complications of cataract surgery 2.pptx

A cataract is a clouding of the natural intraocular crystalline lens that focuses the light entering the eye onto the retina. This cloudiness can cause a decrease in vision and may eventually lead to blindness if left untreated. Cataracts often develop slowly and painlessly, so vision and lifestyle can be affected without a person realizing it. Worldwide, cataracts are the number one cause of preventable blindness. There is no medical treatment to prevent the development or progression of cataracts

1. COMPLICATIONS OF CATARACT SURGERY 1

2. C ONTENTS INTRODUCTION PREOPERATIVE COMPLICATIONS INTRAOPERATIVE COMPLICATIONS EARLY POSTOPERATIVE COMPLICATIONS DELAYED(LATE) POSTOPERATIVE COMPLICATIONS IOL- related COMPLICATIONS SUMMARY REFRENCES 2

3. INTRODUCTION A cataract is a clouding of the natural intraocular crystalline lens that focuses the light entering the eye onto the retina. This cloudiness can cause a decrease in vision and may eventually lead to blindness if left untreated. Cataracts often develop slowly and painlessly, so vision and lifestyle can be affected without a person realizing it. Worldwide, cataracts are the number one cause of preventable blindness. There is no medical treatment to prevent the development or progression of cataracts 3

4. Modern cataract surgery, which is the removal of the cloudy lens and implantation of a clear intraocular lens (IOL), is the only definitive treatment. Cataract surgery has under gone considerable evolution, and, in concert with other developments in engineering and medicine, has resulted in a more successful procedure with fewer complications. 4

5. COMPLICATIONS OF CATARACT SURGERY Preoperative complications Intraoperative complications Early postoperative complications Delayed(late) postoperative complications IOL- related COMPLICATIONS 5

6. PREOPERATIVE COMPLICATIONS Complications related to anesthesia Regional or local anesthesia Retrobulbar block P eribulbar block S ub-tenon block S ub-conjunctival block General anesthesia Topical anesthesia 6

7. (1) Retrobulbar haemorrhages vary in intensity and are more common with Retrobulbar anesthetic injections > Peribulbar injections. Venous or Arterial Orbital swelling, marked proptosis, elevated IOP, reduced mobility vof the globe, inability to separate the eye lids and massive ecchymosis of the eyelids and conjunctiva. 7

8. Management: consists of maneuvers to lower the intra ocular and orbital pressures as quickly as possible Digital massage Intravenous osmotic agents Aqueous Suppressants Lateral Canthotomy and Cantholysis Surgery postponed until IOP, mobility of globe and eyelids normal. Advisable to use other form of anesthesia . 8

9. (2) Oculocardiac reflex, which manifests as bradycardia and/or cardiac arrhythmia, has also been observed due to retrobulbar block.  An intravenous injection of atropine is helpful. (3) Perforation of the globe is a rare but serious complication, occurring when the needle penetrates the eye during a retrobulbar or peribulbar block. 9

10. This complication can lead to severe visual impairment or blindness due to retinal damage, hemorrhage , or retinal detachment. Immediate recognition and prompt, appropriate medical and surgical management, including prophylactic antibiotics and potential repair, are crucial for a positive outcome 10

11. (4) Subconjunctival haemorrhage is a minor complication observed particularly ocular anesthesia and does not need much attention. (5) Spontaneous dislocation of lens in vitreous has also been reported ( in patients with weak degenerated zonules especially with hypermature cataract) during vigorous ocular massage after retrobulbar block.  The operation should be postponed and further management is on the lines of posterior dislocation of lens. (6) Others: CNS complications, ptosis, optic nerve damage 11

12. OPERATIVE COMPLICATIONS 1. Superior rectus muscle laceration 2. Excessive bleeding 3. Incision related complications 4. Injury to the Cornea, Iris and Lens 5. Iris injury and Iridodialysis (tear of iris from root) 6. Complications related to anterior capsulorhexis 7. Posterior capsular rupture 8. Zonular dehiscence 9. Vitreous loss 10. Nucleus drop into the vitreous cavity 11. Posterior loss of lens fragment 12. Suprachoroidal haemorrhage 13. Expulsive choroidal haemorrhage 12

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14. (1) Superior rectus muscle laceration and/or haematoma, may occur while applying the bridle suture.  Usually no treatment is required. (2). Excessive bleeding may be encountered during the preparation of conjunctival flap or during incision into the anterior chamber. Bleeding vessels may be gently cauterized. 14

15. 3. Incision related complications depend upon the type of cataract surgery being performed. i . In conventional ECCE there may occur irregular incision. Irregular incision leading to defective coaptation of wound may occur due to blunt cutting instruments. In manual SICS and phacoemulsification following complications may occur while making the self-sealing tunnel incision. 15

16. 16 Button holing of anterior wall of tunnel can occur because of superficial dissection of the scleral flap. As a remedy abandon this dissection and re enter at a deeper plane from the other side of the external incision.

