1. COMPLICATIONS
OF
CATARACT SURGEY
DR. YOUSAF JAMAL
OPHTHALMOLOGY DEPARTMENT
HMC
(10-07-2010)
2. Introduction
Frequently asked question
Needs to be remembered on finger-tips
No surgery is without complications
Can be answered in many ways
Complications of Cataract surgery2
3. Usual classification
Complications of anesthesia
General anesthesia
Regional / Local anesthesia
Intraoperative
Early postoperative
Late postoperative
Complications of Cataract surgery3
10. PERIBULBAR / RETROBULBAR
ANESTHESIA
Lids trauma (ecchymosis)
Ptosis
s/conj hemorrhage
Muscles damage
Globe penetration & its related complications
Retrobulbar hemorrhage
Optic nerve damage
Putscher-type retinopathy *
Brainstem anesthesia
* Lemagne, J.S., Michiels, X., Van Causenbroeck et al (1990). Putscher-type retinopathy after retrobulbar
anesthesia. Ophthalmology, 97,859-61.
Complications of Cataract surgery10
11. RETROBULBAR HEMORRHAGE
Common complication
Causes proptosis & raised IOP
Incidence of severe RBH = 0-3%
Reported case of CRAO *
Management
Continue with surgery if minimal
Lateral canthotomy for severe cases
* Goldsmith M.O. (1967). Occlusion of central retinal artery following retrobulbar anaesthesia. Ophthalmologica.,
153, 191-6.
Complications of Cataract surgery11
13. BRAINSTEM ANESTHESIA
Life threatening
Mechanism
Entry of agent in ON sheath & then subarachnoid
space
Onset = 2 min, duration = 10-20 min
Manifestations
Confusion, cranial nerve palsies
Convulsions, hemiplegia, quadriplegia
CVS instability, respiratory arrest
Complications of Cataract surgery13
14. The National Survey of Local Anesthesia for
Ocular Surgery conducted by Royal college of
Ophthalmologists reported…
Incidence = 0.034% of severe systemic
reactions like
Shifting pt to ICU
Seizures
Death
Eke, T, and Thompson, J.R. (1999). The National Survey of Local Anesthesia for Ocular Surgery. II. Safety
profiles of local anesthesia techniques. Eye, 13, 196-204.
Complications of Cataract surgery14
15. S/CONJ & S/TENON
ANESTHESIA
Common Rare
Pain on injection (15- Globe perforation
33%) Retrobulbar hemorrhage
Chemosis (6-100%) Hyphema
s/conj hemorrhage (7- Muscle trauma
100%) Diplopia
Spread to CNS
Retinal dysfunction
Orbital cellulitis
Chronic dilated pupils
Indian j ophthalmol 2006;54:77-84
Complications of Cataract surgery15
16. INTRAOPERATIVE
COMPLICATIONS
Wound related Lens related
Iris prolapse Dropped nucleus
Corneal Retained lens mater
Descemet’s membrane Posterior loss of lens
detachment fragments
Corneal burns IOL related
Anterior chamber IOL dislocation
Iridodialysis Posterior segment
flattening of anterior Posterior capsule
chamber rupture
Hyphema Cyclodialysis
Intraoperative floppy iris Suprachoroidal
syndrome effusion & hemorrhage
Complications of Cataract surgery16
17. EARLY POSTOPERATIVE
COMPLICATIONS
Wound related IOP related
Wound leak Raised
Iris prolapse Low
induced astigmatism IOL related
Corneal Decentered
Corneal edema Dislocated
Striate keratopathy Tilted
Anterior chamber Pupillary capture
AC reaction Capsular block syndrome
Hyphema Acute Endophthalmitis
TASS
Vitreous in AC
Complications of Cataract surgery17
19. POSTERIOR CAPSULE RUPTURE
Serious complication…2.9-3.4% cases
May be accompanied by:
vitreous loss
posterior loss of lens fragments
Expulsive hemorrhage
Long-term complications
Up drawn pupil, Uveitis
Glaucoma
Endopthalmitis, Posterior IOL dislocation
R/D & CME
Complications of Cataract surgery19
20. Signs
Sudden deepening of AC
Pupillary dilatation
Visible rupture of PC
Visible vitreous
Complications of Cataract surgery20
21. Management
Depends on magnitude of tear & vitreous prolapse
General guidelines
