ARTICLE

Changes in intraocular pressure

after cataract surgery: Analysis of the
Swedish National Cataract Register Data
Charlotta Zetterstr€
om, MD, PhD, Anders Behndig, MD, PhD, Maria Kugelberg, MD, PhD,
Per Montan, MD, PhD, Mats Lundstr€
om, MD, PhD

PURPOSE: To analyze changes in intraocular pressure (IOP) after cataract surgery based on data
from the Swedish National Cataract Register (NCR).
SETTING: Ophthalmic surgery units in Sweden.
DESIGN: Prospective database study.
METHODS: Data for 2012 through 2014 were obtained prospectively from the NCR. The outcome
register of the NCR has collected data on IOP before and a mean of 37.7 days G 29.1 (SD) after
cataract surgery since 2012.
RESULTS: The analyses were based on 20 437 cataract extractions reported during 1 month each
year to the outcome registry of the NCR. Cataract surgery was found to reduce IOP by a mean of
1.46 mm Hg, which was statistically significant (P < .001). A larger IOP reduction was seen in cases
with a higher preoperative IOP (r Z 0.557, P < .001). Older patients and shorter eyes had a greater
IOP reduction after surgery (P < .001 and P Z .001, respectively). Women had a greater IOP reduc-
tion than men (P Z .04) When high IOP was given as an indication for surgery, the IOP reduction
after cataract surgery was 5.50 mm Hg compared with a reduction of 1.40 mm Hg in patients for
whom this indication was not given (P < .001). Patients with glaucoma or pseudoexfoliation (PXF)
had a more pronounced IOP reduction than patients without these diagnoses (P < .001).
CONCLUSION: Cataract surgery had an IOP-lowering effect, in particular in older patients, women,
short eyes, eyes with high preoperative IOP, and eyes with glaucoma or PXF.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2015; 41:1725–1729 Q 2015 ASCRS and ESCRS

Cataract surgery is one of the most common surgical
procedures performed, with steadily increasing
rates.1 In the past, cataract was the major cause of
visual impairment and blindness, even in high-
income countries. Today, with increasing cataract
surgery performed in these countries, age-related
macular degeneration and uncorrected refractive
error are the main causes of visual impairment.2
The incidence of both cataract and elevated intraoc-
ular pressure (IOP), with or without glaucoma,
increases with age.
Intraocular pressure remains the only known modi-
fiable risk factor in the management of glaucoma
and is well recognized as a primary risk factor for
the development and progression of glaucoma.3 Intra-
ocular pressure–lowering therapy significantly delays
progression, as shown in the Early Manifest Glaucoma
Trial program.4
The aim of this study was to analyze changes in IOP
after cataract surgery using data from the Swedish
National Cataract Register (NCR).
MATERIALS AND METHODS
This database study was based on the NCR and its outcome
registry. The NCR was started in 1992.5 Today, almost all
units performing cataract surgery in Sweden report to the
NCR, with coverage of 96% to 97%. Phacoemulsification is
the technique used in 99% of cases.6

