Complications of cataract surgery

Cataract surgery is one of the most successful surgical procedures performed

in medicine. As in any discipline, however, complications can and do occur.
This chapter provides an approach to the prevention, diagnosis, and
management of many complications associated with cataract surgery,
focusing particularly on those accompanying phacoemulsification.

Preoperative evaluation

The preoperative assessment of a patient with an operable cataract is

important in planning the surgical procedure. The information obtained from
a comprehensive ophthalmic examination of the patient with a cataract may
prevent or minimize the occurrence of untoward situations during the
surgical procedure. The patient’s past medical and ophthalmic history, use of
topical and systemic medications, family history of medical disease, and
allergic history are essential elements of the preoperative evaluation.
Several specific aspects of the comprehensive examination are particularly
germane in preparation for cataract/intraocular lens (IOL) surgery. The
condition of the scleral tissue often determines the type of surgical incision.
Patients with rheumatoid arthritis, for example, may have thinned sclera as a
consequence of scleromalacia. This condition could influence the
ophthalmologist to select an alternative incision site or to perform a corneal
incision.

Preoperative complications

Corneal Abrasion
Visualization of intraocular structures is a key element in successful
intraocular surgery. Preservation of corneal clarity is, therefore, a desirable
goal for surgery. Disruption of the corneal epithelium limits clear visibility.
Care should be taken to ensure corneal clarity during preparations, including
povidone-iodine ( Betadine ) preparations, drape placement, and lid
speculum insertion.

Retrobulbar Hemorrhage
Recent trends in topical anesthesia for cataract surgery notwithstanding,
orbital hemorrhage can be associated with retrobulbar injection and less
commonly with peribulbar injection.
The earliest signs of retrobulbar hemorrhage include a tense, immobile globe
that gives firm resistance to retropulsion, taut eyelids, diffuse
subconjunctival hemorrhage, and, at times, ecchymosis of the lids. Direct or
indirect opthalmoscopy should be performed to assess the status of the
central retinal artery. The goal of treatment of this condition is to maintain
patency of the central retina artery by reducing head against it.

Globe Trauma
Perforation of the globe, although rare, may occur during retrobulbar
anesthesia. Sudden softening of the eye and collapse of the posterior
chamber are he hallmarks of this occurrence. Myopic eyes with a longer
axial length are more susceptible to this injury during peribulbar or
retrobulbar anesthesia. In this instance, the surgery should e stopped, and the
patient should be referred to a vitreoretinal specialist for further evaluation
ad management.

Intraoperative complications

Orbital Adnexa
Inadvertent trauma to the eyelids, superior rectus, and levator occur
infrequently perioperatively or intraoperatively. Injury may include
hemoorhage, neurapraxia, or direct tissue damage. Bridal suture placement
has been implicated as a potential cause of damage to the superior rectus or
to the closely apposed levator complex,which may result in postoperative
ptosis.

Conjunctiva and Episclera

The conjunctiva and episclera are relatively forgiving structures. Significant
manipulation and surgical injury to these are tolerated both functionally ad
cosmetically because they regenerate rapidly after surgery. Significant
distortion of anatomy and scarring will, however, prove important if
concomitant or future glaucoma filtering procedures are planned.

Cornea
Descemet membrane detachment
Detachment of Descemet membrane may occur during the insertion of any
instrument into the anterior chamber, especially large instruments, such as
the phacoemulsification or irrigating – aspirating ( I - A ) tips. The
occurrence of descemet membrane detachment is greater with a relatively
shallow anterior chamber, because there is less space between the cornea
and iris.

Endothelial Trauma
Trauma to the corneal endothelium usually occurs from either direct contact
by instrument or from nuclear fragments that are liberated during
phacoemulsification. In both instances, some degree of proection to injury of
the endothelium is afforded by the use of viscoelastic materials th coat or
bind to the endothelium, and create space in the anterior segment. Trauma
secondary to nuclear fragments creaed during phacoemulsification is also
less likely with the capsulorhexis and in situ phacoemulsification techniques.