17. A, correct incision;  B, Buttonholing of anterior wall of the tunnel; 17

18. Premature entry into the anterior chamber can occur because of deep dissection.  Once this is detected, dissection in that area should be stopped and a new dissection started at a lesser depth at the other end of the tunnel. C, Premature entry into the anterior chamber 18

19. Scleral disinsertion can occur due to very deep groove incision.  In it there occurs complete separation of inferior sclera from the sclera superior to the incision. Scleral disinsertion needs to be managed by radial sutures. 19

20. 4. Injury to the cornea ( Descement's detachment), iris and lens may occur when anterior chamber is entered with a sharp-tipped instrument such as keratome or a piece of razor blade.  A gentle handling with proper hypotony reduces the incidence of such inadvertent injuries. 20

21. 21 5. Iris injury and iridodialysis Iridodialysis , the tearing of the iris at its root or insertion, may occur at the time of insertion of the phaco tip or IOL or already be pre sent from prior trauma. Traction on the iris root during phacoemulsification or irrigation/aspiration (I/A) can cause a tear and subsequent hyphema . If the iridodialysis is small or insignificant, it can be left alone. More extensive iridodialysis , which could cause optical prob lems or be cosmetically significant, may require surgical reattachment by suturing the iris to the sclera 

22. 6. Complications related to anterior capsulorhexis . Continuous curvilinear capsulorhexis (CCC) is the preferred technique for opening the anterior capsule for SICS and phacoemulsification. Following complications may occur: Escaping capsulorhexis i.e., capsulorhexis moves peripherally and may extend to the equator or posterior capsule. 22

23. 23 Small capsulorhexis . It predisposes to posterior capsular tear and nuclear drop during hydrodissection .  It also predisposes to occurrence of zonular deshiscence . Therefore, a small sized capsulorhexis should always be enlarged by 2 or 3 relaxing incisions before proceeding further. Very large capsulorhexis may cause problems for in the bag placement of IOL. Eccentric capsulorhexis can lead to IOL decentration at a later stage.

24. Small Capsulorhexis 24

25. 25 capsulorhexis surgery- guidance.com

26. 7. Posterior capsular rupture (PCR).  It is a dreaded complication during extra capsular cataract extraction. In manual SICS and phacoemulsification PCR is even more feared because it can lead to nuclear drop into the vitreous. The PCR can occur in following situations: During forceful hydrodissection , By direct injury with some instrument such as Sinskey's hook, chopper or phacotip , and During cortex aspiration  26

27. 27 Signs Sudden deepening or shallowing of the AC and momentary pupillary dilatation. The nucleus falls away and cannot be approached by the phaco tip. Vitreous aspirated into the phaco tip ofen manifests with a marked slowing of aspiration. The torn capsule or vitreous gel may be directly visible. Management depends on the magnitude of the tear, the size and type of any residual lens material and the presence or absence of vitreous prolapse.

28. (8) Zonular dehiscence- may occur in all techniques of ECCE but is especially common during nucleus prolapse into the anterior chamber in manual SICS. (9) Vitreous loss .- it is the most serious complication which may occur following accidental rupture of post. Capsule during any technique of ECCE. 28

29. Adequate measures should be taken to prevent this like: To decrease vitreous volume: Preoperative use of hyperosmotic agents like 20 percent mannitol or oral glycerol is suggested. To decrease aqueous volume: Preoperatively acetazolamide 500 mg orally should be used and adequate ocular massage should be carried out digitally after injecting local anaesthesia. To decrease orbital volume adequate ocular massage and orbital compression by use of superpinky , Honan's ball, or 30 mm of Hg pressure by paediatric sphygmomanometer should be carried out. 29

30. Better ocular akinesia and anaesthesia decrease the chances of pressure from eye muscle. Minimizing the external pressure on eyeball by not using eye speculum, reducing pull on bridle suture and overall gentle handling during surgery. Use of Flieringa ring to prevent collapse of sclera especially in myopic patients decreases the incidence of vitreous loss. 30

