Risk factors for a postoperative intraocular pressure

spike after phacoemulsification

Paul D. OBrien,* FRCSI; Su Ling Ho,* FRCSI; Patricia Fitzpatrick, FFPHMI;
William Power,* FRCS
ABSTRACT RSUM

Background: The aim of our study was to examine several potential risk factors for intraocular pressure
(IOP) spikes 2 to 3 hours after phacoemulsification.
Methods: 50 eyes of 50 consecutive patients undergoing uncomplicated phacoemulsification under topical
anesthesia were included in this prospective study. The following variables were recorded: preoperative IOP,
nuclear colour, cortical lens opacity, posterior subcapsular lens opacity, patient age; and presence or absence
of preexisting glaucoma.
Results: The mean IOP at each time interval was as follows: preoperatively, 14.5 (SD 3.4) mm Hg; 23 hours
postoperatively, 23.1 (7.0) mm Hg; and 24 hours postoperatively, 17.0 (6.0) mm Hg.The postoperative IOP
was significantly higher than baseline at 23 hours (p < 0.001) and at 24 hours (p = 0.002). Overall there
were 10 cases (20%) of IOP spikes 23 hours postoperatively. Higher mean baseline IOP was significantly
associated with postoperative IOP spikes (p = 0.013). Patient age, sex, operating surgeon, absolute
phacoemulsification time, lens nuclear colour, cortical opacity, and posterior opacity were not significantly
different between groups with or without an IOP spike (p > 0.05).
Interpretation: Patients with high IOP at the preoperative assessment are more likely to have
IOP spikes after surgery and should be scheduled at the start of the operating list. In a daycase setting with restricted opening hours, postoperative checks in those patients at risk of
IOP spikes can then coincide with the time IOP reaches its peak.
Contexte : Cette tude avait pour objet dexaminer plusieurs facteurs potentiels de risque de pics de
pression intraoculaire (PIO) 2 3 heures aprs la phacomulsification.
Mthodes : Cette tude prospective comprenait 50 yeux de 50 patients conscutifs ayant subi une
phacomulsification sans complication sous anesthsie topique. On a not les variables suivantes : PIO
propratoire, couleur du noyau, opacit du cortex cristallin, opacit sous-capsulaire postrieure, ge du
patient, et prsence ou absence de glaucome prexistant.
Rsultats : chaque tape, la PIO moyenne stablissait ainsi : avant lopration, 14,5 (T 3,4) mm Hg; 2 3
heures aprs lopration, 23,1 (7,0) mm Hg; et 24 heures aprs lopration, 17,0 (0,6) mm Hg. La PIO tait
significativement plus leve quau dpart 2 3 heures aprs lopration (p = 0,001) et 24 heures aprs (p
= 0,002). Dans lensemble, 10 cas (20 %) ont eu des pics de PIO 2 3 heures aprs lopration. Le plus haute
PIO moyenne de dpart a t significativement associe aux pics postopratoires de PIO (p = 0,013). Lge
du patient, le sexe, le chirurgien, le temps absolu de la phacomulsification, la couleur du noyau cristallinien,
lopacit corticale et lopacit postrieure ntaient pas significativement diffrents entre les groupes, avec
ou sans pics de PIO (p > 0,05).
Interprtation : Les patients avec une PIO leve lors de lvaluation propratoire sont plus
sujets avoir des pics de PIO aprs la chirurgie et devraient tre inscrits au dbut de la liste
des oprations. Dans le cadre des activits courantes avec heures douverture restreintes, les
vrifications postopratoires chez ces patients risque de pics de PIO peuvent alors concider
avec le moment o la PIO atteint son sommet.

From *the Royal Victoria Eye & Ear Hospital, Dublin, Ireland, and the
Department of Public Health Medicine and Epidemiology, University
College Dublin, Ireland

Correspondence to: Paul OBrien, FRCSI, Eye Department, Royal

Victoria Eye & Ear Hospital, Adelaide Rd., Dublin 2, Ireland; fax
35312137832; mrpaulobrien@mac.com

Presented at the annual meeting of the European Society of Cataract and

Refractive Surgeons in Paris September 2004

This article has been peer-reviewed. Cet article a t valu par les pairs.

