Peripheral Vision in Patients Following Intraocular Lens Implantation: A Systematic Review and Meta-Analysis

Author: Artal P, Arvaniti M, Dimou P, Stavrinos C, Ginis H, Hervella L, Güell JL.

Geographical coverage: Not reported

Sector: Cataract surgery

Sub–sector: Intraocular lens implantation

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background: Peripheral vision is essential for everyday tasks such as mobility, object detection and spatial orientation. Impairment of peripheral vision is strongly associated with an increased risk of falls, regardless of central visual function. Moreover, image‑quality defects induced by intra‑ocular lenses (IOLs) in the retinal periphery may adversely affect quality of life.

Although cataract surgery is one of the oldest and most frequently performed procedures worldwide, its impact on peripheral image quality has been studied far less than its effect on central vision. A clearer understanding of the performance of modern IOLs in the peripheral retina is therefore required.

Objective: To evaluate the effect of IOL implantation (pseudophakia) on peripheral vision in patients after cataract surgery.

Main findings: Forty‑seven studies (5 963 participants) met the inclusion criteria, and fifteen were eligible for meta‑analysis. Compared with age‑matched healthy controls, the pooled mean deviation (MD) on perimetry was lower in pseudophakic eyes when measured with standard automated perimetry (SAP: MD = ‑2.21 dB, 95 % CI ‑3.89 to ‑0.54), short‑wavelength automated perimetry (SWAP: MD = ‑4.45 dB, 95 % CI ‑6.92 to ‑1.98) and frequency‑doubling technology (FDT: MD = ‑2.77 dB, 95 % CI ‑3.64 to ‑1.90). Pattern standard deviation (PSD) on FDT was higher, indicating more localised defects. Optical studies also showed increased peripheral astigmatism and a myopic shift beyond 20°, reducing image quality relative to phakic eyes. Patient‑reported outcomes indicated high overall satisfaction (pooled score 95.19) and little difficulty with steps and stairs (pooled score 0.23).

Methodology:  PubMed, the Cochrane Central Register of Controlled Trials, Embase, grey literature, the EU Clinical Trials Register and ClinicalTrials.gov were searched in December 2020 for randomised controlled trials, non‑randomised trials and observational studies of adults undergoing cataract surgery with in‑the‑bag IOL implantation. Studies involving ocular conditions other than cataract, surgical complications, previous ocular surgery or paediatric cataract were excluded.

Two reviewers independently screened records and extracted data; disagreements were resolved by a third reviewer. Risk of bias was assessed with ROB 2 for RCTs and MINORS for non‑randomised studies. A multilevel random‑effects meta‑analysis was performed. Heterogeneity was examined with the Q‑test and I² statistic, publication bias with funnel plots and Egger’s test, and sensitivity analyses explored the influence of individual studies.

Applicability/external validity: High heterogeneity, small sample sizes, varied IOL designs and divergent protocols limit the generalisability of the findings. Most patient‑reported outcomes relied on single‑item questions, which may not capture real‑world peripheral performance. Standardised assessment tools and larger, more diverse cohorts are needed to strengthen external validity.

Geographic focus: No geographical limits were applied, but the review did not report the geographical distribution of the included studies.

Summary of quality assessment: Overall confidence in the review’s conclusion is medium. The search strategy was comprehensive and study selection and data extraction were undertaken in duplicate. Appropriate risk‑of‑bias tools were used, and study characteristics were clearly documented. Nonetheless, restriction to English‑language publications, the absence of a list of excluded studies and limited subgroup analysis by risk of bias may have introduced bias.