31. When IOP is high in spite of all above measures and operation cannot be postponed, in that situation a planned posterior-sclerotomy with drainage of vitreous from pars plana will prevent rupture of the anterior hyaloid face and vitreous loss. 31

32. 32 Management of vitreous loss . Once the vitreous loss has occurred, the aim should be to clear it from the anterior chamber and incision site. This can be achieved by performing partial anterior vitrectomy, with the use of automated vitrectors. Partial anterior vitrectomy will reduce the incidence of postoperative problems associated with vitreous loss such as updrawn pupil, iris prolapse and vitreous touch syndrome

33. 33 Z onular dehiscence

34. 34 V itreous loss

35. (10) Nuclear drop into the vitreous cavity . – it occurs phacoemulsification , less frequently with manual SICS. It is a dreadful complication which occur due to sudden & large PCR. Management.- ant. Vitrectomy & cortical clean up. 35

36. (11) Post. Loss of lens fragments - into the vitreous cavity may occur after PCR or zonular dehiscence during phacoemulsification. Rare Potentially serious because it may Result in glaucoma, chronic, uveitis, chronic CME, and even Retinal Detachment. The case should be managed by performing pars plana vitrectomy and removal of nuclear fragments for large pieces and may be reasonable to adapt a conservative approach for small fragments. 36

37. 37 (12) Suprachoroidal haemorrhage A suprachoroidal haemorrhage involves a bleed into the suprachoroidal space from a ruptured posterior ciliary artery. If sufficiently severe it may result in extrusion of intraocular contents (expulsive haemorrhage). It is a dreaded complication, but extremely rare (0.04%) with phacoemulsification. Signs Progressive shallowing of the AC, increased IOP and prolapse of the iris. Vitreous extrusion, loss or partial obscuration of the red reflex and the appearance of a dark mound behind the pupil.

38. 38 In severe cases, posterior segment contents may be extruded into the AC and through the incision . Treatment Immediate treatment involves closure of the incision with a suture. Subsequent treatment, if spontaneous absorption fails to occur, consists of drainage of a large haemorrhage. Th is can be performed 7–14 days later, by which time liquefaction of blood clot has taken place .

39. (13) Expulsive choroidal haemorrhage .-  It is one of the most dramatic and serious complications of cataract surgery.  It usually occurs in hypertensive and patients with arteriosclerotic changes.  It may occur during operation or during immediate postoperative period.  39

40. 40 Its incidence was high in ICCE and conventional ECCE but has decreased markedly with valvular incision of manual SICS and phaco emulsification technique. Characterized by spontaneous gaping of the wound followed by expulsion of the lens, vitreous, retina, uvea, & finally a gush of bright red blood. Although treatment is unsatisfactory, the surgeon should attempt to drain subchoroidal blood by performing an equatorial sclerotomy. Most of the time eye is lost and so evisceration operation has to be performed.

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42. EARLY POSTOPERATIVE COMPLICATION 42

43. EARLY POSTOPERATIVE COMPLICATIONS 1. Hyphaema . collection of blood in ant. Chamber may occur from conjunctival or scleral vessels due to minor ocular trauma. Symptoms Bleeding in front portion of the eye Vision abnormalities Eye pain Photophobia 43

44. Treatment Most hyphaemas absorb spontaneously and need no treatment. hyphaema may be large and associated with rise in IOP. In such cases, IOP should be lowered by acetazolamide and hyperosmotic agents. If the blood does not get absorbed in a weeks time then paracentesis should be done to drain the blood 44

45. IRIS PROLAPSE (2) Iris prolapse – It is usually caused by inadequate suturing of the incision after ICCE & conventional ECCE. Occurs during 1 st or 2 nd postoperative day This complication is less common with manual SICS and phacoemulsification technique. Management: A small prolapse of less than 24 hours duration may be reposited back and wound sutured.  A large prolapse of long duration needs abscission and suturing of wound. 45

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47. STRIATE KERATOPATHY (3) Striate keratopathy.- characterized by mild corneal oedema with descement's fold is a common complication observed during immediate postoperative period.  - Occurs Due to endothelial damage during surgery. Management : Mild striate keratopathy usually disappears spontaneously within a week. Moderate to severe keratopathy may be treated by instillation of hypertonic saline drops (5% sodium chloride) along with steroids. 47

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49. FLAT ANTERIOR CHAMBER (4) Flat anterior chamber-The anterior chamber is Shallow or flat Rare complication due to improved wound closure Wound leak  Cilioc horoidal detachment or hemorrhage Pupillary block due to vitreous bulge 49