Originally received Feb. 6, 2006. Revised Aug. 11, 2006

Accepted for publication Oct. 10, 2006

Risk factors for IOP spikes after phacoOBrien et al

Can J Ophthalmol 2007;42:515

doi:10.3129/can j ophthalmol.06-086

51

Risk factors for IOP spikes after phacoOBrien et al

odern cataract surgery has many benefits, including rapid wound healing, low postoperative complication rates, fast visual recovery time, and high
patient satisfaction. Because of this, many surgeons feel
it is safe to omit the next-day review in favour of sameday review following uncomplicated cataract surgery.14
A transient rise in intraocular pressure (IOP) after
cataract surgery has been well described. This rise is due
to obstruction of the trabecular meshwork by lenticular
debris5 and viscoelastic material6,7 or by inflammation of
the meshwork secondary to dissipated ultrasound
energy.8 If left untreated, uncontrolled postoperative
IOP spikes can result in pain, corneal edema, glaucomatous nerve damage,9,10 and anterior ischemic optic neuropathy.11
Several studies have examined the prophylactic effect
of either preoperative or postoperative ocular hypotensive agents, such as brinzolamide,12 brimonidine,13
travoprost,14 acetazolamide,15 latanoprost,16 apraclonidine,17 dorzolamide,18 and timolol19 to reduce the incidence of postoperative IOP spikes. A significant reduction in postoperative IOP has been shown with several
of these agents1315,19,20 compared with controls, but no
postoperative hypotensive agent has completely prevented the postoperative rise in IOP. To date, no definitive recommendations exist regarding the type of agent
or the need for their use in cataract surgery. The pattern
of IOP change after uneventful phacoemulsification
shows a gradual rise in the early postoperative hours,
reaches its maximum level 5 to 7 hours after surgery, and
is followed by a drop in pressure the day after surgery.8,21
Our aim was to examine several potential risk factors
for IOP spikes, which were defined for this study as
IOPs greater than or equal to 30 mm Hg 2 to 3 hours
after phacoemulsification surgery. This time period was
chosen because it was considered impractical to keep all
patients for 5 to 7 hours after day-case surgery (when
IOP peaks)21 before measuring pressure, whereas examination 2 to 3 hours after surgery should identify those
on the rising curve and allow for appropriate and timely
intervention. Although intracameral miotics may delay
and even reduce the postoperative IOP rise,22,23 we do
not routinely use them, so we felt the 23 hour postoperative IOP check was reasonable.
METHODS

This study comprised 50 eyes of 50 consecutive

patients who had uncomplicated phacoemulsification
cataract surgery with injectable intraocular lens implantation. All surgeries were performed between September
2003 and March 2004 by 1 of 2 surgeons (P.OB, W.P.)

52

CAN J OPHTHALMOLVOL. 42, NO. 1, 2007

using the same technique. All patients provided

informed consent and the study followed the tenets of
the Declaration of Helsinki. No ethical committee
approval was required because no change to our current
clinical practice was involved. Exclusion criteria were
any previous ocular surgery, laser treatment involving
the angle structures, or any previous episode of acute
angle-closure glaucoma.
IOP of every patient was measured by 1 of 2 ophthalmologists (P.OB., S.L.H.) 1 hour preoperatively (before
dilation) and postoperatively at 23 hours and again at 24
hours using the same Goldmann applanation tonometer.
All eyes were dilated after the preoperative IOP measurement with 2.5% phenylephrine, 1% cyclopentolate, and
1% tropicamide. The grade of cataract density was estimated after dilation, according to the lens opacities classification system (LOCS III) grading scale. The examiner
who measured the baseline IOP also graded the cataract
density. Variables recorded were preoperative IOP (baseline IOP), nuclear colour, cortical lens opacity, posterior
subcapsular opacity, patient age, and presence or absence
of preexisting glaucoma.
Surgical technique

Three drops of 0.5% proxymetacaine were instilled

into the lower conjunctival fornix at 2-minute intervals
immediately before surgery. A 2.85-mm 3-step clear
corneal self-sealing incision was made in the superior
cornea and the anterior chamber was filled with 3%
sodium hyaluronate4% chondroitin sulfate (Viscoat
viscoelastic, Alcon, Inc., Puurs, Belgium). Continuous
curvilinear capsulorhexis was followed by hydrodissection and divide-and-conquer phacoemulsification using
a Millennium phacoemulsifier (Storz, Bausch & Lomb,
Rochester, N.Y.). A single-handed technique was used to
remove the remaining cortex and the bag was refilled
with viscoelastic. The incision was enlarged to 3.0 mm to
allow implantation of an injectable intraocular lens
(Allergan SI-30NB, AMO, Irvine, Calif.) into the capsular bag. Irrigationaspiration was performed for at least
30 seconds to remove as much viscoelastic material as
possible from the anterior chamber. The IOL was also
gently rocked to promote release of all visible viscoelastic
material from behind the lens. The anterior chamber was
reformed with balanced saline solution (BSS), and the
corneal wound and side port were hydrated with BSS.
No miotics were used intracamerally at any time during
the procedure. Topical chloramphenicol eyedrops and
dexamethasone with neomycin and polymyxin B ointment were instilled into the conjunctival lower fornix at
the end of the operation. The absolute phacoemulsification time was recorded for each patients surgery.

