COMPLICATIONS OF CATARACT SURGERY

immediate complication

i. Excessive bleeding from conjunctiva during preparation of conjunctival flap. It is managed by gentle cautery.

ii. Damage to superior rectus muscle while passing bridle suture may occur.

iii. Incision related complications: tunnel too short with iris prolapse

                                                                              tunnel too long with wound burn and corneal edema

iv. Complications related to anterior capsulorhexis.

1. too small result in difficulty removing lens

2. too large may result in insuffienct sulcus in case of PC RENT

3. may run out. if cannot be rescued conversion to ECCE and 6mm IOL PMMA implantation is done

v. Injury to cornea, iris and lens may occur.

vi. Iridodialysis may occur during intraoperative manipulations

vii. Rupture of the posterior capsule

viii. Zonular dehiscence may give rise to sunset and sunrise syndrome after implantation of an

intraocular lens.

ix. Vitreous loss

x. Nucleus drop into vitreous cavity:  Refer patient to vitreoretinal surgeon

xi. Posterior loss of lens fragments: upto 25% can be observed. if more refer to vitreoretinal surgeon

xii. Posterior dislocation of IOL: refer to vitreoretinal surgeon

xiii. Expulsive choroidal haemorrhage

Postoperative Complications

1. Early postoperative (within first few days to 4 weeks)

2. hyphema

3. iris prolapse

4. striate keratopathy

5. flat or shallow anterior chamber due to wound leak or ciliochoroidal detachment

6. postoperative anterior uveitis and endophthalmitis

II. Late postoperative (after one month to years)

posterior subcapsular opacity (after or secondary cataract)

cystoid macular edema

delayed chronic postoperative endophthalmitis

retinal detachment

pseudophakic bullous keratopathy

causative organisms: 90% gram positive mainly staph epidermidis and 10% are gram negative

prophylaxis: 

1. povidone iodine 5% istilled in conjunctival sac and left for 3 minutes

2. intracameral cefuroxime at the end of surgery

3. subconjunctival injection of gentamycin and dexamethasone at the end of surgery

4. treatment of blephritis conjunctivitis dacroadenitis etc

5. careful prep and drap

clinical features: symptoms: pain redness reduced vision

signs: 

1. lid swelling

2. conjunctival injection and chemosis and discharge

3. relative afferent pupillary defect

4. corneal haze

5. fibrinous exudate and hypopyon

6. vitritis with impaired view of fundus

differetial diagnosis

1.  retained lens matter

2. vitreous hemorrhage

3. post operative uveitis

4. toxic reaction to viscoelastics etc

5. complicated and prolong surgery

investigations

1. B scan

2. aqueous sampling

3. vitreous sampling

4. conjunctival swabs

5. microbiology

treatment

intravitreal antibiotic are the mainstay of treatment. 

preparation of intravitreal antibiotic vancomycin covers gram positive and ceftazidime covers gram negative organism

A. Begin with a 500 mg ampoule 

B. Add 10 ml water for injection (WFI) or saline and dissolve thoroughly (for a 250 mg vial add 5 ml WFI or saline, for a 1 g vial add 20 ml WFI or saline)

C. Draw up 1 ml of the solution, containing 50 mg of antibiotic

D. Add 1.5 ml WFI or saline giving 50 mg in 2.5 ml

E. Draw up about 0.2 ml (excess to facilitate priming) into a 1 ml syringe. When ready to inject, fit the Rycroft cannula or the needle to be used and discard all but 0.1 ml (contains 2 mg of antibiotic) for injection

amikacin in case of pencillin or cephalosporin allergy but is retinotoxic

A. Presentation: vial contains 500 mg of amikacin in 2 ml of solution

B. Use a 2.5 ml syringe to draw up 1 ml of amikacin solution then 1.5 ml of WFI

C. Inject 0.4 ml of the solution, containing 40 mg of antibiotic, into a 10 ml syringe and dilute to 10 ml (giving 4 mg per ml)

D. Draw up about 0.2 ml (excess to facilitate priming) into a 1 ml syringe. When ready to inject, fit the needle to be used and discard all but 0.1 ml (contains 0.4 mg of antibiotic) for injection

subconjunctival antibiotics.

vanco 50 mg , ceftazidime 125 mg or amikacin 50 mg in peniclline allergy

topical antibiotics

50 mg/ml vanco and ceftazidime

intravitreal steriods

0.1 ml of dexamethasone

parsplana vitrectomy

Pars plana vitrectomy. The Endophthalmitis Vitrectomy Study (EVS) showed a benefit for immediate pars plana vitrectomy in eyes with a visual acuity (VA) of perception of light (not hand movements vision or better) at presentation, with a 50% reduction in severe visual loss. 

Signs of improvement

 include contraction of fibrinous exudate and reduction of AC cellular activity and hypopyon.