Initial IOP Elevation Spike Post-phaco Linked to Retained Lens Fragments

Researchers from this study believe that cataract surgeons should be more vigilant for possible IOP spike in eyes with higher baseline IOP, male sex and glaucoma. Photo: Gleb Sukhovolskiy, OD. Click image to enlarge. While phacoemulsification is generally very safe, cataract surgeons and optometrists should remain aware of the procedure’s potential complications, the implications and management, especially given the high volume of cataract surgeries performed. Retained lens fragment following phaco is an unplanned complication with broad implications for ocular health. Understanding these effects and risk factors can help guide surgical planning by identifying those patients vulnerable to an intraocular pressure (IOP) spike as well as those most likely to have a persistent IOP reduction after cataract removal.In a recent study based out of Bascom Palmer Eye Institute in Miami, researchers used the American Academy of Ophthalmology IRIS Registry (Intelligent Research in Sight) database to characterize the IOP changes following stand-alone phacoemulsification resulting in retained lens fragments as well as differences for eyes with and without glaucoma and provide insight into observed clinical practice regarding secondary intervention.Their study demonstrated that eyes with glaucoma and retained lens fragments are 18% more likely to have an IOP spike in the first postoperative week than eyes without glaucoma. This concern is further compounded by several perioperative considerations for glaucoma patients that undergo cataract surgery that may increase the risk of retained lens fragments. Most secondary interventions occurred around two weeks after initial cataract surgery. For those cases, the study team suggested that surgeons may consider prescribing topical carbonic anhydrase inhibitors to potentially decrease the risk of IOP spike. Still, eyes without an indication for secondary intervention would have their IOP gradually return to baseline level and stabilize after an average of five weeks.The researchers analyzed eyes in the IRIS Registry (Intelligent Research in Sight) that underwent stand-alone phacoemulsification during a six-year period that resulted in retained lens fragments. Daily mean IOP was calculated from postoperative day one to 90. They defined IOP spike as a daily mean IOP >30mm Hg and >10mm Hg above baseline IOP within the first postoperative week. Retained lens fragments were noted in 6,105 eyes with mean baseline IOP of 15.8mm Hg and a mean baseline logMAR visual acuity of 0.57.Of all eyes, 1,795 (29.4%) were classified as glaucoma. For eyes with glaucoma, 1,029 (57.3%) were classified as pre-glaucoma, 162 (9.0%) were considered mild, 164 (9.1%) were characterized as moderate, 75 (4.2%) were classified as severe and 365 (20.3%) had unspecified severity. Eyes classified as glaucoma used an average of 0.51 IOP-lowering medications prior to cataract surgery.There was an initial elevation in daily mean IOP after cataract surgery to 21.2mm Hg that gradually declined but remained greater than baseline IOP until postoperative day 14. The final mean IOP and weeks until IOP stabilization was 15.0mm Hg at five weeks. Intraocular pressure spike occurred in 766 (12.5%) eyes. Factors associated with IOP spike include male sex (odds ratio; OR: 1.47), higher baseline IOP (OR: 1.24 per 3mm Hg) and glaucoma diagnosis (OR: 1.18).“The increased prevalence of IOP spike and relative persistence of IOP elevation with retained lens fragments are especially important to understand for glaucomatous eyes that may not have the physiologic reserve to regulate and withstand this IOP lability,” the study authors wrote in their paper, which was published in Ophthalmology.Click here for the journal source. Rothman AL, Persad LS, Paranjpe VR, et al. Intraocular pressure following phacoemulsification with retained lens fragments in the IRIS Registry (Intelligent Research in Sight). Ophthalmology. October 14, 2025. [Epub ahead of print].This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.