50. Flat anterior chamber 50

51. WOUND LEAK It Is associated with hypotony.        It is diagnosed by Seidel's test.  In this test, a drop of fluorescein is instilled into the lower fornix and patient is asked to blink to spread the dye evenly.  The incision is then examined with slit lamp using cobalt-blue filter. At the site of leakage, fluorescein will be diluted by aqueous. In most cases wound leak is cured within 4 days with pressure bandage and oral acetazolamide.  If the condition persists, injection of air in the anterior chamber and resuturing of the leaking wound should be carried out. 51

52. CILIOCHOROIDAL DETACHMENT It may or may not be associated with wound leak.   Presents as a convex brownish mass in the involved quadrant with shallow anterior chamber In most cases choroidal detachment is cured within 4 days with pressure bandage and use of oral acetazolamide. If condition persists Suprachoroidal drainage Injection of air in the anterior chamber 52

53. PUPILLARY BLOCK Pupillary block due to vitreous bulge after ICCE leads to formation of iris bombe and shallowing of anterior chamber.  If condition persists for 5-7 days permanent peripheral anterior synechiae may be formed leading to secondary angle closure glaucoma 53

54. MANAGEMENT Initially Mydriatic Hyperosmotic agents Acetazolamide If not relieved Laser or surgical peripheral iridectomy 54

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56. POSTOPERATIVE ANTERIOR UVEITIS (5) Postoperative anterior uveitis can be induced by instrumental trauma, undue handling of uveal tissue, reaction to residual cortex or chemical reaction induced by viscoelastics , pilocarpine etc. Management includes more aggressive use of topical steroids, cycloplegics. Rarely systemic steroids (cases with fibrinous reaction) 56

57. Postoperative anterior uveitis 57

58. TOXIC ANTERIOR SEGMENT SYNDROME (6). Toxic Anterior Segment Syndrome Is a rare, non-infectious inflammation of the eyes anterior segment that may occur following cataract surgery. Its caused by a toxic substance entering the eye during the procedure leading to inflammation and possible tissue damage 58

59. The symptoms and signs may mimic those of infectious endophthalmitis. However it presents within 12-48hrs of surgery while endophthalmitis present 3-10days postoperatively. It is usually treated with topical corticosteroids in high dosage and frequency. 59

60. POSTOPERATIVE ENDOPHTHALMITIS (7). Bacterial endophthalmitis. This is one of the most dreaded complications with an incidence of 0.2 to 0.5 percent. The principal sources of infection are contaminated solutions, instruments, surgeon'shands , patient's own flora from conjunctiva, eyelids and air- borne bacteria. 60

61. Ocular pain, diminished vision, lid oedema, conjunctival chemosis and marked circumciliary congestion, corneal oedema, exudates in pupillary area, hypopyon and diminished or absent red reflex . 61

62. 62 Treatment: involves a combination of intravitreal antibiotics to kill the infection, corticosteroids to reduce inflammation, and potentially vitrectomy to remove infected material from the eye. Early diagnosis and treatment are crucial to improve visual outcomes and prevent irreversible vision loss. 

63. These complications may occur after weeks, months or years of cataract surgery. Cystoid macular oedema (CME) Delayed chronic postoperative endophthalmitis Pseudophakic bullous keratopathy (PBK) Retinal detachment (RD) Epithelial ingrowth. Fibrous ingrowth into the anterior chamber After cataract (PCO) Glaucoma 63 LATE POSTOPERATIVE COMPLICATIONS

64. 1. Cystoid macular oedema (CME). CME - collection of fluid in the form of cystic loculi in the henle’s layer of macula. is a relatively common complication of cataract Surgery. Present with Blurring, especially for near tasks, and sometimes distortion. On fundoscopy it gives a honeycomb appearance. On FA- typical flower petal patterns due to leakage of dye from perifoveal capillaries. It is associated with vitreous incarceration in wound and iritis 64 CYSTOID MACULAR EDEMA

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67. DELAYED CHRONIC POSTOPERATIVE ENDOPHTHALMITIS 2. Delayed chronic postoperative endophthalmitis Infection of intraocular tissue is caused when an organism of low virulence becomes trapped within the capsular bag.  May be due to penetrating trauma It has an onset ranging from 4 weeks to years (mean 9 months) postoperatively and typically follows uneventful cataract surgery. 67