Risk factors for IOP spikes after phacoOBrien et al

Statistical analysis

The association between the presence of a postoperative IOP spike at 23 hours and a number of possible
risk factors (patient age, sex, baseline IOP, cataract
density, phacoemulsification time, surgeon, and presence of glaucoma) were calculated by using the 2 test
for comparison of proportions and the t test for comparison of means in 2 groups. Logistic regression was
performed to adjust for confounding factors.
RESULTS

The mean (SD) age of the 23 male and 27 female

patients in this study was 75.2 (7.6) years (range
5989). Of these, 9 patients had a preexisting diagnosis
of primary open-angle glaucoma. One surgeon (P.OB.)
performed 32 operations and the second surgeon (W.P.)
performed the remaining 18.
The mean (SD) IOP at each time interval was as
follows: preoperatively, 14.5 (3.4) mm Hg (range 622);
23 hours postoperatively, 23.1 (7.0) mm Hg (range
1344); and 24 hours postoperatively, 17.0 (6.0) mm
Hg (range 739). Fig. 1 shows the minimum,
maximum, median, and interquartile range of IOPs at
each time interval. The postoperative IOP was significantly higher than baseline IOP at both the 23 hour
interval (p < 0.001) and the 24-hour interval (p =
0.002). Overall there were 10 cases (20%) of IOP spikes
23 hours postoperatively (IOP greater than or equal to
30 mm Hg). The mean values for each numerical variable in both the postoperative spike and the no-spike
groups are shown in Table 1. Higher mean baseline IOP
was significantly associated with postoperative IOP
spikes (p = 0.013). Higher baseline IOP had an unadjusted odds ratio of 1.38 (1.051.81, 95% CI), which
remained significant after adjustment for age (1.38).
The mean nuclear colour, cortical lens opacity, and
posterior subcapsular lens opacity was 3.1, 1.8, and 1.8,
respectively, as graded on the LOCS III grading scale.
The mean (SD) absolute phacoemulsification time was
23.9 (9.9) seconds (range 746 s). Patient age, absolute
phacoemulsification time, lens nuclear colour, cortical
opacity, and posterior opacity were not significantly different between the groups with and without an IOP
spike. Table 2 shows the association between patient sex,
operating surgeon, and presence of preexisting glaucoma
with the risk of an IOP spike 23 hours postoperatively.
None of these variables showed any significant difference between groups.
Two patients had a single 10/0 nylon corneoscleral
suture inserted at the end of surgery. The 23 hour IOPs
in these patients were 27 and 33 mm Hg. Of the 10

patients who had IOP spikes at 23 hours postoperatively, only 2 had IOP greater than 35 mm Hg. Both
these patients received 500 mg of oral acetazolamide
after we applied pressure on the posterior lip of the paracentesis to decompress the anterior chamber. The 24hour postoperative IOP in these 2 patients was 16 and
30 mm Hg. Seven of the other 8 patients with 23 hour
IOP of 3035 mm Hg had an IOP less than 25 mm Hg
at 24 hours. One patient had persistently raised IOP (39
mm Hg) at the 24-hour check-up and was treated with
oral acetazolamide for 2 days.
INTERPRETATION

Transient IOP spikes occur frequently after uncomplicated phacoemulsification. Different studies give varying
incidences of IOP spikes (IOP > 35 mm Hg) in nonglaucomatous eyes, ranging from 10% at 2 hours2 to 26% at

Fig. 1Box-and-whisker graph of median, interquartile, and range

of intraocular pressures (IOP) at each time interval in the overall
group of patients, n = 50.The top of each box represents the third
quartile (75th percentile) and the bottom the first quartile (25th
percentile) of the IOP percentile. The median of each distribution
is indicated by the horizontal line within the box.

