Apply pressure on globe to prevent further drop Surgeon: Stop phaco, inject OVD, pars plana vitrectomy to remove nucleus Prevention: Stable AC, well constructed CCC, proper hydrodissection, dispersive OVD

1. COMPLICATIONS OF
CATARACT SURGERY
P R E S E N T E R : D R . I D D I N D YA B AW E
M O D U L ATO R : D R . L U S O BYA R E B E C C A
M A K E R E R E U N I V E R S I T Y, D E PA R T M E N T O F
O P H T H A L M O LO G Y
M A R C H , 2 0 2 1

2. OUTLINE
• 6 S’
• Preop complications
• Operative
• Early postop
• Late postop

3. 6 S’
• Selection
• Sterility
• Soft eye
• Safe surgery
• Spectacles
• Sequealae (postop complications)

4. PREOP COMPLICATIONS
• Anxiety
• Nausea and gastritis
• Irritative or allergic conjunctivitis
• Corneal abrasion
• Complications due to local anaesthesia: Retrobulbar hemorrhage, OCR, Subconj
hemorrhage, spontaneous dislocation of lens into vitreous

5. RETROBULBAR HEMORRHAGE
• Defn: accum. of blood in retrobulbar space
• C/O: severe pain, loss of vision, N&V.
• O/E: subconj hemorrhage, eyelid ecchymosis, eyelid hematoma, proptosis, elevated
IOP,
• Incidence: 0.1-0.3%
• RFs: preop aspirin, HTN,
• Fear: vascular compromise to optic nerve may result in vision loss!!!

6. MANAGEMENT
• Inform surgeon immediately. Intervene in first 2 hours of onset!!!
• Check pulsation of CRA,
• Lateral canthotomy and cantholysis: decompresses the orbit
• Surgical evacuation of infraorbital hematoma if above fails… localized conj peritomy
• Inferior lateral orbitotomy
• Ocassional A/C paracentesis
• Medical mgt:
• I.V Acetazolamide 500mg
• I.V Hydrocortisone 100mg
• Immediate pressure bandage after instilling one drop of 2% Pilocarpine, then postpone op
for 1 week is advised. (IME)

7. OCR
• Ak.a: Aschner reflex; trigeminovagal reflex
• RFs: orbital injection, direct pressure on globe, elevated IOP
, paed age
• Cardiac manifestations: bradycardia, ectopic beats, nodal rhythms, AV block, Cardiac
arrest, V fib, V, tach, Asystole
• Caution: EKG monitoring must be performed during all ophthalmic surgeries
• Plan: If mild OCR: resolves alone after removing pressure from globe.
• If severe OCR, I.V Atropine 0.4mg or 0.01mg/kg

8. INTRAOPERATIVE COMPLICATIONS
• SR laceration
• Excessive bleeding
• Incision related complications
• Cornea related complications
• Iris related complications
• Capsulotomy related complications
• PCR
• Zonular dehiscence
• Vitreous loss
• Nucleus drop in vitreous
• Posterior loss of lens fragments
• Expulsive choroidal hemorrhage
• IFIS

9. INCISION RELATED COMPLICATIONS
• Button-holing of anterior wall of tunnel
• Due to superficial dissection of scleral flap
• Plan: use deeper plane from other side of
incision

10. INCISION RELATED COMPLICATIONS
• Premature entry into the A/C
• Due to deep dissection
• Plan: abandon dissection in this area;
start new dissection at lesser depth at
other end of tunnel.
• Suture where you entred prematurely
at first

11. INCISION RELATED COMPLICATIONS
• Scleral disinsertion:
• Due to very deep groove incision.
• Complete separation of inferior sclera
from sclera superior to incision
• Plan: radial sutures

12. WOUND LEAK
• Increases risk of endophthalmitis
• Suture wound if IOP low and/or chamber shallow
• If found post-op with stable AC (no shallowing), stable IOP:
-Aqueous suppressant
-Bandage contact lens
-Follow closely for resolution or need to suture
• Consider wound burn if distorted/difficult to close with suture
• Prevention: Good wound architecture, good surgical technique with instruments in
wound during surgery

13. WOUND BURN (CONTRACTURE)
• Excess heat released from phaco handpiece can lead to collagen contracture
• Most commonly seen with:
-Inappropriate sizing of wound and tip/sleeve. Can pinch off irrigation (cooling of tip)
Excessive phacoemulsification with full tip occlusion (warning bells signal occlusion)
-Full occlusion eliminates aspiration (key component to irrigation flow)
-Increase phaco power to clear tip, aspirate OVD overlying lens before beginning to
reduce risk of this complication
MGT: suture wound

14. .