68. Symptoms. Painless mild progressive visual deterioration is typical and fl oaters may be present.  Signs Low-grade anterior uveitis. Th e in fl ammation initially responds well to topical steroids, but recurs when treatment is stopped and may eventually become steroid-resistant. An enlarging capsular plaque composed of organisms sequestrated in residual cortex within the peripheral capsular bag is common. 68

69. 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. Secondary IOL implantation may be considered at a later date. 69

70. Delayed chronic postoperative endophthalmities -  70

71. PSEUDOPHAKIC BULLOUS KERATOPATHY(PBK) 3. Pseudophakic bullous keratopathy(PBK) Is a postoperative corneal oedema produced by surgical or chemical insult to a healthy or compromised corneal endothelium. Associated with cloudy vision. May be transient or permanent. 71

72. 4 . Retinal detachment (RD) This serious postoperative complication is, fortunately, rare Incidence of retinal detachment is higher in aphakic patients as compared to phakics. It has been noted that retinal detachment is more common after ICCE than after ECCE. Other risk factors for aphakic retinal detachment include vitreous loss during operation, associated myopia and lattice degeneration of the retina. 72 RETINAL DETACHMENT (RD)

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75. EPITHELIAL INGROWTH 5. Epithelial ingrowth R arely conjunctival epithelial cells may invade the ant. Chamber through a defect in the incision. Grows and lines the back of cornea and lead to glaucoma In late it may extend to iris and anterior part of vitreous 75

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77. FIBROUS INGROWTH 6 . Fibrous down growth I nto the anterior Chamber may occur very rarely when the cataract wound apposition is not perfect. May cause secondary glaucoma, phthisis bulbi and disorganisation of anterior segment. 77

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79. AFTER CATARACT 7. After cataract(secondary cataract)  “It is the opacity persists or develop after extracapsular lens extraction. Causes. Residual opaque lens matter may persist as after cataract when it is imprisoned between the remains of the anterior and posterior capsule, Proliferative type of after cataract may develop from the left- out anterior epithelial cells. 79

80. TYPES : Soemmering’s ring –thick ring of after cataract formed behind the iris, enclosed between the two layers of capsule. Elshning’s pearls- vacuolated sub capsular epithelial cells are clustered like soap bubbles along the post. Capsule. Fibrosis-type is thought to be due to fibroblastic metaplasia of epithelial cells, which develop contractile qualities. Treatment YAG- laser capsulotomy: this is the standard treatment for visually significant PCO. Its done by making a small, painless opening in the clouded back part of the lens capsule. This allows light to pass through. 80

81. Fibrotic capsule Elshning’s pearls-  Soemmering ’ ring  81 After cataract- (secondary cataract) (PCO)

82. GLAUCOMA 8. Glaucoma- in- aphakia and pseudophakia Associated with inflammation Neovascular glaucoma may occur, specially in diabetic patient the intraocular pressure may remain so high that blindness may ensue 82

83. IOL-RELATED COMPLICATIONS 1. Complications like cystoid macular oedema, corneal endothelial damage, uveitis and secondary glaucoma are seen more frequently with IOL implantation. UGH syndrome refers to concurrent occurrence of uveitis, glaucoma and hyphaema . Occur with anterior chamber and iris supported IOL. 83

84. 2. Malpositions of IOL . D ecentration, subluxation and dislocation. IOL Decentration if the surgeon does not place the lens properly, if the patient's eye has a weak zonular system for holding the lens in place. if the patient suffers trauma, or internal forces change the dynamics of the eye's lens-containing capsule. Patients with lens decentration experience reduced vision, halos, and/or significant glare. The usual remedy is surgical repositioning of the IOL. 84

85. SUBLUXATIONS SUN-SET SYNDROME: Inferior SUN-RISE SYNDROME: Superior LOST LENS SYNDROME: Complete dislocation of IOL into the vitreous cavity. WINDSHIELD WIPER SYNDROME:- It results when a Very small IOL placed vertically in the sulcus. The superior loop moves to the left and right with the movements of the head. 85

86. HORIZONTAL DECENTRATION 86

87. INFERIOR SUBLUXATION 87

88. SUPERIOR SUBLUXATION 88

89. 3. Pupillary capture of the IOL may occur following postoperative iritis or proliferation of the remains of lens fibres. 89

90. SUMMARY 90

91. REFERENCES EYE WIKI KANSKI CLINICAL OPHTHALMOLOGY 10TH EDITION AAO VOL 11 LENS AND CATARACT THE OPHTHALMOLOGY EXAMINATION REVIEW WONG 3RD EDITION 91

92. THANK YOU 92