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PER-OPERATIVE COMPLICATION OF
CATARACT SURGERY
PRESENTED BY
LT. COL. RASHED-UL-HASAN
INTRAOPERATIVE COMPLICATIONS
• Hydro related
• Iris related
• Nucleus related
• I/A related
• IOL insertion related
• Wound Closure related
• Anesthesia related
• SR related
• Conjunctiva related
• Wound related
• Capsulotomy related
ANAESTHESIA RELATED COMPLICATIONS
• Oculocardiac reflex
• Subconjunctival
haemorrhage
• Spontaneous dislocation of
lens
• Globe perforation
• Retrobulbar haemorrhage
• Central spread of anaesthetic
Retinal vascular occlusion
Optic nerve trauma
PERIBULBAR / RETROBULBAR ANESTHESIA
• Lids trauma (ecchymosis)
• Ptosis
• S/conj hemorrhage
• Muscles damage
• Globe penetration
• Retrobulbar hemorrhage
• Optic nerve damage
• Putscher-type retinopathy *
• Brainstem anesthesia
SUB-CONJ & SUB-TENON ANESTHESIA
• Common
• Pain on injection (15-33%)
• Chemosis (6-100%)
• s/conj hemorrhage (7- 100%)
• Rare
• Globe perforation
• Retro bulbar hemorrhage
• Hyphema
• Muscle trauma
• Diplopia
• Orbital cellulitis
OCULOCARDIAC REFLEX
• Manifest as
• Bradycardia
• A-V Block
• Asystole
• Treatment
• Stop stimulation
• IV atropine (0.01 mg/kg)
• Local injection of lidocaine near the eye mus
• Wound related
Button holing
Premature entry
Scleral disinsertion
• Corneal
Descemet’s membrane detachment
Corneal burns
• Anterior chamber
Iridodialysis
Flattening of anterior chamber
Hyphema
Intraoperative floppy iris
syndrome
• Continuous curvilinear capsulorhexis (CCC)
related
Escaping capsulorhexis
Small / large capsulorhexis
Eccentric capsulorhexis
• Lens related
Dropped nucleus
Retained lens mater
Posterior loss of lens fragments
• IOL related
IOL dislocation
• Posterior segment
Posterior capsule rupture
Cyclodialysis
Suprachoroidal effusion &
hemorrhage
POSTERIOR CAPSULE RUPTURE
• Serious complication
• 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
• RD & CME
•Signs
• Sudden deepening of
AC
• Pupillary dilatation
• Visible rupture of PC
• Visible vitreous
• Management
• Depends on magnitude of tear & vitreous prolapse
• General guidelines
• 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
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
RISK FACTORS
• Ocular factors
• Glaucoma
• High myopia
• Posterior capsule rupture
• Chronic ocular
inflammation
• Systemic factors
• HTN
• Chronic lung disease
(COPD)
• Advanced age
• Obesity
• Anticoagulation
• 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
• Management
• Stop surgery
• Immediate closure of wound
• IV mannitol
• Postoperative
• Topical & systemic steroids
• Drainage through sclerotomy after a week
• Refer to VR surgeon for vitrectomy
INTRAOPERATIVE FLOPPY IRIS
SYNDROME (IFIS)
• Trio of
• Iris billowing
• Progressive Intraoperative miosis
• Iris prolapse
• Cause: Tamsulosin or other α 1-blockers for BPH
• Unopposed action of sphincters
• Increased risk of PCR & high IOP
• Pt should be asked to stop it pre-op ?????
 Microincisional surgery
 Low-flow setting PHACO
LENS–IRIS DIAPHRAGM RETROPULSION SYNDROME
(LIDRS)
• characterized by
• posterior displacement of the lens–iris diaphragm with deepening of the anterior chamber,
• posterior iris bowing
• pupil dilation.
• more common
• highly myopic eyes
• eyes that have undergone previous vitrectomy.
• may cause stress on the zonular apparatus and considerable patient discomfort under topical
anesthesia.
• Surgery - difficult due to deep AC.
• Lifting the iris or the anterior capsule is usually sufficient to break the pupillary block and restore
normal anterior chamber depth.
