Cataract Surgery Complications for General Practitioners

1. Eastwood
Eye Surgery
The Unhappy Post Cataract
Surgery Patient
Dr Gagan Khannah
Ophthalmic Surgeon
Eastwood Eye Surgery
Macquarie University Hospital
2014 Ophthalmic GP education Update
Epping Club 24th July 2014

2. Cataract and Refractive Surgery
Cataract surgery and refractive surgery
are now seen as a surgical spectrum
Significantly improved surgical safety and
rehabilitation time has seen cataract
surgery being offered earlier
200,000 Cataract ops/yr in Australia
50,000 Refractive operations
>10% of >60yo have IOLs
Using QAL methodology cataract surgery
is the most cost effective procedure

3. Complications O Cataract Surgery
Complications of Cataract Surgery

4. Complications of Cataract Surgery
•Preoperative complications
•Intraoperative complications
•Postoperative complications
Early (within first few days to 4 weeks)
Late (after 1 month to years)
Intra Ocular Lens related

5. Eastwood
Eye Surgery
Preoperative Issues
(Ophthalmic)
Corneal Transparency and Surface
Disease: Trachoma, Fuch’s, corneal scarring and
vascularisation, corneal dystrophies, OCP, Pterygium
Pupillary abnormalities: poor dilation,correctopia,
polycoria, aniridia, colobomas, Pilocarpine
Ectopia Lentis: Trauma, PXF, Marfan’s, High
Myopia, Ehler’s Danlos
Secondary: Uveitis, Drugs (steroids, amiodorone),
high myopia, Glaukemflecken, diabetic or retinal disease

6. Eastwood
Eye Surgery
Diabetes
Diabetic control MUST be optimal for
cataract / refractive Sx to be successful
Risk of:
– Cystoid macular oedema
– Worsening diabetic retinopathy
– Endophthalmitis
– Post operative inflammation
Ensure tight control for at least 3 months
pre and post surgery

7. Eastwood
Eye Surgery
Posture
Patient must be able to lie at 45O for 20
minutes
Problem with:
– CAL, orthopnoea
– Parkinsons disease, tremors, restless legs
– Neck and Back scoliosis
– Schizophrenia, dementia
LMO / Specialist advise helpful

8. Preoperative complications
1. Anxiety
2. Nausea and gastritis
3. Irritative / allergic conjunctivitis
4. Corneal abrasion
5. Complications due to local anesthesia
• Retrobulbar hemorrahge
• Oculocardiac reflex
• Perforation of globe
• Subconjuctival hemorrahage

9. Retrobulbar Hemorrhage
Accumulation of blood in the orbital spaces
Proptosis, tightness of the lids, chemosis
Pressure bandage after 2% Pilocarpine drops
Degenerated zonules
Hypermature cataract and
Vigorous ocular massage
Spontaneous dislocation of lens

10. Globe perforation SCH
Minor complication observed frequently
Resolves on its own.
Hypotony, poor red reflex, vitreous hge.
Cryopexy or photocoagulation is done

11. Intraoperative complications
Complications related to anterior capsulorrhexis
Escaping capsulorrhexis
Small capsulorrhexis
Very large capsulorrhexis
Eccentric capsulorrhexis
Posterior capsular rupture
Nucleus drop into vitreous
Zonular dehiscence
Vitreous loss
Expulsive choroidal hemorrhage

12. Vitreous loss Management
Insertion of PC-IOL if adequate capsular support present
Sponge or automated anterior vitrectomy

13. Insertion of AC-IOL
If adequate capsular support is absent
1.
Constriction of pupil
Peripheral
iridectomy
Glide insertion
2.
Coating of IOL
with viscoelastic
3.
Insertion of IOL
4.
Suturing of incision

14. Dropped Lens Material

15. Management of posterior loss of lens fragments
Fragments consisting of 25% or more of lens should be removed
Pars plana vitrectomy and removal of lens fragments

16. Eastwood
Eye Surgery
Post-operative issues
All patients informed of RSVP
– R – redness
– S – sensitivity to light
– V – loss of vision
– P – pain
Complications in first week
– Infection: Endophthalmitis / Keratitis
– Raised IOP
– Trauma – No heavy lifting, eye rubbing, straining