15. INJURY TO THE CORNEA
• Descement’s membrane detachment (stripping)
• 43%
• Rx: expansile gas (air) tamponade in AC or using SF6, C3F8, suture back large
detachments

16. .

17. .

18. .

19. IRIS INJURY AND IRIDODIALYSIS
• During intraocular manipulation e.g at time of inserting phacotip or IOL if iris tissue
engaged.
• C/O: excessive glare, double vision
• Grade/degree:
• Massive: >120 deg
• Moderate: 45-120 deg
• Minimal: <45 deg
• Plan:
• Small: left alone
• Large: cobbler’s technique surgical reattachment (double arm suture) ; single pass 4 throw
pupilloplasty; non-appositional repair… (if last two combined: two fold technique, 2018)
• Trocar assisted hangback repair
• Implanting artificial iris devices
• Iris-coloured contact lenses

20. .

21. .

22. DOUBLE ARM SUTURE TECHNIQUE

23. .

24. .

25. .

26. .

27. .

28. .

29. GENERAL PRINCIPLE: PROF. BILL
BARLOW
• “The greater the manipulation of the iris, the greater
the miosis, pigment loss, distortion, flaccid nature,
possible bleeding from the minor iris circle or a root
tear”

30. .

31. CYCLODIALYSIS
• Separation of ciliary body from its insertion at scleral spur
• Cause: surgical manipulation of intraocular tissues
• O/E: Gonioscopy shows a deep-angle recess with a gap between the sclera and ciliary
body
• Rx: repair cyclodialysis cleft if hypotony results; closure with argon laser
photocoagulation

32. .

33. COMPLICATIONS RELATED TO
ANTERIOR CAPSULORRHEXIS
• CCC is preferred technique in MSICS and phaco.
• Complications:
• Escaping capsulorrhexis: moves peripherally, can even go to posterior capsule. Caused by
shallow AC or poor direction of cystitome. Avoidance: force of cutting cystitome centripetally or circumferencially. Down and
inward force!
• Small capsulorrhexis: predisposes to PCR and nuclear drop during hydrodissection. Rx:
enlarge it by 2-3 relaxing incisions before proceeding further
• Very large capsulorrhexis: difficulty in implanting IOL in bag
• Eccentric capsulorrhexis: can cause IOL decentration

34. ESCAPING CAPSULORRHEXIS

35. .

36. .

37. .

38. ECCENTRIC CAPSULORRHEXIS

39. POSTERIOR CAPSULAR RUPTURE
(TEAR)
• Causes:
• -During forceful hydrodissection
• -By direct injury with some instrument e.g Sinskey’s hook, chopper or phacotip
• -During cortex aspiration (accidental PCR)
• -With insertion or rotation of the IOL
• Rate: 2-3%

40. PCR WITH VITREOUS LOSS
INCREASES RISK FOR:
• Endophthalmitis
• Glaucoma
• Bullous keratopathy
• Suprachoroidal hemorrhage
• CME
• RRD
• IOL malpositioning
• Need for further surgery
• Increased surgical time and cost

41. MANAGEMENT OF PCR
• Best management is PREVENTION:
• Stabilize the AC by:
-Well-constructed wound and capsulorrhexis
-Proper fluidics setting (Inflow=outflow): helps to avoid post-occlusion surge
• Instruments:
-Dewey phaco tip (rounded vs sharp edge)
-Soft silicone irrigation/aspiration (I/A) tip
• Surgical techniques:
-Protect capsule with second instrument with final fragment (s) emulsification
-Hydrodissection using dispersive viscoelastic (in select cases) or placement of
viscoelastic to tamponade capsule

42. PCR: PREVENTION
• Recognising higher risk surgical situations:
• Weakened posterior capsule; posterior polar cataract
• Dense (white or brunescent) cataract: little to no cortex to ‘mold’ capsule
• Soft nucleus (e.g young patient with PSC): not much energy needed to penetrate
material
• Zonular weakness:
-PXF,
-prior trauma,
-prior intraocular sugery (e,g PPV)
-Less common causes: congenital; aniridia etc