Use slow irrigation to avoid vitreous disturbance
Retrieve lens fragments if they are visible
Never pull the vitreous
Use vitrector or scissors
Remove vitreous from pupil margin, AC & wound
PCIOL in bag, sulcus, ACIOL, scleral fixation
Complications of Cataract surgery21
22. SUPRACHOROIDAL EFFUSION
& HEMORRHAGE
Rare but dreadful complication
Pathophysiology
Elevated blood pressure, low IOP
Increase in transmural pressure in the choroidal
vascular plexus
Increased vascular permeability
serum, protein molecules into suprachoroidal space
Complications of Cataract surgery22
23. Increased ocular pressure limits the damage
Pain & agitation of pt suggests hemorrhage
Source … long or short posterior Ciliary artery
Expulsive hemorrhage…when SCH results in
expulsion of intraocular contents
Complications of Cataract surgery23
25. Signs
Progressive shallowing of AC
Increased IOP
Iris prolapse, incision gaping
Vitreous extrusion
Loss of red reflex
Dark mass behind pupil
Extrusion of intraocular contents in severe cases
Complications of Cataract surgery25
26. Management
Stop surgery
Immediate closure of wound
IV mannitol
Posterior sclerotomy & drainage…controversial
Postoperative
Topical & systemic steroids
Drainage thru sclerotomy after a week
Refer to VR surgeon for vitrectomy
Complications of Cataract surgery26
28. INTRAOPERATIVE FLOPPY IRIS
SYNDROME (IFIS)
Trio of
Iris billowing
Progressive Intraoperative miosis
Iris prolapse
Cause…Tamsulosin or other α1-blockers for
BPH
Unopposed action of sphincters
Increased risk of PCR & high IOP
Pt should be asked to stop it pre-op
Complications of Cataract surgery28
32. Cause
Irrigating solutions
Used cannula
Instruments rusts
Disposable gloves material
Management
Intraoperative measures
Topical + systemic steroids
Complications of Cataract surgery32
33. CORNEAL EDEMA
Presents…immediate postop period
Causes
Mechanical trauma
Prolonged surgery
Inflammation
Elevated IOP
Nuclear fragments
Results in acute endothelial dysfunction
Complications of Cataract surgery33
34. Surgery induced edema usually resolves in 4-6
weeks
Edema persisting after 3 months usually doesn't
clear
Chronic edema results in Bullous keratopathy &
cause
DV
Irritation, pain
FB sensation
Epiphora
Infectious keratitis
Complications of Cataract surgery34
38. KERATOLYSIS
Frequent association…tear film abnormality
KCS
Sjogren syndrome
Rheumatoid arthritis
Postop topical NSAIDS may also be the cause
Management
Lubrications
Preservative free medicines
Serum eye drops (growth factors)
Systemic tetracyclines
Complications of Cataract surgery38
39. Systemic immunosuppression for collagen disease
Bandage contact lenses
Tarsorrhaphy
Punctal occlusion
AMT
Lamellar KP
Penetrating KP
Complications of Cataract surgery39
40. CHRONIC UVEITIS
Develops weeks or months after surgery
Variable response to topical steroids
Keratic precipitates…usual
Hypopyon…less common
Diagnosis
Clinical findings
Aqueous, vitreous samples
Treatment
I/Vit antibiotic
Removal of lens capsule & IOL
Complications of Cataract surgery40
41. UGH SYNDROME
Cause
Inappropriate IOL size
Contact btw IOL & vascular structure or endothelium
ACIOLs…more notorious
Signs
AC cells & flare
Raised IOP
Hyphema…often
Vitreous wick
Complications of Cataract surgery41
42. Management
Atropine
Topical steroids
Topical NSAIDs
CAI…topical or systemic
Topical β-blocker & α2-agonist
Surgery…if medical Tx fails
Repositioning, replacement or removal of IOL
YAG vitreolysis
Complications of Cataract surgery42
43. POSTERIOR CAPSULAR
OPACIFICATION
Overall, the most common complication
Cause…viable LECs
Types
Sommering rings
Elsching pearls
Capsular fibrosis
