iol related complications in cataract surgery

An intraocular lens is a lens implanted in the eye usually as part of a treatment for cataracts or for correcting other vision problems such as short sightedness and long sightedness; a form of refrac…

1. IOL RELATED COMPLICATIONS -by R.Anitha Bai

2. Outline: Early complications: UGH syndrome Toxic Anterior segment syndrome Pseudophakic Bullous keratopathy Pupillary block glaucoma Lens dislocation

3. Late post operativecomplications: 1.opacification of posterior capsule 2.cystoid macular edema 3.persistent uveitis 4.referactive errors 5.dysphotopsiae

4. Posterior capsule opacification: PCO also called “ after” or “ secondary cataract” is the opacity which follows extracapsular extraction of lens In this , posterior and part of Anterior capsule are left Insitu

5. In other cases, especially when cataract was not mature, some Soft,clear cortex sticks to capsule This becomes partially absorbed by the action of the aqueous humour but often becomes shut off by adhesion of the remains of the anterior to the posterior capsule

6. In such cases, cubical cells which line anterior Capsule also persists ,they continue to fulfill their function of forming new lens fibres, although those formed under these abnormal conditions are abortive and opaque. Sometimes these fibres,enclosed between the two layers of capsule ,form a dense ring behind the iris “RING OF SOMMERRING” it may cause subsequent trouble by becoming dislocated into anterior chamber

7. At other times, subcapsular cells proliferate and instead of forming lens fibres,develop into large Balloon like cells which sometimes fill the pupillary aperture- Elsching pearls If these remnants lie in the pupillary area,dense membrane is formed so that vision is impaired If the previous operation has been followed by iritis ,exudates also adhere to lens remnants and organize, thus contributing a fibrous membrane

8. Anterior capsular opacification

9. Simmering ring

10. Rate of posterior capsule opacification following ECCE and phacoemulsification varies with age of patient, surgeon ,surgical technique , type of intraocular lens used and duration after surgery Higher Rates: Younger patients PMMA lenses Hydrophilic acrylic Lenses

11. Lower rates: Older patients Hydrophobic Acrylic lenses New generation silicon lenses with square edges

12. Treatment: After cataract, if thin ,can be cleared centrally by “ YAG LASER CAPSULOTOLOMY ” In children, they are very thick and may require membranectomy ,removed by using a vitreous cutter

13. Tough and nonpliable membranes have first to be cut into smaller pieces before they can be aspirated into cutting port This is done with an MVR blade or by using vitreous scissors

14. UVEITIS GLAUCOMA HYPHEMA SYNDROME: Also known as “ Ellingson syndrome”. Characterised by chronic inflammation,cystoid macular edema ,secondary iris neovascularization,recurrent hyphemas,and glaucomatous optic neuropathy leading to loss of vision

15. This can occur in any age group with an intraocular lens most commonly occurs in elderly adults Evidence of UGH occurring with in 6 months of intraocular lens implant is consistenly higher in anterior chamber lenses than in iris plane lenses than in posterior chamber lenses Single- piece acrylic IOLs placed within sulcus tend to have high UGH complication rate

16. Symptoms: Patients present with intermittent decreased or blurred vision Intermittent White out of vision Photo phobia Redness Ocular pain Patients ocular discomfort may be out of proportion to ocular findings

17. Signs: microhyphema or hyphema Anterior chamber cells Flare or hypopyon Iris lens contact

18. Iris transillumination defects Dislocated or malpostioned IOL Misplaced haptic Vitreous hemorrhage if the posterior capsule is not intact Increased IOP Gonioscopy performed to look for blood with in angle Increased pigmentation of trabecular meshwork Signs of mechanical erosion

19. Diagnostic procedures: Ultrasound biomicroscopy is often used in the diagnosis of UGH syndrome to aid in visualization of malpostioned IOLs and their Contact with uveal tissue To confirm position of haptics and optics and their relationships to surrounding ocular structures

20. Management: IOL repositioning ,explantation , exchange successfully resolve recurrent episodes of hyphema or uveitis from UGH syndrome UVEITIS: topical corticosteroids for control of anterior inflammation

