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Complications of Cataract Surgery
Prof. Naimatullah Khan Kundi
Head, Department of Ophthalmology
Khyber Medical College Peshawar
Complications of cataract surgery


Complications are varied in time and
scope
1. Intraoperative
2. Immediate postoperative
3. Late postoperative

Therefore it is necessary to observe the
postoperative patients at periodic intervals
Major postoperative complications
of
cataract surgery
Endophthalmitis

Expulsive Haemorrhage

Corneal edema

Delayed choroidal haemorrhage

Wound distortion or disruption

Hyphaema

Shallow or flat anterior chamber

Elevated IOP

Corneal edema

Glaucoma

Detachment of descemet’s

Malignant glaucoma

membrane

Retained lens material

Suprachoroidal haemorrhage or
effusion
Major postoperative complications
of
cataract surgery
•

Vitreous disruption incarceration in the wound

•

Suture induced astigmatism

•

Pupillary capture

•

Complications of IOL implantation

•

Uveitis

•

IOL dislocation

•

Hemorrhage

•

Retinal detachment

•

Cystoid macular edema

•

Retianed lens material

•

Capsular rupture

•

Vitreous loss
Major postoperative complications
of
cataract surgery

 Endophthalmitis


Sterile



Infectious
Acute bacterial endophthalmitis
Incidence - about 1:1,000
Common causative
organisms
• Staph. epidermidis
• Staph. aureus
• Pseudomonas sp.

Source of infection
•

Patient’s own external
bacterial flora is most
frequent culprit

•

Contaminated solutions
and instruments
Environmental flora including
that of surgeon and
operating room personnel

•
Signs of severe endophthalmitis

• Pain and marked visual loss

• Absent or poor red reflex

• Corneal haze, fibrinous exudate and • Inability to visualize fundus with
hypopyon
indirect ophthalmoscope
Signs of mild endophthalmitis

• Mild pain and visual loss
• Anterior chamber cells

• Small hypopyon
• Fundus visible with indirect
ophthalmoscope
Management of Acute Endophthalmitis
1. Preparation of intravitreal injections
2. Identification of causative organisms
• Aqueous samples
• Vitreous samples

3. Intravitreal injections of antibiotics
4. Vitrectomy - only if VA is PL
5. Subsequent treatment
Subsequent Treatment
1. Periocular injections

• Vancomycin 25 mg with ceftazidime 100 mg
or gentamicin 20 mg with cefuroxime 125 mg
• Betamethasone 4 mg (1 ml)

2. Topical therapy
• Fortified gentamicin 15 mg/ml and vancomycin 50 mg/ml drops

• Dexamethasone 0.1%

3. Systemic therapy
• Antibiotics are not beneficial
• Steroids only in very severe cases
Major postoperative complications of
cataract surgery
 Corneal edema


Detached Descemet’s membrane



Mechanical trauma



Vitreo-endothelial touch



IOL-endothelial touch



Toxic solutions
Major postoperative complications of
cataract surgery
 Wound distortion or disruption
 Astigmatism
 Wound leak
 Inadvertent filtering bledb
 Iris prolapse
 Hypotony
Major postoperative complications of
cataract surgery
 Shallow or flat anterior chamber
 Wound leak
 Choroidal detachment or hemorrhage
 Pupillary block
 Ciliary block
Shallow or flat AC
A. Intraoperative
1. Inadequate infusion of BSS
2. Leakage over sized wound
3. External pressure on the globe
4. Positive vitreous pressure more common in:





Obese
Bull necked pts.
COPD
Anxious Pts. Who perform valsalva maneuver

5. Supachoroidal haemorrhage or effusion
Shallow or flat AC (cont’d)
Intraoperative shallow AC
Management






Raise infusion bottle
Place suture across the wound to ↓ its size
External pressure: Readjust surgical drapes or eye
lid speculum
Positive vitreous pressure:





I/V manitol ↓ the ↑ positive pressure and
Allow the case to continue uneventfully

Suprachoroidal hemorrhage or effusion:



Check red reflex
Examine fundus with indirect ophthalmoscope to confirm
diagnosis
Shallow or flat AC (cont’d)
B. Postoperative shallow AC


Postoperative shallow AC → opposition of iris to
angle → PAS → chronic ACG



Irido-vitreal (ICCE) / irido-capsular (ECCE)
synechiae
→ pupillary block



Corneal contact with vitreous / IOL → endothelial
cell loss → chronic corneal edema
Shallow or flat AC (cont’d)
B. Postoperative shallow AC


Causes
1.
2.