Q 2015 ASCRS and ESCRS http://dx.doi.org/10.1016/j.jcrs.2014.12.054 1725

Published by Elsevier Inc. 0886-3350
1726 IOP CHANGES AFTER CATARACT SURGERY
To analyze ocular comorbidities before surgery and indi-
cations for surgery, prospective data were collected from
the NCR. Parameters collected were ocular comorbidities
in the surgical eye, such as glaucoma, macular degeneration,
diabetic retinopathy, cornea guttata, pseudoexfoliation
(PXF), and other. The NCR database has included indica-
tions for surgery since 2012 with the following indications
given: vision loss, anisometropia, other visual impairment,
elevated IOP, and other. One or several indications for
surgery could be registered for each case. The age and sex
for each case are registered together with a personal code
number.
Prospective data were collected from the NCR’s outcome
registry for 2012, 2013, and 2014. Its outcome registry covers
cataract procedures performed each year in Sweden during
March, with coverage of approximately 65%. The outcome
registry of the NCR has recorded data on preoperative and
postoperative IOP since 2012; axial length (AL) has been
registered since 2013.
The study was approved by the Ethics Committee, Lund
University, and the Swedish Data Inspection Board and
was performed in accordance with the tenets of the Declara-
tion of Helsinki.
Statistical Analysis
All statistical calculations were performed using SPSS
software (version 22, SPSS Inc.) A P value less than 0.05
was considered significant.
RESULTS
Table 1 shows the patients' characteristics obtained
from the outcome registry of the Swedish NCR for
March 2012, 2013, and 2014.
Analysis of the 20 437 eyes in the study showed that
cataract surgery reduced the mean IOP by 1.46 mm Hg
(95% confidence interval [CI], 1.41-1.51), from a
Submitted: July 25, 2014.
Final revision submitted: December 21, 2014.
Accepted: December 29, 2014.
From the Department of Clinical Neuroscience (Zetterstr€om, Kugel-
berg, Montan), Division of Ophthalmology and Vision, Karolinska
Institutet, and EyeNet Sweden (Zetterstr€om, Lundstr€om), Blekinge
Hospital, Karolinska; St. Erik Eye Hospital (Kugelberg, Montan),
Stockholm; the Department of Clinical Sciences/Ophthalmology
(Behndig), Umeå University Hospital, Umeå; and the Department
of Clinical Sciences (Lundstr€om) Ophthalmology, Faculty of Medi-
cine, Lund University, Lund, Sweden.
Supported by the Swedish Association of Local Authorities and Re-
gions and the Swedish National Board of Health and Welfare.
Presented in part at the XXXII Congress of the European Society of
Cataract and Refractive Surgeons, London, United Kingdom,
September 2014.
Corresponding author: Charlotta Zetterstr€om, MD, PhD, EyeNet
Sweden, Blekinge Hospital, SE-37185 Karlskrona, Sweden.
E-mail: charlotta.zetterstrom@gmail.com.
J CATARACT REFRACT SURG - VOL 41, AUGUST 2015
Table 1. Patient characteristics obtained from the outcome reg-
istry of the Swedish NCR for March 2012, 2013, and 2014.
Year Cataract Surgeries (n) Mean Age (Y) Women (%)
2012 6142 73.8 60.8
2013 6498 73.8 60.8
2014 7797 73.7 59.6
preoperative mean of 15.98 mm Hg to a postoperative
mean of 14.52; the decrease was statistically significant
(P ! .001, paired-samples t test). The IOP was
measured a mean of 37.7 days G 29.1 (SD) after sur-
gery, and values between 1 mm Hg and 50 mm Hg
were accepted.
A statistically significant correlation was found
between the preoperative IOP and the IOP reduction
postoperatively. Eyes with a high preoperative IOP
had a significantly greater reduction (P ! .01, Pearson
correlation coefficient [r] Z 0.557). When high IOP was
given as an indication for surgery, the preoperative
IOP was 23.60 mm Hg compared with 15.98 mm Hg
in all eyes.
A statistically significant relationship was found
between the age of the patient and the reduction in
IOP. Older patients had a greater IOP reduction after
surgery (P ! .001, 1-way analysis of variance [AN-
OVA]) (Figure 1).
The difference in IOP reduction between men and
women was statistically significant (P Z .019,
independent-samples t test). Women had a greater
IOP reduction after surgery than men (Table 2).
A statistically significant relationship was found
between AL and the reduction in IOP (P Z .001).
The reduction in IOP was greater in shorter eyes
than in longer eyes (ANOVA) (Figure 2).
The IOP change by cataract surgery was dichoto-
mized into a 2 mm Hg reduction or more and a reduc-
tion of 1 mm Hg or less (including elevation of IOP). A
logistic regression analysis with the dichotomized IOP
reduction as a dependent variable and age, sex, AL,
