Some patients may develop anxiety, on the eve of operation due to fear and apprehension of operation.

Anxiolytic drugs such as diazepam 2 to 5mg at bed time usually alleviate such symptoms.

Nowadays preferred drug is Alprazolam

A few patients may develop nausea and gastritis due to preoperative medicines such as acetazolamide and/or glycerol.

Oral antacids and omission of further dose of such medicines usually relieve the symptoms.

It may occur in some patients due to preoperative topical antibiotic drops.

Postponing the operation for 2 days along with withdrawal of such drugs is required.

kellogg.umich.edu sciencephoto.com

It may develop due to inadvertent injury during Schiotz tonometry.

Patching with antibiotic ointment for a day and postponement of operation for 2 days is required.

disease-picture.com Corneal abrasion seen with fluorescein stain.bestpractice.bmj.com

Retrobulbar haemorrhage may occur due to retrobulbar block. Immediate pressure bandage after instilling one drop of 2% pilocarpine and postponement of operation for a week is advised.

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.

Perforation of globe may also occur sometimes. To prevent such catastrophy, gentle injection with blunt-tipped needle is recommended. Further, peribulbar anaesthesia may be preferred over retrobulbar block.

Subconjunctival haemorrhage is a minor complication observed frequently, and does not need much attention.

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Spontaneous dislocation of lens in vitreous has also been reported (in patients with weak and 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

Microspherophakia and spontaneous inferior dislocation of a lens in a ...emedicine.medscape.com

Subluxated lens.eyecareamerica.org

Superior rectus muscle laceration haematoma, may occur while applying the bridle suture.

Usually no treatment is required

During the preparation of conjunctival flap or during incision into the anterior chamber.

Treatment: Cauterization of bleeding vessels.

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.

ii) In manual SICS and phacoemulsification following complications may occur while making

the self-sealing tunnel incision.1) Button holing of anterior wall of tunnel can occur

because of superficial dissection of the scleral flap. 2) As a remedy, abandonthis dissection and re- enter

at a deeper plane from the other side of the external incision.

3) Premature entry into the anterior chamber due to 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.

4) 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.

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.

(tear of iris from root). May occur inadvertently during intraocular

manipulation.

Continuous curvilinear capsulorhexis (CCC) is the preferred technique for opening the anterior capsule for SICS and phacoemulsification. Following complications may occur:

1) Escaping capsulorhexis i.e., capsulorhexis moves peripherally and may extend to the equator or posterior capsule.

2) 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.

3) Very large capsulorhexis may cause problems for in the bag placement of IOL.

4) Eccentric capsulorhexis can lead to IOL decentration at a later stage.

capsulorhexis surgery-guidance.com

May occur in all techniques of ECCE but is especially common during nucleus prolapse into the anterior chamber in manual SICS.

ineedshoes.co.uk

It is the most serious complication which may occur following accidental rupture of posterior capsule during any technique of ECCE.

webeye.ophth.uiowa.edu

1.To decrease vitreous volume: Preoperative use of hyperosmotic agents ex. 20 percent mannitol or oral glycerol.

2. To decrease aqueous volume: Preoperatively acetazolamide 500 mg orally & ocular massage should be carried out digitally after injecting local anaesthesia.

3. 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.

4. Better ocular akinesia and anaesthesia: decrease the chances of pressure from eye muscle.

5. Minimising the external pressure on eyeball by not using eye speculum, reducing pull on bridle suture and overall gentle handling during surgery.

6. Use of Flieringa ring to prevent collapse of sclera especially in myopic patients decreases the incidence of vitreous loss.

7. 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.

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

Posterior loss of lens fragments into the vitreous cavity may occur after PCR or zonular dehiscence during phacoemulsification. It is potentially serious because it may result in glaucoma, chronic uveitis, chronic CME and even retinal detachment.

The case should be managed by vitreoretinal surgeon by performing pars plana vitrectomy and removal of nuclear fragments.

It is one of the most dramatic and serious complications of cataract surgery.

Usually occurs in hypertensives and patients with arteriosclerotic changes.

