Complication of cataract

1. COMPLICATIONS OF
CATARACT SURGERY
Sameer Chapagain
2nd year Resident
MD Ophthalmology
BPKLCOS

2. Layout
• Complications related to Anesthesia
• Intraoperative complications
• Postoperative Complications

3. Complications Related to Anesthesia
• Retrobulbar hemorrhage
• Globe perforation
• Others

4. Types of Anesthesia
• Regional or Local
anesthesia
• Retrobulbar Block
• Peribulbar Block
• Sub-Tenon Block
• Sub-Conjunctival Block
• General Anesthesia
• Topical Anesthesia

5. Retrobulbar Hemorrhage
• Retrobulbar block > Peribulbar
Block
• Venous or Arterial
• Sudden onset of Proptosis,
Ecchymosis and swelling or
lids, reduced motility of globe,
chemosis, Elevated IOP
• Optic Atrophy

6. Retrobulbar Hemorrhage
• Management:
• Digital massage
• Intravenous Mannitol
• Aqueous Suppressants
• Lateral Canthotomy and Cantholysis
• Surgery postponed until IOP, mobility of globe and
eyelids normal
• Advisable to use other form of anesthesia.

7. Globe Perforation
• Eyes with higher axial length
Myopic Eye, posterior staphyloma, previous
scleral buckling
• Deep Set Eyes
• Entry common Infero-temporal site
• Check for exit wound as well
• Acute Hypotony, Poor red reflex, Ocular pain
(poking through sensation)
• USG B scan helpful in determining site of
perforation
• Management
• Laser to seal retinal tear
• Vitrectomy is indicated if intraocular injection of
drugs, bleeding

8. Others
• Anaphylaxis
• Central spread of anaesthetic agent
• Retinal vein occlusion
• Optic nerve trauma
• Oculocardiac reflex
• Subconjunctival hemorrhage
• Spontaneous Dislocation of lens

9. Intraoperative Complications
• Incision and wound Complications
• Descemet’s Detachment
• Thermal wound burns
• Shallow or flat anterior chamber
• Intraoperative Floppy Iris Syndrome
• Iridodialysis and Iris trauma
• Zonular dialysis
• Cyclodialysis
• Lens Iris Diaphragm Retropulsion Syndrome
• Posterior Capsule Rupture
• Capsular Block Syndrome
• Suprachoroidal effusion and Hemorrhage
• Expulsive Choroidal hemorrhage

10. Incision and Wound
Complications

11. Incision and Wound
Complications….
• Button hole
• Due to superficial dissection
of scleral flap
• Tunnel is fashioned at deeper
level
• Premature entry
• Small : a new dissection
started at lesser depth
• Large : tunnel abandoned
and sutured

12. Incision and Wound
Complications….
• Full thickness scleral incision
• Suturing of the incision
• Improper tunnel formation
• Difficulty in the surgery
• Bleeding from incision site in SICS
• Adequate cautery

13. Descemet’s Detachment
• Mecahnical cause
• Instruments: Dull knife, Keratome, irrigator, phaco
handpiece
• Solutions: BSS, viscoelastics
• IOL insertion

14. Descemet’s Detachment….
• Presents with
• Corneal edema with
epithelial bullae
• Transparent tags curling
inward from corneal
incision
• Clear line separates
edematous and normal
cornea (usually)

15. Descemet’s Detachment….
• Small detachments may resolve spontaneously
• Reattachment with air or expansile gas ( SF6 or
C3F8)
• Larger detachments can be sutured.
• Descemet Membrane Endothelial Keratoplasty
(DMEK)

16. Thermal Wound Burns
• Inadequate cooling of phaco
tip due to insufficient flow
of irrigation fluid or
occlusion of outflow system
• Whitening of corneal tissue,
contraction , wound gape
(fish mouthing) and leakage.
• Suturing, sliding scleral flap
or patch grafts needed for
adequate closure.