Anterior chamber Hyphema

Intraocular blood can limit both intraoperative visualization and
postoperative visual acuity. Other potential complications of blood in the
anterior chamber include premature miosis intraoperatively; delayed or
incomplete miosis at the end of surgery; and an increased risk of corectopia,
papillary capture, IOL decentration, and posterior capsule opacification
postoperatively. Finally, intraocular hemorrhage in creases the severity and
duration of the postoperative inflammatory response.

Iris
During the preoperative evaluation, the surgeon determines the suitability of
the patient for phacoemulsification or extracapsular cataract extraction
( ECCE ), considering the nature of nuclear hardness, related ocular
conditions, and the relative ease and completeness of pupil dilatation.
Various techniques to widen the pupil are available to facilitate
phacoemulsification. These include radial sphincterotomy, multiple
sphincterotomies, sector iridectomy, or the use of devices to widen the
papillary aperture, such as iris retractors.

Lens
Extension of anterior capsulotomy radial tear
The conventional can-opener anterior capsulotomy consists of multiple
small radial tears. During other portions of the extracapsular procedure,
nucleus removal, and irrigation and aspiration, these small tears can extend
to the lens equator and, at times, even extend to the posterior capsule.
Similar events can also occur with the so-called envelope technique. Other
factors contributing to the development of radial tears include insufficient
corneoscleral wound length and an anterior capsulotomy opening that is too
small, each of which may cause greater resistance to nucleus expression
during ECCE; significant posterior pressure; and high pressure of the I-A
bottle.
CAPSULORHEXIS. Capsulorhexis is a method of creating a smooth-
edged, continuous tear capsulotomy that obviates many of the problems
arising with the can-opener type of anterior capsulotomy.

Posterior capsular tears

A tear in the posterior capsule may occur during various stages of cataract
surgery. Posterior capsular tear and vitreous loss increase the risk of
postoperative sequelae, including the development of cystoid macular edema
and retinal detachment. However, with appropriate recognition and proper
surgical management, a posterior chamber IOL ( either in the ciliary sulcus
or in capsular bag ) can be implanted, and a good surgical outcome can be
anticipated.

MANAGEMENT. In general, management of posterior capsular tears

depends on the period during the surgery when the rent or tear is noted,
presence of vitreous in the anterior chamber, and experience of the surgeon.

Posterior capsule tears during ECCE. Although it is unlikely for capsular

rupture to the occur before nucleus expression, if a posterior capsule tear is
noted before nucleus removal, steps should be taken to remove the nucleus
atraumatically from the eye without widening the posterior capsular defect.
Nuclear material is poorly tolerated in the vitreous cavity and may be
associated with an intense inflammatory reaction and ultimately a retinal
detachment.

Posterior capsule tears during phacoemulsification. If a tear in the

posterior capsule is encountered during phacoemulsification, the decision to
continue phacoemulsification of the nucleus or convert to an ECCE depends
on the skill and experience of the surgeon. If one elects to convert to ECCE,
the nucleus fragments can be removed with a lens loop. Alternatively, if the
surgeon decides to continue with phacoemulsification , use of a viscoelastic
agent to tamponade a small rent or insertion of a sheets glide to block a
larger one often permits successful completion of phacoemulsification.
Another management option includes the conversion of a linear posterior
capsule tear into a continuous round capsulorhexis. A second instrument
may be used either to direct nuclear remnants away from the posterior
capsule tear or block the posterior capsule rent physically to prevent the loss
of nuclear material into the posterior chamber.

Loss of nucleus into the vitreous cavity. Loss of the lens nucleus into the
vitreous is relatively rare but requires prompt attention. Management
depends on the surgeon’s experience with vitreoretinal techniques. For
surgeons who do not usually perform vitreoretinal surgery, we recommend
thoroughly clearing the anterior segment of residual nuclear and cortical
material, as well as vitreous while maintaining as much of the anterior and
posterior capsules as possible. A posterior chamber IOL can be implanted at
this time. The wound is closed appropriately and the patient referred to a
vitreoretinal surgeon for pars plana nucleus removal. In those instances in
which the surgeon is adept with vitreoretinal surgery, the nucleus can be
removed by means of a pars plana or combined approach at the time of the
primary surgery.