43. RISK FACTORS FOR PCR
• OCULAR FACTORS:
• Difficult cataracts (brunescent, morgagnian, PXF, PPC)
• Pre-existing zonulysis/subluxated cataracts
• Glaucoma
• High myopia
• Increase in vitreous pressure observed after retrobulbar anaesthesia
• Small pupils
• Poor visibility (corneal opacities – scar, shagreen, arcus, band K, pterygium, poor
surface)

44. OTHER RISK FACTORS FOR OCR
• PATIENT FACTORS:
• Hypertension
• Chronic lung disease
• Obese patient with short thick neck
• Uncooperative
• Demented
• High nose bridge
• Deep seated eyes
• INTRAOPERATIVE FACTORS:
• Small CCC
• Unstable AC
• Wound distortion – striae
• Inappropriate phaco settings
• Zonulysis
• OTHER FACTORS:
• Inexperienced surgeon
• Poor operating microscope
• Inadequate sedation/anaesthesia

45. CLINICAL SIGNS OF PCR
• Presence of ring reflex in the posterior capsule – outline of PCR seen
• Inability to aspirate soft lens matter (vitreous stuck to port)
• Poor followability of nuclear fragments, inability to rotate a previously mobile nucleus
• Peaked pupil
• Vitreous seen in AC
• Sudden deepening of AC and PC
• Fragments disappear from view
• Pupil-snap sign: PC rupture during hydrodissection
• Movement of iris with phaco probe due to vitreous strands

46. PCR MANAGEMENT GOALS
• Every maneuver is made to avoid extending tear
• Maintain chamber stability: pressure gradient drives vitreous
• No irrigation toward tear/vitreous: hydration of vitreous/disruption of vitreous
• Use OVD copiously but not excessively: fill space with OVD to control gradient; overfill can propagate tear

47. PCR MANAGEMENT DEPENDS ON:
• Stage of operation at which PCR occurs, commonly during:
-Nucleus expression/removal of last fragment
-Aspiration of soft lens
-IOL insertion
• Size and extent of PCR
• Presence or absence of vitreous loss

48. .

49. MANAGEMENT OF PCR
• Stop the surgery and assess the situation
• Evaluate location and size of tear; this will determine response.
• Don’t suddenly remove instruments as it would decompress the AC, causing extension of
the capsular tear and further enabling the vitreous to prolapse forward.
• Instead, maintain the phaco needle’s position and continue to irrigate without aspiration.
• Next, inject a dispersive viscoelastic through the side port in the area of capsular
compromise.
• In addition to stabilizing the anterior chamber, this helps to push back any vitreous and
maintains the integrity of the anterior hyaloid face.
• Only now can the phaco tip be removed from the eye.

50. .

51. NO VITREOUS LOSS! MGT OF NUCLEUS
• Avoid loss of nuclear material through PCR into posterior segment.
• Removal of nucleus should be done carefully, using either a dispersive viscoelastic bed or a
surgical glide for protection.
• If there are large fragments of nucleus remaining, they should be phacoemulsified in the
anterior chamber. Use dispersive viscoelastic to maintain the chamber and keep vitreous
away from the phaco needle.
• If most of the nucleus remains, and PCR is large, convert to ECCE, remove nucleus with lens
loop or spoon.
• Not recommended to retrieve nuclear fragments from deep vitreous. If in anterior vitreous,
do anterior vitrectomy, remove cortex and place sulcus IOL, but leave nucleus removal to a
VR colleague

52. IF THERE IS VITREOUS LOSS!!!
• If vitreous prolapse has occurred, remove all vitreous from A/C
• Vitrectomy reduces chance of vitreoretinal traction or vitreous adherence to IOL.
• Vitreous may be stained with unpreserved triamcinolone for better visualization. Avoid
manually externalizing and cutting the vitreous through the incision… RD
• Options: 2-port anterior vitrectomy, PPV
• Vitrectomy settings:
-Cut I/A mode
-High cut rate
-Low aspiration rate
-Separate irrigation
-Consider Pars plana approach for vitrector (select cases)