and preoperative IOP as independent variables
was performed. All independent variables except
sex were significantly related to the IOP reduction
(Table 3).
When high IOP was given as an indication for sur-
gery, the IOP reduction after cataract surgery was pro-
nounced, being as high as 5.50 mm Hg compared with
1.40 mm Hg in patients who did not have this indica-
tion (P ! .001, independent-samples t test) (Table 4).
Table 4 also shows that patients with glaucoma and
PXF had significantly greater IOP reduction after cata-
ract extraction than patients without these diagnoses
(P ! .001, independent-samples t test).
 IOP CHANGES AFTER CATARACT SURGERY
Figure 1. Mean reduction in IOP after cataract surgery distributed
across different age groups (x-axis). Age is given in quartiles for
the total sample. Error bars with 95% CI (P ! .001, ANOVA).
Altogether, 2464 of the operated eyes had elevated
IOP given as an indication for cataract surgery. Of
these, 2016 (81.8%) had glaucoma, 870 (35.3%) had
PXF, and 310 (12.6%) had neither of these diagnoses.
DISCUSSION
The IOP-lowering effect of cataract surgery has been
known for a long time.7,8 It is probably the result of
the thinness of the inserted intraocular lens (IOL)
compared with that of the natural crystalline lens
and that lens exchange deepens the anterior
chamber.9,10 Changes in IOP after cataract surgery
are proportional to IOL thickness as well as to
changes in anterior chamber areas and in degree of
angle opening as evaluated by anterior segment opti-
cal coherence tomography (AS-OCT).11,12 Therefore,
AS-OCT images could probably assist in predicting
which eyes are most likely to benefit from cataract
surgery in terms of IOP reduction.13
In an earlier study,8 patients were followed over a
long time; an increased IOP over years was observed.
However, when cataract surgery was performed, no
Figure 2. Mean reduction in IOP distributed across quartiles of AL
(mm) (x-axis). Error bars with 95% CI (P Z .028, ANOVA).
J CATARACT REFRACT SURG - VOL 41, AUGUST 2015
1727
Table 2. Mean reduction in IOP in women and men after cata-
ract surgery according to data from the outcome registry of the
Swedish NCR.*
Mean IOP Reduction
Sex (mm Hg) 95% CI
Women (n Z 12 331) 1.51 1.44, 1.57
Men (n Z 8106) 1.38 1.30, 1.47
CI Z confidence interval; IOP Z intraocular pressure
*Difference statistically significant (P Z .040, independent-samples t test)
significant change in IOP was seen over time. We
found that older patients benefited more from cataract
surgery than younger patients in terms of the IOP-
lowering effect. This is related to the thin IOL and
the thickening of the crystalline lens with age. An
increase in crystalline lens thickness with age has
been shown using AS-OCT in unaccommodated
eyes, with an average lens thickness of 4.46 mm at
the age of 60 to 75 years.14 The mean age of patients
in the NCR in 2012 was 73.8. Foldable IOLs used in
Sweden today have a thickness of approximately 1.0
mm. Narrowing of the anterior chamber angle with
age also has been shown in an OCT study.15
The same mechanism is probably also responsible for
the more pronounced IOP-lowering effect in eyes with a
short AL and a relatively large crystalline lens. In a
study by Shin et al.,9 the reduction in IOP was correlated
with the increase in the angle opening. This is in accor-
dance with an earlier study16 in which cataract surgery
deepened the anterior chamber and widened the ante-
rior angle in nanophthalmic eyes, which had a signifi-
cant IOP-lowering effect. We also found a greater IOP
reduction after surgery in women than in men, which
is in accordance with women having a shorter AL.17
In clinical practice, elevated IOP has been accepted
as an indication for cataract surgery, in particular in
cases with primary angle-closure glaucoma. Clear
lens extraction has been proposed for elevated IOP in
these cases.18 Also, a sustained IOP reduction has
been shown in closed-angle glaucoma.19 When
elevated IOP was used as an indication in the NCR,
most cases had glaucoma or PXF; however, as many
as 12.6% had neither of these diagnoses and probably
had ocular hypertension. The Ocular Hypertension
Treatment Study (OHTS)20 found that postoperative
IOP was significantly lower than preoperative IOP,
and a greater reduction in postoperative IOP occurred
in eyes with the higher preoperative IOP. The
OHTS also found a lowering effect of surgery on IOP
in the long term. It is possible that lifelong treatment
with IOP-lowering therapy could be avoided in
selected cases with ocular hypertension after
phacoemulsification.
1728 IOP CHANGES AFTER CATARACT SURGERY