17. Shallow or Flat Anterior Chamber
• Intraoperative causes
• Inadequate Infusion
• Leakage through an oversized incision
• External pressure on globe
• Positive vitreous pressure
• Fluid misdirection syndrome
• Suprachoroidal effusion or hemorrhage

18. Shallow or Flat Anterior Chamber….
• If reason of loss of chamber depth is not apparent : reduce
aspiration, increase bottle height, check incision
• If incision is large partial suture to keep chamber formed
• Readjust surgical drapes or speculum to relieve external
pressure
• Positive vitreous pressure : common in obese, thick necked,
COPD, Anxious
• Loss of anterior chamber depth and raised IOP : Check red
reflex to evaluate possibility of suprachoroidal hemorrhage

19. Shallow or Flat Anterior Chamber….
• Posterior fluid misdirection syndrome :
Fluid infused in anterior chamber is
misdirected into vitreous cavity via intact
zonular fibers or zonular and capsular tear
Increase in vitreous volume
Forward displacement of lens iris
diaphragm
Shallowing of anterior chamber

20. Shallow or Flat Anterior Chamber….
• Management
• Gentle posterior pressure on lens and reinflation of bag
using OVDs
• Intravenous mannitol infusion
• Insert 20-23 gauge needle through pars plana into
vitreous and gently aspirate the fluid
• Vitreous aspiration through pars plana vitrectomy tip
inserted through sclerotomy with infusion of BSS or
Injection of OVDs into anterior chamber

21. Intraoperative Floppy Iris
Syndrome (IFIS)
Iris billowing and floppiness
Iris prolapse into incisions
Progressive pupillary miosis
Iris trauma, PCR and vitreous loss ; especially
when unexpected

22. IFIS….
• Associated with alpha adrenergic antagonists
Selective alpha
1a
• Tamsulosin
• Silodosin
Non-Selective
alpha 1
• Alfuzocin
• Prazocin
• Doxazocin
• Terazocin
Other Drugs
• Labetalol
• Chlorpromazine
• Donepezil
• Minaserin
• Rispiridone
– History of use of this drugs preoperatively

23. IFIS….
• Preoperative Atropine
• Intracameral alpha adrenergic agonists
(phenylephrine or epinephrine)
• Proper Incision location and construction to
prevent wound leak
• Iris hooks and pupil expansion rings for stabilization
• Viscodilation of pupil and concave iris surface by
highly retentive OVDs
• discontinuation of fluid inflow prior to instrument
withdrawal
• Low flow settings
Measures to reduce intraoperative effects of
IFIS
Esen F et al Cutan Ocul Toxicol 2018 volume 37 issue 3, efficacy and safety of low concenteration bisulphiite containing intracameral
epinephrine and topical atropine treatment for prevention of floppy iris syndrome

24. Iridodialysis and Iris Trauma
• Tearing of iris at its root or
insertion
• Iridodialysis and iris trauma
can occur during insertion of
removal of instruments if iris
tissue gets engaged
• Intraoperative hyphema
• Iris trauma can lead to
chronic mydriasis
• Glare and cosmetic concern

25. Iridodialysis and Iris Trauma….
• Small and insignificant iridodialysis need no
treatment
• Large iridodialysis is managed by surgical
reattachment.
• Pupillary cerclage, artificial iris devices can alleviate
symptoms
• Iris colored contact lens

26. Zonular Dialysis
• Intraoperative : Pseudoexfoliation
Syndrome
• Marfan syndrome, Ocular trauma
• Zonules separate from their origin
during intraocular maneuvers :
• Traumatic capsulorrhexis
• Excessive manipulation of nucleus
• Inadvertent aspiration of anterior or
posterior capsule during
irrigation/aspiration
• Capsular tension rings are used to
overcome the complication

27. Cyclodialysis
• Separation of ciliary body from its insertion at
scleral spur
• Surgical manipulation of intraocular tissue
• Deep angle recess with gap between sclera and
ciliary body on gonioscopy
• Closure of defect if hypotony persists
• Argon laser photocoagulation or suturing

28. Lens-Iris Diaphragm
Retropulsion Syndrome (LIDRS)
• Posterior displacement of lens-Iris
diaphragm
• Deepening of anterior chamber, pupil
dilatation, posterior iris bowing
• Highly myopic eyes, previously
vitrectomised eyes
• High infusion pressure in AC
• Stresses zonular apparatus and patient
discomfort
• Difficult surgery
• Lifting the iris off the anterior capsule

29. Ruptured Posterior Capsule
• Can happen during :
• Capsulorrhexis
• Hydrodissection
• Phacoemulsification of
nucleus
• Lens extraction
• IOL insertion
• Irrigation and aspiration
• Presents with
• Sudden deepening of anterior chamber
• momentary dilatation followed by constriction of pupil
• Tipping of one pole of nucleus
• Descent of nucleus into the vitreous space

30. Ruptured Posterior Capsule…..
• Issues:
• Dislocation of lens fragments into vitreous
• Prolapse of vitreous into AC leading to vitreoretinal traction
• Placement of IOL
• Evaluation of the location and size of the tear will help
determine appropriate response
• Small rent during emulsification
• Compartmentalization of vitreous using OVDs
• Low flow low vacuum settings to remove remaining nuclear
and cortical material
• Low phaco power