53. IOL PLACEMENT
• Stability of remaining capsule!
• If posterior capsule support for intracapsular placement of IOL is inadequate, preserve
the anterior capsule to enable capture of lens optic in capsular bag with haptics placed
in ciliary sulcus. 3-piece IOL with TD of 12.5mm
• A single piece acrylic IOL is not suitable for the ciliary sulcus because of possibility of
UGH, decentration
• With absence of capsular support :
-A PC IOL can be used, suturing the haptics to the iris or by fixing haptics to the sclera
through the ciliary sulcus. (reduce power by 0.5D)… Osher Bounce test
-Insert AC IOL, particularly in elderly patients. Add 1mm to HCD.
-Leave aphakic (large PCR with inadequate posterior capsule support and AC IOL
contraindicated)
Avoid silicone lenses in PCR, higher rates of endophthalmitis

54. CHECKLIST AT END OF OPERATION
• Obvious vitreous at pupil borders?
• Inject miotic agent… round pupil observed?
• Traction at wound edge with weck sponge….. Peaking of pupil? Or movement of iris
when sweeping AC with Sinski (Marionette sign)
• Inject air bubble …. Regular round bubble observed?
• Sweep iris…. Movement of AC?
• Close wound with 10-0 nylon

55. POST-OP VITREOUS LOSS AFTER PCR
• If vitrectomy was required, a thorough dilated exam in the early post-op period is
indicated to evaluate for retinal pathology
• Post-op presentation of vitreous:
• If vitreous is entrapped in wound, risk of ‘wicking’ present, infection risk elevated.
-can stain at slit lamp with fluorescein (bright green temporary stain) if externalised. Take
to OR for removal is this is the case
-If vitreous is incarcerated in wound, but not externalised, can consider YG vitreolysis
• Regardless of presentation, must be dealt eith to eliminate traction which creates risk
of retinal tear and CME.

56. ZONULAR DEHISCENCE
• Rupture of the fibrous strands connecting the ciliary body and the crystalline lens of
the eye
• RFs:
-PXF
-Extraocular trauma
-Surgical trauma
-Marfan’s syndrome
-If patient had RD, and silicone oil used to fix the detachment
O/E: lens jiggles when patient to look back and forth
Rx: CTR. Cionni type 1L for right handed, and 2C for left handed.

57. .

58. VITREOUS LOSS
• Most feared complication after PCR.
• Prevention:
• To decrease vitreous volume;
-preop use of hyperosmotic agents like 20% mannitol or oral glycerol
-to decrease aqueous volume: preop: Acetazolamide 500mg orally
-to decrease orbital volume: adequate ocular massage and orbital compression using:
superpinky, Honan Ball, or 30mmHg of Paed sphygmomanometer
• If vitreous loss has occurred; aim is to clear it from the AC and incision site. Anterior
vitrectomy

59. .

60. NUCLEUS DROP IN VITREOUS CAVITY
• More common in phaco; high pressure AC system; less in MSICS
• TYPES:
-prior to nucleus removal
-during nucleus removal
-after nucleus removal
Signs of impending nucleus drop:
-runaway capsulorrhexis
-pupil-snap sign (pupils suddenly constricts)
-nuclear tilt
-receding nucleus
-difficult to rotate nucleus

61. NUCLEAR DROP
• PREVENTION
• Good sized and shaped
• Careful hydrodissection
• Clear endpoints in nuclear
management
• Recognition of occult PCR
• MANAGEMENT:
• No attempt should be made to
fishout nucleus from the vitreous
• Refer to VR surgeon after a thorough
anterior vitrectomy and cortical
cleanup

62. .

63. POSTERIOR LOSS OF LENS
FRAGMENTS
• After PCR, or zonular dehiscence
• Complications: glaucoma, chronic uveitis, chronic CME, RD
MGT:
• Refer to VR Surgeon; for PPV, and removal of lens fragments

65. .