Choroidal detachment

3.

Pupillary block

4.

Ciliary block

5.



Wound leak

Suprachoroidal hemorrhage

Cases associated with ocular hypotension are 2ndry to wound
leakage / choroidal detachment



Slow or intermittent wound leaks may coexist with formed AC
Shallow or flat AC (cont’d)
B. Postoperative shallow AC
Seidel Test:


To detect an area of wound leakage



Instill one drop of 2% fluorescein and examine the incision
with cobalt blue filter on the SL



Aqueous dilution of fluorescein at the site of leakage will
produce contrasting area of green stain



Occasionally aqueous flow is so slight that gentle pressure on
the globe is necessary to confirm the site of leakage
Postoperative shallow AC (cont’d)
Management
Several Options
1.

Cycloplegics and pressure patching

2.

CAI and topical beta blockers: ↓ Aqueous flow through
the woung

3.

Corticosteroid avoidence: Enhance local wound
reaction to faciliatte spontaneous closure

4.

Therapeutic contact lens help in opposing wound
edges and ↓ aqueous flow through the wound

5.

Tissue adhesive: may seal the wound

6.

Surgical
Postoperative shallow AC (cont’d)
Management
 These measures are appropriate for minor wound
leaks

 Many patients develop associated ciliochoroidal
detachment which resolves spontaneously after
wound closure
Postoperative shallow AC (cont’d)
Management
Surgical approach with reformation of AC and
wound repair indicated:


If no improvement occurs in 24 – 46 hours



If obvious wound separation is present



Iris prolapse



IOL contact with corneal endothelium
Postoperative shallow AC(cont’d)
Complications (shallow AC)


Early postoperative Pupillary block glaucoma may follow
resolved wound leak



Late Pupillary block glaucoma is caused by postoperative
uveitis with irido-vitreous / irido-capsular synechiae
formation



AC IOL Placement without PI may be associated with early
or late postoperative pupillary block glaucoma



Ciliary block glaucoma caused by aqueous sequestration
within the vitreous body with flat AC & ↑ IOP
Postoperative shallow AC (cont’d)
Pupillary block glaucoma
Treatment
1. Pupillary dilation
2. Laser or surgical iridotomy
3. Vitretcomy preferred treatment for ciliary
block glaucoma
Corneal edema
Factors:



↑IOP
Endothelial cell damage



Edema in the immediate postoperative period



Incidence is increased in preexisting endothelial
Dysfunction



Acute endothelial decompensation with increase in
corneal thickness
Corneal edema (cont’d)
Causes:
1. Mechanical trauma
2. Prolonged intraocular irrigation
3. Inflammmation
4. Increased IOP
 Resolves in 4 – 6 weeks
 Corneal edema persisting after 3 months will usually
not clear and may require penetrating keratoplasty
Brown McLean Syndrome


This clinical condition occurs after cataract surgery
(most frequently ICCE)



Etiology unknown



Consists of peripheral corneal edema with clear
central cornea



Edema typically starts inferiorly and progresses
circumfrentially but spares the central cornea



It rarely progresses to clinically significant central
corneal edema
Vitreo-corneal adherence and persistent
corneal edema


Early / late



Uncomplicated ICCE or complicated ECCE



Early recognition and treatment are essential to
prevent development of irreversible corneal edema

Treatment:
1. Anterior vitrectomy (Limbus / PP)
2. Penetrating keratoplasty with vitrectomy in more
advanced cases
Tixic solutions


Certain solutions can be toxic to corneal
endothelium when:
 Irrigated
 Inadvertently injected