21. Intraocular hypertension: IOP lowering topical and systemic medications 1.Prostaglandin analogies 2.beta - adrenergic antagonists 3.Alpha- adrenergic agonist 4.carbobic anhydrase inhibitors Parasympathomimetic agents: “Pilocarpine” -avoided due to its miotic effects

22. Hyphema: limited activity,head elevation,cycloplegics for ciliary spasm or photo phobia Topical corticosteroids for associated inflammation

23. IOL DISLOCATION AND DECENTERATION: Dislocated iol may be either inside capsule or outside the capsule

24. Causes of Dislocation: INTRACAPSULAR: M/C cause zonular degradation associated with Pseudoexfoliation Syndrome Trauma Previous vitreoretinal surgery Capsular contraction Retinitis pigmentosa

25. High myopia Uveitis Congenital conditions that affect zonular integrity

26. EXTRA CAPSULAR: M/C cause sulcus placement of an inadequately sized iol May also occur in setting of: 1.decentered or oversized capsulorrhexis 2.localized zonular defects 3.capsular defects 4.IOL haptic damage

27. Decentration will cause : 1.glare 2.reflections 3.multiple images Decentration of any PCIOL -1. pupillary capture 2.any component of UGH syndrome due to contact with uveal tissue

28. Fancy names attached to various complications: SUNSET SYNDROME: inferoir subluxation of lens SUN RISE SYNDROME : Superior subluxation of lens LOST LENS SYNDROME : refers to complete dislocation of IOL into vitreous cavity

29. WINDSHIELD WIPER SYNDROME : It results when Very small Iol is placed vertically in sulcus

30. IOL GLARE,DYSPHOTOPSIA : Glare can result - diameter of IOL optic is smaller than diameter of scotopic pupil Optics with square edge design and multifocal IOLs are more likely to produce glare and halos

31. Treatment of minor decentration- - Miotics to constrict pupil over IOL optic - Cycloplegics to reduce iris chafing by IOL optic in pigment dispersion or recurrent hyphema Severe cases of IOL decentration- Iol repositioning Stabilization with sutures Exchange

32. If dislocation is complete- pars Plana vitrectomy to relieve lens and elevate it into anterior segment,then will be suture fixated to iris or sclera through anterior approach Scleral fixated IOL: Complications: Vitreous or suprachoroidal haemorrhage Lens tilting

33. CME Retinal tears or detachment Suture erosion Infection IRIS SUPPORTED LENS: becomes dislocated or associated with corneal edema or UGH syndrome, it should be surgically exchanged

34. Pupillary capture: Post operative pupillary capture of iol optic: | due to | Synechiae between iris and underlying posterior capsule ,

35. Symptoms: glare Photo phobia Chronic uveitis Unintended myopia Monocular Diplopia

36. Treatment: Patient is asymptomatic, it can be left untreated Symptomatic requires surgical repositioning of lens Acute pupillary capture: Pharmologic manipulation of pupil with Patient in supine position If conservative management fails, surgical intervention may be required in order to free iris,lyse synechiae,reposition the lens

37. Pseudophakic Bullous keratopathy: Defined as post operative condition that can occur as a complication of cataract extraction surgery and IOL placement Insult to endothelium and long term cell damage May manifest in immediate post operative peroid or symptoms may not present for many years

38. PSEUDOPHAKIC BULLOUS KERATOPATHY: It occurs mainlydue to ACIOL,IRIS FIXATED LENS Clinical features: Decreased vision initially painless Glare and halo Pain- when epithelial and sub epithelial bullae develop and rupture resulting in severe pain as underlying nerve endings are exposed

39. Erosive symptoms- present as discomfort,photophobia,foreign body sensation,watering When scarring occurs: Cornea is opaque and compact Pain is decreased Vision Reduced to hand motion Corneal Sensation is decrease or absent Peripheral corneal vascularization may occur

40. Pathophysiology: Irreversible corneal edema due to endothelial damage. | During IOL insertion | Endothelial damage | Endothelial Pump failure | Corneal Edema,epithelial bullae