Posterior capsule tears during cortical cleanup. When a posterior capsule tear
occurs during cortical cleanup, the surgeon should weigh the potential risks
in pursuing residual cortex and causing additional trauma to the posterior
capsule and zonules. In most cases, leaving cortex behind is well tolerated,
and it often resorbs over time.

Zonular Dialysis
Preoperative evaluation may reveal several clues that zonular integrity is
compremised, most important of which are phacodonesis and iridodonesis.
Weakened or absent zonules cause lens and iris tremulousness with eye
movements. Visible vitreous strands in the anterior chamber also indicate
imperefect zonular in tegrity in anterior chamber. Less subtle signs are the
edge of the lens visible within the pupi, indicative of a greater degree of
zonular dialysis sufficient to cause lens subluxation. Unequal chamber
depths are also indicative of lens luxation.

IOL insertion after posterior capsular tear

After cortical cleanup and, if necessary, anterior vitrectomy, one must decide
where the intraocular lens should be placed. The anterior and posterior lens
capsules should be clearly visualized and their structural integrity assessed.

Management of residual viscoelastic

At the conclusion of surgery in which a posterior capsule tear has occurred ,
an important decision arises regarding any viscoelastic agent that had been
injected into the eye intraoperatively. Any attempt at removal of viscoelastic
material risks the creation of intraocular pressure flux.

Vitreous Loss

Measures to prevent vitreous loss include limiting posterior pressure and

avoiding sudden changes in anterior chamber volume by controlled nucleus
expression during ECCE, the use of low phacoemulsification power, and
low I-A rates during cortical cleanup. Jaffe and associated reported a 30%
incidence of vitreous loss, however, even by experienced surgeons.

Retina

Intraoperative retinal complications are relatively few. Photic maculopathy

has become more common with the greater light intensity capability of
modern operating microscopes. The key factor in the development of photic
maculopathy is the intraoperative surgical time. Once the cataractous lens,
which acts as a natural light filter, is removed, one should attempt to
minimize potential damage to he retina. This goal is accomplished bye the
use of a light filter in all aspects of the surgery that do not require precise
intraaxial visualization.

Expulsive choroidal hemorrhage

Expulsive choroidal hemorrhage is one of the most dreaded complications of

cataract surgery. Taylor reported an incidence of 0,2% in 1974.
Histopathologic studies have demonstrated that rupture of the posterior
ciliary arteries is the underlying pathophysiologic event responsible for the
development of expulsive choroidal hemorrhage. The leading theory is that
the sudden hypotony secondary to surgical decompression of the globe leads
to rupture of the blood vessels, most commonly occurring during the
delivery of the lens nucleus in an ECCE. Although its cause is most likely
multifactorial, reported risk factors include advanced age, uveitis, glaucoma,
hypertension, atherosclerotic heart disease, myopia, an acute rise in systemic
blood pressure intraoperatively, intrinsic vascular fragility, anticoagulation
therapy, and a history of expulsive choroidal hemorrhage in the fellow eye.
Postoperative complications

Endophthalmitis
Because endophthalmitis is covered in a separate chapter in this book, we
discuss only those points regarding endophthalmitis that are pertinent to
cataract surgery.
The onset of symptoms of endophthalmitis after cataract surgery is usually
sudden, with pain and decreased visual acuity within 1 to 4 days
postoperatively. The initial symptoms may be difficult to differentiate from
routine postoperative iritis and intraocular inflammation, as both produce
conjunctival and episcleral injection, in addition to cells and flare in the
anterior chamber.

