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

ABSTRACT Topic To determine the literature-pooled incidence of postoperative binocular diplopia after cataract surgery, additionally stratified by route of anesthetic administration. Clinical Relevance 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. Methods/Literature Reviewed 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 risk of bias assessment using the Risk of Bias (RoB) in Non-randomized Studies of Interventions (ROBINS-I), RoB-2, and Joanna Briggs Institute (JBI) risk of bias tools. Certainty of evidence was rated through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) 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. Results 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%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=0.5-3.0%, 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 0.12-0.51, 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 risk of bias concerns. Conclusion 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.