cataract surgery complications
TRANSCRIPT
COMPLICATIONS OF
CATARACT SURGEY
COMPLICATIONS OF
CATARACT SURGEY
DR. YOUSAF JAMALOPHTHALMOLOGY DEPARTMENT
HMC
(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
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Usual classification
Complications of anesthesia General anesthesia Regional / Local anesthesia
Intraoperative Early postoperative Late postoperative
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ANESTHESIA COMPLICATIONS
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GENERAL ANESTHESIA
Respiratory complications Laryngoscope & intubation Respiratory obstruction & spasm (isoflurane) Hypoxemia (N2O) Hypercapnia / Hypocapnia Hypoventilation Aspiration pneumonia Chest infections
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Cardiovascular complications Hypertension Hypotension Cardiac arrhythmias Death (halothane)
Neurological complications Headache Delayed recovery Perioperative neuropathy Hallucinations & unpleasant dreams (ketamine)
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Postoperative nausea & vomiting (propofol, etomidate)
Temperature changes Hypothermia Hyperthermia (atropine, halothane)
Allergic drug reactions Itching Anaphylaxis
Hypotension, arrhythmia, tachycardia Bronchospasm, cough, dyspnea
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Complications of positioning Air embolism Nerve palsies
Brachial plexus, Radial nerve, Ulnar nerve Skin necrosis
Miscellaneous Renal dysfunction (enflurane) Muscle pain (succinylcholine)
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REGIONAL ANESTHESIA
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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.
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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.
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Complications of Cataract surgery 13
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
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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.
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S/CONJ & S/TENON ANESTHESIA
Common Pain on injection (15-
33%) Chemosis (6-100%) s/conj hemorrhage (7-
100%)
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
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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
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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
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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
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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
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Signs Sudden deepening of AC Pupillary dilatation Visible rupture of PC Visible vitreous
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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
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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
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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
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RISK FACTORS
Ocular factors Glaucoma High myopia Posterior capsule
rupture Chronic ocular
inflammation
Systemic factors HTN Chronic lung disease Advanced age Obesity Anticoagulation
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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
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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
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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
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Management Careful incision architecture Viscodilatation Microincisional surgery Low-flow settings Iris retractors Pupil expansion rings
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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
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Complications of Cataract surgery 32
Cause Irrigating solutions Used cannula Instruments rusts Disposable gloves material
Management Intraoperative measures Topical + systemic steroids
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CORNEAL EDEMA
Presents…immediate postop period Causes
Mechanical trauma Prolonged surgery Inflammation Elevated IOP Nuclear fragments
Results in acute endothelial dysfunction
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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
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Complications of Cataract surgery 36
Management Corneal edema
Topical hyper osmotic agents Topical steroids Bandage contact lens
Bullous keratopathy Penetrating keratoplasty Endothelial keratoplasty Gunderson conj flap AMT
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Complications of Cataract surgery 38
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
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Systemic immunosuppression for collagen disease Bandage contact lenses Tarsorrhaphy Punctal occlusion AMT Lamellar KP Penetrating KP
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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
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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
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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
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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
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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
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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
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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
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Treatment Nd:YAG capsulotomy
Indications BCVA decreased bcz of hazy PC Hazy PC causing inadequate fundus view Monocular Diplopia or glare
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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)
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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
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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
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MACULAR INFARCTION
Very rare Clinically similar to CRAO Cause
s/conj injection of aminoglicosides for Endopthalmitis prophylaxis
Gentamicin…greatest risk Amikacin & tobramycin also
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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
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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
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Complications of Cataract surgery 56
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
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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.
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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
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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
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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
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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
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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
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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
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Complications of Cataract surgery 66
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
PPV
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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
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Management Vitreous + aqueous samples Antibiotics
I/vit Topical steroids Removal of capsular bag, IOL, residual cortex PPV
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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
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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
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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
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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
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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
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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
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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
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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
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7. Early postop complication of cataract surgery are all of following except
a. Iris prolapse
b. Hyphema
c. Striate keratopathy
d. CME
Ans. d
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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
above
Ans. 4
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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
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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
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