May occur during operation or during immediate postoperative period.

webeye.ophth.uiowa.edu ophthalmicphotography.info

Its incidence was high in ICCE and conventional ECCE but has decreased markedly with valvular incision of manual SICS and phacoemulsification technique.

It is characterised by spontaneous gaping of the wound followed by expulsion of the lens, vitreous, retina, uvea and 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.

Collection of blood in the anterior chamber

May occur in conjunctival or scleral vessels

Symptoms1.Bleeding in front portion of the eye2.Vision abnormalities3.Eye pain 4.Photophobia

Most hyphaemas absorb spontaneously thus need no treatment

Large hyphaemas and those associated with rise in IOP

1. IOP should be lowered by acetazolamide and hyperosmotic agents

2. If the blood does not get absorbed in a weeks time then paracentesis should be done to drain the blood

http://en.wikipedia.org/wiki

It is usually caused by inadequate suturing of the incision after ICCE and conventional ECCE

Occurs during first or second postoperative day

Less common with manual SICS and phacoemulsification technique

Small prolapse1.Reposited back and wound sutured

Large prolapse1.Abscission and suturing of wound

webeye.ophth.uiowa.edu

Characterised by mild corneal oedema with Descemets folds

Observed during immediate postoperative period

Occurs due to endothelial damage during surgery

Mild keratopathy1.Disappears spontaneously within a week

Moderate to severe keratopathy1.Hypertonic saline drops(5% sodium

chloride)2.Steroids

http://webeye.ophth.uiowa.edu/eyeforum/atlas/thumbnails/band6-371X340.jpg

Rare complication

Due to improved wound closure

3 types1.With wound leak2.Ciliochoroidal detachment3.Pupil block due to vitreous bulge

Flat anterior chamber with wound leak

Associated with hypotony

Diagnosed by Seidels test

Most cases wound leak is cured within 4 days 1.Pressure bandage2.Oral acetazolamide

If the condition persists 1. Injection of air in the anterior chamber2.Resuturing of the leaking wound

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Ciliochoroidal detachment

Presents as a convex brownish mass in the involved quadrant with shallow anterior chamber

Most cases cured within 4 days1.Pressure bandage2.Oral acetazolamide

If condition persists1.Suprachoroidal drainage2. Injection of air in the anterior chamber

http://www.djo.harvard.edu/files/2620_317.jpg

Pupil block due to vitreous bulge

After ICCE

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

Initially1.Mydriatic2.Hyperosmotic agents3.Acetazolamide

If not relieved1.Laser or surgical peripheral iridectomy

Due to1. Instrumental trauma2.Undue handling of uveal tissue3.Reaction to residual cortex4.Chemical reaction induced by viscoelastics,

pilocarpine

‣ Aggressive use of topical steroids Dexamethasone eye drops 4 to 6 times a day Betamethasone eye ointment at bed time

‣ Cycloplegics 1% atropine sulfate eye ointment or drops instilled 2 to 3 times

a day

‣ NSAIDs Aspirin Phenylbutazone

‣ Rarely systemic steroids (cases with fibrinous reaction)

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http://www.pfofflaserandeye.com/The%20Informed%20Patient/Dangerous%20Symptoms/Endophthalmitis.gif

Late Late complication of complication of cataract surgerycataract surgery

Cystoid macular oedemaEndophthalmitisPseduphakic bullous keratopathyRetinal detachmentEpithelial ingrowthFibrous downgrowthGlaucomaToxic Anterior Segment SyndromePosterior capsule opacifictionPhimosis

Swelling or edema of the central part of the retina, called macula(henle’s layer)

Does not produce any visual problem On funduscopy it gives honeycomb appearance

It is associated with vitreous incarceration in wound and iritis

Infection of intaocular tissueLow virulence organism trapped in the capsular bag

may be due to penetrating trauma

Swelling or edema of the corneaassociated with cloudy visionmay be transient or permanentDisplacement or dislocation of the intraocular lens implant may rarely occur

Common after ICCE Higher in aphakic patient Risk factor :- vitreous loss myopia lactic degeneration of retina

Cell may invade the anterior chamber through a defect in incision

Grows and lines the back of cornea and lead to glaucoma

In late it may extend to iris and anterior part of vitreous

Cause secondary glaucoma, disorganisationof anterior segment and phthisis bulbi

Associated with inflammationNeovascular glaucoma may occur, specially in diabetic patient

the intraocular pressure may remain so high that blindness may ensue

Is a non-infectious inflammatory condition that may occur following cataract surgery.

