Cataract complications


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Cataract complications

  1. 1. Complications of Cataract Surgery Prof. Naimatullah Khan Kundi Head, Department of Ophthalmology Khyber Medical College Peshawar
  2. 2. Complications of cataract surgery  Complications are varied in time and scope 1. Intraoperative 2. Immediate postoperative 3. Late postoperative Therefore it is necessary to observe the postoperative patients at periodic intervals
  3. 3. Major postoperative complications of cataract surgery Endophthalmitis Expulsive Haemorrhage Corneal edema Delayed choroidal haemorrhage Wound distortion or disruption Hyphaema Shallow or flat anterior chamber Elevated IOP Corneal edema Glaucoma Detachment of descemet’s Malignant glaucoma membrane Retained lens material Suprachoroidal haemorrhage or effusion
  4. 4. Major postoperative complications of cataract surgery • Vitreous disruption incarceration in the wound • Suture induced astigmatism • Pupillary capture • Complications of IOL implantation • Uveitis • IOL dislocation • Hemorrhage • Retinal detachment • Cystoid macular edema • Retianed lens material • Capsular rupture • Vitreous loss
  5. 5. Major postoperative complications of cataract surgery  Endophthalmitis  Sterile  Infectious
  6. 6. Acute bacterial endophthalmitis Incidence - about 1:1,000 Common causative organisms • Staph. epidermidis • Staph. aureus • Pseudomonas sp. Source of infection • Patient’s own external bacterial flora is most frequent culprit • Contaminated solutions and instruments Environmental flora including that of surgeon and operating room personnel •
  7. 7. Signs of severe endophthalmitis • Pain and marked visual loss • Absent or poor red reflex • Corneal haze, fibrinous exudate and • Inability to visualize fundus with hypopyon indirect ophthalmoscope
  8. 8. Signs of mild endophthalmitis • Mild pain and visual loss • Anterior chamber cells • Small hypopyon • Fundus visible with indirect ophthalmoscope
  9. 9. Management of Acute Endophthalmitis 1. Preparation of intravitreal injections 2. Identification of causative organisms • Aqueous samples • Vitreous samples 3. Intravitreal injections of antibiotics 4. Vitrectomy - only if VA is PL 5. Subsequent treatment
  10. 10. Subsequent Treatment 1. Periocular injections • Vancomycin 25 mg with ceftazidime 100 mg or gentamicin 20 mg with cefuroxime 125 mg • Betamethasone 4 mg (1 ml) 2. Topical therapy • Fortified gentamicin 15 mg/ml and vancomycin 50 mg/ml drops • Dexamethasone 0.1% 3. Systemic therapy • Antibiotics are not beneficial • Steroids only in very severe cases
  11. 11. Major postoperative complications of cataract surgery  Corneal edema  Detached Descemet’s membrane  Mechanical trauma  Vitreo-endothelial touch  IOL-endothelial touch  Toxic solutions
  12. 12. Major postoperative complications of cataract surgery  Wound distortion or disruption  Astigmatism  Wound leak  Inadvertent filtering bledb  Iris prolapse  Hypotony
  13. 13. Major postoperative complications of cataract surgery  Shallow or flat anterior chamber  Wound leak  Choroidal detachment or hemorrhage  Pupillary block  Ciliary block
  14. 14. Shallow or flat AC A. Intraoperative 1. Inadequate infusion of BSS 2. Leakage over sized wound 3. External pressure on the globe 4. Positive vitreous pressure more common in:     Obese Bull necked pts. COPD Anxious Pts. Who perform valsalva maneuver 5. Supachoroidal haemorrhage or effusion
  15. 15. Shallow or flat AC (cont’d) Intraoperative shallow AC Management     Raise infusion bottle Place suture across the wound to ↓ its size External pressure: Readjust surgical drapes or eye lid speculum Positive vitreous pressure:    I/V manitol ↓ the ↑ positive pressure and Allow the case to continue uneventfully Suprachoroidal hemorrhage or effusion:   Check red reflex Examine fundus with indirect ophthalmoscope to confirm diagnosis
  16. 16. Shallow or flat AC (cont’d) B. Postoperative shallow AC  Postoperative shallow AC → opposition of iris to angle → PAS → chronic ACG  Irido-vitreal (ICCE) / irido-capsular (ECCE) synechiae → pupillary block  Corneal contact with vitreous / IOL → endothelial cell loss → chronic corneal edema
  17. 17. Shallow or flat AC (cont’d) B. Postoperative shallow AC  Causes 1. 2. Choroidal detachment 3. Pupillary block 4. Ciliary block 5.  Wound leak Suprachoroidal hemorrhage Cases associated with ocular hypotension are 2ndry to wound leakage / choroidal detachment  Slow or intermittent wound leaks may coexist with formed AC