Table 3. Multivariable test of the relationship between preoperative variables and IOP reduction after a cataract extraction.*

Exponentiation of B

Independent Variable B Coefficient Standard Error P Value Value 95% CI

Age 0.018 0.002 !.001 1.018 1.014, 1.022

Preoperative IOP 0.292 0.006 !.001 1.339 1.322, 1.356
Axial length 0.042 0.013 .001 0.959 0.935, 0.983

CI Z confidence interval; IOP Z intraocular pressure

*Logistic regression analysis. Dependent variable is IOP reduction dichotomized into a 2 mm Hg reduction or more (1) and a reduction of 1 mm Hg or less
(including elevation of IOP) (0). Independent variables are age, preoperative IOP, and axial length.

Glaucoma was the most common diagnosis when
the indication was elevated IOP, and IOP reduction
in this patient group was larger than in the group of
patients who did not have glaucoma. Performing cata-
ract extraction before glaucoma surgery has numerous
benefits, and this procedure has been found to be
appropriate in selected cases.19,21 In an earlier study,21
50% of eyes with mild to moderate open-angle glau-
coma had an unmedicated IOP of 21 mm Hg or less
1 year after cataract surgery. One inclusion criterion
in that study was an IOP of 24 mm Hg or less
controlled with 1 to 3 medications.
Eyes with PXF have a higher risk for developing both
nuclear cataract and glaucoma22,23 and also have a
higher IOP than controls.8 In our analysis of NCR
data, we found that when elevated IOP was an indica-
tion for cataract surgery, 35.3% of eyes had PXF. It has
Table 4. Reduction in IOP after cataract surgery in eyes with
indication of elevated IOP, glaucoma, and PXF according to
data from the Swedish NCR (indications) and the outcome reg-
istry of the NCR (outcomes).
IOP Reduction
(mm Hg)
Characteristic Patients (n) Mean 95% CI
previously been suggested that phacoemulsification
has a protective effect concerning glaucoma progres-
sion in eyes with PXF. This was thought to be because
of the IOP-lowering effect of the lens exchange.24
Limitations of our study are its short follow-up and
that neither locally administered ocular corticosteroids
nor glaucoma medications were known. However, the
data from the follow-up visit are taken from the NCR’s
outcome registry, to which surgical units report their
follow-up control. This takes somewhere between a
few days to 1 month in Sweden. Because this was a
database study, we have to accept different routines
in different settings. Also, to our knowledge, most sur-
gical clinics in Sweden administer corticosteroids
drops for 3 to 4 weeks after cataract surgery, and
IOP changes from corticosteroid drops often occur
later.25 The protocol does not include questions con-
cerning glaucoma medication, and this is a limitation.
However, modification of this medication during the
short follow-up does not happen very often.
In summary, phacoemulsification had an IOP-
lowering effect, particularly in older patients, women,
short eyes, and eyes with high preoperative IOP, glau-
coma, or PXF.
P Value*

Indication of !.001
elevated IOP WHAT WAS KNOWN
Yes 286 5.50 4.68, 6.33  Cataract surgery has an IOP-lowering effect in normal
No 20 151 1.40 1.35, 1.45 eyes, eyes with ocular hypertension, and eyes with
Glaucoma !.001
glaucoma.
Yes 1842 2.28 2.04, 2.53
No 18 595 1.38 1.33, 1.43  A greater reduction in IOP occurs in eyes with high preop-
PXF !.001 erative IOP.
Yes 1903 2.30 2.09, 2.51
No 18 534 1.37 1.32, 1.42
Glaucoma and !.001 WHAT THIS PAPER ADDS
pseudoexfoliation
 A more pronounced IOP-lowering effect after cataract sur-
Yes 490 2.53 1.98, 3.07
No 19 947 1.43 1.38, 1.48
gery was found in older patients, women, and eyes with a
short AL.
CI Z confidence interval; IOP Z intraocular pressure; PXF Z
pseudoexfoliation  The prospective database study showed the IOP-lowering
*Independent-samples t test effect after cataract surgery in a large population.

J CATARACT REFRACT SURG - VOL 41, AUGUST 2015

 IOP CHANGES AFTER CATARACT SURGERY 1729

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