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Cataract surgery complications

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    • 1. COMPLICATIONS OFCATARACT 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
    • 4. ANESTHESIACOMPLICATIONS Complications of Cataract surgery4
    • 5. GENERAL ANESTHESIA Respiratory complications  Laryngoscope & intubation  Respiratory obstruction & spasm (isoflurane)  Hypoxemia (N2O)  Hypercapnia / Hypocapnia  Hypoventilation  Aspiration pneumonia  Chest infections Complications of Cataract surgery5
    • 6.  Cardiovascular complications  Hypertension  Hypotension  Cardiac arrhythmias  Death (halothane) Neurological complications  Headache  Delayed recovery  Perioperative neuropathy  Hallucinations & unpleasant dreams (ketamine) Complications of Cataract surgery6
    • 7.  Postoperative nausea & vomiting (propofol, etomidate) Temperature changes  Hypothermia  Hyperthermia (atropine, halothane) Allergic drug reactions  Itching  Anaphylaxis  Hypotension, arrhythmia, tachycardia  Bronchospasm, cough, dyspnea Complications of Cataract surgery7
    • 8.  Complications of positioning  Air embolism  Nerve palsies  Brachial plexus, Radial nerve, Ulnar nerve  Skin necrosis Miscellaneous  Renal dysfunction (enflurane)  Muscle pain (succinylcholine) Complications of Cataract surgery8
    • 9. REGIONAL ANESTHESIA Complications of Cataract surgery9
    • 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
    • 12. Complications of Cataract surgery12
    • 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 pupilsIndian 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
    • 18. LATE POSTOPERATIVE COMPLICATIONS Wound related  Anterior chamber  Astigmatism  Chronic uveitis Corneal  UGH syndrome  Bullous keratopathy  Iris atrophy / cysts  Corneal decompensation  IOL related  Corneal melting  Malposition, glare  Brown-McLean  PCO & Phimosis syndrome  Posterior segment  Epithelial down growth  Retinal light toxicity IOP related  Macular infarction  Glaucoma  CME  R/D  Chronic Endophthalmitis Complications of Cataract surgery18
    • 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
    • 24. RISK FACTORS Ocular factors  Systemic factors  Glaucoma  HTN  High myopia  Chronic lung disease  Posterior capsule  Advanced age rupture  Obesity  Chronic ocular  Anticoagulation inflammation Complications of Cataract surgery24
    • 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
    • 27. Complications of Cataract surgery27
    • 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
    • 29.  Management  Careful incision architecture  Viscodilatation  Microincisional surgery  Low-flow settings  Iris retractors  Pupil expansion rings Complications of Cataract surgery29
    • 30. TOXIC ANTERIOR SEGMENT SYNDROME (TASS) Form of sterile non-infectious Endophthalmitis Presentation  12-24 hrs  Decreased VA  Marked AC reaction  Hypopyon…occasionally  May have pain & photophobia  Diffuse limbus to limbus corneal edema  Dilated, irregular or non-reactive pupil  Raised IOP Complications of Cataract surgery30
    • 31. Complications of Cataract surgery31
    • 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 doesnt clear Chronic edema results in Bullous keratopathy & cause  DV  Irritation, pain  FB sensation  Epiphora  Infectious keratitis Complications of Cataract surgery34
    • 35. Complications of Cataract surgery35
    • 36. Management Corneal edema  Topical hyper osmotic agents  Topical steroids  Bandage contact lens Bullous keratopathy  Penetrating keratoplasty  Endothelial keratoplasty  Gunderson conj flap  AMT Complications of Cataract surgery36
    • 37. Complications of Cataract surgery37
    • 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
    • 45. Complications of Cataract surgery45
    • 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
    • 55. Complications of Cataract surgery55
    • 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
    • 64. Complications of Cataract surgery64
    • 65. Complications of Cataract surgery65
    • 66. Management Vitreous + aqueous samples Antibiotics  I/vit, periocular, topical, oral Steroids  Oral…when fungal infection is excluded  Topical…for ant uveitis  Periocular…if systemic steroids contraindicated PPV Complications of Cataract surgery66
    • 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
    • 68. Complications of Cataract surgery68
    • 69. Management Vitreous + aqueous samples Antibiotics  I/vit Topical steroids Removal of capsular bag, IOL, residual cortex PPV Complications of Cataract surgery69
    • 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
    • 72. Complications of Cataract surgery72
    • 73. Complications of Cataract surgery73
    • 74. 1. in cataract surgery in which PCR & vitreous presents in AC, ant vitrectomy is complete whena. Vitreous is removed from woundb. A PCIOL can be placedc. The surgeon can see the retinad. Vitreous is removed anterior to the posterior lens capsuleAns. d Complications of Cataract surgery74
    • 75. 2. Most common complication of retrobulbar anesthesia isa. Globe perforationb. Retrobulbar hemorrhagec. Perforation of optic nerve sheathd. s/conj hemorrhageAns. d Complications of Cataract surgery75
    • 76. 3. Which of following preoperative measures has proven most effective in reducing risk of Endophthalmitisa. Administering oral amoxicillin 3 days before surgeryb. Topical antibiotics for 2 weeks following surgeryc. Decreasing duration of surgeryd. Administering topical 5% Povidone-iodine solution at time of surgerye. Injecting Vancomycin into the I/A solutionAns. d Complications of Cataract surgery76
    • 77. 4. Appropriate management of retrobulbar hemorrhage includes all of the following excepta. Proceeding with surgery if red reflex is maintainedb. Promptly applying firm pressure on the globec. Observing the optic nerve & fundus with an indirect ophthalmoscoped. Administering CAI or mannitol to reduce IOPe. Performing lateral canthotomy if proptosis, increased IOP, and tight eyelids persist after other measures have been undertaken to relieve orbital swellingAns. a Complications of Cataract surgery77
    • 78. 5. Systemic use of α1-antagonists for treatment of BPH may cause IFIS by which of following mechanismsa. Atrophy of iris sphinctersb. Competitive binding to postsynaptic nerve endings of iris dilatorc. Loss of iris stromad. Atrophy of posterior pigment epitheliume. Metabolic alkalosis of aqueousAns. b Complications of Cataract surgery78
    • 79. 6. Expulsive hemorrhage associated cataract surgery is usually due to rupture of which vessels?a. Vortex veinb. Long posterior Ciliary arteryc. Short posterior Ciliary arteryd. Retinal arterye. ChoriocapillarisAns. c Complications of Cataract surgery79
    • 80. 7. Early postop complication of cataract surgery are all of following excepta. Iris prolapseb. Hyphemac. Striate keratopathyd. CMEAns. d Complications of Cataract surgery80
    • 81. 8. Vitreous loss leads to…a. Up drawn pupilb. Astigmatismc. Uveitisd. CME1. a+c, 2. a+b+c, 3. a+b+d, 4. a+c+d, 5. none of aboveAns. 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 edemaa. Elevated IOPb. Chemical toxicityc. Epithelial down growthd. Surgical traumaAns. c Complications of Cataract surgery83
    • 84. NEXT Journal club Dr Manzoor Lecture Dr Kabir (Phaco) Complications of Cataract surgery84