17. Eastwood
Eye Surgery
Post-operative complications
Pt c/o reduced or altered vision
– First day = pre existing disease
– First week = endophthalmitis = Emergency
– First fortnight = Macula oedema
– Glare / halos = IOL effect, Stromal haze
– > 3 months gradual reduction = posterior
capsule opacification = Rx YAG laser
– Flashes and floaters = posterior vitreous
detachment = possible retinal detachment

18. Hyphema
Blood in Anterior Chamber
Conjunctival/scleral vessels
Management:
Spontaneous absorption
Acetazolamide (if IOP increases)
Paracentesis (if persistent)

19. Striate keratopathy
Cause
Fuch’s Endothelial Dystrophy
Damage to endothelium during
surgery
Treatment
Most cases resolve within few
days
Occasionally persistent cases
may require corneal graft
Corneal edema and folds in Descemet’s membrane

20. Post operative uveitis
Frequent instillation of steroid drops and ointment cover at night.
Brighter red reflex (to differentiate from endophthalmitis).
If worsening of symptoms within 6-12hrs…think of endophthalmitis.

21. Retained Lens material in AC

22. Acute Bacterial Endophthalmitis
Common causative organisms
• Staph. epidermidis
• Staph. Aureus
•Strep
•Gram -ve
•
Source of infection
Patient’s own external bacterial flora
is most frequent culprit
Contaminated solutions and
instruments

23. Eastwood
Eye Surgery
Endophthalmitis
Prevention of
endophthalmitis
/keratitis
– Betadine preop
– Wound closure
– Post operative
antibiotics
Rate < 1 in 4000
Treatment very
effective early

24. Preoperative Prophylaxis for Endophthalmitis
Treatment of pre existing infections
Staphylococcal blepharitis Chronic conjunctivitis
Chronic dacryocystitis Infected socket

25. Peroperative Prophylaxis for Endophthalmitis
Meticulous prepping and draping
Instillation of Povidone iodine Postoperative injection of ABx

26. Management of Acute endophthalmitis
1. Preparation of intravitreal injections
2. Identification of causative organisms
1. Aqueous samples
2. Vitreous samples
3. Intravitreal injections of antibiotics
4. Vitrectomy - only if VA is PL
5. Subsequent treatment of intensive
topical +/- oral antibiotics
Mini vitrector

27. Sampling and injections
Mark 4mm behind limbus Vitreous tap/aspiration
Injection of Antibiotics

28. Eastwood
Eye Surgery
Post-operative issues
Complications in first month
– Local allergy to eye meds esp Chlorsig
– Imbalance to vision
– Foreign body sensation – dry eyes, wound
irritation, epithelial defect

29. Late Postoperative Complications
Cystoid macular edema
Delayed chronic postoperative endophthalmitis
Pseudophakic bullous keratopathy
Retinal detachment
After cataract/Posterior Capsular Opacification

30. Retinal Detachment &
Cystoid macular oedema
after cataract surgery

31. • RD increased in incidence after cataract surgery
– Controversy as to what that incidence is
– Rate of RD 1%, 5x greater risk at 10 years
– Newer studies suggest a much lower rate of RD
• Risk factors
– Myopia, axial length >25mm
– Lattice degeneration, prior RD, males
– Intraoperative complications
– Laser capsulotomy
Retinal detachment after
cataract surgery

32. Retinal Detachment - Risk Factors
Disruption of posterior capsule Lattice degeneration
Intra operative vitreous loss
Laser capsulotomy , particularly
in high myopia
Treat prophylactically before or
soon after surgery

33. • Risk significantly higher in younger patients
– Confirmed in a number of studies
– NZ study of 1800 uncomplicated phaco cases
– 10 year review
– Age < 50: RD rate 5%
– Age > 70: RD rate 0.64%
• Advise need for urgent review if symptoms of RD
– Particularly for high risk groups
– Over 50% of pseudophakic RD in first year
– Most still present with macula off detachments
– Reinforce messages when following patients over time
Retinal detachment after
cataract surgery