PCO is actually misnomer bcz its not the
capsule which opacifies…rather an opaque
membrane develops over the PC *
* Indian J Ophthalmol 2004;52:99-12
Complications of Cataract surgery43
44. Sommering rings
Adherence of anterior & posterior capsule with
proliferation of equatorial LECs
Elsching pearls
Posterior migration of clusters of equatorial LECs
along PC…(bladder cells, wedl cells)
most commonly seen & in children
Capsular fibrosis
Anterior LECs proliferation
Complications of Cataract surgery44
46. Factors affecting PCO formation
Age of pt
Hx of intraocular inflammation
PXF
Size of Capsulorrhexis
Cortical cleanup
In the bag IOL
IOL design
IOL material
Modification of IOL surface
Time since surgery
Complications of Cataract surgery46
47. Pooled multiple reports..PCO rates=28% at 5 yrs
IOL material analysis…incidence at 3 yrs
PMMA=56%
Silicone=40%
Acrylic=10%
YAG capsulotomy rates
Acrylic=0.9%
Silicone=12-21%
PMMA=27-33%
American academy of ophthalmology,section 11, 2008-2009
Complications of Cataract surgery47
48. Treatment
Nd:YAG capsulotomy
Indications
BCVA decreased bcz of hazy PC
Hazy PC causing inadequate fundus view
Monocular Diplopia or glare
Complications of Cataract surgery48
49. Prevention
Hydrodissection-enhanced cortical cleanup
In-the-bag (capsular) fixation
Capsulorrhexis edge on IOL surface
IOL biocompatibility
Use of heparin in irrigating solutions (05 IU/ml)
Complications of Cataract surgery49
50. RETINAL LIGHT TOXICITY
Prolonged exposure to illumination of operating
microscope can result in:
Increased risk of CME
Burn to RPE
Mechanism
Removal of cataract (natural filter) exposes RPE to
blue light & near-UV radiations
Foveal burn…VA is reduced
Extrafoveal burn…paracentral scotoma
Complications of Cataract surgery50
51. Safety measures
Minimum direct foveal exposure
Minimum but optimal light intensity
Manufacturer approved lights
Add filter to block light < 515nm
Use oblique lighting if possible
Complications of Cataract surgery51
52. MACULAR INFARCTION
Very rare
Clinically similar to CRAO
Cause
s/conj injection of aminoglicosides for Endopthalmitis
prophylaxis
Gentamicin…greatest risk
Amikacin & tobramycin also
Complications of Cataract surgery52
53. CYSTOID MACULAR EDEMA
Common cause of decreased vision after
complicated or uncomplicated cataract surgery
Increased peri foveal capillary permeability
associated with generalized vascular instability
Other factors
Intraocular inflammation
Vitreomacular traction
Excessive UV-light exposure
PCR, Vitreous loss
Iris prolapse
Transient or prolonged hypotony
Complications of Cataract surgery53
54. Symptoms & Signs
Unexplained decreased VA
Loss of contrast sensitivity
FFA findings
Petaloid appearance of macula
Retinal thickening on OCT
Angiographic CME…1-19% after ECCE
Clinical CME…1-2% after ECCE
Even low rates with phaco
Complications of Cataract surgery54
56. Natural course
Peak incidence…06-10 weeks after surgery
95% uncomplicated cases spontaneously resolve in
06 months
CME frequency is high in…
poorly controlled postop inflammation
Malpositioned IOLs
Diabetics
Preexisting Epiretinal membranes
Previous occurrence of CME
Complications of Cataract surgery56
57. Management
Topical Ketorolac 0.5% & prednisolone acetate
1%...demonstrated to be effective in chronic CME
Subtenon or intravitreal Triamcinolone also effective
Surgery…for not responders to medicines
Vitrectomy to relieve traction
IOL exchange
Heier JS, Topping TM, Baumann W, Dirks MS, Chern S. ketorolac versus prednisolone versus combination
therapy in the treatment of acute pseudophakic cystoid macular edema. Ophthalmology.2000;107:2034-8.