Cause:
 Temporary
 Permanent

Into AC

Corneal edema
Corneal complications of phacoemulsification
 Heat: transferred from the vibrating probe to the cornea


Tight wound prevents adequate irrigation fluid along
the probe



Occlusion of irrigation / aspiration tubing

 Holding phaco tip too close to the corneal endothelium:
Corneal complications of phacoemulsification
 The US energy causes:
 Injury to cornea
 Loss of endothelial cell

C. Edema on 1st postoperative
day/delayed for months to years

 In corneal edema develops during:
 Phacoemulsification and
 Decreases visualization

Convert to nuclear expression
technique
Detachment of descemet’s membrane
Results in stromal swelling and epithelial bullae
localized in the area of detachment
Causes:
 When Instrument / IOL is introduced through
cataract incision.
 Inadvertent fluid injection between descemet’s
membrane and stroma
Treatment:
 Small detachments can be reattached with air
tamponade in AC
 Large detachments can be sutured back into place

Suprachoroidal haemorrhage or effusion


Occurs intraoperatively



Choroidal effusion with or without suprachoroidal
haemorrhage



Choroidal effusion may be difficult to differentiate from
choroidal haemorrhage (clinically)



Both complications may occur in patients with:


HT



Obesity



Glaucoma



Chronic ocular inflammation
Suprachoroidal haemorrhage or effusion


Choroidal effusion may be precursor of suprachoroidal
haemorrhage



Or haemorrhage may represent spontaneous rupture of
choroidal vasculature (in patients with underlying vascular
disease)



Choroidal effusion tents veins and arteries that course
through sclera and supply choroid



Disruption of these vessels lead to suprachoroidal
haemorrhage

(cont’d)
Suprachoroidal haemorrhage or effusion

(cont’d)

Treatment:


Rapid wound closure with elevation of IOP to tamponade
the extravasated plasma or blood



Sclerostomy in one or more quadrants posterior to ora
serrata to drain blood



Elevated IOP serves both to stop bleeding and to
extravasate suprachoroidal blood
Expulsive Haemorrhage


Rare but serious intraoperative problem



Requires immediate action

Presentation:


Sudden ↑ IOP



Darkening of red reflex



Wound gap



Iris prolapse



Expulsion of lens and vitreous



Bright red blood
Expulsive Haemorrhage (cont’d)
Treatment:


Immediate closure of the wound with sutures /
digital pressure



Perform posterior selerotomies (5 – 7 mm
posterior to limbus) to permit suprachoroidal
haemorrhage blood to escape and allow
repositioning of prolapsed intraocualr tissues
and closure of the wound
Delayed choroidal haemorrhage
Early postoperative period (less common)

Presentation:


Sudden onset of pain



Loss of vision



Shallow AC



↑ IOP



Wound intact / disrupted
Delayed choroidal haemorrhage

(cont’d)

Management:
Observation:
If wound intact and IOP controlled, limited
haemorrhage may be observed and resolve
spontaneously
Surgical drainage:
1.
2.
3.
4.
5.

Wound disruption
Persistent shallow AC
Uncontrolled glaucoma
Adherent choroidals (kissing)
Persistent choroidal detachment
Delayed choroidal haemorrhage

(cont’d)

Medical Management:
1. Systemic corticosteroids
2. Ocular hypotensive agents (topical / oral)
3. Close observation
Hyphaema
 Early / Late
 Early:

Immediate postoperative period




 Late:

Origin: Incision / Iris
Mild resolves spontaneously
Mixed with blood / viscoelastic –
resolution longer

Months / years after surgery


Origin: wound vascularization / erosion
of vascular tissue by lens implant
Hyphaema (cont’d)
 Complications (prolonged hyphaema):
 ↑ IOP
 Corneal blood staining

 Management:
 IOP monitored closely and treated in the usual medial
fashion
 Argon laser photocoagulation of the bleeding vessels
stop / prevent rebleeding
 With-holding antiplatelet therapy (Those who receive)
until hyphaema resolves. Also risk of continued /
recurrent bleeding reduced
Elevated IOP
 Mild and selflimiting
 Significant and sustained
 Causes:











