This document discusses various complications that can occur during or after cataract surgery, grouped into complications of anesthesia, intraoperative complications, early postoperative complications, and late postoperative complications. Some key complications mentioned include respiratory issues under general anesthesia, retinal damage from retrobulbar anesthesia, dropped nuclei or posterior capsule rupture during surgery, elevated eye pressure issues, cystoid macular edema long-term, and rare but serious issues like suprachoroidal effusion and hemorrhage. Risk factors and management strategies are also briefly covered for some complications.

1. COMPLICATIONS
OF
CATARACT 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. ANESTHESIA
COMPLICATIONS
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 pupils
Indian 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 doesn't
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 when
a. Vitreous is removed from wound
b. A PCIOL can be placed
c. The surgeon can see the retina
d. Vitreous is removed anterior to the posterior lens
capsule
Ans. d
Complications of Cataract surgery74

75. 2. Most common complication of retrobulbar anesthesia is
a. Globe perforation
b. Retrobulbar hemorrhage
c. Perforation of optic nerve sheath
d. s/conj hemorrhage
Ans. d
Complications of Cataract surgery75

76. 3. Which of following preoperative measures has proven
most effective in reducing risk of Endophthalmitis
a. Administering oral amoxicillin 3 days before surgery
b. Topical antibiotics for 2 weeks following surgery
c. Decreasing duration of surgery
d. Administering topical 5% Povidone-iodine solution at
time of surgery
e. Injecting Vancomycin into the I/A solution
Ans. d
Complications of Cataract surgery76

77. 4. Appropriate management of retrobulbar hemorrhage
includes all of the following except
a. Proceeding with surgery if red reflex is maintained
b. Promptly applying firm pressure on the globe
c. Observing the optic nerve & fundus with an indirect
ophthalmoscope
d. Administering CAI or mannitol to reduce IOP
e. Performing lateral canthotomy if proptosis, increased
IOP, and tight eyelids persist after other measures
have been undertaken to relieve orbital swelling
Ans. a
Complications of Cataract surgery77

78. 5. Systemic use of α1-antagonists for treatment of BPH may
cause IFIS by which of following mechanisms
a. Atrophy of iris sphincters
b. Competitive binding to postsynaptic nerve endings of iris
dilator
c. Loss of iris stroma
d. Atrophy of posterior pigment epithelium
e. Metabolic alkalosis of aqueous
Ans. b
Complications of Cataract surgery78

79. 6. Expulsive hemorrhage associated cataract surgery is
usually due to rupture of which vessels?
a. Vortex vein
b. Long posterior Ciliary artery
c. Short posterior Ciliary artery
d. Retinal artery
e. Choriocapillaris
Ans. c
Complications of Cataract surgery79

80. 7. Early postop complication of cataract surgery are all of
following except
a. Iris prolapse
b. Hyphema
c. Striate keratopathy
d. CME
Ans. d
Complications of Cataract surgery80

81. 8. Vitreous loss leads to…
a. Up drawn pupil
b. Astigmatism
c. Uveitis
d. CME
1. a+c, 2. a+b+c, 3. a+b+d, 4. a+c+d, 5. none of
above
Ans. 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 edema
a. Elevated IOP
b. Chemical toxicity
c. Epithelial down growth
d. Surgical trauma
Ans. c
Complications of Cataract surgery83

84. NEXT
 Journal club
 Dr Manzoor
 Lecture
 Dr Kabir (Phaco)
Complications of Cataract surgery84