Unexpected scenarios in some cataract cases

1. Eslam Elkohly, FRCS (Glasgow)

2.  According to the World Health
Organization (WHO), cataract
is the leading cause of blindness
and visual impairment in the
world (47.9%).
 According to VISION 2020
conducted by WHO, it was
expected there will be 40
million people still blind from
cataract by 2020.
 Cataract accounts for 50% of
blindness in most African and
Asia countries.
 In 2017, 3.8 million cataract
surgeries have been performed
in the US.
Therefore, we have to be very careful
in every step before, during and after
the Sx to get the optimal outcome.

3. History taking
 Age:
- Young: cause of cataract (Trauma, DM, Bronchial Asthma,
Uveitis, … )
Please note, I will keep this slide and add on it till the end of the lecture.

4. Case 1
 32-year-old male patient.
 C/O: Defective vision, OD, 3
years.
 No systemic illness, No H/O
trauma.
 BCVA: 2/60 OD, 6/6 OS!!
 IOP: 18 mm Hg.
 Right dense PSC cataract!
 Pupil: No RAPD, intact
sphincter.
 Fundus hardly seen but retina
was flat, confirmed by B scan.
DrEslamElkohly

5. DrEslamElkohly

6. PSC cataract? Easy surgery?!

7.  Main incision made. I’ve been asked to look at the screen
of the phaco machine to check my settings!
 Back to the surgery > The AC is full of blood!
- NVs? PDR, CRVO, ….
- Angle? FHU?!
- Iris? Vascularized lesion!
- Behind the iris? AC is not shallow, pressure is OK!
I pressurized the AC with viscoelastic and waited for 2
minutes then washed the OVD. Again blood, but the
source is seen now, it is coming from the angle!
Bleeding stopped, I put suture and postponed the Sx!!

8. 2 hours
later!

9. Source of hge!
DrEslamElkohly

10. Then!
 I discharged the patient.
 I put him on topical steroids, antibiotics and anti-
glaucoma.
 FU given.

11. 2 dayslater
All overlooked
Signs seen!
I discovered that I have misseda clear case of FHU during the examination

14.  Iris heterochromia with the right iris a bit atrophic !

15. Koeppe Nodule
DrEslamElkohly

16. Other cases!!
 I did more 6 cases of
cataract in patients with
FHU and confident in
the diagnosis and ready.
 However, I did not see
bleeding in any of them.

17. DrEslamElkohly DrEslamElkohly
DrEslamElkohly
DrEslamElkohly

18.  Iris heterochromia with the right iris a bit atrophic !
DrEslamElkohlyDrEslamElkohly

19. DrEslamElkohly
Twigs vessels

20. KPs
DrEslamElkohly

21. Fuchs Heterochromic Uveitis
 Take a careful Hx of antiglaucoma medicatios.
 Examine your patient thoroughly (BCVA, IOP, back of the
cornea, gonioscopy, …)
 Do B scan in a case of too dense cataract and OCT macula
to exclude CME.
 Counsel your patient on the postop. spikes in IOP, reasons
of defective vision he might have other than cataract
(vitreous opacities, CME)
 Not every case of FHU will bleed once you create the main
incision.

22. Cont. History taking
 Age:
- Young: cause of cataract (Trauma,
DM, BA, Uveitis, … ) visual needs,
expectations.
- Old: medical Hx, Surgical Hx
(successful?, pain, Anaesthesia ….),
don’t forget the Hx of refractive Sx.
 Obesity
 Systemic diseases (DM, HTN, IHD,
anticoagulants, BA, BPH, RA)
DrEslamElkohly
Be careful: There is a risk of corneal melting after cataract Sx in cases with uncontrolled
Rheumatoid arthritis!!

23. Case 2
 I was observing a resident doing a case of
dense cataract in an otherwise medically
free patient.
 Obese, the only history is BPH on Flomax.
 Pupil mid-dilated, the patient is quiet.
 After capsulorhexis, the patient started to
complain he is distressed and wanted to
remove the drape. His oxygen saturation
was 98%. I took the case and finished it in
minutes under the stress of listening to the
chest of the patient with crepitations!!!!!!

24.  I was shocked when I removed the
drape and found the face of the
patient cyanosed and a lot of sweat.
 He was a case of CHF and the patient
was shifted to ICU!!
 He did not mention as his Sx was
cancelled before in another hospital!
 The case was not picked up by the
physician responsible for the preop.
Preparation!
Stress on the serious systemic illnesses
one by one while taking the history.

25. Cont. History taking
 Age:
- Young: cause of cataract (Trauma, DM, BA,
Uveitis, … ) visual needs, expectations.
- Old: medical Hx, Surgical Hx (successful?,
pain, Anaesthesia ….), don’t forget the Hx of
refractive Sx.
 Obesity
 Systemic diseases (DM, HTN, IHD,
anticoagulants, BA, BPH, RA)
 Mental health!