  18. 18. Shallow or flat AC (cont’d) B. Postoperative shallow AC Seidel Test:  To detect an area of wound leakage  Instill one drop of 2% fluorescein and examine the incision with cobalt blue filter on the SL  Aqueous dilution of fluorescein at the site of leakage will produce contrasting area of green stain  Occasionally aqueous flow is so slight that gentle pressure on the globe is necessary to confirm the site of leakage
  19. 19. Postoperative shallow AC (cont’d) Management Several Options 1. Cycloplegics and pressure patching 2. CAI and topical beta blockers: ↓ Aqueous flow through the woung 3. Corticosteroid avoidence: Enhance local wound reaction to faciliatte spontaneous closure 4. Therapeutic contact lens help in opposing wound edges and ↓ aqueous flow through the wound 5. Tissue adhesive: may seal the wound 6. Surgical
  20. 20. Postoperative shallow AC (cont’d) Management  These measures are appropriate for minor wound leaks  Many patients develop associated ciliochoroidal detachment which resolves spontaneously after wound closure
  21. 21. Postoperative shallow AC (cont’d) Management Surgical approach with reformation of AC and wound repair indicated:  If no improvement occurs in 24 – 46 hours  If obvious wound separation is present  Iris prolapse  IOL contact with corneal endothelium
  22. 22. Postoperative shallow AC(cont’d) Complications (shallow AC)  Early postoperative Pupillary block glaucoma may follow resolved wound leak  Late Pupillary block glaucoma is caused by postoperative uveitis with irido-vitreous / irido-capsular synechiae formation  AC IOL Placement without PI may be associated with early or late postoperative pupillary block glaucoma  Ciliary block glaucoma caused by aqueous sequestration within the vitreous body with flat AC & ↑ IOP
  23. 23. Postoperative shallow AC (cont’d) Pupillary block glaucoma Treatment 1. Pupillary dilation 2. Laser or surgical iridotomy 3. Vitretcomy preferred treatment for ciliary block glaucoma
  24. 24. Corneal edema Factors:   ↑IOP Endothelial cell damage  Edema in the immediate postoperative period  Incidence is increased in preexisting endothelial Dysfunction  Acute endothelial decompensation with increase in corneal thickness
  25. 25. Corneal edema (cont’d) Causes: 1. Mechanical trauma 2. Prolonged intraocular irrigation 3. Inflammmation 4. Increased IOP  Resolves in 4 – 6 weeks  Corneal edema persisting after 3 months will usually not clear and may require penetrating keratoplasty
  26. 26. Brown McLean Syndrome  This clinical condition occurs after cataract surgery (most frequently ICCE)  Etiology unknown  Consists of peripheral corneal edema with clear central cornea  Edema typically starts inferiorly and progresses circumfrentially but spares the central cornea  It rarely progresses to clinically significant central corneal edema
  27. 27. Vitreo-corneal adherence and persistent corneal edema  Early / late  Uncomplicated ICCE or complicated ECCE  Early recognition and treatment are essential to prevent development of irreversible corneal edema Treatment: 1. Anterior vitrectomy (Limbus / PP) 2. Penetrating keratoplasty with vitrectomy in more advanced cases
  28. 28. Tixic solutions  Certain solutions can be toxic to corneal endothelium when:  Irrigated  Inadvertently injected Cause:  Temporary  Permanent Into AC Corneal edema
  29. 29. Corneal complications of phacoemulsification  Heat: transferred from the vibrating probe to the cornea  Tight wound prevents adequate irrigation fluid along the probe  Occlusion of irrigation / aspiration tubing  Holding phaco tip too close to the corneal endothelium:
  30. 30. Corneal complications of phacoemulsification  The US energy causes:  Injury to cornea  Loss of endothelial cell C. Edema on 1st postoperative day/delayed for months to years  In corneal edema develops during:  Phacoemulsification and  Decreases visualization Convert to nuclear expression technique
  31. 31. Detachment of descemet’s membrane Results in stromal swelling and epithelial bullae localized in the area of detachment Causes:  When Instrument / IOL is introduced through cataract incision.  Inadvertent fluid injection between descemet’s membrane and stroma Treatment:  Small detachments can be reattached with air tamponade in AC  Large detachments can be sutured back into place 
  32. 32. Suprachoroidal haemorrhage or effusion  Occurs intraoperatively  Choroidal effusion with or without suprachoroidal haemorrhage  Choroidal effusion may be difficult to differentiate from choroidal haemorrhage (clinically)  Both complications may occur in patients with:  HT  Obesity  Glaucoma  Chronic ocular inflammation