It is usually treated with topical corticosteroids in high dosage and frequency.

posterior capsular cells undergo hyperplasia and cellular migration, showing up as a thickening, opacification and clouding of the posterior lens capsule

This may compromise visual acuity corrected using a laser device Nd-YAG laser (neodymium-yttrium-aluminum-garnet)

INTRAOCULAR LENS RELATED COMPLICATIONS

Cystoid macular oedema Corneal endothelial damage Uveitis Secondary glaucoma Hyphaema. UGH SYNDROME is especially very

common with anterior chamber and iris supported IOL.

UGH SYNDROME

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.

SUBLUXATIONS

SUN-SET SYNDROME: Inferior SUN-RISE SYNDROME: Superior

LOST LENS SYNDROME: Complete

dislocation of IOL into the vitreous cavity.

WINDSHIELD WIPER SYNDROME:- Very small IOL placed vertically in the

sulcus.

The superior loop moves left and right with the movements of the head.

TOXIC LENS SYNDROME

Uveal inflammation is excited by:-

Ethylene gas (in early cases)

Lens material (in late cases).

HORIZONTAL DECENTRATION

flylib.com

flylib.com

flylib.com

serious complication since the interior of the eye becomes exposed to infectious agents.

Low intraocular pressure following the surgery can be an indicator.

A bandage contact lens is typically

placed over the surgical site, usually sufficient to slow the leak adequately to allow natural healing. If the leak persists, surgical measures used to repair the problem.

A retinal tear ocular fluid to seep behind the retina

After surgery, the patient experiences flashes and floaters in the field of vision.

Patients referred to a retinal specialist who may take immediate steps to repair the problem,

A common problem following a cataract surgery .

Cataract patients who have a history of refractive surgery are at greater risk of IOL power miscalculation.

This is largely due to difficulties that may be encountered during the determination of corneal refractive powers, such as using the wrong keratometry values.

This is particularly true after myopic keratorefractive surgery.

IOL power miscalculations lead to severe ANISOMETROPIA

Options are available for subsequent correction …….

spectacles or contact lenses keratorefractive surgery IOL Exchange Supplementary IOLs (ie, polypseudophakia),

supplementary IOLs implanted in the ciliary sulcus anterior to the primary

implant, can be easier and safer surgical options.

Because IOL exchange may be associate with increased risk of capsular rupture or zonular dehiscence with vitreous loss,supplementary IOL is also an acceptable option.

OF PHACOEMULSIFICATION

http://www.cohneyecenter.com/phaco.jpg

Thermal burns Iris trauma Posterior capsular rupture Nucleus drop Endophthalmitis Flattening of anterior chamber Iridodialysis Hyphema

A portion of the phaco energy is lost as heat, which is conducted into the eye via the titanium tip.

The tip is constantly cooled by the infusion fluid from the outer sleeve of the probe tip.

For any reason if this fluid flow is hampered, the potential for thermal damage can rapidly occur within few seconds.

The surgeon should stop and check the irrigation and aspiration, incase a thermal burn is noticed.

If a burn has occurred, the surgeon must adequately suture the wound with multiple sutures to prevent post operative leak.

http://adrianhoe.com/adrianhoe/images/blog/phaco_lateral.jpg

Iris damage during phaco is due to iris prolapse or direct injury from tip of the U/S handpiece.

Injury may cause loss of pigmentation, flaccidity, bleeding, pupillary irregularity or even cystoid macular edema.

If the iris is already damaged, phaco should be done by using low aspiration rates.

eyeworld.org/images/New_Articles/2010/04/29_b.jpg

Iris damagewww.retinalphysician.com/archive%5C2010%5CJun

Iris burn

A Major complication of Phaco Occurs due to:

• Direct action of the U/S tip on the capsule • Rarely due to sharp nuclear fragments..etc.