41. Prevention: Minimal instrumentation Careful IOL Implantation Protect Endothelium by viscoelastics Maintain AC prevent DM detachment Treat post operative inflammation

42. Management: MEDICAL : 1.Hypertonic 5%salin e drops 2.Anti -inflammatory and IOP lowering agent 3.Bandage contact lenses SURGICAL: 1.Penetrating keratoplasty 2.Endothelial keratoplasty

43. 1.Hypertonic agents: Sodium chloride 2% and 5% solution and ointment It creates a hypertonic tear film,thereby drawing water out of cornea Side effects: Burning or irritation Allergic reactions

44. 2.Anti inflammatory and IOP lowering agents: Ketorolac 0.4% S/E : burning,stinging,itching,headache Iop lowering agents: Brimonidine - 0.2% BD Timolol - 0.5% BD

45. 3.Ruptured epithelial bullae: Antibiotic ointment, cycloplegics Recurrent Ruptured bullae: anterior stromal Micropuncture or PTK 4.Bandage contact lens : Useful as an adjunct to medical treatment for temporary relief of corneal pain and discomfort To shield cornea and epithelium from eyelid

46. They must not be too tight as this may worsen the edema especially when used at night They can increase risk of infections,therefore antibiotics are prescribed for corneal edema patients using bandage lenses A broad spectrum antibiotic such as polymyxin B e/d or ointment 2-4 times /day for 7-10 days is recommended

47. 5.conjucttival flap or AMG : Indicated when Vision is low and pain is intractable 6.corneal transplantation: Indicated when vision Is decreased significantly by Corneal edema or when pain becomes intractable

48. DYSPHOTOPSIA: POSITIVE DYSPHOTOPSIA - described as glare,streaks,flashes or halos of light in midperiphery Common - truncated square edged iols

49. NEGATIVE DYSPHOTOPSIA: Described as an arcuate dark or dim Cresent- shaped region,usually In temporal field Occurs - setting of PCIOL centred in capsular bag with anterior capsule edge overlapping the lens optic Common- smaller,square edged optic designs

50. Treatment : Initially observation is advised Surgery: For patients with prolonged symptoms and compromised vision Repositioning of optic anterior to capsulorhexis by reverse optic capture through capsulorhexis or sulcus fixation of appropriate PCIOL with larger optic may be successful

51. Implantation of piggy back iol or anterior capsulotomy is successful

52. CYSTOID MACULAR EDEMA: Irvin Gass syndrome- m/c cause of post operative decreased vision CME- associated with intraocular inflammation May be mediated through release of prostaglandins and leukotrienes

53. Surgical and Post -operative risk factors: Posterior capsule rupture Vitreous loss,iris prolapse Prolonged surgical time Improper IOL postioning Retained lens fragments Poorly controlled postoperative inflammation

54. Medical treatment : Inflammatory drugs-1.topical corticosteroids 2.NSAIDS If topical medications fail,-1.Sub- tenons steroid injection 2.intravitreal injection of corticosteroids

55. Intravitreal vascular endothelial growth factor - used when does not responding to Conventional treatment If IOL - malpostioned and contributing to chronic uveitis ,repositioning or exchange may be useful

56. Complications with ACIOLs: Intraoperative: 1.Hyphema 2.vitreous Complications 3.pupil deformations Early post-operative: 1.Pupillary block 2.striate keratopathy 3.Uveal reactions 4.Endoophthalmitis

57. Late- post operative: 1.cystoid Macular edema 2.retinal detachment 3.secondary glaucoma 4.bullous keratitis 5.Iol dislocation 6.late uveitis

58. PCIOL COMPLICATIONS : Intraoperative : 1.Hyphema 2.corneal lesions Early post operative: 1.straite keratitis 2.mild uveitis

59. Late post - operative : 1.bullous keratitis 2.eccentric displacement of IOL 3.Sunset syndrome 4.Erosions and defective iris transparency 5.late uveitis 6.Retinal detachment 7.cystoid Macular edema 8.opacification of posterior capsule

