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COMPLICATIONS IN

CATARACT SURGERY
HEMORRHAGE
SYSTEMIC ANTICOAGULATION

• no increased risk of hemorrhagic complication


• no increase in the risk of medical complications
• In general, patients undergoing cataract surgery with topical or
sub-Tenon anesthesia do not require cessation of anticoagulant
therapy.
• If the surgeon is considering discontinuation of anticoagulants,
consultation with the patient’s primary care physician is
recommended
RETROBULBAR HEMORRHAGE

• More common with retrobulbar anesthetic injections (0.44%-


0.71%) than with peribulbar injections
• Venous Retrobulbar hemorrhage are usually self-limited and
tend to spread slowly.
• Often do not require treatment
RETROBULBAR HEMORRHAGE

• Arterial Retrobulbar hemorrhage


• occur more rapidly
• associated with taut orbital swelling, marked proptosis, elevated IOP, reduced
mobility of the globe, inability to separate the eyelids, and massive ecchymosis of the
eyelids and conjunctiva
• causes an increase in orbital volume and associated orbital pressure, which can
restrict the vascular supply to the globe
• Large orbital vessels may be occluded
• Tamponade of the smaller vessels in the optic nerve may occur
RETROBULBAR HEMORRHAGE
DIAGNOSIS
• Rapid onset of eyelid and conjunctival ecchymosis and tightening of the orbit.
• elevated IOP
• pulsation or occlusion of the central retinal artery in severe cases
RETROBULBAR HEMORRHAGE
MANAGEMENT
• Maneuvers to lower the intraocular and orbital pressure as quickly as
possible.
• digital massage
• intravenous osmotic agents
• aqueous suppressants
• lateral canthotomy
• Cantholysis
• localized conjunctival peritomy (to allow egress of blood),
• anterior chamber paracentesis
RETROBULBAR HEMORRHAGE
MANAGEMENT
• The planned surgery should be postponed
• use another form of anesthesia for the second attempt at surgery
RETROBULBAR HEMORRHAGE

• Other potential complications of retrobulbar injections include:


• central retinal artery occlusion
• ischemic optic neuropathy
• toxic neuropathy or myopathy
• Diplopia
• Ptosis
• inadvertent subdural injections with possible CNS depression and apnea
HYPHEMA

• usually originates from the incision or the iris


• commonly mild and resolves spontaneously
• Resolution may take longer if vitreous is mixed with the blood
• Hyphema occurring months to years after surgery is usually the
result of incision vascularization or erosion of vascular tissue in
the iris or ciliary body by an IOL haptic or optic edge.
• The two major complications from prolonged hyphema are
elevated IOP and corneal blood staining
HYPHEMA
MANAGEMENT
• IOP should be monitored closely and initially treated medically, although it
may be difficult to control if the blood is mixed with the OVD used during
the procedure
• Surgical evacuation is occasionally necessary
• Argon laser photocoagulation of the bleeding vessel, often performed
through a goniolens, may stop the bleeding or prevent rebleeding.
HYPHEMA
MANAGEMENT

• antiplatelet or anticoagulation therapy may be withheld


• reposition or exchange an IOL
SUPRACHOROIDAL EFFUSION OR
HEMORRHAGE
• usually occurs intraoperatively
• typically presents as a forward prolapse of ocular structures
• generally accompanied by a change in the red reflex
• Clinically, may be difficult to differentiate from suprachoroidal hemorrhage.
• Patient agitation and pain followed by an extremely firm globe suggest
suprachoroidal hemorrhage
SUPRACHOROIDAL EFFUSION OR
HEMORRHAGE
• more common in the presence of associated hypertension,
arteriosclerotic cardiovascular disease, tachycardia, obesity, high myopia,
glaucoma, advanced age, nanophthalmos, choroidal hemangioma associated
with Sturge-Weber syndrome, or chronic ocular inflammation