Conway MD, Canakis C, Livir-Rallatos C, Peyman GA. intravitreal Triamcinolone acetonide for refractory chronic
pseudophakiccystoid macular edema. J Cataract Rfract Surg. 2003;29:27-33.
Complications of Cataract surgery57
58. RETINAL DETACHMENT
Usually occurs within 6 months after surgery or
post capsulotomy
Frequency…
2-3% after ICCE
0.5-2.0% after ECCE
Approx 1% after phaco
American academy of ophthalmology, section 11; 2008-2009
Complications of Cataract surgery58
59. Predisposing factors…
Axial myopia…>25mm or > 6D…15% increased risk
Age < 50 yrs
Lattice degeneration
Previous retinal tear or detachment
Hx of RD in fellow eye
Family Hx of RD
PCR
Vitreous loss…07% increased risk
YAG capsulotomy…4-fold risk
American academy of ophthalmology, section 11; 2008-2009
Complications of Cataract surgery59
60. Factors decreasing frequency of RD
Intact posterior capsule
Delaying capsulotomy for 3-6 months after surgery
Allows time for PVD and less disruption of VR
interface
Management
Pre-op lattice or breaks should be considered for Tx
PPV, encircling band, internal drainage, and
intraocular tamponade are effective and efficient
methods of repairing primary pseudophakic retinal
detachments
Complications of Cataract surgery60
61. ENDOPHTHALMITIS
An inflammatory condition of the intraocular
cavities (aqueous or vitreous) usually caused by
infection
Estimated incidence…0.15%
Risk factors
Age > 80 yrs
DM, secondary IOL implantation
PCR, combined surgery
Complications of Cataract surgery61
62. Pathogenesis
Lids & conjunctival flora…most common source
Contaminated instruments & solutions
Theater environment, surgeon & other staff
Organisms
Gram +ve…85-90%
S. epidermidis…70%
S. aureus, streptococcus spp & other gram +ve..15-20%
Gram -ve…5-6%
Pseudomonas, proteus, P.acnes
Complications of Cataract surgery62
63. ACUTE ENDOPHTHALMITIS
Presents…2-5 days post surgery up to 6 weeks
Fulminant course, Gram +ve organisms mainly
Features
Severe pain & visual loss
Chemosis, conjunctival injection & discharge
RAPD
Corneal haze
Fibrinous exudates, Hypopyon
Vitritis, poor fundus view
Complications of Cataract surgery63
67. CHRONIC ENDOPHTHALMITIS
Presents…weeks to months to years (9 months)
Low virulence organisms
P.acnes…mainly
S. epidermidis, corynebacterium, Candida
Features
Mild or no pain
Visual loss
Low grade ant uveitis, mutton fat KPs
Vitritis common but not Hypopyon
Complications of Cataract surgery67
70. PREVENTION OF
ENDOPHTHALMITIS
Preoperative
Treatment of pre-existing infections
Blepharitis, conjunctivitis, CDC, fellow eye
Topical quinolone 3 days preoperative…controversial
Perioperative
Proper eye, adnexa & nearby organs swab
Povidone-iodine 5% drops in conjunctival sac
Proper draping
Aseptic technique & instruments
Intracameral cefuroxime at end, water-tight closure
Complications of Cataract surgery70
71. TAKE HOME MESSAGE
Complication free surgery is a dream…BUT
Surgeon must be aware of complications & their
proper management
Proper anesthesia techniques, sterilization &
patient preparation…mandatory
Complications of Cataract surgery71
74. 1. in cataract surgery in which PCR & vitreous presents in