Signs include:• Pupil snap back sign• Deepening of ant. Chamber• Loss of piece of nucleus• Reduction in the aspiration due to obstruction by

vitreous. Once a rent in post. Capsule has occurred ,one should try

and minimize its extension with loss of vitreous. One should convert procedure to ECCE.

<eyeworld.org>

Hard nucleus is seen dropping to right after posterior capsule rupturewww.osnsupersite.com/images

This is another major complication of phaco.

During the process the nucleus drops through capsular tear into the vitreous.

This can lead to complications like uveitis, retinal detachment etc.

Endophthalmitis is a serious infection of the intraocular tissues, usually following intraocular surgery, or penetrating trauma.

Glaucoma may occur and it may be very difficult to control. It is usually associated with inflammation, specially when little fragments or chunks of the nucleus get access to the vitreous cavity.

Patients may experience Spontaneous bleeding from the wound and Recurrent inflammation after surgery. Flashing, floaters, and double vision may also occur a few weeks after surgery.

Surgeons may come across situations where proceeding with phaco can lead to serious complications, at times like this the procedure is converted to ECCE.

This requires special skills, caution and early recognition of intraoperative problems which signals the need for conversion.

Basic purpose:• Limit endothelial damage• Avoid risk of nuclear drop into vitreous cavity.

Small pupil

Prolonged phaco time [hard cataracts]

Posterior capsular rupture

Corneal thermal burns

Intraoperative detection or occurrence of subluxation

Malfunction of handpiece or machine

It is a inflammation of inner coat of eye …………..It may occur following the intraocular surgery such as cataract or glaucoma filtration surgery etc./…..

1. EXOGENOUS INFECTIONS• Perforating injuries• Perforation of infected corneal ulcer• Post-operative

2.ENDOGENOUS OR METASTATIC INFECTIONS

By haemogenous spread mainly due to septicemia,

Caries of teeth etc

Lids - Blepharitis Lacrimal system –dacryocystitis. Orbital cellulitis Infected corneal ulcers Thrombophlebitis

SYMPTOMS

OCULAR PAIN

REDNESS

LACRIMATION

PHOTOPHOBIA

MARKED LOSS OF VISION

Swollen lidsChemosis ,Circumcorneal congestion,Odeamatous cornea….Cloudy and ring infiltration, in exogenous form, edges of wound become yellow and necrotic.

Occurrence can be prevented by using pre-operative, intraoperative,post-operative antibiotics.

In infectious cases immediate and intensive broad spectrum antibiotics is administered by topical, subconjunctival,I.V or even by intra vitreal routes.

Systemic steroids to control inflammation

ANTIBIOTICS: AMIKACIN OR TOBRAMYCIN EYE DROPS OR VANCOMYCETINE OR CEFAZOLINE 50mg/dl EVERY 15- 30MIN ALTERNATELY

2ND CHOICE CIPROFLOXACIN EYE DROPS EVERY 30MIN

STEROIDS: 1%DEXAMETHASONE QID

CYCLOPEGICS: ATROPINE 1% OR HOMATROPINE EYE DROPS TDS OR QID

ANTIBIOTICS FORTIFIED CONCENTRATION

SUBCONJUNCTIVAL DOSE

AMIKACIN SULFATE 50mg/ml 25mg/0.5ml

CEFALORIDINE 50mg/ml 100mg/0.5ml

CEFAZOLINE 50mg/ml 1oomg/0.75ml

CEFTRIAXONE 50mg/ml 100mg/0.5ml

GENTAMYCIN 50mg/ml 20mg/0.5ml

TOBRAMYCIN 50mg/ml 20mg/0.5ml

CIPROFLOXACIN 50mg/ml -

DRUGS DOSE

AMIKACIN 400micro g/0.1ml

AMPHOTERICIN B 5mg/0.1ml

CEFAZOLIN 2.25mg/0.5ml

CLINDAMYCIN 1mg/0.1ml

VANCOMYCIN 1mg/0.1ml

DEXAMETHASONE 400micro g/0.1ml

Some cases need therapeutic Vitrectomy for debulking the vitreous of organisms and their

toxinsPreventing subsequent tractional retinal

detachment

ANTIBIOTICS; AMIKACIN 7,5mg/kg/day in 3divided doses with cefazoline 0.5QID for 7-10 days OR CIPROFLOXACIN I.V 200mg BD 2-4 days followed by 500mg orally BD