Retained viscoelastic material in AC, PC, behind the IOL]
Pupillary block
Ciliary block
Hyphaema
Endophthalmitis
Retained lens material (phacolytic / phacoanaphylatic
reaction)
Iris pigment release
Preexisting glaucoma
Corticosteroid usage
PAS (early postoperative flat AC when eye inflammed) →
2ndry glaucoma
Elevated IOP

(cont’d)

Treatment:

 Mild and selflimiting:
 Does not require prolonged anti-glaucoma
therapy
 IOP elevation lasts for a few days and is
amenable to medical treatment
 Significant and sustained rise of IOP:
 May necessitate timely and specific
management in several circumstances
 Treat the underlying cause of IOP elevation
Malignant glaucoma (ciliary block glaucoma
 Posterior dissection of aqueous into the vitreous body
and 2ndry rise of IOP
 IOP rise may occur inspite of patent iridectomy
Treatment
 Cycloplegics – to move lens-iris diaphragm posteriorly
 Disruption of anterior hyaloid face and vitreous to reestablish
a channel for aqueous to come forward

Techniques:
 Mechanical disruption (knife)
 ND: YAG Laser
 PPV
Retained lens material
 Small lens material (cortical) better tolerated
and require no surgical intervention
 More likely resorb over time
 Nuclear material incite significant inflammatory
reaction
 Inflammatory reaction may be difficult to
differentiate from microbial endophthalmitis
Retained lens material (cont’d)
Treatment:
 Observation
 Cycloplegic drugs
 Corticisteroids
 Surgical intervention
Retained lens material (cont’d)
Treatment:
 Surgical intervention
 Large amount of lens material
 Inflammation not controlled by topical
medication
 2ndry hypotony / increased IOP from
inflammation
 PC intact:
 Simple aspiration
 PC ruptured: (Potential for lens-vitreous admixture)
 Vitrectomy
Vitreous disruption incarceration in the wound
 Rupture of anterior vitreous face (ICCE/ECCE)
 Anterior migration through pupil
 Vitreous traction: - Retinal breaks and RD
 Vitreous incarceration in the wound → chronic ocular
inflammation with / without CME
 Vitreous transparent, its presence datected by:  Touching / Manipulating the wound / iris with sponge or spatula:Adherent vitreous becomes apparent / cause movement of the
pupil
Vitreous disruption incarceration in the wound (cont’d)
 Management
 Cutting vitreous strands and removed by suction cutter /
cellulose sponges

 ND:YAG laser / anterior vitrecotmy

 PPV:

Chronic ocular
inflammation with CME
and vitreous incarcerated
in the wound

if cornea shows considerable compromise (to
reduce surgical trauma)
Suture induced astigmatism
 Tight sutures:


post-operative astigmatism, Steepens the cornea
in the direction of sutures

 Removing sutures 6 – 8 wks postoperatively
may alleviate astigmatism

 Wound leak:


Significant against the rule astigmatism

 Secondary intra-ocular infection:


Entry of organisms into the eye through suture
tract
Pupillary capture
Causes
 PS (Iris and PC Adhesions)
 Improper placement of IOL haptics
 Anterior displacement of PC IOL optic (non
angulated IOL in ciliary sulcus)
 Inadvertent flipping over of angulated IOL so
it angles anteriorly
 Positive vitreous pressure from behind the
optic of IOL
Pupillary capture (cont’d)
Management
 Asymptomatic:
 Problem cosmetic – patient can be left untreated
 Occasionally glare, photophobia, monocular diplopia

 In bag placement has decreased the occurrence of
pupillary capture
 Symptomatic:
 Pharmacological manipulation of pupil with mydriatics to
free iris
 Surgical intervention – free iris / break synechiae
Implant displacement
Decentration

Optic capture

•

•
May occur if one haptic is inserted Reposition may be necessary
into sulcus and other into bag

•

Remove and replace if severe
Complications of IOL implantation
1.

Decentration and dislocation

2.

Uveitis – glaucoma – hyphaema (UGH)
syndrome

3.