31. Ruptured Posterior Capsule…..
• Small rent in posterior capsule during aspiration of
cortex
• Attempt in removing remaining cortex without
expanding the tear
• Low flow I/A
• Manual dry aspiration technique
• OVDs used to maintain anterior chamber
• Convert tear in posterior capsule into round posterior
capsulorrhexis to prevent expansion

32. Ruptured Posterior Capsule…..
• Large capsular tear with
most of the nucleus
remaining
• Phacoemulsification
should be abandoned
• Conversion into ECCE or
SICS
• OVDs used to float the
nucleus anteriorly
• Removal of nucleus using
wire Vectis or lens loop
• Retrieval of nuclear
fragments from vitreous
cavity should not be
done.

33. Ruptured Posterior Capsule…..
• Vitreous prolapse
• Vireous in anterior chamber associated with
chronic inflammation, corneal edema, retinal
detachment, CME, endophthalmitis and glaucoma
• Removal of all vitreous from the anterior chamber
• Vitreous can be stained with triamcinolone for better
visualization
• Anterior vitrectomy via main incision
• 2 port anterior vitrectomy
• Nd: YAG laser vitreolysis
• Vitreous reaching incision on ocular surface or causing
corneal compromise : Posteior vitrectomy may be
preferrable

34. Ruptured Posterior Capsule…..
• If Posterior capsular support for intracapsular IOL
placement insufficient IOL can be inserted into
ciliary sulcus
• If capsular integrity insufficient : ACIOL, Iris claw
lens or SFIOL can be inserted
• Dislocated lens fragments into vitreous is
approached within 1-2 weeks via PPV
• IOL can dislocate into vitreous if IOL implanted in
bag in presence of large rent.

35. Capsular Block Syndrome
• Intracapsular accumulation of liquefied
material behind lens or IOL and
subsequent occlusion of anterior
capsulotomy
• Intraoperative : Hydrodissection and can
cause posterior capsule blowout
• Early postoperative : OVD gets trapped
between posterior capsule and IOL
• Late postoperative(years after surgery):
accumulation of milky and turbid fluid
between posterior capsule and IOL
(byproducts of trapped, residual lens
epithelial cells)

36. Capsular Block Syndrome…..
• Can cause myopic shift.
• Posterior synechiae and secondary glaucoma
• Managed using Nd:YAG laser
• Anterior capsulotomy peripheral to the optic
• Posterior capsulotomy

37. Suprachoroidal Effusion or
Hemorrhage
• More common in patients with
Hypertension, Tachycardia, High myopia,
glaucoma, older, nanophthalmos, chronic
ocular inflammation
• Occurs intraoperatively or late in
prolonged ocular hypotony
• Clinically difficult to differentiate the
conditions (effusion may be precursor to
hemorrhage)
• Less likely in small incision surgery

38. Suprachoroidal Effusion or
Hemorrhage….
• Forward prolapse of ocular structures;
vitreous, lens diaphragm and iris
• Generally change in red reflex
• Patient agitation and Pain
• Firm globe

39. Expulsive Suprachoroidal
Hemorrhage
• Rare but serious
• Intraoperatively
• Presents as sudden increase in IOP and
acute onset of pain with
• Darkening of red reflex
• Incision gape
• Iris prolapse
• Expulsion of lens, vitreous and bright red
blood

40. Expulsive Suprachoroidal
Hemorrhage….
• Closing the incisions with digital pressure or
sutures immediately
• Prolapsed vitreous excised and uveal tissue
reposited
• Posterior sclerotomies in one or more
quadrants, 5-7mm away from the limbus
• Sclerotomies can be left open to allow further
drainage.
• If incision closed without posterior sclerotomy
terminate surgery Observe 7-14days and
refer to vitreoretinal surgeon for drainage
of hemorrhage

41. Postoperative Complications
• Corneal Edema
• Brown-Mclean Syndrome
• Induced Astigmatism and Unexpected refractive results
• Corneal Melting
• Postoperative shallow anterior chamber
• Elevated IOP
• Toxic Anterior Segment Syndrome
• Postoperative Shallow Anterior Chamber
• Postoperative Uveitis
• Retained Lens Materia
• Decentration and Dislocation of IOL
• IOL Opacification and discoloration
• Pupillary Capture
• Ciliary Block Glaucoma