LENS - IRIS DIAPHRAGM
RETROPULSION SYNDROME (LIDRS)
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
Complication of catarct surgery

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Complication of catarct surgery

  • 1. PER-OPERATIVE COMPLICATION OF CATARACT SURGERY PRESENTED BY LT. COL. RASHED-UL-HASAN
  • 2.
  • 3. INTRAOPERATIVE COMPLICATIONS • Hydro related • Iris related • Nucleus related • I/A related • IOL insertion related • Wound Closure related • Anesthesia related • SR related • Conjunctiva related • Wound related • Capsulotomy related
  • 4. ANAESTHESIA RELATED COMPLICATIONS • Oculocardiac reflex • Subconjunctival haemorrhage • Spontaneous dislocation of lens • Globe perforation • Retrobulbar haemorrhage • Central spread of anaesthetic Retinal vascular occlusion Optic nerve trauma
  • 5. PERIBULBAR / RETROBULBAR ANESTHESIA • Lids trauma (ecchymosis) • Ptosis • S/conj hemorrhage • Muscles damage • Globe penetration • Retrobulbar hemorrhage • Optic nerve damage • Putscher-type retinopathy * • Brainstem anesthesia
  • 6. SUB-CONJ & SUB-TENON ANESTHESIA • Common • Pain on injection (15-33%) • Chemosis (6-100%) • s/conj hemorrhage (7- 100%) • Rare • Globe perforation • Retro bulbar hemorrhage • Hyphema • Muscle trauma • Diplopia • Orbital cellulitis
  • 7. OCULOCARDIAC REFLEX • Manifest as • Bradycardia • A-V Block • Asystole • Treatment • Stop stimulation • IV atropine (0.01 mg/kg) • Local injection of lidocaine near the eye mus
  • 8. • Wound related Button holing Premature entry Scleral disinsertion • Corneal Descemet’s membrane detachment Corneal burns • Anterior chamber Iridodialysis Flattening of anterior chamber Hyphema Intraoperative floppy iris syndrome
  • 9. • Continuous curvilinear capsulorhexis (CCC) related Escaping capsulorhexis Small / large capsulorhexis Eccentric capsulorhexis • Lens related Dropped nucleus Retained lens mater Posterior loss of lens fragments • IOL related IOL dislocation • Posterior segment Posterior capsule rupture Cyclodialysis Suprachoroidal effusion & hemorrhage
  • 10. POSTERIOR CAPSULE RUPTURE • Serious complication • 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 • RD & CME
  • 11. •Signs • Sudden deepening of AC • Pupillary dilatation • Visible rupture of PC • Visible vitreous
  • 12. • Management • Depends on magnitude of tear & vitreous prolapse • General guidelines • 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
  • 13. 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
  • 14. RISK FACTORS • Ocular factors • Glaucoma • High myopia • Posterior capsule rupture • Chronic ocular inflammation • Systemic factors • HTN • Chronic lung disease (COPD) • Advanced age • Obesity • Anticoagulation
  • 15. • 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
  • 16. • Management • Stop surgery • Immediate closure of wound • IV mannitol • Postoperative • Topical & systemic steroids • Drainage through sclerotomy after a week • Refer to VR surgeon for vitrectomy
  • 17. INTRAOPERATIVE FLOPPY IRIS SYNDROME (IFIS) • Trio of • Iris billowing • Progressive Intraoperative miosis • Iris prolapse • Cause: Tamsulosin or other α 1-blockers for BPH • Unopposed action of sphincters • Increased risk of PCR & high IOP • Pt should be asked to stop it pre-op ?????  Microincisional surgery  Low-flow setting PHACO
  • 18. LENS–IRIS DIAPHRAGM RETROPULSION SYNDROME (LIDRS) • characterized by • posterior displacement of the lens–iris diaphragm with deepening of the anterior chamber, • posterior iris bowing • pupil dilation. • more common • highly myopic eyes • eyes that have undergone previous vitrectomy. • may cause stress on the zonular apparatus and considerable patient discomfort under topical anesthesia. • Surgery - difficult due to deep AC. • Lifting the iris or the anterior capsule is usually sufficient to break the pupillary block and restore normal anterior chamber depth.
  • 19. LENS - IRIS DIAPHRAGM RETROPULSION SYNDROME (LIDRS)
  • 20. 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