Ophthalmology lectures by Dr Zeinab Medani

1. Complications of
cataract surgery
by dr. zeinab medani mohammed ali

2. Operative and post operative complications
• Rupture of the posterior lens capsule
• Posterior loss of lens fragments
• Posterior dislocation of IOL
• Suprachoroidal hemorrhage
• Acute postoperative endophthalmitis
• Delayed-onset postoperative endophthalmitis

3. Continue
• Posterior capsular opacification
• Anterior capsular fibrosis and contraction
• Cystoid macular oedema
• Dysphotopsia
• Corneal decompensation
• Ptosis
• Malposition of the IOL
• Retinal detachment Refractive ‘surprise

4. Rupture of the posterior lens capsule
• Capsular rupture may be accompanied by vitreous loss, posterior
migration of lens material and, rarely, expulsive haemorrhage.
• Sequel to vitreous loss include CMO, retinal detachment,
endophthalmitis, updrawn pupil, uveitis , vitreous
wick syndrome, glaucoma and posterior dislocation of the IOL

5. • Signs
• ○ Sudden deepening or shallowing of the AC and momentary
pupillary dilatation
• ○ The nucleus falls away and cannot be approached by the
phaco tip.
• ○ The torn capsule or vitreous gel may be directly visible

6. • Management depends on the magnitude of the tear, the size and type of a
residual lens material and the presence or absence of vitreous prolapse.
Small tear >>> posterior chamber IOL implantation
a large tear will usually allow ciliary sulcus placement of a PC IOL
Acetylcholine solution is used to constrict the pupil following
implantation of a PC IOL or prior to inserting a AC IOL.
Insufficient capsular support may necessitate implantation of an AC IOL
Importantly, an iridectomy is needed to prevent pupillary block

7. •Posterior loss of lens fragments
• Dislocation of fragments of lens material into the vitreous cavity
after zonular dehiscence or posterior capsule rupture is rare but
potentially serious as it may result in glaucoma, chronic uveitis,
retinal detachment or chronic CMO
Small fragments  conservative approach
Large fragments  PPV

8. • Posterior dislocation of IOL
Dislocation of an IOL into the vitreous cavity is rare.
• Loss can occur via a posterior capsular dehiscence, or in an eye with
fragile zonular attachments (e.g. pseudoexfoliation) the entire capsular bag
may dislocate. Complications include vitreous haemorrhage, retinal
detachment, uveitis and chronic CMO.
Treatment involves pars plana vitrectomy with IOL removal, repositioning
or exchange depending on the extent of capsular support.

10. • Suprachoroidal hemorrhage involves a bleed into the suprachoroidal space from a
ruptured posterior ciliary artery
Sings
• Progressive shallowing of the AC, increased IOP and of the iris.
• ○ Vitreous extrusion, loss or partial obscuration of the red eflex and the appearance of a
dark mound behind the pupil.
Contributing factors include advanced age, glaucoma, increased axial length, systemic
cardiovascular disease, vitreous loss and conversion from phacoemulsification to ECCE.

11. • Contributing factors include advanced age, glaucoma, increased axial
length, systemic cardiovascular disease, vitreous loss and conversion from
phacoemulsification to ECCE.
Immediate treatment involves closure of the incision with a suture.
Postoperatively, intensive topical and systemic steroids should be used
with standard antibiotic treatment and IOP management.
Subsequent treatment drainage of a large haemorrhage , PPV in case of
RD

12. • Acute postoperative endophthalmitis
• Risk factors are difficult to establish but may include operative
complications such as posterior capsule rupture, prolonged procedure
time, combined procedure (e.g. with vitrectomy),
• clear corneal sutureless incision, temporal incision, wound leak on the first
day, delaying postoperative topical antibiotics until the day after surgery,
topical anaesthesia, adnexal disease and diabetes.

14. • Pathogens. About 90% are Gram-positive and 10% Gram-negative.
Staphylococcus epidermidis is the most common
• The source of infection usually cannot be identified with certainty.
• It is thought that the flora of the eyelids and conjunctiva are the most
frequent source, including contamination via incisions in the early
postoperative stages. Other potential sources include contaminated
solutions and instruments, environmental air and the surgeon, and other
operating room personnel.

15. • Prophylaxis
Instillation of 5% povidone-iodine into the conjunctival fornices
Scrupulous preparation of the surgical site
Treatment of pre-existing infections
Antibiotic prophylaxis
Intracameral cefuroxime or moxifloxacin injected at the end of surgery
Postoperative subconjunctival injection can achieve bactericidal levels in the AC for at
least 1–2 hours
Preoperative topical fluoroquinolone
Early resuturing of leaking wounds
Reviewing personal surgical practice

16. • Clinical features
• • Symptoms. Pain, redness and visual loss.
• • Signs vary according to severity.
• ○ Eyelid swelling, chemosis, conjunctival injection and discharge.
• ○ A relative afferent pupillary defect is common.
• ○ Corneal haze.
• ○ Fibrinous exudate and hypopyon .
• ○ Vitritis with an impaired view of the fundus and loss of the red reflex.