34. • Most common cause suboptimal vision
• Not a disease but clinical finding (Irvine-Gass)
• Symptoms usually between 2-12 weeks
• Peak incidence at 6 weeks
• Rare cases after 6 months
• “My spectacles are not right”
Pseudophakic
cystoid macular oedema

35. Cystoid macular edema
Postoperative decrease in vision
Fluid accumulation within sensory retina in
macular area
Confirmed by FFA – Petaloid appearance

36. • Symptoms and signs
– Reduced VA and distortion
– Inflammation
– Blunted or yellowish foveal reflex, frank cysts
– OCT will confirm diagnosis, but not always cause
– May still need FFA
Pseudophakic
cystoid macular oedema

37. • Angiographic CME
– Some macular leak in 10-20%
– Clinical CME in approximately 1%
– Most cases will improve spontaneously
• Prevention
– Prostaglandin PGF2a and inflammation
– NSAID pre and post-op
– High risk cases, Avastin or IVTA
– Minimise surgical complications (20% if vitreous loss)
Pseudophakic
cystoid macular oedema

38. • Natural history
– Without treatment, 80% resolve between 3-12 months
– If persist for > 6 months, only 30% return to 6/12
– Difficult to predict
– Treat all patients for recovery and avoid chronic CME
• Treatment
– Rule out other causes
– Topical steroids and NSAIDs
– Subtenon’s or intravitreal steroids
– IVTA improves function at 3 months
– Refractory CME – Avastin
– Combination IVTA/Avastin?
Pseudophakic
cystoid macular oedema

39. Bilateral Pseudophakic
cystoid macular oedema

40. Delayed chronic postoperative endophthalmitis
Late onset, persistent low grade uveitis
May be granulomatous.
Caused by Propionibacterium acnes
or Staphylococcus epidermidis.
Low virulence organisms trapped in
capsular bag
Seen as white plaque on posterior capsule
Signs

41. Treatment of chronic endophthalmitis
Initially good response to topical steroids Recurrence after cessation of treatment
Inject intravitreal vancomycin
Removal of IOL &capsular bag if unresponsive

42. Pseudophakic bullous keratopathy
Hypertonic agents (ointment or eye drops)
Bandage contact lens,
Corneal Graft
Intraoperative endothelial injury
Pre existing endothelial pathology
Chronic Inflammation – cell loss
Stromal oedema with epithelial oedema
Blurred vision early in the morning and improving later in the day
Chronic edema leads to scarring

43. After cataract/posterior capsular opacification
Elschnig pearls Fibrosis
Proliferation of lens epithelium
Occurs after 3 to 5 years
Usually occurs within 2 to 6 months
May involve remnants of anterior capsule
And cause phimosis

44. Treatment of PCO
Nd: YAG Laser capsulotomy
Accurate focusing is vital
Apply series of punctures in cruciate
pattern
3mm opening is adequate
Potential complications
Damage to implant
CME
Retinal detachment (in high myopes)

45. • Always treat
dry eyes and
get stable
keratometry
Dry Eye

46. • Treatment Options
– IOL repositioning
– IOL exchange
– Piggyback IOL insertion
• ‘Sulcoflex’
– Astigmatic Keratotomy
– Laser Vision correction (PRK or LASIK)
Residual Refractive error

47. IOL related complications
ACIOLs: Corneal endothelial damage, Uveitis,
Glaucoma
Uveitis Glaucoma Hyphema(UGH) syndrome
Malpositions of IOL
•Sunset syndrome
•Sunrise syndrome
•Lost lens syndrome
•Windshield wiper syndrome
Pupillary capture of IOL

48. Sunrise syndrome
Sunset syndrome
Misplacement of superior haptic in the
ciliary sulcus,
The inferior haptic being placed in the bag
Undetected anterior capsule rupture
extending inferiorly allowing the inferior
haptic to escape through the defect

49. Subluxed IOL

50. PXF Bilateral Subluxed IOLs

51. Thank You