  33. 33. Suprachoroidal haemorrhage or effusion  Choroidal effusion may be precursor of suprachoroidal haemorrhage  Or haemorrhage may represent spontaneous rupture of choroidal vasculature (in patients with underlying vascular disease)  Choroidal effusion tents veins and arteries that course through sclera and supply choroid  Disruption of these vessels lead to suprachoroidal haemorrhage (cont’d)
  34. 34. Suprachoroidal haemorrhage or effusion (cont’d) Treatment:  Rapid wound closure with elevation of IOP to tamponade the extravasated plasma or blood  Sclerostomy in one or more quadrants posterior to ora serrata to drain blood  Elevated IOP serves both to stop bleeding and to extravasate suprachoroidal blood
  35. 35. Expulsive Haemorrhage  Rare but serious intraoperative problem  Requires immediate action Presentation:  Sudden ↑ IOP  Darkening of red reflex  Wound gap  Iris prolapse  Expulsion of lens and vitreous  Bright red blood
  36. 36. Expulsive Haemorrhage (cont’d) Treatment:  Immediate closure of the wound with sutures / digital pressure  Perform posterior selerotomies (5 – 7 mm posterior to limbus) to permit suprachoroidal haemorrhage blood to escape and allow repositioning of prolapsed intraocualr tissues and closure of the wound
  37. 37. Delayed choroidal haemorrhage Early postoperative period (less common) Presentation:  Sudden onset of pain  Loss of vision  Shallow AC  ↑ IOP  Wound intact / disrupted
  38. 38. Delayed choroidal haemorrhage (cont’d) Management: Observation: If wound intact and IOP controlled, limited haemorrhage may be observed and resolve spontaneously Surgical drainage: 1. 2. 3. 4. 5. Wound disruption Persistent shallow AC Uncontrolled glaucoma Adherent choroidals (kissing) Persistent choroidal detachment
  39. 39. Delayed choroidal haemorrhage (cont’d) Medical Management: 1. Systemic corticosteroids 2. Ocular hypotensive agents (topical / oral) 3. Close observation
  40. 40. Hyphaema  Early / Late  Early: Immediate postoperative period     Late: Origin: Incision / Iris Mild resolves spontaneously Mixed with blood / viscoelastic – resolution longer Months / years after surgery  Origin: wound vascularization / erosion of vascular tissue by lens implant
  41. 41. Hyphaema (cont’d)  Complications (prolonged hyphaema):  ↑ IOP  Corneal blood staining  Management:  IOP monitored closely and treated in the usual medial fashion  Argon laser photocoagulation of the bleeding vessels stop / prevent rebleeding  With-holding antiplatelet therapy (Those who receive) until hyphaema resolves. Also risk of continued / recurrent bleeding reduced
  42. 42. Elevated IOP  Mild and selflimiting  Significant and sustained  Causes:           Retained viscoelastic material in AC, PC, behind the IOL] Pupillary block Ciliary block Hyphaema Endophthalmitis Retained lens material (phacolytic / phacoanaphylatic reaction) Iris pigment release Preexisting glaucoma Corticosteroid usage PAS (early postoperative flat AC when eye inflammed) → 2ndry glaucoma
  43. 43. Elevated IOP (cont’d) Treatment:  Mild and selflimiting:  Does not require prolonged anti-glaucoma therapy  IOP elevation lasts for a few days and is amenable to medical treatment  Significant and sustained rise of IOP:  May necessitate timely and specific management in several circumstances  Treat the underlying cause of IOP elevation
  44. 44. Malignant glaucoma (ciliary block glaucoma  Posterior dissection of aqueous into the vitreous body and 2ndry rise of IOP  IOP rise may occur inspite of patent iridectomy Treatment  Cycloplegics – to move lens-iris diaphragm posteriorly  Disruption of anterior hyaloid face and vitreous to reestablish a channel for aqueous to come forward Techniques:  Mechanical disruption (knife)  ND: YAG Laser  PPV
  45. 45. Retained lens material  Small lens material (cortical) better tolerated and require no surgical intervention  More likely resorb over time  Nuclear material incite significant inflammatory reaction  Inflammatory reaction may be difficult to differentiate from microbial endophthalmitis
  46. 46. Retained lens material (cont’d) Treatment:  Observation  Cycloplegic drugs  Corticisteroids  Surgical intervention
  47. 47. Retained lens material (cont’d) Treatment:  Surgical intervention  Large amount of lens material  Inflammation not controlled by topical medication  2ndry hypotony / increased IOP from inflammation  PC intact:  Simple aspiration  PC ruptured: (Potential for lens-vitreous admixture)  Vitrectomy