Cornea

Wound leak
Postoperative wound leaks occur less commonly today as a result of
improved surgical techniques, instrumentation, and suture materials.
However, problems in either the creation or the closure of the wound may
increase the possibility of a wound leak.

Corneal edema
Corneal stromal edema is most commonly a transient postoperative
phenomenon secondary to compromised endothelial function after
intraocular surgery. If, however, corneal edema persists postoperatively, this
may reflect irreversible endothelial damage.

Epithelial downgrowth
Epithelial downgrowth is a serious but rare complication after cataract
surgery, with a reported incidence of less than 0,1% by Weiner and
associates in a 30year clinicopathologic review. Given the vastly improved
surgical technique and suture materials that have been incorporated within
the last decade or so, the incidence of this grave complication is probably
even lower than this reported value.

Fibrous ingrowth
Fibrous ingrowth is another rare complication related to poor wound closure.
The source of the fibroblasts that cause fibrous ingrowth is controversial,
with likely sources including subepithelial connective tissue, corneal or
limbal stroma, and metaplastic endothelium. The clinical appearance of
fibrous in growth may be similar to epithelial downgrowth , with a
retrocorneal membrane that has advanced over the angle structures, iris,
pupil, and ciliary body. One clinical distinction is the presence of an
advancing irregular border of fibrous tissue in fibrous ingrowth, as opposed
to the generally well-defined border of heaped-up epithelial cells that are
seen epithelial downgrowth.

Increased intraocular pressure/ Glaucoma

Elevated intraocular pressure in the postoperative period is often transient,

with restoration of normal intraocular pressure with little or on treatment.
Outflow through the trabecular meshwork may be decreased in the early
postoperative period by inflammatory cells, blood, fibrin, viscoelastic, and
lens and iris debris. In addition, there is usually same component of
trabeculitis that occurs after cataract extraction. These forms of secondary
glaucoma may be treated with agents that inhibit aqueous production ( ie,
beta blockers and carbonic anhydrase inhibitors). In addition, topical steroid
may be helpful in suppressing the release of inflammatory cells into the
aqueous as well as decreasing trabeculitis. Conversely, steroid induced intra
ocular pressure elevation may occur, with an increased prevalence in
patients with preexisting primary open-angle glaucoma.

Hypotony

The most common causes of postoperative hypotony are wound leak and
ciliochoroidal detachment, although these two entities are often found
together. Jaffe and coworkers summarized the clinical situations encountered
in hypotony as follows : (1) wound leak and a normal anterior chamber
depth – no ciliary body detachment; (2) wound leak and shallow anterior
chamber depth – probable ciliary body detachment; and (3) no wound leak
and shallow anterior chamber depth – probable ciliary body detachment.

Hyphema

Postoperative hyphema usually presents within the first postoperative week.

Although the most common source of a postoperative hyphema is blood that
was present during surgery and has remained in the eye, there are several
causes for new bleeding into the anterior chamber in the postoperative
period.
Uveitis

Postoperative inflammation is an expected consequence of cataract surgery.

In most patients the inflammation is easily managed with topical steroids
and dissipates within several weeks, with little or no permanent sequelae. In
a few patients, however, inflammation may be more pronounced or more
protracted in its course, particularly in those whose complications have
occurred during surgery.

IOL Dislocation

Posterior chamber IOL may become malpositioned in four basic ways: pupil
capture, decentration, windshield- wiper syndrome, and sunset syndrome.

Vitreous Hemorrhage

Vitreous hemorrhage is an uncommon occurrence after cataract surgery. The

most common cause of blood in the vitreous cavity after cataract surgery is
secondary to the passage of blood from the anterior chamber. The blood
may traverse through the zonules if the posterior capsule is intact, or through
a break in the posterior capsule or zonular attachments.

Retinal detachment
Approximemately 1% to 3% of patient undergoing cataract extraction
subsequently develop rhegmatogenous retinal detachment. This compares
with an overall incidence of 0,005% to 0,01% in the general population, so
that the relative risk among patients undergoing cataract extraction is 100 to
200 times the general risk.