Does standalone phacoemulsification lower intraocular pressure in glaucomatous eyes? A systematic review and meta-analysis

Abstract

We evaluated the effect of phacoemulsification on intraocular pressure (IOP) and the reduction of glaucoma medications in patients with glaucoma. Our protocol was registered in PROSPERO (CRD42024533437). We conducted a systematic search in PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science for randomized clinical trials (RCTs) with at least 10 eyes and a 12-month minimum follow-up. Risk of bias assessment was performed using the Cochrane risk-of-bias tool. A random-effects model meta-analysis was used, and heterogeneity was assessed using Cochran’s Q and I² statistics. We included 41 RCTs with a total of 2315 eyes in the phacoemulsification-alone group. In ACG patients, the pooled effect showed a percentage of IOP reduction (IOPR%) of 35.22% with a mean IOP reduction of −9.51 mmHg, p < 0.001 at 12 months, and an IOPR% of 27.47% with a mean reduction of −6.37 mmHg, p < 0.001 at 24 months. For OAG patients, the pooled effect showed an IOPR% of 18.94% with a significant absolute change of −4.35 mmHg, p < 0.001 at 12 months, and IOPR% of 16.95% with an absolute IOP change of −3.83 mmHg, p < 0.001 at 24 months. In ACG patients, medication use decreased by 67.13% at 12 months and 51.58% at 24 months (p < 0.001 for both), while in OAG patients, the reduction was 45.52% at 12 months and 50.19% at 24 months (p < 0.001). In conclusion, standalone phacoemulsification significantly lowers IOP and reduces the need for glaucoma medications in patients with glaucoma.

Intraocular Pressure after Uneventful Phacoemulsification in Diabetic and Nondiabetic Patients: A Prospective Observational Study

“… 24 This reduction carries significant clinical relevance, as phacoemulsification not only improves visual acuity but also contributes to long-term ocular health by lowering IOP, thereby reducing glaucoma progression or the future need for additional pressure-lowering interventions. 25 These findings reinforce the role of phacoemulsification as both a rehabilitative and pressure-modifying procedure, highlighting the importance of vigilant postoperative monitoring to ensure sustained benefit across patient groups.…”

Intraocular Pressure after Uneventful Phacoemulsification in Diabetic and Nondiabetic Patients: A Prospective Observational Study

“… 24 This reduction carries significant clinical relevance, as phacoemulsification not only improves visual acuity but also contributes to long-term ocular health by lowering IOP, thereby reducing glaucoma progression or the future need for additional pressure-lowering interventions. 25 These findings reinforce the role of phacoemulsification as both a rehabilitative and pressure-modifying procedure, highlighting the importance of vigilant postoperative monitoring to ensure sustained benefit across patient groups.…”

Should Schlemm Canal-Based MIGS Be Combined with Cataract Surgery in Patients Receiving Topical Glaucoma Therapy? A Cataract Surgeon-Oriented Review

“…The IOP-lowering effect of cataract surgery alone is well recognized, but the magnitude of this effect is variable. In eyes with ocular hypertension or open-angle glaucoma, phacoemulsification alone has been reported to reduce IOP by approximately 3-4 mmHg in some cohorts, whereas larger reductions, often approximately 8-9 mmHg, have been reported in eyes with angle-closure mechanisms or higher baseline IOP [2][3][4][63][64][65]. In medically treated open-angle glaucoma, however, cataract surgery alone may not achieve sufficient IOP reduction or medication discontinuation [5,6,64].…”

“…In eyes with open-angle glaucoma, normal-tension glaucoma, pseudoexfoliation glaucoma with an open angle, or steroid-induced glaucoma, Schlemm canal-based MIGS may be considered when the target IOP is compatible with a mid-teens range (approximately 13-17 mmHg) and medication reduction is clinically meaningful. In contrast, in eyes with narrow angles, primary angle closure, or primary angle-closure glaucoma, the effect of cataract surgery or lens extraction alone should first be considered, because lens extraction can deepen the anterior chamber and widen the angle [2][3][4][5][6]76,77]. When residual peripheral anterior synechiae, insufficient IOP control, or persistent medication burden remains a concern after lens-related mechanisms have been addressed, goniosynechialysis-assisted trabeculotomy or goniotomy may be considered in selected eyes with adequate visualization [97].…”

“…Cataract surgery alone may be reasonable in patients with stable glaucoma controlled with a single medication, minimal or no visual field progression, no major medication-related ocular surface symptoms, and no strong desire to reduce treatment burden [2,[4][5][6]55,[63][64][65]. Cataract extraction may produce modest IOP reduction, and in some eyes this may be adequate [2,4,[63][64][65].…”

Intraocular Pressure after Uneventful Phacoemulsification in Diabetic and Nondiabetic Patients: A Prospective Observational Study