Corneal edema and pseudo-phakic
bullous keratopathy

4.

Wrong power IOL
Complications of IOL implantation (cont’d)
Decentration and dislocation
Causes


Asymmetric hapitc placemnt:


One in bag and other in sulcus. IOL designed for
bag fixation prone to decentration / dislocation




when one / both haptics are placed in sulcus
Insufficient zonular support
Irregular fibrosis of posterior capsule
Complications of IOL implantation (cont’d)
Decentration and dislocation

(cont’d)

Management


Rotation of IOL



Reposition IOL haptics



Replace capsule fixated IOL with PC sulcus
fixated IOL



IOL exchange with AC IOL / Trans-sclerally
sutured PC IOL (complete IOL dislocation)
Complications of IOL implantation (cont’d)
Uveitis-glaucoma-hyphaema (UGH) syndrome
 UGH syndrome was first described in the context of
rigid AC IOLs
 Classic triad (UGH) or individual elements may occur

Causative Factors:
1. Inappropriate IOL size
2. Contact between implant and vascular structures
3. Defects in implant manufacturing
4. Idiosyncretic reaction of patient to implant
Complications of IOL implantation (cont’d)
Uveitis-glaucoma-hyphaema (UGH) syndrome
Treatment
 Topical anti-inflammatory medications
 Topical anti-glaucoma medications
 IOL removal (symptoms not alleviated / threaten
retinal or corneal function)
Complications of IOL implantation (cont’d)
Corneal edema and pseudo-phalic bullous
keratopathy
Causes
1.
2.
3.
4.
5.

Surgical trauma
IOL type: - Iris fixated / closed loop flexible AC IOL
Vitreous contact with corneal edothelium
Glaucoma
Corneal endothelial dystrophy (Fuchs) – increased
risk of developing postoperative corneal edema
even after smooth, a traumatic surgery
Complications of IOL implantation (cont’d)
Corneal edema and pseudo-phalic bullous
keratopathy
Symptoms
1.
2.
3.
4.
5.

Corneal edema → BK
↓ VA
Irritation
FB Sensation
Epiphora

6. Infective keratitis (occasionally)
Complications of IOL implantation (cont’d)
Corneal edema and pseudo-phalic bullous
keratopathy
Management
1. Topical hyperosmotic agents
2. Topical steroids
3. Bandage (therapeutic) contact lens

Early
Stage

4. Penetrating keratoplasty (recurrent pain, infective
keratitis, ↓ VA)
Complications of IOL implantation (cont’d)
Wrong power IOL
A.

1. Miscalculation
2. Manufacturing defect

B. If magnitude of implant error produce symptomatic
anisometropia; replace IOL with appropriate power
Cataract complications
Cataract complications