66. EXPULSIVE CHOROIDAL HEMORRHAGE
• One of most dramatic and serious complications of cataract surgery
• Characterised by spontenous gapping of wound, then expulsion of lens, vitreous,
retina, uvea and finally a gush of bright red blood…. “self-evisceration”!!!
RFs:
• -conventional ECCE
• -ICCE
• -HTN
• -Artherosclerosis
• -chronic lung disease
• -short thick neck (obesity)
• -severe myopia
• -PCR during surgery
• -glaucoma

67. .• O/E:
• Darkening (loss) of red reflex
• Incision gape
• Iris prolapse
• Expulsion of lens, vitreous, and bright red bloos
• Elevated IOP
• MGT:
• Stop surgery
• Immediate wound closure with 4.0 silk suture
• I.V Mannitol
• Attempt to drain suprachoroidal blood by doing an equatorial sclerotomy (decompresses
the globe)
• Most of the time, eye is lost, so evisceration is done!!!

68. .

69. INTRAOPERATIVE FLOPPY IRIS
SYNDROME (IFIS)
• Intraop triad of:
• -iris billowing and floppiness
• -iris prolapse into the incisions
• -progressive pupillary miosis
• Higher rates of surgical complications, iris trauma, PCR, vitreous loss.
• Can be: mild, moderate or severe

70. MEDS ASSOCIATED WITH IFIS
• Selective a1a-adrenergic antagonists
• -tamsulosin
• -tamsulosin and dutasteride
• Non-selective a1-adrenergic antagonists
• -alfuzosin
• -doxazosin
• -prazosin
• -terazosin
• Other drugs with alpha-adrenergic
antagonist activity:
-chlorpromazine
-donepezil
-labetalol
-naftopidil
-risperidone

71. INTERVENTIONS TO REDUCE EFFECTS
OF IFIS
• Use preoperative atropine
• Intracameral injection of alpha-adrenergic agonists like phenylephrine or epinephrine
• Careful attention to incision location and construction to reduce wound leak
• Use iris hooks or pupil expansion rings for stabilization
• Use of bimanual microincision surgical techniques
• Employment of highly retentive OVDs to ‘viscodilate’ the pupil and maintain a concave
iris near the incision
• Discontinuation of fluid inflow prior to withdrawal of instruments to prevent and iris
egress
• Use of low-flow settings to minimize anterior chamber turbulence and eliminate a
higher pressure gradient posterior to iris

72. .

73. EARLY POST OPERATIVE
COMPLICATIONS
• Hyphema
• Iris prolapse
• Flat AC
• Striate keratopathy
• Postop anterior uveitis
• TASS
• Endophthalmitis

74. HYPHEMA
• RFs: PXF, Fuch’s heterochromic uveitis, anterior segment neovascularization, vascular tufts at
pupillary margin
• Grades: …Micro, Grade 1, 2 3, 4
• Treatment:
• Most resolve spontaneously
• Resolution might take longer if vitreous is mixed with blood
• If hyphema is large and associated with high IOP
, lower the IOP with acetazolamide and
mannitol.
• If blood isn’t absorbed within one week, then a paracentesis should be done to drain the
blood
• Two major complications: Elevated IOP
, corneal blood staining
• If hyphema occurs several years after surgery, it’s due to incision vascularization,,, do argon

75. ,

76. IRIS PROLAPSE
• Risk: inadequate suturing of incision after ICCE and conventional ECCE
• Less with phaco and MSICS
• Plan:
• -A small prolapse of less than 24 hours duration may be reposited back and wound
sutured.
• -A large prolapse of long duration needs abscission and suturing of wound
•

77. .

78. STRIATE KERATOPATHY
• Mild corneal edema with Descemet’s folds
• Due to endothelial damage during surgery
• Plan: mild striate kertopathy usually disappears spontaneously within one week
• Moderate-severe keratopathy is treated by instilling hypertonic saline drops (5% NaCl)
along with steroids

79. .

80. FLAT (SHALLOW OR NONFORMED)
ANTERIOR CHAMBER
• Due to wound leak, ciliochoroidal detachment or pupil block
• 1) flat AC with wound leak:
-associated with hypotony
-dx: siedel’s test. Fluorescein will be diluted at site of leakage by aqueous
-Rx: pressure bandage for 4 days and oral acetazolamide
If condition persists, injection of air in AC and resuturing of the leaking wound.

81. .

82. .

83. .

84. 2) CILIOCHOROIDAL DETACHMENT
• It may or may not be associated with wound leak
• Presents as a convex brownish mass in involved quadrant with shallow AC
• Rx: pressure bandage for 4 dyas plus oral acetazolamide
• If condition persists , suprachoroidal drainage with injection of air in AC is indicated.