17. • Differential diagnosis
Retained lens material in the AC
Vitreous hemorrhage
Postoperative uveitis
Toxic reaction to the use of inappropriate or contaminated irrigating fluid
Complicated or prolonged surgery may result in corneal edema and
uveitis.
Identification of pathogens
Samples for culture should be obtained from aqueous and vitreous +
conjunctival swab

18. • Treatment
• • Intravitreal antibiotics are the key to management
Antibiotics commonly used in combination are ceftazidime, which will kill
most Gram-negative organisms (including Pseudomonas aeruginosa) and
vancomycin to address Gram-positive cocci
Subconjunctival antibiotic injections
Topical antibiotics are of limited benefit
Oral antibiotics. Fluoroquinolones, clarythromycin

19. • Oral steroids to limit destructive complications of the inflammatory
process. Prednisolone
Periocular steroids. Dexamethasone or triamcinolone should be
considered if systemic therapy is contraindicated.
• • Topical dexamethasone 0.1% 2-hourly initially for anterior uveitis.
• • Topical mydriatic such as atropine 1% twice daily.

20. Intravitreal steroids may reduce inflammation in the short
term but do not influence the final visual outcome
Pars plana vitrectomy

21. • Delayed-onset postoperative endophthalmitis
• Pathogenesis
• Develops when an organism of low virulence, such as P. acnes, becomes
trapped within the capsular bag (saccular endophthalmitis).
• Onset ranges from 4 weeks to years (mean 9 months) postoperatively
• It may rarely be precipitated by laser capsulotomy release of the organism.

23. • Diagnosis
• • Symptoms. Painless mild progressive visual deterioration is typical and
floaters may be present.
• • Signs
• ○ Low-grade anterior uveitis, sometimes with medium-large keratic
precipitates. A degree of vitritis is common.

24. • Initial management. Later-generation fluoroquinolones, such as
moxifloxacin
• Treatment if persistent
• ○ Intravitreal antibiotics alone are usually unsuccessful in resolving the
infection.
• ○ Removal of the capsular bag, residual cortex and IOL, requiring pars plana
vitrectomy

25. • Posterior capsular opacification
is the most common late complication of uncomplicated cataract surgery
occurring in 20–25% of patients
• It is caused by the proliferation of lens epithelial cells that have remained
within the capsular bag following cataract extraction.
• PMMA IOLs are particularly prone to PCO. Implant design is more
important than material. A square optic edge appears to inhibit PCO

27. • Diagnosis
• • Symptoms include persistent slowly worsening blurring, glare and
sometimes monocular diplopia.
• • VA is variably reduced
• Signs typically include more than one pattern of opacification.

28. • Treatment
• Nd:YAG laser (termed a posterior capsulotomy)

29. • Anterior capsular fibrosis and contraction
• Risk factors include a small capsulorhexis, pseudoexfoliation syndrome ,
retinitis pigmentosa and plate-haptic silicone IOL.
• If severe, Nd:YAG laser anterior capsulotomy may be required

31. • Cystoid macular oedema
• Symptomatic CMO is uncommon and it is mild and transient
• It occurs more often after complicated surgery and has a peak incidence 6-10
weeks
• Risk factors include epiretinal membrane, a history of CMO in the other
eye, operative complications such as posterior capsular rupture with vitreous
loss, particularly with vitreous incarceration into the incision site, anterior
chamber IOL, secondary IOL implantation, topical prostaglandin treatment,
diabetes and uveitis

33. • Symptoms. Blurring, especially for near tasks and sometimes distortion.
• Treatment. One or a combination of the following modalities may be used.
• Anterior vitrectomy or YAG laser applied to a vitreous wick if present.
• Topical NSAIDs
• Steroids. Topically, by periocular or intravitreal injection.
• Carbonic anhydrase inhibitors given systemically or topically.
• Intravitreal anti-VEGF agents.
• Pars plana vitrectomy may be useful for CMO refractory to medical therapy

34. • Dysphotopsia
• Up to 1 in 10 patients complain of annoying visual phenomena following
uncomplicated cataract surgery with monofocal IOL implantation
• Symptoms. A dark shadow in the temporal periphery (negative
dysphotopsia – often the most troublesome), haloes, peripheral or central
flaring or flashes (positive dysphotopsia) and possibly monocular diplopia

35. • Treatment
• Reassurance
• Positive nocturnal symptoms can be helped with gentle pupillary constriction
(e.g. brimonidine), but dilatation may help negative dysphotopsia
• IOL exchange (round-edged) may be considered.

36. • Corneal decompensation
• Eyes with pre-existing corneal endothelial pathology, particularly low cell
counts, are at increased risk.
• Causes of significant oedema include a dense nucleus, complicated or
prolonged surgery, pseudoexfoliation, intraoperative endothelial trauma and
elevated postoperative IOP.

38. • Malposition of the IOL
• malposition may be associated with both optical and structural problems.
• Significant malposition may require repositioning or replacement
occasionally with an iris or scleral-fixated lens.

40. • Retinal detachment
• Rhegmatogenous retinal detachment (RRD) is uncommon after
uncomplicated phacoemulsification with IOL implantation. Preoperative risk
factors include lattice degeneration, retinal breaks and high myopia. The key
intraoperative risk is vitreous loss. Pars plana vitrectomy is usually the
surgical modality employed for pseudophakic RRD.

41. • Refractive ‘surprise’
• Under or over correction
• Treatment
• spectacles or contact lens
• IOL exchange
• Corneal refractive surgery
• sulcus IOL implantation

42. •
Thanks