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Cataract complications

  • 1. Complications of Cataract Surgery Prof. Naimatullah Khan Kundi Head, Department of Ophthalmology Khyber Medical College Peshawar
  • 2. Complications of cataract surgery  Complications are varied in time and scope 1. Intraoperative 2. Immediate postoperative 3. Late postoperative Therefore it is necessary to observe the postoperative patients at periodic intervals
  • 3. Major postoperative complications of cataract surgery Endophthalmitis Expulsive Haemorrhage Corneal edema Delayed choroidal haemorrhage Wound distortion or disruption Hyphaema Shallow or flat anterior chamber Elevated IOP Corneal edema Glaucoma Detachment of descemet’s Malignant glaucoma membrane Retained lens material Suprachoroidal haemorrhage or effusion
  • 4. Major postoperative complications of cataract surgery • Vitreous disruption incarceration in the wound • Suture induced astigmatism • Pupillary capture • Complications of IOL implantation • Uveitis • IOL dislocation • Hemorrhage • Retinal detachment • Cystoid macular edema • Retianed lens material • Capsular rupture • Vitreous loss
  • 5. Major postoperative complications of cataract surgery  Endophthalmitis  Sterile  Infectious
  • 6. Acute bacterial endophthalmitis Incidence - about 1:1,000 Common causative organisms • Staph. epidermidis • Staph. aureus • Pseudomonas sp. Source of infection • Patient’s own external bacterial flora is most frequent culprit • Contaminated solutions and instruments Environmental flora including that of surgeon and operating room personnel •
  • 7. Signs of severe endophthalmitis • Pain and marked visual loss • Absent or poor red reflex • Corneal haze, fibrinous exudate and • Inability to visualize fundus with hypopyon indirect ophthalmoscope
  • 8. Signs of mild endophthalmitis • Mild pain and visual loss • Anterior chamber cells • Small hypopyon • Fundus visible with indirect ophthalmoscope
  • 9. Management of Acute Endophthalmitis 1. Preparation of intravitreal injections 2. Identification of causative organisms • Aqueous samples • Vitreous samples 3. Intravitreal injections of antibiotics 4. Vitrectomy - only if VA is PL 5. Subsequent treatment
  • 10. Subsequent Treatment 1. Periocular injections • Vancomycin 25 mg with ceftazidime 100 mg or gentamicin 20 mg with cefuroxime 125 mg • Betamethasone 4 mg (1 ml) 2. Topical therapy • Fortified gentamicin 15 mg/ml and vancomycin 50 mg/ml drops • Dexamethasone 0.1% 3. Systemic therapy • Antibiotics are not beneficial • Steroids only in very severe cases
  • 11. Major postoperative complications of cataract surgery  Corneal edema  Detached Descemet’s membrane  Mechanical trauma  Vitreo-endothelial touch  IOL-endothelial touch  Toxic solutions
  • 12. Major postoperative complications of cataract surgery  Wound distortion or disruption  Astigmatism  Wound leak  Inadvertent filtering bledb  Iris prolapse  Hypotony
  • 13. Major postoperative complications of cataract surgery  Shallow or flat anterior chamber  Wound leak  Choroidal detachment or hemorrhage  Pupillary block  Ciliary block
  • 14. Shallow or flat AC A. Intraoperative 1. Inadequate infusion of BSS 2. Leakage over sized wound 3. External pressure on the globe 4. Positive vitreous pressure more common in:     Obese Bull necked pts. COPD Anxious Pts. Who perform valsalva maneuver 5. Supachoroidal haemorrhage or effusion
  • 15. Shallow or flat AC (cont’d) Intraoperative shallow AC Management     Raise infusion bottle Place suture across the wound to ↓ its size External pressure: Readjust surgical drapes or eye lid speculum Positive vitreous pressure:    I/V manitol ↓ the ↑ positive pressure and Allow the case to continue uneventfully Suprachoroidal hemorrhage or effusion:   Check red reflex Examine fundus with indirect ophthalmoscope to confirm diagnosis
  • 16. Shallow or flat AC (cont’d) B. Postoperative shallow AC  Postoperative shallow AC → opposition of iris to angle → PAS → chronic ACG  Irido-vitreal (ICCE) / irido-capsular (ECCE) synechiae → pupillary block  Corneal contact with vitreous / IOL → endothelial cell loss → chronic corneal edema
  • 17. Shallow or flat AC (cont’d) B. Postoperative shallow AC  Causes 1. 2. Choroidal detachment 3. Pupillary block 4. Ciliary block 5.  Wound leak Suprachoroidal hemorrhage Cases associated with ocular hypotension are 2ndry to wound leakage / choroidal detachment  Slow or intermittent wound leaks may coexist with formed AC
