Extracapsular cataract extraction

complications of cataract surgery
by J.mghanga

1. EXTRACAPSULAR CATARACT EXTRACTION (ECCE)
Definition
Extracapsular cataract surgery is a category of eye surgery in which
the lens of the eye is removed while the elastic capsule covering it is
left partially intact to allow implantation of an intra ocular lens.
This surgery is contrasted to Intracapsular cataract extraction (ICCE)
an older procedure in which the surgeon removes the whole lens
with its capsule.
Types
1. Conventional ECCE

a) Standard ECCE – here an incision measuring 10mm -12mm is
made on the sclera in which the Lens contents are removed.

b) Small incision cataract surgery (SICS) –here the lens nucleus
is removed through a scleral incision which is smaller than
standard ECCE and measures 5mm -6m

2. Phacoemulsification

In phacoemulsification the lens nucleus is broken inside the
capsule by Ultrasound energy and removed by aspiration
through limbal incision measuring 3mm – 5mm

2. COMPLICATIONS OF EXTRACAPSULAR
CATARACT SURGERY

1. COMPLICATIONS DUE TO LOCAL ANAESTHESIA

a) Retrobulbar Haemorrage – due to Retrobulbar block
 Apply immediate pressure after instilling 2% Pilocarpine and
postpone operation for a week

b) Oculocardiac reflex – manifests as bradycardia or cardiac
arrhythmia
 Give intravenous Atropine

c) Perforation of globe
 Gentle injection with blunt tipped needle and peribulbar
Anaesthesia may be preferred over Retrobulbar

d) Subconjunctival Haemorrage - is a minor complication and
does not require attention

e) Spontaneous dislocation of lens in vitreous has been reported
during vigorous ocular massage after retrobulbar block
 Postpone the operation

3. 2. INTRAOPERATIVE COMPLICATIONS

a) Superior rectus muscle laceration and/ or Haemorrage
may occur while applying bridle suture
 No treatment required
b) Excessive bleeding may be encountered during
preparation of conjunctival flap or during incision into
anterior chamber
 Cauterize bleeding vessels
c) Button holing of anterior wall of tunnel can occur due to
superficial dissection of the scleral flap
d) Premature entry can occur due to deep dissection and will
result in non-creation of self-sealing corneal valve
 Stop dissection into that area and start a lesser
depth at the other end of tunnel
e) Scleral disinsertion can occur due to very deep groove
incision –this leaves complete separation of inferior sclera
from sclera superior to the incision
 Scleral disinsertion to be managed by radial sutures
f) Descemet’s detachment - Injury to cornea, iris and lens
may occur when anterior chamber is entered by a sharp
object such as keratome
 Gentle handling and proper hypotony reduces such
incidences. Maintain anterior chamber with
viscoelastic
g) Iridodialysis and iris injury may occur during intra ocular
manipulation

4. h) Complications related to anterior capsulorhexis – The
continuous curvilinear capsulorhexis (CCC) is the most
preferred in SICS and Phaco. The following can occur -:
 Escaping Capsulorhexis i.e. capsulorhexis moving
peripherally and may extend to equator or
posterior capsule
 Small Capsulorhexis – predisposes to posterior
capsule tear and nuclear drop during
hydrodisection and also zonula dehiscence
 Very large capsulorhexis – may cause problems
with in bag placement of IOL
 Eccentric capsulorhexis – can lead to IOL
decentration at a later stage

i) Posterior capsular tear/rapture (PCR) – it’s a dreaded
complication and can lead to nuclear drop into vitreous.
Occurs during –
 Forceful hydrodisection
 Direct injury with instruments like Sinskey’s hook
and chopper or phaco tip
 Cortex aspiration.

j) Zonular dehiscence – occurs during nucleus prolapse into
anterior chamber in manual SICS

k) Vitreous loss – occurs after PCR

l) Raised intra ocular pressure – can be controlled by -:

 Decrease Vitreous volume - by preoperative use of
hyperosmotic agents (20% mannitol or oral
Glycerol)

5.  Decrease Aqueous Volume – preoperative
acetazolamide 500mg PO and adequate ocular
massage to be done digitally after injecting local
anaesthesia.
 Decrease orbital volume – by ocular massage and
orbital compression by use of super pinky / Honan’s
ball or 30mm of Hg by pediatric
sphygmomanometer
 Good akinesia and anaesthesia decreases pressure
from eye muscle
 Minimizing external pressure on eyeball by using
wire speculum

m) Nucleus drop in vitreous cavity – occurs due to large
and sudden PCR, mostly in phacoemulsification and less
frequent in manual SICS
 Management is anterior vitrectomy and cortical
clean up

n) Loss of lens fragments posteriorly into the vitreous cavity
occurs after PCR or zonular dehiscence during phaco. This
will lead to glaucoma, chronic uveitis and Retinal
detachment.
 Management – pars plana vitrectomy and removal
of nuclear fragment

6. 3. POST OPERATIVE COMPLICATIONS

I) EARLY POST OPERATIVE COMPLICATIONS

a) Hyphaema – collection of blood in anterior chamber may
occur from conjunctiva or scleral vessels due to minor
ocular trauma
 Treatment – most Hyphaema absorb
spontaneously
 Early Hyphaema (immediate post operation period)
- Caused by incision on iris
- Its normally mild and resolves spontaneously
- If mixed blood and viscoelastic the resolution takes
longer
 Late Hyphaema (months years after surgery)
- Caused by wound vascularization / erosion of
vascular tissues by lens implant

b) Iris prolapse – common in ICCE and conventional ECCE due
to inadequate suturing of the incision (not in Phaco and
SICS)
 Management – a prolapse of less than 24hrs can be
reposited and sutured.
Large prolapse of long duration needs excision and
wound suture
c) Flat anterior chamber – shallow or flat anterior chamber
Can be due to –
- Wound leak
- Choroidal detachment or hemorrhage
- Pupillary block
- Ciliary block

7. II) LATE POSTOPERATIVE COMPLICATION
 Cystoid macular oedema
 Delayed chronic postoperative endopthalmitis
 Pseudophakic bullous keratopathy
 Retinal detachment
 Epithelial ingrowth
 Fibrous down growth
 Glaucoma
 After cataract

a) Delayed Chronic Post-Operative Endopthalmitis -Occurs
when an organism of low virulence get trapped within the
capsular bag.
Starts between 4 weeks to years (mean 9 months) post
operatively
Signs –
 Late onset
 Persistent, low grade uveitis
 Low virulence
 White opaque in posterior capsule

b) Pseudophakic bullous keratopathy (PBK) - Post-operative
corneal edema produced by surgical or chemical insult to a
healthy or compromised corneal epithelium

c) Retinal detachment (RD)- Rare but more common in my
myopics after intraoperative operations

8. d) Epithelial ingrowth - Rarely conjunctival epithelial cells
may invade anterior chamber through a defect in the
anterior chamber

e) Fibrous down growth in the anterior chamber – occurs
rarely when the cataract wound apposition is not perfect.
May cause secondary glaucoma, phthisis bulbi

f) After cataract (secondary cataract) PCO –it’s the opacity
that persists or develop after ECCE

Types –
 Dense membranous – presents as a thickened
posterior capsule
 Soemmerings’s ring – thick ring of after cataract
behind the iris enclosed behind the two layers of the
capsule
 Elshning’s pearls

9. INTRA OCULAR LENS COMPLICATIONS