42. Postoperative Complications
• Uveitis Glaucoma Hyphema Syndrome
• Posterior Capsular Opacity
• Anterior Capsular Fibrosis and Phimosis
• Hyphema
• Delayed Suprachoroidal hemorrhage
• Endophthalmitis
• Cystoid Macular Edema
• Retinal Detachment
• Retinal light toxicity
• Epithelial or fibrous ingrowth

43. Corneal Edema
• immediate post-operative period or late complication
• Preexisting corneal endothelial dysfunction predisposes
to corneal edema
(Fuchs dystrophy, Low endothelial cell density)

44. Corneal edema….
• Causes
Surgical
Trauma
Chemical
Injury
IOL related Endothelial
contact
Elevated IOP
High Phaco
Energy
Toxic anterior
Segment
Syndrome
IOL-Endothelial
touch
Flat chamber
centrally
• Wound leak
• Ciliary block
• Suprachoroid
al effusion
Inflammation
Mechanical
injury from
instruments
Preservatives in
intraocular
solutions
Uveitis-
Hyphema-
Glaucoma
Syndrome
Lens fragments Residual toxic
chemicals in
instruments
Rigid anterior
chamber IOL
Flat chamber
peripherally
• Pupillary
block
• Iris bombe
Descemet
membrane
detachment
Improper
concentration
of intraocular
solutions

45. Corneal edema….
• Diminished vision
• DM folds
• Striae Keratopathy
• Permanent loss of
endothelial cells leads to
pseudophakic bullous
keratopathy

46. Corneal Edema
• Management
• Early stages : Topical hyperosmotic agents,
corticosteroids and /or aqueous suppressants
• Pseudophakic bullous keratopathy can be managed by
• Anterior Stromal Puncture
• Lamellar or penetrating Keratoplasty

47. Brown-McLean Syndrome
• Unknown etiology
• ICCE>>> ECCE and
Phacoemulsification
• Peripheral corneal edema with
clear central cornea (5-7mm
zone)
• Starts inferiorly and spreads
circumferentially
• Central corneal guttae and
brown pigment on endothelium
in edematous areas

48. Induced Astigmatism
• Localized change in corneal
curvature because of
incisions or burns
• Flattening effect on the
axis of incision
• Large incisions and
incisions closer to corneal
apex are more prone
• Well constructed corneal,
scleral incisions of <3mm
will induce <1.00D
astigmatism

49. Corneal Melting
• Associated with preexisting tear film
abnormalities (KCS, Sjogren syndrome, RA)
• Preoperative use of topical diclofenac and
other NSAIDS increases risk
• Perioperative preservative free Lubricating
drops, punctal occlusion, bandage contact
lens, tarsorrhaphy
• Amniotic membrane graft, penetrating or
lamellar keratoplasty

50. POSTOPERATIVE SHALLOW
ANTERIOR CHAMBER
• Flat anterior chamber can cause permanent
damage to ocular structures
• Causes
• Leaking incision
• Choroidal detachment
• Pupillary block
• Ciliary block
• Capsular block
• Suprachoroidal hemorrhage

51. POSTOPERATIVE SHALLOW
ANTERIOR CHAMBER
• Classified according to etiology and level of IOP
• Prolonged apposition of iris to angle structures can
lead to PAS formation and chronic angle closure
glaucoma
• Iridovitreal or Iridocapsular synechiae can lead to
pupillary block
• Corneal contact with vitreous or IOL can lead to
chronic corneal edema due to endothelial cell loss

52. • Ocular hypotension (<10 mm Hg)
• Secondary to leakage from incision site or
secondary to choroidal or ciliary body detachment
• Asymptomatic if leaking incision is plugged by iris
• Prolonged hypotony may lead to ciliochoroidal
detachment that resolves after incision closure.
• Reformation of anterior chamber and wound
closure indicated if
• No improvement occurs within 24-48 hours
• Obvious wound gape is present
• Iris prolapse
• IOL in contact with corneal endothelium
• Late hypotony without obvious leakage may result
from RD, Cyclodialysis, Filtering bleb formation or
persistent uveitis

53. POSTOPERATIVE SHALLOW
ANTERIOR CHAMBER
• Shallow anterior chamber with normal or high IOP
• Pupillary block
• Ciliary block
• Capsular block
• Suprachoroidal hemorrhage
• Iridovitreal or iridocapsular synechiae
• Failure to perform peripheral iridectomy after ACIOL
• Peripheral iridotomy is usually effective