  • 18. Shallow or flat AC (cont’d) B. Postoperative shallow AC Seidel Test:  To detect an area of wound leakage  Instill one drop of 2% fluorescein and examine the incision with cobalt blue filter on the SL  Aqueous dilution of fluorescein at the site of leakage will produce contrasting area of green stain  Occasionally aqueous flow is so slight that gentle pressure on the globe is necessary to confirm the site of leakage
  • 19. Postoperative shallow AC (cont’d) Management Several Options 1. Cycloplegics and pressure patching 2. CAI and topical beta blockers: ↓ Aqueous flow through the woung 3. Corticosteroid avoidence: Enhance local wound reaction to faciliatte spontaneous closure 4. Therapeutic contact lens help in opposing wound edges and ↓ aqueous flow through the wound 5. Tissue adhesive: may seal the wound 6. Surgical
  • 20. Postoperative shallow AC (cont’d) Management  These measures are appropriate for minor wound leaks  Many patients develop associated ciliochoroidal detachment which resolves spontaneously after wound closure
  • 21. Postoperative shallow AC (cont’d) Management Surgical approach with reformation of AC and wound repair indicated:  If no improvement occurs in 24 – 46 hours  If obvious wound separation is present  Iris prolapse  IOL contact with corneal endothelium
  • 22. Postoperative shallow AC(cont’d) Complications (shallow AC)  Early postoperative Pupillary block glaucoma may follow resolved wound leak  Late Pupillary block glaucoma is caused by postoperative uveitis with irido-vitreous / irido-capsular synechiae formation  AC IOL Placement without PI may be associated with early or late postoperative pupillary block glaucoma  Ciliary block glaucoma caused by aqueous sequestration within the vitreous body with flat AC & ↑ IOP
  • 23. Postoperative shallow AC (cont’d) Pupillary block glaucoma Treatment 1. Pupillary dilation 2. Laser or surgical iridotomy 3. Vitretcomy preferred treatment for ciliary block glaucoma
  • 24. Corneal edema Factors:   ↑IOP Endothelial cell damage  Edema in the immediate postoperative period  Incidence is increased in preexisting endothelial Dysfunction  Acute endothelial decompensation with increase in corneal thickness
  • 25. Corneal edema (cont’d) Causes: 1. Mechanical trauma 2. Prolonged intraocular irrigation 3. Inflammmation 4. Increased IOP  Resolves in 4 – 6 weeks  Corneal edema persisting after 3 months will usually not clear and may require penetrating keratoplasty
  • 26. Brown McLean Syndrome  This clinical condition occurs after cataract surgery (most frequently ICCE)  Etiology unknown  Consists of peripheral corneal edema with clear central cornea  Edema typically starts inferiorly and progresses circumfrentially but spares the central cornea  It rarely progresses to clinically significant central corneal edema
  • 27. Vitreo-corneal adherence and persistent corneal edema  Early / late  Uncomplicated ICCE or complicated ECCE  Early recognition and treatment are essential to prevent development of irreversible corneal edema Treatment: 1. Anterior vitrectomy (Limbus / PP) 2. Penetrating keratoplasty with vitrectomy in more advanced cases
  • 28. Tixic solutions  Certain solutions can be toxic to corneal endothelium when:  Irrigated  Inadvertently injected Cause:  Temporary  Permanent Into AC Corneal edema
  • 29. Corneal complications of phacoemulsification  Heat: transferred from the vibrating probe to the cornea  Tight wound prevents adequate irrigation fluid along the probe  Occlusion of irrigation / aspiration tubing  Holding phaco tip too close to the corneal endothelium:
  • 30. Corneal complications of phacoemulsification  The US energy causes:  Injury to cornea  Loss of endothelial cell C. Edema on 1st postoperative day/delayed for months to years  In corneal edema develops during:  Phacoemulsification and  Decreases visualization Convert to nuclear expression technique
  • 31. Detachment of descemet’s membrane Results in stromal swelling and epithelial bullae localized in the area of detachment Causes:  When Instrument / IOL is introduced through cataract incision.  Inadvertent fluid injection between descemet’s membrane and stroma Treatment:  Small detachments can be reattached with air tamponade in AC  Large detachments can be sutured back into place 