AC, ant vitrectomy is complete when
a. Vitreous is removed from wound
b. A PCIOL can be placed
c. The surgeon can see the retina
d. Vitreous is removed anterior to the posterior lens
capsule
Ans. d
Complications of Cataract surgery74
75. 2. Most common complication of retrobulbar anesthesia is
a. Globe perforation
b. Retrobulbar hemorrhage
c. Perforation of optic nerve sheath
d. s/conj hemorrhage
Ans. d
Complications of Cataract surgery75
76. 3. Which of following preoperative measures has proven
most effective in reducing risk of Endophthalmitis
a. Administering oral amoxicillin 3 days before surgery
b. Topical antibiotics for 2 weeks following surgery
c. Decreasing duration of surgery
d. Administering topical 5% Povidone-iodine solution at
time of surgery
e. Injecting Vancomycin into the I/A solution
Ans. d
Complications of Cataract surgery76
77. 4. Appropriate management of retrobulbar hemorrhage
includes all of the following except
a. Proceeding with surgery if red reflex is maintained
b. Promptly applying firm pressure on the globe
c. Observing the optic nerve & fundus with an indirect
ophthalmoscope
d. Administering CAI or mannitol to reduce IOP
e. Performing lateral canthotomy if proptosis, increased
IOP, and tight eyelids persist after other measures
have been undertaken to relieve orbital swelling
Ans. a
Complications of Cataract surgery77
78. 5. Systemic use of α1-antagonists for treatment of BPH may
cause IFIS by which of following mechanisms
a. Atrophy of iris sphincters
b. Competitive binding to postsynaptic nerve endings of iris
dilator
c. Loss of iris stroma
d. Atrophy of posterior pigment epithelium
e. Metabolic alkalosis of aqueous
Ans. b
Complications of Cataract surgery78
79. 6. Expulsive hemorrhage associated cataract surgery is
usually due to rupture of which vessels?
a. Vortex vein
b. Long posterior Ciliary artery
c. Short posterior Ciliary artery
d. Retinal artery
e. Choriocapillaris
Ans. c
Complications of Cataract surgery79
80. 7. Early postop complication of cataract surgery are all of
following except
a. Iris prolapse
b. Hyphema
c. Striate keratopathy
d. CME
Ans. d
Complications of Cataract surgery80
81. 8. Vitreous loss leads to…
a. Up drawn pupil
b. Astigmatism
c. Uveitis
d. CME
1. a+c, 2. a+b+c, 3. a+b+d, 4. a+c+d, 5. none of
above
Ans. 4
Complications of Cataract surgery81
82. 9. A 78 yrs old man scheduled for cataract surgery, has
past Hx of expulsive hemorrhage in fellow eye with
NPL. All of the following are steps to prevent expulsive
hemorrhage except..
a. Use of Honan balloon after anesthesia
b. Wound closure with 10/0 nylon
c. Clear corneal incision
d. Keeping BP well controlled during surgery
Ans. c
Complications of Cataract surgery82
83. 10. A 68 yrs old man underwent phaco + PCIOL. On first
postop day, he had mild corneal edema. Edema
persisted for 1 week more. Which is not the cause of
persistent corneal edema
a. Elevated IOP
b. Chemical toxicity
c. Epithelial down growth
d. Surgical trauma
Ans. c
Complications of Cataract surgery83
84. NEXT
Journal club
Dr Manzoor
Lecture
Dr Kabir (Phaco)
Complications of Cataract surgery84