“… 24 This reduction carries significant clinical relevance, as phacoemulsification not only improves visual acuity but also contributes to long-term ocular health by lowering IOP, thereby reducing glaucoma progression or the future need for additional pressure-lowering interventions. 25 These findings reinforce the role of phacoemulsification as both a rehabilitative and pressure-modifying procedure, highlighting the importance of vigilant postoperative monitoring to ensure sustained benefit across patient groups.…”

Should Schlemm Canal-Based MIGS Be Combined with Cataract Surgery in Patients Receiving Topical Glaucoma Therapy? A Cataract Surgeon-Oriented Review

“…The IOP-lowering effect of cataract surgery alone is well recognized, but the magnitude of this effect is variable. In eyes with ocular hypertension or open-angle glaucoma, phacoemulsification alone has been reported to reduce IOP by approximately 3-4 mmHg in some cohorts, whereas larger reductions, often approximately 8-9 mmHg, have been reported in eyes with angle-closure mechanisms or higher baseline IOP [2][3][4][63][64][65]. In medically treated open-angle glaucoma, however, cataract surgery alone may not achieve sufficient IOP reduction or medication discontinuation [5,6,64].…”

“…In eyes with open-angle glaucoma, normal-tension glaucoma, pseudoexfoliation glaucoma with an open angle, or steroid-induced glaucoma, Schlemm canal-based MIGS may be considered when the target IOP is compatible with a mid-teens range (approximately 13-17 mmHg) and medication reduction is clinically meaningful. In contrast, in eyes with narrow angles, primary angle closure, or primary angle-closure glaucoma, the effect of cataract surgery or lens extraction alone should first be considered, because lens extraction can deepen the anterior chamber and widen the angle [2][3][4][5][6]76,77]. When residual peripheral anterior synechiae, insufficient IOP control, or persistent medication burden remains a concern after lens-related mechanisms have been addressed, goniosynechialysis-assisted trabeculotomy or goniotomy may be considered in selected eyes with adequate visualization [97].…”

“…Cataract surgery alone may be reasonable in patients with stable glaucoma controlled with a single medication, minimal or no visual field progression, no major medication-related ocular surface symptoms, and no strong desire to reduce treatment burden [2,[4][5][6]55,[63][64][65]. Cataract extraction may produce modest IOP reduction, and in some eyes this may be adequate [2,4,[63][64][65].…”

Intraocular Pressure after Uneventful Phacoemulsification in Diabetic and Nondiabetic Patients: A Prospective Observational Study

“… 24 This reduction carries significant clinical relevance, as phacoemulsification not only improves visual acuity but also contributes to long-term ocular health by lowering IOP, thereby reducing glaucoma progression or the future need for additional pressure-lowering interventions. 25 These findings reinforce the role of phacoemulsification as both a rehabilitative and pressure-modifying procedure, highlighting the importance of vigilant postoperative monitoring to ensure sustained benefit across patient groups.…”

Should Schlemm Canal-Based MIGS Be Combined with Cataract Surgery in Patients Receiving Topical Glaucoma Therapy? A Cataract Surgeon-Oriented Review

“…The IOP-lowering effect of cataract surgery alone is well recognized, but the magnitude of this effect is variable. In eyes with ocular hypertension or open-angle glaucoma, phacoemulsification alone has been reported to reduce IOP by approximately 3-4 mmHg in some cohorts, whereas larger reductions, often approximately 8-9 mmHg, have been reported in eyes with angle-closure mechanisms or higher baseline IOP [2][3][4][63][64][65]. In medically treated open-angle glaucoma, however, cataract surgery alone may not achieve sufficient IOP reduction or medication discontinuation [5,6,64].…”

“…In eyes with open-angle glaucoma, normal-tension glaucoma, pseudoexfoliation glaucoma with an open angle, or steroid-induced glaucoma, Schlemm canal-based MIGS may be considered when the target IOP is compatible with a mid-teens range (approximately 13-17 mmHg) and medication reduction is clinically meaningful. In contrast, in eyes with narrow angles, primary angle closure, or primary angle-closure glaucoma, the effect of cataract surgery or lens extraction alone should first be considered, because lens extraction can deepen the anterior chamber and widen the angle [2][3][4][5][6]76,77]. When residual peripheral anterior synechiae, insufficient IOP control, or persistent medication burden remains a concern after lens-related mechanisms have been addressed, goniosynechialysis-assisted trabeculotomy or goniotomy may be considered in selected eyes with adequate visualization [97].…”

“…Cataract surgery alone may be reasonable in patients with stable glaucoma controlled with a single medication, minimal or no visual field progression, no major medication-related ocular surface symptoms, and no strong desire to reduce treatment burden [2,[4][5][6]55,[63][64][65]. Cataract extraction may produce modest IOP reduction, and in some eyes this may be adequate [2,4,[63][64][65].…”