60. Iris supported lens: 1.Transillumination Defects 2.chronic inflammation 3.CME 4.Distortion on pupillary dilatation 5.Endothelial decompensation

61. Capsular bag syndrome Caused by intracapsular accumulation of liquefied material posterior to nucleus or IOL Early post Operative CBS- when residual OVD becomes trapped within capsular bag b/w posterior capsule and posterior surface of IOL this causes a myopic shift in Refractive error from anterior displacement of lens optic

62. If CBS -UNTREATED: lead to 1. posterior synechiae 2.secondary glaucoma Treatment- ND yag laser anterior capsulotomy

63. Unexpected Refractive errors: Results due to preoperative error in measurement of axial length or in keratometry Readings Choosing correct IOL power is Difficult in: 1.high hyperopia 2.High myopia 3.prior Vitrectomy 4.patients undergoing simultaneous penetrating keratoplasty

64. 5.patients with silicone oil in vitreous cavity 6.patients who have had prior refractive surgery Unexpected post operative Refractive errors: D/t inversion of an angulated IOL or placement of lens in sulcus when it was calculated for placement in capsular bag If Visual acuity- less than expected early in postoperative course and is confirmed by refraction,incorrect lens power may be suspected

65. If Post operative Refractive error- produces symptomatic ametropia,anisometropia,or Patient dissatisfaction ,then surgeon can consider: medical Treatment: Refraction for glasses or contact lens wear Surgical treatment: Keratorefractive surgery - if Error < 2D , no corneal pathology, no glare/halos/contrast sensitivity complaints

66. IOL ROTATION- cylinder error due to improper placement of toric IOL at time of surgery ,< 1-2 months from initial surgery Piggy back IOL- hyperopia surprise,zonuloplasty or posterior capsular tears IOL EXCHANGE- Error > 2D, Known source of error

67. Postoperative uveitis: After cataract extraction, all eyes exhibit some degree of intraocular inflammation With uncomplicated cataract Surgery and use of post operative topical corticosteroids, NSAIDS,most eyes are typically free of inflammation by 3-4 weeks post-operatively

68. Complicated cases requiring manipulation of intraocular tissues,involving vitreous loss or prolapse,or requiring sulcus fixation of an IOL may have prolonged recovery Low grade inflammation lasting more than 4 weeks raises possibility of chronic infection,retained lens fragments,IOL malpostion

69. Bacterial pathogens: 1.Propionibacterium access 2.Staphylococcus epidermis Patients with pre-existing uveitis may have excessive post-operative inflammation but Generally do well with SICS with IOL implantation in capsular bag

70. Surgeons- acrylic Iol material over silicone in patients with pre-existing uveitis to reduce risk of inflammation Management: Focuses on causes Surgery- correction of mechanical issues with IOL implantation, vitreous incarceration,retained lens fragments

71. Toxic Anterior segment syndrome: Acute sterile postoperative inflammation Symptoms and signs: Mimic endopthalimitis Photophobia Reduction in visual acuity Corneal edema Marked anterior chamber reaction Occasionally hypopyon

72. TASS - 12 to 48 after surgery Include diffuse limbus- to -limbus corneal edema, anterior chamber fibrinous exudates Dilated, irregular, non-reactive pupil elevated IOP Changes Limited to anterior chamber Pain is much milder than infection

73. Prevention of TASS: use preservative and bisulfite -free medications Properly mix and dose intracameral antibiotics, anesthetics,or other medications Flush OVD’S from ophthalmic instruments Avoid use of enzymes and detergents in cleaning the instruments Properly clean and maintain autoclave steam sterilizer systems

74. Other causes : Surgical glove residue or talc on instruments or IOL use of denatured OVD substitution of sterile Water for balanced salt solution Intra-ocular use of inappropriate irrigating solutions,antibiotics

75. Treatment: Intensive topical corticosteroids Systemic corticosteroids Frequent monitoring of IOP Reassess for signs of bacterial infection

76. References: Parsons disease of eye American academy of ophthalmology

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