54. Elevated IOP
• Mild, self-limited rise in IOP is common
following cataract surgery
• Significant and sustained elevation requires
timely management
• OVD retained in eye after cataract surgery is
the most common cause
• Dispersive agents and high viscosity agents
• Proper visco wash prevents
• Medical management with anti glaucoma
drugs

55. Elevated IOP….
Without angle
closure
• Hyphema
• TASS
• Endophthalmitis
• Retained lens matter
• Uveitis
• Iris pigment release
• Preexisting glaucoma
• Corticosteroid use
• Vitreous in AC
• Ghost cell glaucoma
• Alpha chymotrypsin use
With angle closure
• Pupillary block
• Ciliary block
• Epithelial ingrowth
• Neovascular glaucoma
• PAS

56. Toxic Anterior Segment Syndrome (TASS)
• Acute sterile postoperative
inflammation
• Typically presents within
hours of surgery with
• Photohobia
• Severe reduction of visual
acuity
• Diffuse limbus to limbus
Corneal edema
• Marked anterior chamber
reaction with hypopyon

57. Toxic Anterior Segment Syndrome….
• Caused by inadvertent introduction of substance
toxic to corneal endothelium or uvea
• Skin cleansers containing chlorhexidine
• Subconjunctival injections and topical ointments
• Improperly cleaned surgical instruments
• Surgical glove residue or talc on instruments or IOLs
• Use of denatured OVD
• Substitution of sterile water for BSS
• Intraocular use of inappropriate irrigating solutions,
antibiotics or anesthetics
• Residue of detergents, enzymatic cleaners or OVD in
reusable instruments.

58. Toxic Anterior Segment Syndrome….
• Prevention by careful cleaning, rinsing and air drying
of reusable cannulas or disposable ones.
• Avoiding use of any nonphysiologic or preserved
solutions
• Use of intensive topical corticosteroids until
inflammation subsides
• Brief course of systemic corticosteroids
• Frequent follow up to monitor IOP and reassess
signs of infection

59. TASS Findings Endophthalmitis
12-24 hours Onset Usually 3-7 days
Usually absent Lid swelling/
Chemosis
Usually present
Mild pain Pain severe
More profuse
Limbus t limbus
Corneal edema Localized near wound
Immediate and
marked
AC reaction Over a long period
Fixed /dilated Pupil Reactive
High IOP Generally not
increased
Anechoic vitreous B- Scan Vitreous opacities
present
Negative Culture Positive

60. Postoperative Uveitis
• Nearly all eyes exhibit some degree of intraocular
inflammation post surgery
• most eyes are free of inflammation 3-4 weeks
postoperatively with topical steroids or NSAIDS
• Complicated cases requiring manipulation of
intraocular tissue (sphincterotomy, iridectomy or
repair

61. Postoperative Uveitis
• Conditions that predispose to increased
inflammation
• Pre-existing Uveitis
• Intraoperative manipulation of intraocular
tissue
• Vitreous loss or prolapse
• Sulcus fixation of IOL
• Children
• Diabetes
• Pseudoexfoliation syndrome
• Pigment dispersion syndrome
• Retained lens fragments
• IOL malposition

62. Postoperative Uveitis….
• Phacolytic Uveitis
• Symathetic Ophthalmia:
• Eye undergoing cataract surgery is inciting eye
• Fellow eye is sympathizing eye

63. Retained Lens Material
• Lens material may remain in
the anterior chamber angle,
posterior chamber behind
iris or migrate into vitreous
cavity
• Phacoemulsification > ECCE
• Dispersive OVDs > Cohesive
OVDs
• Found earlier in anterior
chamber than in posterior
chamber

64. Retained Lens Material
• Present with varying degree of inflammation
• Uveitis
• Elevated IOP
• Corneal edema
• Vitritis
• Cortical matter retention is less symptomatic than
nuclear matter

65. Retained Lens Material….
• Anti inflammatory (corticosteroids)
• Hypotensive drops and carbonic anhydrase
inhibitors
• Surgical management required if:
• Presence of large and visually significant amount of lens
material
• Inflammation not controlled by topical medications
• Medically unresponsive elevated IOP resulting from
inflammation
• Corneal edema
• Associated retinal detachment or tears
• Associated endophthalmitis

66. Retained Lens Material….
• Retained lens fragments in AC with intact posterior
capsule : Irrigation and aspiration or
viscoexpression via phacoemulsification incision
• Lens fragments in vitreous cavity: Pars plana
vitrectomy and removal of lens fragments
• Can be removed in same setting
• Surgery performed within 1-2 weeks resulted in better
vision and lower likelihood of retinal detachment,
glaucoma and chronic inflammation in compared to
delayed surgery1