85. .

86. 3) PUPIL BLOCK
• Due to vitreous bulge
• After ICCE
• Leads to formation of iris bombe and shallowing of AC
• If condition persists for 5-7 days, permanent peripheral anterior synechiae (PAS) may
be formed leading to secondary angle closure glaucoma
• Pupil block glaucoma is managed initially with mydriatic, hyperosmotic agents (e.g
20% mannitol) and acetazolamide
• If not relieved, then laser or surgical peripheral iridotomy should be done to bypass
the pupillary block

87. .

88. POSTOPERATIVE ANTERIOR UVEITIS
• Can be induced by:
• -instrumental trauma
• -undue handling of uveal tissue
• Reaction to residual cortex or chemical reaction induced by OVDs, pilocarpine etc.
• Mgt:
• -more aggressive use of topical steroids, cycloplegics and NSAIDs
• -rarely systemic steroids may be required in cases with severe fibrinous reaction

89. TOXIC ANTERIOR SEGMENT SYNDROME
• Defn: an acute sterile postoperative inflammation
• S&S:
• -mimics endophthalmitis
• -photophobia
• -severe reduction in VA
• -corneal edema
• -marked AC reaction
• -occasionally sterile hypopyon

90. DISTINGUISHING FEATURES OF TASS
• Diffuse limbus-to-limbus corneal edema
• AC fibrinous exudate
• A dilated, irregular or non-reactive pupil
• Elevated IOP
• Pathology limited to AC
• TASS presents within hours of surgery, whereas acute infectious endophthalmitis
develops 2-7 days postoperatively
• Pain in TASS is less than in infection
• PATHOPHYSIOLOGY
• The acute inflammatory response induces cellular necrosis and/or apoptosis as well as
extracellular damage.

91. .

92. RISK FACTORS OF TASS
• Any medication injected in or around the eye or placed topically at the time of surgery
can be implicated in TASS.
• Preservatives and pH incompatibilities can lead to TASS as can contaminants from
sterilization.
• Intraocular solutions with inappropriate chemical composition, concentration, pH, or
osmolality
• - Preservatives
• - Denatured ophthalmic viscosurgical devices
• - Enzymatic detergents
• - Bacterial endotoxin
• - Oxidized metal deposits and residues
• - Intraocular lens residues

93. PREVENTION AND TREATMENT OF
TASS
• Prevention:
• -careful cleaning, rinsing and air drying
of reusable cannulas
• -using disposable instrumentation
• -avoiding intraocular use of any
nonphysiologic or preserved solutions
• Treatment of TASS:
• -topical steroids
• -systemic steroids
• Frequent follow-up; monitor IOP,
assess for signs of bacterial infection

94. COMPLICATIONS OF TASS
• • Glaucoma
• • Tonic pupil
• • Persistent corneal edema

95. BACTERIAL ENDOPHTHALMITIS
• Defn: suppurative inflammation of the inner structures of the eyeball
• RFs:
• -DM
• -Older age
• -Male gender
• -Vitreous loss
• -PCR
• -Wound leaks
• -Use of clear corneal incisions
• -Complicated or prolonged surgery
• Can be: acute form or indolent/chronic

96. S&S OF ENDOPHTHALMITIS
• Symptoms
• -mild to severe ocular pain
• -vision loss
• -floaters
• -photophobia
• Signs
• -vitreous inflammation
• Eyelid or periorbital edema
• Ciliary injection
• Chemosis
• AC inflammation
• Hypopyon
• Decreased VA
• Corneal edema
• Retinal hemorrhages

97. .

98. ETIOLOGY
• Gram positive coagulase negative bacteria:
• Staph epidermidis (70%)
• Staph aureus (9.9%)
• Strep speues (9.0%)
• Enterocus spp (2.2%)
• Gram negative spp (5.9%)

99. PREVENTION AND TREATMENT OF
ENDOPHTHALMITIS
• Prevention
• Preop topical antibiotics
• Povidone iodine, 10% and 5%
• Ix: VA, AC tap, Vitreous tap, culture
and gram stain
• Treatment
• Do VA as soon as you suspect
Endophthalmitis
• Blind: evisceration
• Vision better than PL; PPV +
intravitreal antibiotics (vanco) +
topical antibiotics
• If VA is HM and better; do AC tap for
cultures with subsequent intravitreal
injection of antibiotics

100. .
• Vancomycin 1mg/0.1ml; 3 doses on alternate days or
• Ceftazidinme 2.25mg/0.1ml or
• Amikacin 0.4mg/0.1ml
• EVS: Vanco + amikacin
• If improvement seen then, topical and subconj antibiotics
• Chronic or delayed-onset endophthalmitis best treated with vitreous biopsy and
intraocular antibiotics

101. .

