complications of cataract surgery by J.mghanga

1. EXTRACAPSULAR CATARACT EXTRACTION (ECCE)
Definition
Extracapsular cataract surgery is a category of eye surgery in which
the lens of the eye is removed while the elastic capsule covering it is
left partially intact to allow implantation of an intra ocular lens.
This surgery is contrasted to Intracapsular cataract extraction (ICCE)
an older procedure in which the surgeon removes the whole lens
with its capsule.
Types
1.Conventional ECCE
a) Standard ECCE – here an incision measuring 10mm -12mm is
made on the sclera in which the Lens contents are removed.
b) Small incision cataract surgery (SICS) –here the lens nucleus
is removed through a scleral incision which is smaller than
standard ECCE and measures 5mm -6m
2.Phacoemulsification
In phacoemulsification the lens nucleus is broken inside the
capsule by Ultrasound energy and removed by aspiration
through limbal incision measuring 3mm – 5mm

2. COMPLICATIONS OF EXTRACAPSULAR
CATARACT SURGERY
1.COMPLICATIONS DUE TO LOCAL ANAESTHESIA
a) Retrobulbar Haemorrage – due to Retrobulbarblock
 Apply immediate pressure after instilling2% Pilocarpineand
postpone operationfor a week
b) Oculocardiac reflex – manifests as bradycardiaor cardiac
arrhythmia
 Give intravenousAtropine
c) Perforation of globe
 Gentle injectionwith blunttipped needle and peribulbar
Anaesthesia may be preferred over Retrobulbar
d) Subconjunctival Haemorrage - is a minor complicationand
does not require attention
e) Spontaneous dislocation of lens in vitreous has been reported
during vigorous ocularmassage after retrobulbarblock
 Postpone the operation

3. 2. INTRAOPERATIVE COMPLICATIONS
a) Superior rectus muscle laceration and/ or Haemorrage
may occur while applyingbridle suture
 No treatment required
b) Excessive bleeding may be encountered during
preparationof conjunctivalflapor during incision into
anteriorchamber
 Cauterize bleedingvessels
c) Button holingof anteriorwall of tunnel can occur due to
superficial dissection of the scleral flap
d) Premature entry can occur due to deep dissection and will
result in non-creationof self-sealing corneal valve
 Stop dissection into that area and start a lesser
depth at the other end of tunnel
e) Scleral disinsertion can occur due to very deep groove
incision–this leaves complete separation of inferior sclera
from sclera superior to the incision
 Scleral disinsertion to be managed by radial sutures
f) Descemet’s detachment - Injury to cornea, iris and lens
may occur when anterior chamber is entered by a sharp
object such as keratome
 Gentle handlingand proper hypotonyreduces such
incidences. Maintainanteriorchamber with
viscoelastic
g) Iridodialysis and iris injury may occur during intra ocular
manipulation

4. h) Complicationsrelated to anterior capsulorhexis – The
continuouscurvilinearcapsulorhexis(CCC) is the most
preferred in SICS and Phaco. The followingcan occur -:
 Escaping Capsulorhexis i.e. capsulorhexismoving
peripherallyand may extend to equatoror
posterior capsule
 Small Capsulorhexis – predisposes to posterior
capsule tear and nucleardrop during
hydrodisectionand also zonuladehiscence
 Very large capsulorhexis – may cause problems
with in bag placement of IOL
 Eccentric capsulorhexis – can lead to IOL
decentrationat a later stage
i) Posterior capsular tear/rapture (PCR) – it’s a dreaded
complicationand can lead to nucleardrop into vitreous.
Occurs during –
 Forceful hydrodisection
 Direct injury with instruments like Sinskey’s hook
and chopper or phaco tip
 Cortex aspiration.
j) Zonular dehiscence – occurs during nucleus prolapse into
anteriorchamber in manualSICS
k) Vitreous loss – occurs after PCR
l) Raised intra ocular pressure – can be controlledby -:
 Decrease Vitreous volume - by preoperative use of
hyperosmotic agents (20% mannitolor oral
Glycerol)

5.  Decrease Aqueous Volume – preoperative
acetazolamide500mg PO and adequate ocular
massage to be done digitallyafter injecting local
anaesthesia.
 Decrease orbital volume – by ocularmassage and
orbital compression by use of super pinky / Honan’s
ball or 30mm of Hg by pediatric
sphygmomanometer
 Good akinesiaand anaesthesiadecreases pressure
from eye muscle
 Minimizingexternal pressure on eyeballby using
wire speculum
m) Nucleus drop in vitreous cavity – occurs due to large
and sudden PCR, mostly in phacoemulsificationandless
frequent in manual SICS
 Management is anteriorvitrectomy and cortical
clean up
n) Loss of lens fragments posteriorly into the vitreouscavity
occurs after PCR or zonulardehiscence during phaco. This
will lead to glaucoma, chronic uveitisand Retinal
detachment.
 Management – pars planavitrectomy and removal
of nuclear fragment

6. 3. POST OPERATIVE COMPLICATIONS
I) EARLY POST OPERATIVE COMPLICATIONS
a) Hyphaema – collection of blood in anterior chamber may
occur from conjunctivaor scleral vessels due to minor
oculartrauma
 Treatment – most Hyphaemaabsorb
spontaneously
Early Hyphaema (immediate post operation period)
- Caused by incision on iris
- Its normally mild and resolves spontaneously
- If mixed bloodand viscoelastic the resolutiontakes
longer
Late Hyphaema (months years after surgery)
- Caused by wound vascularization/ erosion of
vasculartissues by lens implant
b) Iris prolapse – common in ICCE and conventionalECCE due
to inadequatesuturing of the incision(not in Phaco and
SICS)
 Management – a prolapse of less than 24hrs can be
reposited and sutured.
Large prolapse of long durationneeds excision and
wound suture
c) Flat anterior chamber – shallow or flat anteriorchamber
Can be due to –
- Wound leak
- Choroidaldetachment or hemorrhage
- Pupillaryblock
- Ciliary block

7. II) LATE POSTOPERATIVE COMPLICATION
 Cystoid macular oedema
 Delayed chronic postoperative endopthalmitis
 Pseudophakicbullouskeratopathy
 Retinal detachment
 Epithelial ingrowth
 Fibrous down growth
 Glaucoma
 After cataract
a)Delayed Chronic Post-Operative Endopthalmitis -Occurs
when an organism of low virulence get trapped within the
capsularbag.
Starts between 4 weeks to years (mean 9 months) post
operatively
Signs –
 Late onset
 Persistent, low grade uveitis
 Low virulence
 White opaquein posterior capsule
b)Pseudophakicbullouskeratopathy (PBK) - Post-operative
corneal edema produced by surgical or chemical insult to a
healthy or compromised corneal epithelium
c) Retinal detachment (RD)- Rare but more common in my
myopics after intraoperativeoperations

8. d)Epithelial ingrowth - Rarely conjunctivalepithelial cells
may invadeanterior chamber through a defect in the
anteriorchamber
e)Fibrous down growth in the anterior chamber – occurs
rarely when the cataract wound appositionisnot perfect.
May cause secondary glaucoma, phthisisbulbi
f) After cataract (secondary cataract) PCO –it’s the opacity
that persists or develop after ECCE
Types –
 Dense membranous – presents as a thickened
posterior capsule
 Soemmerings’s ring – thick ring of after cataract
behindthe iris enclosed behindthe two layers of the
capsule
 Elshning’s pearls

9. INTRA OCULAR LENS COMPLICATIONS