67. Ciliary Block Glaucoma
• Malignant Glaucoma, aqueous misdirection
or vitreous block
• Anterior rotation of ciliary body and posterior
misdirection of aqueous into vitreous
• Mostly seen in eyes with prior angle closure
glaucoma
• Small eyes with open angles are predisposed.
• IOP may be elevated despite a patent
iridotomy or iridectomy

68. Ciliary Block Glaucoma ….
Anterior movement of lens iris diaphragm, poor
vitreous fluid conductivity and choroidal expansion
(ciliolenticular block)
Central and peripheral portion of AC narrows
Secondary rise in IOP due to angle obstruction

69. Ciliary Block Glaucoma ….
• Medical management:
• Cycloplegia with atropine
• Aqueous suppression with beta adrenergic
antagonists, alpha adrenergic agonists, and or topical
carbonic anhydrase inhibitors.
• Hyperosmotic agents
• Surgical management
• Nd:YAG laser iridozonulohyaloidotomy
• Vitrectomy (to disrupt anterior vitreous face and
vitreous-ciliary body interface

70. Cystoid Macular Edema
(Irvine-Gass syndrome)
• Common cause of
postoperative
decreased vision
• Peak incidence 6-10
weeks postoperatively
• Clinically significant
CME : Intracapsular
surgery (2-10%) >
Extracapsular (1-2%) >
Phacoemulsification
(0.10-2.35%)

71. Cystoid Macular Edema….
Risk Factors
PREOPERATIVE INTRA AND POST OPERATIVE
Coexisting Uveitis Posterior capsular rupture
Preexisting Epiretinal
membrane
Prolonged surgical time
Diabetes mellitus and
Diabetic Retinopathy
Retained lens fragments
Previous Retinal vein
Occlusions
Poorly controlled
postoperative inflammation
Retinitis pigmentosa Transient or prolonged
hypotony
Past history of CME Improper IOL positioning

72. Cystoid Macular Edema….
Risk Factors
Intraocular inflammation
(PGs and Leukotrienes)
Increased Perifoveal capillary
permeability
Accumulation of fluid in inner nuclear
and outer plexiform layers

73. Cystoid Macular Edema….
• Risk reduced by postoperative use of
topical NSAIDS or corticosteroids (alone or
in combination)
• Management by use of topical NSAIDS or
corticosteroids (alone or in combination)
• Sub-tenon or intravitreal injection of
corticosteroids.
• Intravitreal Anti-VEGFs
• Surgery to manage source of chronic CME
(retained fragment, malpositioned IOL
contributing to chronic uveitis)

74. Complications of IOL
Implantation

75. Decentration and Dislocation
• Reported incidence of
symptomatic subluxation or
dislocation of IOL after
uncomplicated cataract
surgery id 0.19-3.00%
• Intracapsular (lens inside the
capsule) or Extracapsular
(lens outside the capsule)
• Cause of intracapsular
dislocation is lack of zonular
support

76. Decentration and
Dislocation…
Intracapsular Extracapsular
Pseudoexfoliation syndrome Sulcus placement of
inadequate sized IOL
Trauma Decentered or Oversized
Capsulorrhexis
Previous vitreoretinal surgery Localized zonular defects
Capsular contraction IOL haptic damage
High myopia
Uveitis

77. Decentration and Dislocation…..
• Causes Glare and reflections or multiple images
• Contact with Uveal tissue : Pupillary capture,
Uveitis-Glaucoma-Hyphema syndrome

78. Decentration and Dislocation…..
• Minor decentration can be managed by miotics to
constrict pupil over IOL optic or cycloplegics to reduce
iris chafing by IOL optic or haptics
• Laser pupilloplasty: to realign pupillary aperture with
IOL optical centre.
• IOL repositioning, stabilization with sutures or Exchange
in severe cases.