102. .

103. LATE POSTOP COMPLICATIONS
• CME
• PBK
• RD
• Delayed endophthalmitis
• Epithelial ingrowth
• Fibrous downgrowth
• After cataract
• Glaucoma-in-aphakia

104. CME
• A.k.a : Irvine-Gass syndrome
• Common cause of postop decreased vision
• Pathogenesis unknown
• Defn: collection of fluid in the form of cystic loculi in the Henle’s layer of the macula
• Pathophysiology:
• -increased perifoveal capillary permeability with accumulation of fluid in the inner
nuclear and outer plexiform layers
• -associated with intraocular inflammation
• -mediated thru release of prostaglandins and leukotrienes

105. O/E
• FUNDOSCOPY: honey comb appearance

106. FLUORESCEIN ANGIOGRAPHY
• Petaloid appearance of cystic spaces in macula due to leakage of dye from perifoveal
capillaries.

107. SD-OCT
• Cystic areas of low reflectivity and retinal thickening .

108. PREOP RISK FACTORS
• Coexisting uveitis
• Preexisting epiretinal membranes
• Vitreomacular traction
• DM
• DM retinopathy
• Previous retinal vein occlusion
• Retinitis pigmentosa
• Previous occurrence of CME
• Prostaglandin analogues

109. SURGICAL AND POST OP RISK
FACTORS
• Posterior capsular rupture
• Vitreous loss
• Iris prolapse
• Prolonged surgical time
• Improper IOL positioning
• Retained lens material/fragments
• Poorly controlled postop inflammation
• Transient or prolonged hypotony

110. MEDICAL TREATMENT OF CME
• Topical steroids +/- NSAIDS 3/12
• If topicals fail, then subtenon’s steroid injections or intravitreal injections
• In refractory cases, systemic carbonic anhydrase inhibitors may be beneficial
• Intravitreal anti-VEGF in cases not responding to conventional treatment

111. SURGICAL THERAPY OF CME
• Indicated when an inciting source of chronic CME can be defined and the edema fails
to respond to medical therapy
• Any retained lens fragments must be removed
• Nd:YAG laser vitreolysis or vitrectomy can be used to remove vitreous adhering to
cataract incision in order to relieve iris deformity or vitreomacular traction
• If IOL is mapositioned and contributing to chronic uveitis, repositioning or exchange
may be helpful

112. DELAYED CHRONIC
ENDOPHTHALMITIS
• When; 4 weeks to years; mean 9 months
• Caused by organisms of low virulence: e.g Propionibacterium acne or staph
epidermidis

113. PSEUDOPHAKIC BULLOUS
KERATOPATHY
• A continuation of postop corneal edema produced by surgical or chemical insult to a
healthy or compromised corneal endothelium
• Common indication of penetrating keratoplasty
• RFs:
• -iris-dip lenses
• Closed-loop ACIOLs
• Fuchs corneal dystrophy

114. .

115. .

116. RETINAL DETACHMENT
• Higher incidence in aphakic patients than in phakic
• More common after ICCE than ECCE
• RFs:
• -vitreous loss after PCR
• -early onset PVD
• -associated myopia (AL>25mm)
• -younger age; male gender
• -lattice degeneration of retina
• Previous RD
• Plan: PPV +/- scleral buckle. Success rate: 85%

117. .

118. .

119. EPITHELIAL INGROWTH
(DOWNGROWTH)
• Conjuctival epithelial cells invading the AC through defect in incision
• Grayish sheetlike growth in the TM, iris, ciliary body, posterior corneal surface
• Implication: intractable glaucoma
• Rx:
• -en-block excision of involved tissue
• -full-thickness corneo-scleral graft
• -cryotherapy
• Glaucoma: timolol, GDD

120. .

