Incidence of Postoperative Diplopia after Cataract Surgery: A Systematic Review and Meta-Analysis.

Abstract

To determine the literature-pooled incidence of postoperative binocular diplopia after cataract surgery, additionally stratified by route of anesthetic administration. Postoperative binocular diplopia is a rare yet distressing complication after cataract surgery. The literature-pooled incidence of postoperative binocular diplopia may assist ophthalmologists with educating patients on the likelihood of this complication prior to proceeding with surgery. This study was prospectively registered (CRD420251020603). MEDLINE, EMBASE, and Cochrane CENTRAL were searched on November 24, 2024 and updated January 20, 2026 to identify studies reporting on the incidence of postoperative binocular diplopia after cataract surgery, along with utilized routes of preoperative anesthesia. Independent paired reviewers completed article screening, data extraction, and RoB assessment using the RoB in Non-randomized Studies of Interventions, RoB-2, and Joanna Briggs Institute RoB tools. Certainty of evidence was rated through the Grading of Recommendations Assessment, Development and Evaluation approach. Random-effects meta-analyses were conducted to estimate pooled incidences and comparative odds ratios (ORs) for postoperative binocular diplopia, stratified by anesthesia route of administration. We identified 22 studies for inclusion in analysis. Overall, 21 studies (88 470 cataract surgeries; 408 binocular diplopia events) reported the incidence of postoperative binocular diplopia yielding a pooled incidence of 0.9% (95% confidence interval [CI] = 0.4%-1.9%, I² = 97.7%). Stratified by anesthesia route, the pooled incidence of postoperative binocular diplopia was 0.01% (95% CI = 0.0%-15.33%, I² = 0.0%) with topical anesthesia, 1.2% (95% CI = 0.5%-13.0%, I² = 96.5%) with peribulbar anesthesia, and 0.2% (95% CI: 0.1%-0.4%, I² = 80.6%) with retrobulbar anesthesia. Two studies (20 975 surgeries; 40 diplopia events) reported diplopia incidence stratified by retrobulbar versus topical anesthesia routes. From these studies, topical anesthesia was significantly associated with lower odds of postoperative diplopia than retrobulbar anesthesia (OR = 0.25, 95% CI 0.12-10.51, I² = 0.0%, P < 0.001). Between-study heterogeneity was substantial across incidence analyses. Certainty of evidence was rated "very low" in all incidence analyses and "low" in comparative analysis for RoB concerns. Very low-certainty evidence estimates the literature-pooled risk of postoperative binocular diplopia after cataract surgery, stratified by route of preoperative anesthesia. These results may equip cataract surgeons to more effectively counsel patients on the expected risk of postoperative binocular diplopia. The author has no/the authors have no proprietary or commercial interest in any materials discussed in this article.