catsurgerycomplications-130325111456-phpapp02 2.pdf

Complications of cataract surgery

1. COMPLICATIONS

OF
CATARACT SURGEY
Dr. A G Malavika

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
Usual classification
Complications of anesthesia
General anesthesia
Regional / Local anesthesia

3. Complications of Cataract surgery3
Intraoperative
Early postoperative
Late postoperative
ANESTHESIA
COMPLICATIONS
GENERAL ANESTHESIA
Respiratory complications
Laryngoscope & intubation
Respiratory obstruction & spasm (isoflurane)

4. Complications of Cataract surgery4
Hypoxemia (N2O)
Hypercapnia / Hypocapnia
Hypoventilation
Aspiration pneumonia
Chest infections
Cardiovascular complications
Hypertension
Hypotension
Cardiac arrhythmias
Death (halothane)
Neurological complications

5. Complications of Cataract surgery5
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

6. Complications of Cataract surgery6
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)

7. Complications of Cataract surgery7
REGIONAL ANESTHESIA
PERIBULBAR / RETROBULBAR
ANESTHESIA
Lids trauma (ecchymosis)
Ptosis
s/conj hemorrhage
Muscles damage
Globe penetration & its related complications
Retrobulbar hemorrhage

8. Complications of Cataract surgery8
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

9. Complications of Cataract surgery9
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.

10. Complications of Cataract surgery10

BRAINSTEM ANESTHESIA
Life threatening

11. Complications of Cataract surgery11
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…

12. Complications of Cataract surgery12
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.

13. Complications of Cataract surgery13
S/CONJ & S/TENON
ANESTHESIA
Common
Pain on injection (15-
33%)
Chemosis (6-100%)
s/conj hemorrhage (7100%)
Rare
Globe perforation
Retrobulbar hemorrhage
Hyphema
Muscle trauma
Diplopia
Spread to CNS
Retinal dysfunction
Orbital cellulitis

14. Complications of Cataract surgery14
Chronic dilated pupils
Indian j ophthalmol 2006;54:77-84

15. Complications of Cataract surgery15
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

16. Complications of Cataract surgery16
Posterior capsule rupture
Cyclodialysis
Suprachoroidal effusion &
hemorrhage
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
EARLY POSTOPERATIVE
COMPLICATIONS

17. Complications of Cataract surgery17
IOL related
Decentered
Dislocated
Tilted
Pupillary capture
Capsular block syndrome
Acute Endophthalmitis
Wound related
Astigmatism
Corneal
Bullous keratopathy
Corneal decompensation
Corneal melting
Brown-McLean
syndrome
Epithelial down growth
IOP related
Glaucoma
Anterior chamber
Chronic uveitis
LATE POSTOPERATIVE
COMPLICATIONS

18. Complications of Cataract surgery18
UGH syndrome
Iris atrophy / cysts
IOL related
Malposition, glare
PCO & Phimosis
Posterior segment
Retinal light toxicity
Macular infarction
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

19. Complications of Cataract surgery19
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

20. Complications of Cataract surgery20
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

21. Complications of Cataract surgery21
SUPRACHOROIDAL EFFU SION
& 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

22. Complications of Cataract surgery22
Pain & agitation of pt suggests hemorrhage
Source … long or short posterior Ciliary artery
Expulsive hemorrhage…when SCH results in
expulsion of intraocular contents

23. Complications of Cataract surgery23
RISK FACTORS
Ocular factors
Glaucoma
High myopia
Posterior capsule rupture
Chronic ocular
inflammation
Systemic factors
HTN
Chronic lung disease
Advanced age
Obesity
Anticoagulation
Signs
Progressive shallowing of AC
Increased IOP
Iris prolapse, incision gaping

24. Complications of Cataract surgery24
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

25. Complications of Cataract surgery25
Drainage thru sclerotomy after a week
Refer to VR surgeon for vitrectomy

26. Complications of Cataract surgery26
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

27. Complications of Cataract surgery27
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

28. Complications of Cataract surgery28
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

29. Complications of Cataract surgery29
Raised IOP

Cause
Irrigating solutions

30. Complications of Cataract surgery30
Used cannula
Instruments rusts
Disposable gloves material
Management
Intraoperative measures
Topical + systemic steroids
CORNEAL EDEMA
Presents…immediate postop period
Causes
Mechanical trauma

31. Complications of Cataract surgery31
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

32. Complications of Cataract surgery32
DV
Irritation, pain
FB sensation
Epiphora
Infectious keratitis

33. Complications of Cataract surgery33

Management

34. Complications of Cataract surgery34
Corneal edema
Topical hyper osmotic agents
Topical steroids
Bandage contact lens
Bullous keratopathy
Penetrating keratoplasty
Endothelial keratoplasty
Gunderson conj flap
AMT

35. Complications of Cataract surgery35

KERATOLYSIS
Frequent association…tear film abnormality
KCS
Sjogren syndrome

36. Complications of Cataract surgery36
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

37. Complications of Cataract surgery37
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

38. Complications of Cataract surgery38
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

39. Complications of Cataract surgery39
Raised IOP
Hyphema…often
Vitreous wick
Management
Atropine
Topical steroids
Topical NSAIDs
CAI…topical or systemic
Topical β-blocker & α2-agonist
Surgery…if medical Tx fails
Repositioning, replacement or removal of IOL

40. Complications of Cataract surgery40
YAG vitreolysis
POSTERIOR CAPSULAR
OPACIFICATION
Overall, the most common complication
Cause…viable LECs
Types
Sommering rings
Elsching pearls
Capsular fibrosis

41. Complications of Cataract surgery41
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

42. Complications of Cataract surgery42
Anterior LECs proliferation

Factors affecting PCO formation
Age of pt
Hx of intraocular inflammation
PXF

43. Complications of Cataract surgery43
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%

44. Complications of Cataract surgery44
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

45. Complications of Cataract surgery45
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

46. Complications of Cataract surgery46
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

47. Complications of Cataract surgery47
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

48. Complications of Cataract surgery48
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

49. Complications of Cataract surgery49
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

50. Complications of Cataract surgery50

51. Complications of Cataract surgery51
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

52. Complications of Cataract surgery52
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…

53. Complications of Cataract surgery53
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

54. Complications of Cataract surgery54
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

55. Complications of Cataract surgery55
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

56. Complications of Cataract surgery56
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

57. Complications of Cataract surgery57
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

58. Complications of Cataract surgery58

59. Complications of Cataract surgery59

Management
Vitreous + aqueous samples

60. Complications of Cataract surgery60
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

61. Complications of Cataract surgery61
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

62. Complications of Cataract surgery62

Management
Vitreous + aqueous samples

63. Complications of Cataract surgery63
Antibiotics
I/vit
Topical steroids
Removal of capsular bag, IOL, residual cortex
PPV
PREVENTION OF
ENDOPHTHALMITIS
Preoperative
Treatment of pre-existing infections
Blepharitis, conjunctivitis, CDC, fellow eye

64. Complications of Cataract surgery64
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

65. Complications of Cataract surgery65
Surgeon must be aware of complications &
their proper management
Proper anesthesia techniques, sterilization &
patient preparation…mandatory

66. Complications of Cataract surgery66

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

67. Complications of Cataract surgery67
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

68. Complications of Cataract surgery68
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

69. Complications of Cataract surgery69
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

70. Complications of Cataract surgery70
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

71. Complications of Cataract surgery71
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

72. Complications of Cataract surgery72
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

73. Complications of Cataract surgery73
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

74. Complications of Cataract surgery74
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

75. Complications of Cataract surgery75
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