26. Case 3
 70-year-old medically free, female patient.
 Loss of vision in the only seeing eye, HM.
 The other eye lost due to complicated cataract Sx.
 The patient looks very quiet, does not talk much. I thought
she is deaf/mute but her relatives denied.
 Sent for dilation, biometry and B scan.
 White cataract, looks not so hard, not intumescent, good
dilation, clear cornea and retina in place by B scan.
 But the patient did not talk too much, just Yes/No answers!
It is worth mentioning here that it is critical to know why the other eye was lost and since
when! Complicated Sx, trauma or inflammation, ….

27.  During LA injection she felt some pain but still the Normal!
 When I put the drape, she started to shout but with some
reassurance, she kept quiet.
 When I punctured the capsule for rhexis formation, she started to
shout and cry very loudly, started to hold the drape aiming to
remove it, moving her head and the hole body!
 I called assistants from other rooms to hold her head, arms and
legs. Unfortunately, there was no anaesthesia setting!
 Under that huge stress, I finished the case by a miracle!

28.  Next day I found her quiet again, doing fine and IOL in
place and vision improved.
 Her son apologized that he had hidden her case as her
surgery had been cancelled before because of that.
 She was a case of
Schizophrenia !!!!!!!!!
Talk to your patient thoroughly before the surgery and try to pick up his general case!

29. Cont. History taking
 Age:
- Young: cause of cataract (Trauma, DM, BA, Uveitis, … )
visual needs, expectations.
- Old: medical Hx, Surgical Hx (successful?, pain,
Anaesthesia ….), don’t forget the Hx of refractive Sx.
 Obesity
 Systemic diseases (DM, HTN, IHD, anticoagulants, BA,
BPH, RA)
 Mental health!
 His Complaint!

30. Case 4
 59-year-old female patient presented to one of our
colleagues.
 DM – HTN
 Diagnosed with cataract, OU
 BCVA 6/12 OU.
 Bilateral nuclear cataract II.
 Posterior segment normal.
 Underwent uneventful phaco Sx in both eyes.

31. 1 month postop.
 Cornea clear
 IOLs in the bag.
 Posterior segment normal.
 BCVA 6/6.
 The patient is Unhappy!!!
 She was complaining of watery right eye, not of the
vision!!!

32. It was the chronic
dacryocystitis
bothering her
more than the
cataract!!
DrEslamElkohly
DrEslamElkohly
Listen to your patient carefully
and respect his complaint.

33. History taking and general look
 Age:
- Young: cause of cataract (Trauma, DM, BA, Uveitis, … )
visual needs, expectations.
- Old: medical Hx, Surgical Hx (successful?, pain,
Anaesthesia ….), don’t forget the Hx of refractive Sx.
 Obesity
 Systemic diseases (DM, HTN, IHD, anticoagulants, BA,
BPH, RA)
 Mental health!
 His Complaint!
 Look at the globe: sunken, deviated, scars around, …

34. The General look
DrEslamElkohly

35. Examination!
Verythinrim!
DrEslamElkohly
Always remember, multiple pathology is the rule. Examine carefully and dig for signs!

36. Case 5
 This patient was
scheduled for
cataract Sx and
came to me for
2nd opinion. On
examination, I
found altered
foveal reflex.
 OCT macula
showed
vitreomacular
traction!!

37. Case 6
 I reached the
end in this nice
case
 The Irrigating
cannula went as
a bullet behind
the IOL during
stromal
hydration of
the wound as
the cannula
was blocked by
viscoelastic.
 Anterior
vitrectomy and
reversed optic
captureDrEslamElkohly
Accept the complications and audit your work to improve your outcome
Test the fitting of the cannula
before use

38. Case 7: Be ready for complications!
A 54-year-old patient
Diabetic, hypertensive
UCVA: 6/36 & BCVA: 6/9 OU; however, he has not used
glasses and refuses to use them !!
 Refraction: + 4.00 Sph. OU
IOP: 20 mm Hg
Lens: NS ++ OU
Gonioscopy: G II, No PAS
 OCT-ONH: Normal
Fundus: Mild NPDR

39. 
 UCVA: 6/6
 IOP: 16 mm Hg in the operated eye.
1 week later: the other eye was operated by one of our colleagues,
but:
 UCVA: 6/36
 PCR, residual lens matter in the bag

40. Refused any intervention by the 2nd surgeon !
I did limited anterior vitrectomy, removal of the residual lens
matter, IOL repositioning.
1 week later:
UCVA: 6/9
Steroids tapered down.
1 month later:
UCVA: 6/18
Sudden altitudinal filed defect!

41. NAION

43. Case 8: 3 weeks post-phaco
 VA: HM
 Severe stromal edema
 AC: could not be assessed
 Retina in place by B-scan
 Surgery was uneventful according to his surgeon.
 No improvement, on frequent topical steroids and
hypertonic saline

45. Take home message
 Practicing ophthalmology in general has to be through
digging for the history and signs.
 The cataract case is not a lens but the whole patient.
 Do not depend completely on the patient’s history and
examine your patient carefully.
 Confidence is a good thing provided you have done
your role meticulously.
 No complications means no practice.
 We will learn to the end of our life.