Cataract surgery complications

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

2. Complications of Cataract surgery2
Introduction
Frequently asked question
Needs to be remembered on finger-tips
No surgery is without complications
Can be answered in many ways

3. Complications of Cataract surgery3
Usual classification
Complications of anesthesia
General anesthesia
Regional / Local anesthesia
Intraoperative
Early postoperative
Late postoperative

4. Complications of Cataract surgery4
ANESTHESIA
COMPLICATIONS

5. Complications of Cataract surgery5
GENERAL ANESTHESIA
Respiratory complications
Laryngoscope & intubation
Respiratory obstruction & spasm (isoflurane)
Hypoxemia (N
2
O)
Hypercapnia / Hypocapnia
Hypoventilation
Aspiration pneumonia
Chest infections

6. Complications of Cataract surgery6
Cardiovascular complications
Hypertension
Hypotension
Cardiac arrhythmias
Death (halothane)
Neurological complications
Headache
Delayed recovery
Perioperative neuropathy
Hallucinations & unpleasant dreams (ketamine)

7. Complications of Cataract surgery7
Postoperative nausea & vomiting (propofol, etomidate)
Temperature changes
Hypothermia
Hyperthermia (atropine, halothane)
Allergic drug reactions
Itching
Anaphylaxis
Hypotension, arrhythmia, tachycardia
Bronchospasm, cough, dyspnea

8. Complications of Cataract surgery8
Complications of positioning
Air embolism
Nerve palsies
Brachial plexus, Radial nerve, Ulnar nerve
Skin necrosis
Miscellaneous
Renal dysfunction (enflurane)
Muscle pain (succinylcholine)

9. Complications of Cataract surgery9
REGIONAL ANESTHESIA

10. Complications of Cataract surgery10
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.

11. Complications of Cataract surgery11
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.

12. Complications of Cataract surgery12

13. Complications of Cataract surgery13
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

14. Complications of Cataract surgery14
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.

15. Complications of Cataract surgery15
S/CONJ & S/TENON
ANESTHESIA
Common
Pain on injection (15-
33%)
Chemosis (6-100%)
s/conj hemorrhage (7-
100%)
Rare
Globe perforation
Retrobulbar hemorrhage
Hyphema
Muscle trauma
Diplopia
Spread to CNS
Retinal dysfunction
Orbital cellulitis
Chronic dilated pupils
Indian j ophthalmol 2006;54:77-84

16. Complications of Cataract surgery16
INTRAOPERATIVE
COMPLICATIONS
Wound related
Iris prolapse
Corneal
Descemet’s membrane
detachment
Corneal burns
Anterior chamber
Iridodialysis
flattening of anterior
chamber
Hyphema
Intraoperative floppy iris
syndrome
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

17. Complications of Cataract surgery17
EARLY POSTOPERATIVE
COMPLICATIONS
Wound related
Wound leak
Iris prolapse
induced astigmatism
Corneal
Corneal edema
Striate keratopathy
Anterior chamber
AC reaction
Hyphema
TASS
Vitreous in AC
IOP related
Raised
Low
IOL related
Decentered
Dislocated
Tilted
Pupillary capture
Capsular block syndrome
Acute Endophthalmitis

18. Complications of Cataract surgery18
LATE POSTOPERATIVE
COMPLICATIONS
Wound related
Astigmatism
Corneal
Bullous keratopathy
Corneal decompensation
Corneal melting
Brown-McLean
syndrome
Epithelial down growth
IOP related
Glaucoma
Anterior chamber
Chronic uveitis
UGH syndrome
Iris atrophy / cysts
IOL related
Malposition, glare
PCO & Phimosis
Posterior segment
Retinal light toxicity
Macular infarction
CME
R/D
Chronic Endophthalmitis

19. Complications of Cataract surgery19
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

20. Complications of Cataract surgery20
Signs
Sudden deepening of AC
Pupillary dilatation
Visible rupture of PC
Visible vitreous

21. Complications of Cataract surgery21
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

22. Complications of Cataract surgery22
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

23. Complications of Cataract surgery23
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

24. Complications of Cataract surgery24
RISK FACTORS
Ocular factors
Glaucoma
High myopia
Posterior capsule
rupture
Chronic ocular
inflammation
Systemic factors
HTN
Chronic lung disease
Advanced age
Obesity
Anticoagulation