• Much less likely to occur with small incision phacoemulsification


• Suprachoroidal effusion may be a precursor to suprachoroidal
hemorrhage
EXPULSIVE SUPRACHOROIDAL
HEMORRHAGE
• rare but serious condition
• Occurs intraoperatively
• usually presents as a sudden increase in IOP accompanied by acute onset
of pain and the following:
• darkening of the red reflex
• Incision gape
• iris prolapse
• expulsion of the lens, vitreous, and bright red blood
EXPULSIVE SUPRACHOROIDAL
HEMORRHAGE
• surgeon must close the incision with sutures or digital pressure.
• Prolapsed vitreous should be excised and uveal tissue, reposited
• the surgeon may consider posterior sclerotomies to allow the escape of suprachoroidal
blood to decompress the globe, enable repositioning of prolapsed intraocular tissue, and
facilitate permanent closure of the cataract incision.
• Drainage of suprachoroidal blood
• sclerotomies in one or more quadrants, 5–7 mm posterior to the limbus
DELAYED SUPRACHOROIDAL HEMORRHAGE

• may occur in the early postoperative period


• far more common after glaucoma filtering procedures
• may also arise following laser photocoagulation or cryotherapy

• sudden onset of pain, loss of vision, and shallowing of the anterior


chamber
DELAYED SUPRACHOROIDAL HEMORRHAGE

• Predisposing factors for postoperative choroidal hemorrhage or effusion


include:
• prolonged hypotony
• wound leak
• unrecognized scleral perforation
• Trauma
• Uveitis
• Cyclodialysis
• excessive filtration
DELAYED SUPRACHOROIDAL HEMORRHAGE
MANAGEMENT
• If the incision remains intact and the IOP can be controlled medically
• may be observed and frequently will resolve spontaneously
• If the incision is not intact, surgical revision may be sufficient to allow the hemorrhage to
resolve
DELAYED SUPRACHOROIDAL HEMORRHAGE
MANAGEMENT
• Medical management consists of:
• systemic corticosteroids, topical and oral ocular hypotensive agents for elevated IOP, topical
cycloplegia, and close observation.

• Surgical drainage of the suprachoroidal space if:


• flat anterior chamber
• medically uncontrolled glaucoma
• Persistent
• adherent (kissing) choroidal detachments
ENDOPHTHALMITIS
ENDOPHTHALMITIS

• rare but dreaded complication of cataract surgery


• Early diagnosis and prompt treatment are essential
• Incidence: 0.04% and 0.20%
• Factors that increase the risk of infection include diabetes mellitus, older age, male
gender, complicated or prolonged surgery, vitreous loss, posterior capsule rupture,
wound leaks, and possibly the use of clear corneal incisions
ENDOPHTHALMITIS

• Infectious endophthalmitis may present in an acute form or in a more


indolent or chronic form
• Chronic: lower pathogenicity organisms
• mild to severe ocular pain, vision loss, floaters, and photophobia
• hallmark of endophthalmitis: vitreous inflammation
ENDOPHTHALMITIS

• other signs include:


• eyelid or periorbital edema
• ciliary injection
• Chemosis
• anterior chamber inflammation
• Hypopyon
• decreased visual acuity
• corneal edema
• retinal hemorrhages
ENDOPHTHALMITIS

• Most cases present within 3–10 days of surgery, with a median of 6 days,
as reported in the Endophthalmitis Vitrectomy Study (EVS)
• A significant percentage (22%) of cases presented 2–6 weeks after surgery.
ENDOPHTHALMITIS

• The most common bacterial causes


• gram positive coagulase-negative Staphylococcus epidermidis (70%)
• Staphylococcus aureus (9.9%)
• Streptococcus species (9.0%)
• other gram-positive bacteria (3.1%)
• Enterococcus species (2.2%)
• gram-negative bacteria (5.9%)

• Most infections are caused by organisms similar to the patients’ own


periocular bacterial flora.
ENDOPTHALMITIS
PREVENTION
• preoperative 10% povidone-iodine skin prep
• povidone-iodine 5% drops
• careful eyelid and eyelash draping,
• sterile technique
• Meticulous attention to watertight incision
• Prophylactic preoperative and postoperative topical antibiotics
• The clinical presentation is often diagnostic, but occasionally the clinician
may be able to diagnose sterile endophthalmitis only by excluding possible
infectious causes
• appropriate aqueous and vitreous cultures
ENDOPHTHALMITIS
TREATMENT
• based on the results of the EVS
• As soon as a clinical diagnosis of endophthalmitis is suspected
• Needle biopsy for anterior chamber and vitreous samples for culture and
Gram stain
• Fortified topical antibiotics may be started if doing so does not delay
referral to a vitreoretinal specialist.
• VA is light perception: Immediate pars plana vitrectomy and antibiotic
injections are indicated
• When the visual acuity is hand motions or better: a less-invasive anterior
chamber and vitreous biopsy for cultures with subsequent intravitreal
injection of antibiotics may be sufficient
• To expedite the delivery of antibiotics, this procedure can be performed in
the office under sterile conditions
• the mainstay of treatment for both remains broad-spectrum intravitreal
antibiotics
• Vancomycin 1 mg and ceftazidime 2.25 mg or amikacin 0.4 mg are preferred
• Fortified topical or subconjunctival antibiotics are administered in the period following
intravitreal antibiotic injection while waiting for culture results
• Topical cycloplegic and corticosteroid drops are advised
• Intravenous or oral antibiotics have shown little benefit
• Intravitreal corticosteroids are frequently used because of their theoretical role in
reducing inflammation and scarring
RETINAL COMPLICATIONS
CYSTOID MACULAR EDEMA

