Sugammadex and intraocular pressure: systematic review with meta-analysis and trial sequential analysis

Elevated intraocular pressure (IOP) during emergence from general anesthesia may precipitate visual complications, particularly in patients with predisposing ocular conditions. Anticholinergics used with neostigmine for neuromuscular blockade reversal can transiently increase IOP, whereas sugammadex avoids anticholinergic use and may offer a safer ocular profile. This meta-analysis aimed to compare the effects of sugammadex versus neostigmine-anticholinergic combinations on IOP after extubation.

We systematically searched PubMed, Embase, Scopus, Web of Science, and Google Scholar from inception to September 30, 2025. Eligible studies were randomized controlled trials (RTCs) comparing sugammadex with neostigmine plus atropine in adult surgical patients undergoing general anesthesia, reporting IOP as an outcome. Data extraction and risk of bias assessment were performed following standard methodological practices. Meta-analysis was performed using a random-effects model. Trial sequential analysis (TSA) was used to evaluate the conclusiveness of findings. The review was reported in accordance with PRISMA guidelines.

Three RCTs with a total of 156 patients were included. Compared with neostigmine-atropine, sugammadex was associated with significantly lower IOP at 1 min (mean difference [MD], - 3.95 mmHg; 95% confidence interval [CI], - 5.75 to - 2.14; P < 0.001) and 5 min (MD, - 3.84 mmHg; 95% CI, - 5.01 to - 2.66; P < 0.001) after extubation. No statistically significant differences were observed at 2-10 min. Mean arterial pressure and heart rate were similar between groups. TSA confirmed conclusive evidence at 1 and 5 min.

Sugammadex was associated with improved early post-extubation IOP control without hemodynamic compromise. However, the evidence is based on a small number of heterogeneous trials and limited to short-term postoperative measurements, and the findings should be interpreted with caution.