cataract surgery complications

COMPLICATIONS OF

CATARACT SURGEY

COMPLICATIONS OF

CATARACT SURGEY

DR. YOUSAF JAMALOPHTHALMOLOGY DEPARTMENT

(10-07-2010)

Complications of Cataract surgery 2

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

Intraoperative Early postoperative Late postoperative

ANESTHESIA COMPLICATIONS

GENERAL ANESTHESIA

Respiratory complications Laryngoscope & intubation Respiratory obstruction & spasm (isoflurane) Hypoxemia (N2O) Hypercapnia / Hypocapnia Hypoventilation Aspiration pneumonia Chest infections

Cardiovascular complications Hypertension Hypotension Cardiac arrhythmias Death (halothane)

Neurological complications 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

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)

REGIONAL ANESTHESIA

PERIBULBAR / RETROBULBAR ANESTHESIA

Lids trauma (ecchymosis) Ptosis s/conj hemorrhage Muscles damage Globe penetration & its related complications Retrobulbar hemorrhage 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 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.

BRAINSTEM ANESTHESIA

Life threatening 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…

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.

S/CONJ & S/TENON ANESTHESIA

Common Pain on injection (15-

33%) Chemosis (6-100%) s/conj hemorrhage (7-

Rare Globe perforation Retrobulbar hemorrhage Hyphema Muscle trauma Diplopia Spread to CNS Retinal dysfunction Orbital cellulitis Chronic dilated pupils

Indian j ophthalmol 2006;54:77-84

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

Posterior capsule rupture

Cyclodialysis Suprachoroidal

effusion & hemorrhage

EARLY POSTOPERATIVE COMPLICATIONS

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

IOL related Decentered Dislocated Tilted Pupillary capture Capsular block syndrome

Acute Endophthalmitis

LATE POSTOPERATIVE COMPLICATIONS

Wound related Astigmatism

Corneal Bullous keratopathy Corneal decompensation Corneal melting Brown-McLean

syndrome Epithelial down growth

IOP related Glaucoma

Anterior chamber Chronic uveitis 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

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 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

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

Increased ocular pressure limits the damage Pain & agitation of pt suggests hemorrhage Source … long or short posterior Ciliary artery Expulsive hemorrhage…when SCH results in

expulsion of intraocular contents

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 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 Drainage thru sclerotomy after a week Refer to VR surgeon for vitrectomy

INTRAOPERATIVE FLOPPY IRIS SYNDROME (IFIS)

Trio of Iris billowing Progressive Intraoperative miosis Iris prolapse

Cause…Tamsulosin or other 1-blockers for BPH Unopposed action of sphincters

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

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 Raised IOP

Cause Irrigating solutions Used cannula Instruments rusts Disposable gloves material

Management Intraoperative measures Topical + systemic steroids

CORNEAL EDEMA

Presents…immediate postop period Causes

Mechanical trauma 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 DV Irritation, pain FB sensation Epiphora Infectious keratitis

Management Corneal edema

Topical hyper osmotic agents Topical steroids Bandage contact lens

Bullous keratopathy Penetrating keratoplasty Endothelial keratoplasty Gunderson conj flap AMT

KERATOLYSIS

Frequent association…tear film abnormality KCS Sjogren syndrome 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 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

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 Raised IOP Hyphema…often Vitreous wick

Management Atropine Topical steroids Topical NSAIDs CAI…topical or systemic Topical -blocker & 2-agonist

Surgery…if medical Tx fails Repositioning, replacement or removal of IOL YAG vitreolysis

POSTERIOR CAPSULAR OPACIFICATION

Overall, the most common complication Cause…viable LECs Types

Sommering rings Elsching pearls Capsular fibrosis

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

Anterior LECs proliferation

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

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

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 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 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

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 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

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

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… 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 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 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 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

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

Management Vitreous + aqueous samples Antibiotics

I/vit, periocular, topical, oral Steroids

Oral…when fungal infection is excluded Topical…for ant uveitis Periocular…if systemic steroids contraindicated

CHRONIC ENDOPHTHALMITIS

Presents…weeks to months to years (9 months) Low virulence organisms

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

Management Vitreous + aqueous samples 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 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 Surgeon must be aware of complications & their

proper management Proper anesthesia techniques, sterilization &

patient preparation…mandatory

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

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

3. Which of following preoperative measures has proven most effective in reducing risk of Endophthalmitis

a. Administering oral amoxicillin 3 days before surgeryb. Topical antibiotics for 2 weeks following surgeryc. Decreasing duration of surgeryd. Administering topical 5% Povidone-iodine solution at

time of surgerye. Injecting Vancomycin into the I/A solution

Ans. d

4. Appropriate management of retrobulbar hemorrhage includes all of the following except

a. Proceeding with surgery if red reflex is maintainedb. Promptly applying firm pressure on the globec. Observing the optic nerve & fundus with an indirect

ophthalmoscoped. Administering CAI or mannitol to reduce IOPe. Performing lateral canthotomy if proptosis, increased

IOP, and tight eyelids persist after other measures have been undertaken to relieve orbital swelling

Ans. a

5. Systemic use of 1-antagonists for treatment of BPH may cause IFIS by which of following mechanisms

a. Atrophy of iris sphinctersb. Competitive binding to postsynaptic nerve endings of iris

dilatorc. Loss of iris stromad. Atrophy of posterior pigment epitheliume. Metabolic alkalosis of aqueous

Ans. b

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

a. Iris prolapse

b. Hyphema

c. Striate keratopathy

d. CME

Ans. d

8. Vitreous loss leads to…a. Up drawn pupilb. Astigmatism c. Uveitisd. CME1. a+c, 2. a+b+c, 3. a+b+d, 4. a+c+d, 5. none of

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

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 IOPb. Chemical toxicityc. Epithelial down growthd. Surgical trauma

Ans. c

Journal club Dr Manzoor

Lecture Dr Kabir (Phaco)

cataract surgery complications

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