Table 1Association of age, baseline IOP, cataract

density, and absolute phaco time with presence of
postoperative IOP spike
Postop spike No postop spike
(n = 10)
(n = 40)

Variable
Age, years
Baseline IOP, mm Hg
Nuclear colour
Cortical lens opacity
Posterior lens opacity
Absolute phaco time, s

74.7
16.8
3.3
1.97
1.89
23.8

75.3
13.9
3.1
1.77
1.75
24.0

p
value
0.82
0.013*
0.55
0.62
0.81
0.97

*Statistically significant.

CAN J OPHTHALMOLVOL. 42, NO. 1, 2007

53

Risk factors for IOP spikes after phacoOBrien et al

4 to 6 hours.15 Our 20% incidence of 23 hour IOP

spikes was higher than the 10% described by Thirumalai
and Baranyovits. Our results differed because we included
patients with preexisting glaucoma and we defined a spike
as an IOP greater than or equal to 30 mm Hg.
Patients with preexisting glaucoma have been shown
to have nearly a 3-fold higher risk of developing a postoperative IOP spike both at 3 to 7 hours4 and at 24
hours.24 Barak et al showed that nearly half of all glaucoma patients develop an IOP rise greater than 15 mm
Hg after surgery.25 Surprisingly, we failed to demonstrate a significantly higher risk of an IOP spike in the
glaucoma patients. The reason for this discrepancy was
that too few patients in the study (only 9 of 50) had
glaucoma. We found, however, that 30% of those with
an IOP spike had glaucoma compared with only 15% of
those with no IOP spike, and it seems likely that if the
study sample were larger this difference would have
become statistically significant. A sudden rise in IOP in
patients with glaucomatous damage constitutes an additional risk factor in this group and probably warrants
prophylactic topical or systemic treatment, either preoperatively or immediately postoperatively. The number of
topical antihypertensive medications used by glaucoma
patients was not compared to the IOP rise because of
the small number of glaucoma patients in this study.
Our most notable finding was that the risk of IOP
spikes correlated with the preoperative IOP value. This
is useful clinically as it allows us to schedule those
patients with higher preoperative IOP measurements
earlier on the operating list. We can then measure the
postoperative IOP in these patients 5 hours after
surgery, when the pressure rise nears its peak, whereas
those less likely to have an IOP spike (low preoperative
IOP) can be operated on later in the day and have 2hour postoperative IOP measurements. This allows us to
examine those most at risk at the appropriate time (5
hours postoperatively) in a day-case setting with
restricted hours of staffing.
We found no correlation between the absolute (or
equivalent) phacoemulsification time and the 23 hour
postoperative IOP. These findings are consistent with
those of Schwenn et al,26 who similarly reported no cor-

Table 2Association of male sex, surgeon, and

glaucoma with postoperative IOP spike
Variable
Male sex
Surgeon (P.OB.)
Presence of glaucoma

54

Postop spike
(n = 10)
4/10
6/10
3/10

No postop spike
(n = 40)
19/40
26/40
6/40

CAN J OPHTHALMOLVOL. 42, NO. 1, 2007

p
value
0.67
0.77
0.27

relation between mean ultrasound equivalent time and

6-hour postoperative IOP levels. Another study8 found
a significant correlation between absolute phacoemulsification time and 24-hour postoperative IOP.
Nevertheless, because IOP tends to return to baseline
levels 24 hours after surgery, this association provides no
clinical basis to improve patient care the day after
surgery. We therefore feel that phacoemulsification time
and preoperative cataract density have no value in predicting IOP spikes.
Only 2 patients had corneoscleral sutures inserted at
the end of surgery. The mean IOP in these patients was
30 mm Hg at 23 hours, which was high compared to
the overall group (23.1 mm Hg). This finding was consistent with another study that showed significantly
higher early postoperative IOP in those patients who
were sutured compared with those with a corneoscleral
tunnel incision.21 It may therefore be prudent to instill
an ocular hypotensive agent at the end of surgery if a
suture is required.
Patients with high IOP at the preoperative assessment
are more likely to have IOP spikes after surgery and
should, together with those with pre-existing glaucoma,
be scheduled at the start of the operating list. In a daycase setting with restricted opening hours this allows the
postoperative check in those at risk of IOP spikes to
coincide with the time when IOP is at its peak.
The authors have no proprietary or financial interest in any
products mentioned in this paper and received no grant
toward funding this study.

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Key words: intraocular pressure spike, phacoemulsification, risk
factors

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