Complication of catarct surgery

Cataract surgery (Phaco/SICS)

1. PER-OPERATIVE COMPLICATION OF CATARACT SURGERY Presented by LT. COL. Rashed-UL-Hasan

2. INTRAOPERATIVE COMPLICATIONS Hydro related Iris related Nucleus related I/A related IOL insertion related Wound Closure related   Anesthesia related SR related Conjunctiva related Wound related Capsulotomy related

3. ANAESTHESIA RELATED COMPLICATIONS Oculocardiac reflex Subconjunctival haemorrhage Spontaneous dislocation of lens Globe perforation Retrobulbar haemorrhage Central spread of anaesthetic Retinal vascular occlusion Optic nerve trauma

4. PERIBULBAR / RETROBULBAR ANESTHESIA Lids trauma (ecchymosis) Ptosis S/ conj hemorrhage Muscles damage Globe penetration Retrobulbar hemorrhage Optic nerve damage Putscher -type retinopathy * Brainstem anesthesia

5. Sub-CONJ & Sub-TENON ANESTHESIA Common Pain on injection (15-33%) Chemosis ( 6-100 %) s/ conj hemorrhage (7- 100%) Rare Globe perforation Retro bulbar hemorrhage Hyphema Muscle trauma Diplopia Orbital cellulitis

6. Oculocardiac reflex Manifest as Bradycardia A-V Block Asystole Treatment Stop stimulation IV atropine (0.01 mg/kg) Local injection of lidocaine near the eye muscle

7. Wound related Button holing Premature entry Scleral disinsertion Corneal Descemet’s membrane detachment Corneal burns Anterior chamber Iridodialysis Flattening of anterior chamber Hyphema Intraoperative floppy iris syndrome

8. Continuous curvilinear capsulorhexis (CCC) related Escaping capsulorhexis Small / large capsulorhexis Eccentric capsulorhexis 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

9. POSTERIOR CAPSULE RUPTURE Serious complication 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 RD & CME

10. Signs Sudden deepening of AC Pupillary dilatation Visible rupture of PC Visible vitreous

11. Management Depends on magnitude of tear & vitreous prolapse General guidelines 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

12. 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

13. RISK FACTORS Ocular factors Glaucoma High myopia Posterior capsule rupture Chronic ocular inflammation Systemic factors HTN Chronic lung disease (COPD) Advanced age Obesity Anticoagulation

14. 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

15. Management Stop surgery Immediate closure of wound IV mannitol Postoperative Topical & systemic steroids Drainage through sclerotomy after a week Refer to VR surgeon for vitrectomy

16. INTRAOPERATIVE FLOPPY IRIS SYNDROME (IFIS) Trio of Iris billowing Progressive Intraoperative miosis Iris prolapse Cause: Tamsulosin or other α 1 -blockers for BPH Unopposed action of sphincters Increased risk of PCR & high IOP Pt should be asked to stop it pre-op ????? Microincisional surgery Low-flow setting PHACO

17. Lens–Iris Diaphragm Retropulsion Syndrome (LIDRS) characterized by posterior displacement of the lens–iris diaphragm with deepening of the anterior chamber, posterior iris bowing pupil dilation. more common highly myopic eyes eyes that have undergone previous vitrectomy. may cause stress on the zonular apparatus and considerable patient discomfort under topical anesthesia. Surgery - difficult due to deep AC. Lifting the iris or the anterior capsule is usually sufficient to break the pupillary block and restore normal anterior chamber depth.

18. Lens - Iris Diaphragm Retropulsion Syndrome (LIDRS)

19. 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