121. /

122. FIBROUS DOWNGROWTH
• More prevalent than epithelial ingrowth
• Happens when wound apposition is not perfect
• May cause:
• -secondary glaucoma
• -disorganization of anterior segment
• -phthisis bulbi

123. AFTER CATARACT
• A.k.a secondary cataract
• Opacity which persists or develops after extracapsular cataract lens extraction
• Causes
• -residual opaque lens matter
• -proliferative type of after cataract can occur from the left-out anterior capsule
epithelial cells

124. CLINICAL TYPES
• May present as:
• -thickened posterior capsule
• -dense membranous after cataract
• -Soemmering’s ring: - a thick ring of after cataract formed behind the iris, enclosed
between the 2 layers of capsule
• -Elschnig’s pearls; here vacuolated subcapsular epithelial cells are clustered like soap
bubbles along the posterior capsule.

125. TREATMENT
• Thin membranous after cataract and thickened posterior capsule are best treated by
YAG-laser capsulotomy or dissection with cystitome or Zeigler’s knife
• Dense membranous after cataract needs surgical membranectomy
• Soemmering’s ring after cataract with clean central posterior capsule needs no
treatment
• Elschnig’s pearls involving the central part of the posterior capsule can be treated with
YAG-laser capsulotomy or discussion with cystitome.

126. .

127. GLAUCOMA-IN-APHAKIA AND
PSEUDOPHAKIA
• 1) Raised IOP with deep anterior chamber in early postoperative period
• Due to:
• -hyphema
• -inflammation
• -retained cortical matter or vitreous filling the AC
• 2) Secondary angle-closure glaucoma due to flat AC:
• -Following long-standing wound leak
• 3)Secondary angle-closure glaucoma due to pupil block:
• -Following annular synechiae or vitreous herniation

128. .• 4) Undiagnosed preexisting primary open-angle glaucoma
• 5) steroid-induced glaucoma
• -due to postop corticosteroids after cataract surgery
• 6) epithelial ingrowth
• 7) aphakic/pseudophakic malignant glaucoma

129. .

130. IOL RELATED COMPLICATIONS
• 1) CME
• 2) UGH syndrome
• 3) Malposition of IOL
• 4) Pupillary capture of the IOL
• 5) TASS

131. UGH (ELLINGSON SYNDROME)
• Concurrent occurrence of uveitis, glaucoma and hyphema
• First described in context of rigid or closed-loop ACIOLs
• Causes:
• -inappropriate IOL sizing
• -contact between the implant and vascular structures or the corneal endothelium
• -defects in implant manufacturing
• Medical treatment:
• -cycloplegics
• -topical anti-inflammatory
• -ocular hypotensive medications

132. SURGICAL APPROACH
• Indication:
• -If medical therapy does not sufficiently address the findings
• -If inflammation threatens either retinal or corneal function
• To do: IOL removal
• -Challenge: inflammatory scars, esp in the AC angle or posterior to iris
• -Solution: amputate the haptics from the optic and remove the lens piecemeal,
• -rotating the haptic material out of the synechial tunnels to minimize trauma to eye
• In some cases, it is safer to leave portions of the haptics in place
• Early lens explantation may reduce the risk of corneal decompression and CME

133. MALPOSITION OF IOL
• Inform of:
• -decentration
• -subluxation
• -dislocation
• Some fancy names:
• -sunset syndrome (inferior subluxation of IOL)
• -sunrise syndrome (superior subluxation of IOL)
• -Lost lens syndrome: -complete dislocation of an IOL into the vitreous cavity
• -Windshield wiper syndrome:
-occurs when a very small IOL is placed vertically in the sulcus.
-in this the superior loop moves to the left and right, with movements of the head

134. .

135. .

136. PUPILLARY CAPTURE OF THE IOL
• Following postop iritis or proliferation of the remains of lens fibres

137. COMPLICATIONS OF PHACO
• Thermal burns (wound burn)
• Iris trauma
• PCR
• Nucleus drop
• Endophthalmitis
• Flattening of AC; surge
• Iridodialysis
• Hyphema
• Endothelial cell damage… corneal edema

138. REFERENCES
• AAO, Bk 11
• Wong
• Khuranah
• Cataract Coach
• PubMed