Cataract surgery complications

COMPLICATIONS
OF
CATARACT SURGEY
DR. YOUSAF JAMAL
OPHTHALMOLOGY DEPARTMENT
HMC
(10-07-2010)

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

Usual classification
 Complications of anesthesia
 General anesthesia
 Regional / Local anesthesia
 Intraoperative
 Early postoperative

 Late postoperative


ANESTHESIA
COMPLICATIONS


GENERAL ANESTHESIA
 Respiratory complications
 Laryngoscope & intubation
 Respiratory obstruction & spasm (isoflurane)
 Hypoxemia (N2O)
 Hypercapnia / Hypocapnia
 Hypoventilation
 Aspiration pneumonia
 Chest infections


 Cardiovascular complications
 Hypertension
 Hypotension
 Cardiac arrhythmias
 Death (halothane)
 Neurological complications
 Headache
 Delayed recovery
 Perioperative neuropathy
 Hallucinations & unpleasant dreams (ketamine)


 Postoperative nausea & vomiting (propofol, etomidate)
 Temperature changes
 Hypothermia
 Hyperthermia (atropine, halothane)
 Allergic drug reactions
 Itching
 Anaphylaxis
 Hypotension, arrhythmia, tachycardia
 Bronchospasm, cough, dyspnea


 Complications of positioning
 Air embolism
 Nerve palsies
 Brachial plexus, Radial nerve, Ulnar nerve
 Skin necrosis
 Miscellaneous
 Renal dysfunction (enflurane)
 Muscle pain (succinylcholine)


REGIONAL ANESTHESIA


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.


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.


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


 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.


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


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

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

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


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


 Signs
 Sudden deepening of AC
 Pupillary dilatation
 Visible rupture of PC
 Visible vitreous


 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


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


 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


RISK FACTORS
 Ocular factors  Systemic factors
 Glaucoma  HTN
 High myopia  Chronic lung disease
 Posterior capsule  Advanced age
rupture  Obesity
 Chronic ocular  Anticoagulation
inflammation


 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
 Posterior sclerotomy & drainage…controversial
 Postoperative
 Topical & systemic steroids
 Drainage thru 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 α1-blockers for
BPH
 Unopposed action of sphincters
 Increased risk of PCR & high IOP
 Pt should be asked to stop it pre-op


 Management
 Careful incision architecture
 Viscodilatation
 Microincisional surgery
 Low-flow settings
 Iris retractors
 Pupil expansion rings


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


 Cause
 Irrigating solutions
 Used cannula
 Instruments rusts
 Disposable gloves material
 Management
 Intraoperative measures
 Topical + systemic steroids


CORNEAL EDEMA
 Presents…immediate postop period
 Causes
 Mechanical trauma
 Prolonged surgery
 Inflammation
 Elevated IOP
 Nuclear fragments
 Results in acute endothelial dysfunction


 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


Management
 Corneal edema
 Topical hyper osmotic agents
 Topical steroids
 Bandage contact lens
 Bullous keratopathy
 Penetrating keratoplasty
 Endothelial keratoplasty
 Gunderson conj flap
 AMT

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


 Systemic immunosuppression for collagen disease
 Bandage contact lenses
 Tarsorrhaphy
 Punctal occlusion
 AMT
 Lamellar KP
 Penetrating KP


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

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


 Management
 Atropine
 Topical NSAIDs
 CAI…topical or systemic
 Topical β-blocker & α2-agonist
 Surgery…if medical Tx fails
 Repositioning, replacement or removal of IOL
 YAG vitreolysis


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


 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


 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


 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


 Treatment
 Nd:YAG capsulotomy
 Indications
 BCVA decreased bcz of hazy PC
 Hazy PC causing inadequate fundus view
 Monocular Diplopia or glare


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)


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


 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


MACULAR INFARCTION
 Very rare
 Clinically similar to CRAO

 Cause
 s/conj injection of aminoglicosides for Endopthalmitis
prophylaxis
 Gentamicin…greatest risk
 Amikacin & tobramycin also


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


 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


 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


 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.


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


 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


 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


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


 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

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


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

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


Management
 Vitreous + aqueous samples
 Antibiotics
 I/vit
 Removal of capsular bag, IOL, residual cortex

 PPV


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


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


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


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


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

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

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

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

7. Early postop complication of cataract surgery are all of
following except

a. Iris prolapse
b. Hyphema
c. Striate keratopathy
d. CME

Ans. d


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


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

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


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 Dr Manzoor

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Cataract surgery complications

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