  48. 48. Vitreous disruption incarceration in the wound  Rupture of anterior vitreous face (ICCE/ECCE)  Anterior migration through pupil  Vitreous traction: - Retinal breaks and RD  Vitreous incarceration in the wound → chronic ocular inflammation with / without CME  Vitreous transparent, its presence datected by:  Touching / Manipulating the wound / iris with sponge or spatula:Adherent vitreous becomes apparent / cause movement of the pupil
  49. 49. Vitreous disruption incarceration in the wound (cont’d)  Management  Cutting vitreous strands and removed by suction cutter / cellulose sponges  ND:YAG laser / anterior vitrecotmy  PPV: Chronic ocular inflammation with CME and vitreous incarcerated in the wound if cornea shows considerable compromise (to reduce surgical trauma)
  50. 50. Suture induced astigmatism  Tight sutures:  post-operative astigmatism, Steepens the cornea in the direction of sutures  Removing sutures 6 – 8 wks postoperatively may alleviate astigmatism  Wound leak:  Significant against the rule astigmatism  Secondary intra-ocular infection:  Entry of organisms into the eye through suture tract
  51. 51. Pupillary capture Causes  PS (Iris and PC Adhesions)  Improper placement of IOL haptics  Anterior displacement of PC IOL optic (non angulated IOL in ciliary sulcus)  Inadvertent flipping over of angulated IOL so it angles anteriorly  Positive vitreous pressure from behind the optic of IOL
  52. 52. Pupillary capture (cont’d) Management  Asymptomatic:  Problem cosmetic – patient can be left untreated  Occasionally glare, photophobia, monocular diplopia  In bag placement has decreased the occurrence of pupillary capture  Symptomatic:  Pharmacological manipulation of pupil with mydriatics to free iris  Surgical intervention – free iris / break synechiae
  53. 53. Implant displacement Decentration Optic capture • • May occur if one haptic is inserted Reposition may be necessary into sulcus and other into bag • Remove and replace if severe
  54. 54. Complications of IOL implantation 1. Decentration and dislocation 2. Uveitis – glaucoma – hyphaema (UGH) syndrome 3. Corneal edema and pseudo-phakic bullous keratopathy 4. Wrong power IOL
  55. 55. Complications of IOL implantation (cont’d) Decentration and dislocation Causes  Asymmetric hapitc placemnt:  One in bag and other in sulcus. IOL designed for bag fixation prone to decentration / dislocation   when one / both haptics are placed in sulcus Insufficient zonular support Irregular fibrosis of posterior capsule
  56. 56. Complications of IOL implantation (cont’d) Decentration and dislocation (cont’d) Management  Rotation of IOL  Reposition IOL haptics  Replace capsule fixated IOL with PC sulcus fixated IOL  IOL exchange with AC IOL / Trans-sclerally sutured PC IOL (complete IOL dislocation)
  57. 57. Complications of IOL implantation (cont’d) Uveitis-glaucoma-hyphaema (UGH) syndrome  UGH syndrome was first described in the context of rigid AC IOLs  Classic triad (UGH) or individual elements may occur Causative Factors: 1. Inappropriate IOL size 2. Contact between implant and vascular structures 3. Defects in implant manufacturing 4. Idiosyncretic reaction of patient to implant
  58. 58. Complications of IOL implantation (cont’d) Uveitis-glaucoma-hyphaema (UGH) syndrome Treatment  Topical anti-inflammatory medications  Topical anti-glaucoma medications  IOL removal (symptoms not alleviated / threaten retinal or corneal function)
  59. 59. Complications of IOL implantation (cont’d) Corneal edema and pseudo-phalic bullous keratopathy Causes 1. 2. 3. 4. 5. Surgical trauma IOL type: - Iris fixated / closed loop flexible AC IOL Vitreous contact with corneal edothelium Glaucoma Corneal endothelial dystrophy (Fuchs) – increased risk of developing postoperative corneal edema even after smooth, a traumatic surgery
  60. 60. Complications of IOL implantation (cont’d) Corneal edema and pseudo-phalic bullous keratopathy Symptoms 1. 2. 3. 4. 5. Corneal edema → BK ↓ VA Irritation FB Sensation Epiphora 6. Infective keratitis (occasionally)
  61. 61. Complications of IOL implantation (cont’d) Corneal edema and pseudo-phalic bullous keratopathy Management 1. Topical hyperosmotic agents 2. Topical steroids 3. Bandage (therapeutic) contact lens Early Stage 4. Penetrating keratoplasty (recurrent pain, infective keratitis, ↓ VA)
  62. 62. Complications of IOL implantation (cont’d) Wrong power IOL A. 1. Miscalculation 2. Manufacturing defect B. If magnitude of implant error produce symptomatic anisometropia; replace IOL with appropriate power