• Irvine-Gass Syndrome
• Common cause of post-operative decreased vision
• Increased perifoveal capillary permeability with accumulation of fluid in the inner nuclear
and outer plexiform layers
• often associated with intraocular inflammation
CYSTOID MACULAR EDEMA

• unexplained reduction in vision


• Fundoscopy or FA: Characteristic petaloid appearance of cystic spaces in the macula
• SD-OCT: cystic areas of low reflectivity and retinal thickening
• Angiographic evidence occurs in 40-70% ICCE patients and 1-19% in ECCE patients
• Clinicially significant CME: vision loss 20/40 level or worse
• Incidence 2-10% after ICCE and 1-2% after ECCE

• Peak incidence 6-10 weeks after surgery


• Spontaneous resolution in 95% of uncomplicated cases usually within 3-12 months
CYSTOID MACULAR EDEMA

• Risk Factors
• Use of topical epinephrine and dipivefrin for aphakic glaucoma
• Prostaglandin analogues in patients who undergone recent intraocular surgery
• Preoperative risk factors:
• Coexisting uveitis
• Preexisting epiretinal membrane
• Vitreomacular traction
• Diabetes mellitus and diabetic retinopathy
• Previous retinal vein occlusion
• Retinitis pigmentosa
• Previous CME
CYSTOID MACULAR EDEMA

• Surgical and postoperative risk factors


• posterior capsule rupture
• vitreous loss
• iris prolapse
• prolonged surgical time
• improper IOL positioning
• retained lens fragments
• poorly controlled postoperative inflammation
• transient or prolonged hypotony
CYSTOID MACULAR EDEMA
MANAGEMENT
• Reduced risk with postoperative prophylactic use of topical corticosteroids and/or
NSAID drops.
• For chronic postoperative CME
• Topical corticosteroids, NSAIDS, or both and may take 3-6 months
• If topical treatment fails: sub-tenon steroid injection or intravitreal injections of CS
• For refractory cases: intravitreal anti VEGF
CYSTOID MACULAR EDEMA
MANAGEMENT
• For chronic postoperative CME
• Surgical therapy if inciting source can be identified and edema fails to respond to medical
therapy
• Retained lens fragment should be removed
• Nd:YAG laser vitreolysis or vitrectomy to remove adhering vitreous to the cataract incision
• Repositioning of malpositioned IOL contributing to chronic uveitis
RETINAL LIGHT TOXICITY
RETINAL LIGHT TOXICITY

• Prolonged exposure to illuminating filament of microscope


• Unfiltered blue light and near-UV radiation
• Increased risk of CME or burn to RPE
• Central or paracentral scotoma may result in RPE burn

• Minimize retinal exposure to operating microscope light


• Filtering wavelength below 515 nm
• Using pupillary shields and oblique lighting
RETINAL DETACHMENT
RETINAL DETACHMENT

• Rhegmatogenous Retinal Detachment (RRD)


• Uncommon but serious complication
• Incidence of Pseudophakic RRD 0.2%-3.6%
• Occurs most frequently within 1 year of surgery, 6 months after posterior capsulotomy
• Fourfold increase risk after cataract surgery compared to fellow phakic eye
• 6 to 10 times greater incidence with axial length >25mm
• Younger age (4x greater risk with age <60 years)
• Male gender
• Lattice degeneration of the retina
• Previous retinal tear or detachment in the surgical eye
• History of RD in the fellow eye
• Family history of RD