25. Complications of Cataract surgery25
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

26. Complications of Cataract surgery26
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

27. Complications of Cataract surgery27

28. Complications of Cataract surgery28
INTRAOPERATIVE FLOPPY IRIS
SYNDROME (IFIS)
Trio of
Iris billowing
Progressive Intraoperative miosis
Iris prolapse
Cause…Tamsulosin or other a
1
-blockers for
BPH
Unopposed action of sphincters
Increased risk of PCR & high IOP
Pt should be asked to stop it pre-op

29. Complications of Cataract surgery29
Management
Careful incision architecture
Viscodilatation
Microincisional surgery
Low-flow settings
Iris retractors
Pupil expansion rings

30. Complications of Cataract surgery30
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

31. Complications of Cataract surgery31

32. Complications of Cataract surgery32
Cause
Irrigating solutions
Used cannula
Instruments rusts
Disposable gloves material
Management
Intraoperative measures
Topical + systemic steroids

33. Complications of Cataract surgery33
CORNEAL EDEMA
Presents…immediate postop period
Causes
Mechanical trauma
Prolonged surgery
Inflammation
Elevated IOP
Nuclear fragments
Results in acute endothelial dysfunction

34. Complications of Cataract surgery34
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

35. Complications of Cataract surgery35

36. Complications of Cataract surgery36
Management
Corneal edema
Topical hyper osmotic agents
Topical steroids
Bandage contact lens
Bullous keratopathy
Penetrating keratoplasty
Endothelial keratoplasty
Gunderson conj flap
AMT

37. Complications of Cataract surgery37

38. Complications of Cataract surgery38
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

39. Complications of Cataract surgery39
Systemic immunosuppression for collagen disease
Bandage contact lenses
Tarsorrhaphy
Punctal occlusion
AMT
Lamellar KP
Penetrating KP

40. Complications of Cataract surgery40
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

41. Complications of Cataract surgery41
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

42. Complications of Cataract surgery42
Management
Atropine
Topical steroids
Topical NSAIDs
CAI…topical or systemic
Topical b-blocker & a
2
-agonist
Surgery…if medical Tx fails
Repositioning, replacement or removal of IOL
YAG vitreolysis

43. Complications of Cataract surgery43
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

44. Complications of Cataract surgery44
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

45. Complications of Cataract surgery45

46. Complications of Cataract surgery46
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

47. Complications of Cataract surgery47
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

48. Complications of Cataract surgery48
Treatment
Nd:YAG capsulotomy
Indications
BCVA decreased bcz of hazy PC
Hazy PC causing inadequate fundus view
Monocular Diplopia or glare

49. Complications of Cataract surgery49

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)

50. Complications of Cataract surgery50
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

51. Complications of Cataract surgery51
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

52. Complications of Cataract surgery52
MACULAR INFARCTION
Very rare
Clinically similar to CRAO
Cause
s/conj injection of aminoglicosides for Endopthalmitis
prophylaxis
Gentamicin…greatest risk
Amikacin & tobramycin also

53. Complications of Cataract surgery53
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

54. Complications of Cataract surgery54
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

55. Complications of Cataract surgery55

56. Complications of Cataract surgery56
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

57. Complications of Cataract surgery57
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.

58. Complications of Cataract surgery58
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

59. Complications of Cataract surgery59
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

60. Complications of Cataract surgery60
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

61. Complications of Cataract surgery61
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

62. Complications of Cataract surgery62
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

63. Complications of Cataract surgery63
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

64. Complications of Cataract surgery64

65. Complications of Cataract surgery65

66. Complications of Cataract surgery66
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

67. Complications of Cataract surgery67
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

68. Complications of Cataract surgery68

69. Complications of Cataract surgery69
Management
Vitreous + aqueous samples
Antibiotics
I/vit
Topical steroids
Removal of capsular bag, IOL, residual cortex
PPV

70. Complications of Cataract surgery70
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

71. Complications of Cataract surgery71
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

72. Complications of Cataract surgery72

73. Complications of Cataract surgery73

74. Complications of Cataract surgery74
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

75. Complications of Cataract surgery75
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

76. Complications of Cataract surgery76
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

77. Complications of Cataract surgery77
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

78. Complications of Cataract surgery78
5. Systemic use of a
1
-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

79. Complications of Cataract surgery79
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

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

81. Complications of Cataract surgery81
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

82. Complications of Cataract surgery82
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

83. Complications of Cataract surgery83
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

84. Complications of Cataract surgery84
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