ORAL CORTICOSTEROIDS; STARTED AFTER 24hrs of intensive antibiotic therapy………….Adaily therapy regime with PREDNISOLONE …FIRST DOSE OF 60mg followed by 50,40,30,20,10 mg for 2days

POSTERIOR CAPSULAR OPACIFICATION(PCO)

POSTERIOR CAPSULAR OPACIFICATION

Secondary cataractA posterior capsule opacity is the presence

of a hazy membrane (capsule) just behind an intraocular lens implant.

PCO has been recognised since the origin of extracapsular cataract surgery (ECCE) and was noted by Sir Harold Ridley in his first IOL implantations.PCO is a major problem in paediatric cataract surgery where the incidence approaches 100%

CAUSES OF PCO

PERSISTANCE OF RESIDUAL OPAQUE LENS MATTER

PROLIFERATION OF ANTERIOR EPITHELIAL CELLS

DENSE MEMBRANOUS

SOEMMERING’S RING

ELSCHNIG’S PEARLS

DENSE MEMBRANOUS CATARACT

SOURCE:eyerounds.org

SOURCE:revoptom.com New lens fibres trapped between the anterior and posterior capsules

ELSCHNIG’S PEARLS

ELSCHNIG’S PEARLS

Clinical Manifestations

The interval between surgery and PCO varies widely, ranging from three months to four years after the surgery

Young age is a significant risk factor for PCO, and its occurrence is a virtual certainty in paediatric patients.

Visual symptoms do not always correlate to the observed amount of PCO.

Some patients with significant PCO on slitlamp examination are relatively asymptomatic .

Others have significant symptoms with mild apparent haze, which is reversed by capsulotomy

Prevention of PCO

Surgery-related factors to reduce PCO:

Hydrodissection-enhanced cortical cleanup

• In-the-bag (capsular) fixation

• Small Capsulorhexis – so the edge of capsule is on IOL surface

Four IOL-Related Factors to Reduce PCO:A. IOL biocompatibility

B. Maximal IOL Optic-Posterior Capsule Contact.

C. Barrier Effect of the IOL Optic.

D. Shape of IOL

TYPES OF PCO TREATMENT

Thin membranous Nd- YAG Laser capsulotomy Discission with cystitome or zeigler’s knife

Dense membranous surgical membranectomy

Soemmering’s ring no treatment

Elschnig’s pearls YAG Laser capsulotomy discission with cystitome

TREATMENT

Nd-YAG laser (neodymium-yttrium-aluminum-garnet) is used to disrupt and clear the central portion of the opacified posterior lens capsule (posterior capsulotomy).

This creates a clear central visual axis for improving visual acuity. In very thick opacified posterior capsules, a surgical (manual) capsulectomy is the surgical procedure performed.

Nd-YAG Laser Capsulotomy

Type of laser: The Nd-YAG laser is an optically pumped

solid-state laser that can produce very high-power emissions.

Mechanism of action: a YAG laser is used to open the posterior

capsule centrally.

the laser treatment is performed with a slit-lamp delivery system using an appropriate contact lens (i.e., Abraham capsulotomy YAG lens) to stabilize the eye and focus the laser beam.

The YAG laser causes photodisruption with the shock wave travelling anteriorly

Source:alcon.com

SOURCE:laserengraver.com

COMPLICATIONS OF YAG LASERThe most important risk of the procedure is retinal detachment

May be rarely associated with complications such as: transient rise in IOP

enhanced risk of retinal detachment particularly marked in axial myopia cystoid macular oedema

IOL subluxation

lens optic damage/pitting Endophthalmitis

vitreous prolapse into the anterior chamber and

anterior hyaloid disruption