79. Pupillary Capture
• Formation of synechiae between iris
and underlying posterior capsule
• Improper placement of IOL haptics
• Shallowing of anterior chamber
• Anterior displacement of PCIOL optic
• Placement of non angulated IOL in ciliary
sulcus
• placement of angulated IOL with IOL
vault anterior
• Sommering ring formation
• Asymmetric capsular contraction

80. Pupillary Capture….
• Symptoms
• Glare
• Photophobia
• Chronic uveitis
• Unintended myopia
• Monocular diplopia

81. Pupillary Capture….
• Prevention
• Placement of posteriorly angulated PCIOL in
bag
• Creation of anterior capsulorrhexis smaller
than lens optic
• Management
• Asymptomatic patient : can be left untreated
• Symptomatic : surgical intervention
• Free the iris
• Lyse synechiae
• Manage capsule contraction
• Reposition the lens

82. Uveitis-Glaucoma-Hyphema
Syndrome
• Classic triad or individual components
occur as a result of
• Inappropriate IOL sizing
• Contact between implant and vascular
structures or corneal endothelium
• Defects in implant manufacturing
• Described in context of rigid or closed
loop IOLs
• Can occur in PCIOL if contact between lens
haptics and uveal tissue occurs

83. Uveitis-Glaucoma-Hyphema
Syndrome….
• Medical management with cycloplegics,
anti-inflammatory and ocular hypotensive
medications
• Surgical management by IOL removal if
retinal or corneal function threatened.
• If scarring is present piecemeal removal of
IOL or leaving portions of haptics in situ
may be done.

84. Unexpected Refractive Results
• Preoperative error in measurement of axial
length and keratometry values
• Measurement of IOL power difficult in
• Silicon oil
• Penetrating keratoplasty or prior refractive
surgery
• Intraoperatively placement of lens in sulcus
• IOL exchange, piggyback IOL or secondary
keratorefractive procedures can be
considered

85. Epithelial or Fibrous ingrowth
• Growth of epithelium or
fibrovascular tissue
intraocularly through incision
over endothelium, angle, iris
• Presents with elevated IOP,
clumps of cells floating in the
anterior chamber, gray
retrocorneal membrane,
abnormal iris surface
• No treatment is universally
successful.
• Membrane excision with 5-
fluorouracil
• IOP control: Medical, filtering
surgery, drainage devices

86. IOL Opacification or discoloration
• Can happen immediately or over years
• Deposits or precipitates on surface of IOL
• Influx of water in hydrophobic IOL (glistenings)
• Staining of IOL by capsular dyes or medications
• IOL coating by silicon oil
• Progressive degradation of IOL material (snowflake
degeneration of PMMA IOLs)

87. Posterior Capsule Opacification
• common late complication by
ECCE and Phacoemulsification
• Occurs as a result of
continued viability of lens
epithelial cells after cataract
surgery.
• Opaque membranes formed
are a result of proliferating
epithelial cells, fibroblastic
metaplasia and collagen
deposition

88. PCO…..
Factors Influencing Formation
• Age of patient
• History of Intraocular inflammation
• Quality of cortical cleanup
• Presence of Pseudoexfoliation Syndrome
• Time elapsed since surgery
• Presence of intraocular silicon oil
• Design of the lens (posterior convex or
truncated square edge design decreases)
• Material of lens (Hydrogel > PMMA > silicone>
Hydrophobic acrylic)

89. PCO…..
• Presents with
• Diminution of visual acuity
• Monocular diplopia
• Maddox rod effect
• Patterns :
• Soemmering ring
• Elschnig pearls

90. PCO…..
• Management
• Nd. YAG laser capsulotomy
• Surgical capsulotomy

91. Anterior Capsule Fibrosis and
Phimosis
• Fibrosis is associated with clouding of anterior
capsule.
• Phimosis occurs because of contraction of anterior
capsule due to circumferential fibrosis
• Glare
• Phimosis: stress on zonular fibers and in the bag
subluxation of IOL optic

92. • Nd: YAG capsulotomy indications
• Visual acuity symptomatically decreased because of PCO
• Hazy posterior capsule preventing clear view of ocular
fundus required for diagnostic or therapeutic purpose
• Monocular diplopia, a Maddox rod-like effect or glare
• Anterior capsular phimosis causing encroachment on
visual axis, excessive traction on zonular fibers, or
alteration of lens optic position
• Capsular block syndrome

93. Hyphema
• Immediate postoperative period or late complication
• Risk increases in
• Pseudoexfoliation
• Anterior segment neovascularization
• Fuchs heterochromic uveitis
• Vascular tufts at pupillary margin

94. Hyphema….
• Immediate post operative hyphema is
usually mild and resolves spontaneously
• Longer time of resolution if vitreous is
mixed with blood
• Elevated IOP and Corneal blood staining
• IOP lowering agents and Surgical
evacuation(occasionally)

95. Hyphema….
• Months to years after surgery
• Result of
• incision vascularization
• Erosion of vascular tissue in iris or ciliary body
by IOL haptic or optic edge
• LASER Photocoagulation of bleeder via
goniolens
• Antiplatelet therapy may be withheld
• Reposition or exchange IOL

