Management of acute intraocular pressure elevation following cataract surgery: a retrospective cohort study

Acute intraocular pressure (IOP) spike is a relatively common complication following cataract surgery. However, there is a lack of evidence guiding treatment decision for IOP spike. Thus, the purpose of this study is to compare the relative effectiveness of commonly used management strategies for post-cataract surgery IOP spikes on post-operative day 1 (POD1). In this retrospective cohort study, we analyzed adult patients who underwent standalone cataract surgery and experienced a POD1 IOP spike that was managed with IOP-lowering medication use alone, wound manipulation alone, a combination of IOP-lowering medication and wound manipulation, or observation, between January 2020 and May 2025. The primary outcome measures were percentage IOP reduction achieved on POD1 and the likelihood of sustained IOP control (≤ 21 mmHg) at the next and final postoperative visits. A total of 306 eyes of 306 patients were included in the study. On POD1, the percentage IOP reduction achieved was significantly greater in the “wound manipulation only” (55.95%) and “combination of medication use and wound manipulation” (60.86%) groups than in the “medication use only” group (32.15%; p < 0.0001 and p < 0.0001, respectively). In contrast, the proportion of patients with IOP controlled at the next postoperative visit was higher in the “medication use only” (81.20%) group than in the “wound manipulation only” group (58.10%; p = 0.004). In this cohort, wound manipulation was associated with better acute IOP spike control on POD1 while medication use was associated with superior IOP control at the next postoperative visit. Our findings suggest that a combination of the two strategies may yield the best outcomes for the acute and sustained IOP control following cataract surgery. IOP spike is a relatively common complication following cataract surgery and is commonly managed with IOP-lowering medication, wound manipulation, a combination of the two interventions, and observation. Wound manipulation may be superior to medication in lowering IOP on POD1, while medication use may be superior in achieving sustained IOP control. A combination of medication use and wound manipulation may provide patients with the combined benefits of both acute and sustained control of elevated IOP.