 1991;36:79-112.
11. Persalo R. Phaco-emulsification of cataract in eyes with
glaucoma. Acta Ophthalmol Scand 1997;75:299-300.
12. Shingleton BJ, Gamell LS, ODonoghue MW, Baylus SL,
King R. Long term changes in IOP after clear corneal
phaco-emulsification: Normal patients versus glaucoma
suspect and glaucoma patients. J Cataract Refract Surg
1999;25:885-90.
13. Kim JW. Comparative study of intraocular pressure change
after cataract surgery: Phacoemulsification and extracapsular
cataract extraction. Korean J Ophthalmol 1996;10:104-8.
14. Steuhl KP, Marahrens P, Frohn C, Frohn A. Intraocular
pressure and anterior chamber depth before and after
extracapsular cataract extraction with posterior chamber lens
implantation. Ophthalmic Surg 1992;23:233-7.
15. Kerstetter JR, Brubaker RF, Wilson SE, Kullerstrand LJ.
Prostaglandin F2 alpha-1-isopropylester lowers intraocular
pressure without decreasing aqueous humor flow. Am J
Ophthalmol 1988;105:30-4.
16. Wollensak J, Seiler T. Hypotension syndrome caused
by shrinkage of the lens capsule. Klin Monbl Augenheilkd
1986;188:242-4.
17. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical
power analyses using G*Power 3.1: Tests for correlation
and regression analyses. Behavior Research Methods
2009;41;1149-60.
Cite this article as: Pal VK, Agrawal A, Suman S, Pratap VB. Long-term
change in intraocular pressure after extracapsular cataract extraction with
posterior chamber intraocular lens implantation versus phacoemulsifcation
with posterior chamber intraocular lens implantation in Indians. Middle East
Afr J Ophthalmol 2013;20:332-5.
Source of Support: Nil, Confict of Interest: None declared.
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