96. Delayed Suprachoroidal
Hemorrhage
• Predisposing Factors
• Prolonged hypotony
• Wound leak
• Unrecognized scleral perforation
• Trauma
• Cyclodialysis
• Presents with sudden onset of pain, loss
of vision and shallowing of anterior
chamber

97. Delayed Suprachoroidal
Hemorrhage….
• Managed by IOP lowering agents, Systemic
corticosteroids, cycloplegic agents if
limited hemorrhage and incisions intact
• If incision is not intact surgical revision of
incision.
• Surgical drainage of suprachoroidal space if
there is flat anterior chamber, medically
uncontrolled glaucoma, persistent or
adherent choroidal detachment

98. Endophthalmitis

99. • Rare but dreadful complication that can lead to
severe loss of vision or eye.
• Incidence rates between 0.04% to 0.2%(source)
• Acute form (occurring within 6 weeks of
surgery) or chronic (weeks to months after
surgery)
• Predisposing factors
• Diabetes mellitus
• Older age
• Male gender
• Complicated or prolonged surgery
• Vitreous loss
• Posterior capsular rupture

100. Endophthalmitis….
• Source of infection is patients’ own periocular
flora
• Endophthalmitis vitrectomy Study (EVS) found
the causes to be
• Gram positive coagulase negative
Staphylococcus epidermidis (70%)
• Staphylococcus aureus ( 9.9%)
• Streptococcus species (9.0)%
• Other gram positive bacteria (3.1%)
• Enterococcus species (2.2%)
• Gram negative bacteria (5.9%)

101. Endophthalmitis….
SYMPTOMS SIGNS
Mild to severe ocular
pain
Hallmark : Vitreous
inflammation
Vision loss Eyelid or periorbital
edema
Floaters Ciliary injection
Photophobia Chemosis
Corneal Edema
Anterior chamber
inflammation with
Hypopyon
Reduced Visual acuity
Retinal hemorrhages

102. Endophthalmitis….
• Chronic endophthalmitis
presents with decreased
vision, little or no pain.
• Presence or a nidus of
infection within the eye
• Common Organisms
• Propionibacterium acnes
• Staphylococcus epidermidis
• Fungi

103. Endophthalmitis….
• PREVENTIVE MEASURES
• Preoperative 10% povidone-iodine skin prep
• Povidone-iodine 5% eye drops
• Careful eyelid and eyelash draping
• Sterile technique
• Watertight incision closure
• Prophylactic pre and post operative antibiotics
• Endophthalmitis study group of ESCRS reported
decrease in a decrease in endophthalmitis from
0.34% to 0.07% in patients given intracameral
cefuroxime at the end of surgery
• Intracameral vancomycin, moxifloxacin or broad
spectrum cephalosporin

104. Endophthalmitis…. (management)
• AC and vitreous tap for culture and
sensitivity : appropriate antibiotics
• Pars plana vitrectomy and Intravitreal
antibiotics if vision is reduced to Light
Perception.
• Vision Hand movement or better :
Intravitreal antibiotics
• Vancomycin 1mg and Ceftazidime 2.25 or
amikacin 0.4mg including Dexamethasone
1mg

105. Management…..
• Subconjunctival antibiotics
• Topical antibiotics, cycloplegics,
corticosteroids
• Chronic Endophthalmitis is treated with
vitreous biopsy and intravitreal antibiotics
• Vitrectomy, posterior capsulotomy or even
IOL exchange is required to remove nidus
of infection

106. Retinal Detachment
• RRD uncommon but
Serious
• ICCE> ECCE >
Phacoemulsification
• Risk of RRD in
pseudophakic eyes 4 fold
higher when compared to
fellow phakic eye
• Occurs most frequently
within 1 year of surgery

107. Retinal Detachment….
• Most acute RRD are secondary to PVD
• Uncomplicated cataract surgery is risk
factor for earlier onset of PVD.
• Risk of RRD in cataract surgery with PCR is
increased by ten fold.
• Pars plana vitrectomy with or without
buckle

108. Retinal Light Toxicity
• Exposure to Unfiltered blue light and near
Ultraviolet radiation (from illuminating
filament of microscope)
• RPE burn occurs
• Central or paracentral scotoma
• Minimizing retinal exposure time, filtering
light wavelengths below 515nm and use of
pupillary shields and oblique lighting
reduce risk

109. Reference