  • 32. Suprachoroidal haemorrhage or effusion  Occurs intraoperatively  Choroidal effusion with or without suprachoroidal haemorrhage  Choroidal effusion may be difficult to differentiate from choroidal haemorrhage (clinically)  Both complications may occur in patients with:  HT  Obesity  Glaucoma  Chronic ocular inflammation
  • 33. Suprachoroidal haemorrhage or effusion  Choroidal effusion may be precursor of suprachoroidal haemorrhage  Or haemorrhage may represent spontaneous rupture of choroidal vasculature (in patients with underlying vascular disease)  Choroidal effusion tents veins and arteries that course through sclera and supply choroid  Disruption of these vessels lead to suprachoroidal haemorrhage (cont’d)
  • 34. Suprachoroidal haemorrhage or effusion (cont’d) Treatment:  Rapid wound closure with elevation of IOP to tamponade the extravasated plasma or blood  Sclerostomy in one or more quadrants posterior to ora serrata to drain blood  Elevated IOP serves both to stop bleeding and to extravasate suprachoroidal blood
  • 35. Expulsive Haemorrhage  Rare but serious intraoperative problem  Requires immediate action Presentation:  Sudden ↑ IOP  Darkening of red reflex  Wound gap  Iris prolapse  Expulsion of lens and vitreous  Bright red blood
  • 36. Expulsive Haemorrhage (cont’d) Treatment:  Immediate closure of the wound with sutures / digital pressure  Perform posterior selerotomies (5 – 7 mm posterior to limbus) to permit suprachoroidal haemorrhage blood to escape and allow repositioning of prolapsed intraocualr tissues and closure of the wound
  • 37. Delayed choroidal haemorrhage Early postoperative period (less common) Presentation:  Sudden onset of pain  Loss of vision  Shallow AC  ↑ IOP  Wound intact / disrupted
  • 38. Delayed choroidal haemorrhage (cont’d) Management: Observation: If wound intact and IOP controlled, limited haemorrhage may be observed and resolve spontaneously Surgical drainage: 1. 2. 3. 4. 5. Wound disruption Persistent shallow AC Uncontrolled glaucoma Adherent choroidals (kissing) Persistent choroidal detachment
  • 39. Delayed choroidal haemorrhage (cont’d) Medical Management: 1. Systemic corticosteroids 2. Ocular hypotensive agents (topical / oral) 3. Close observation
  • 40. Hyphaema  Early / Late  Early: Immediate postoperative period     Late: Origin: Incision / Iris Mild resolves spontaneously Mixed with blood / viscoelastic – resolution longer Months / years after surgery  Origin: wound vascularization / erosion of vascular tissue by lens implant
  • 41. Hyphaema (cont’d)  Complications (prolonged hyphaema):  ↑ IOP  Corneal blood staining  Management:  IOP monitored closely and treated in the usual medial fashion  Argon laser photocoagulation of the bleeding vessels stop / prevent rebleeding  With-holding antiplatelet therapy (Those who receive) until hyphaema resolves. Also risk of continued / recurrent bleeding reduced
  • 42. Elevated IOP  Mild and selflimiting  Significant and sustained  Causes:           Retained viscoelastic material in AC, PC, behind the IOL] Pupillary block Ciliary block Hyphaema Endophthalmitis Retained lens material (phacolytic / phacoanaphylatic reaction) Iris pigment release Preexisting glaucoma Corticosteroid usage PAS (early postoperative flat AC when eye inflammed) → 2ndry glaucoma
  • 43. Elevated IOP (cont’d) Treatment:  Mild and selflimiting:  Does not require prolonged anti-glaucoma therapy  IOP elevation lasts for a few days and is amenable to medical treatment  Significant and sustained rise of IOP:  May necessitate timely and specific management in several circumstances  Treat the underlying cause of IOP elevation
  • 44. Malignant glaucoma (ciliary block glaucoma  Posterior dissection of aqueous into the vitreous body and 2ndry rise of IOP  IOP rise may occur inspite of patent iridectomy Treatment  Cycloplegics – to move lens-iris diaphragm posteriorly  Disruption of anterior hyaloid face and vitreous to reestablish a channel for aqueous to come forward Techniques:  Mechanical disruption (knife)  ND: YAG Laser  PPV
  • 45. Retained lens material  Small lens material (cortical) better tolerated and require no surgical intervention  More likely resorb over time  Nuclear material incite significant inflammatory reaction  Inflammatory reaction may be difficult to differentiate from microbial endophthalmitis
  • 46. Retained lens material (cont’d) Treatment:  Observation  Cycloplegic drugs  Corticisteroids  Surgical intervention
  • 47. Retained lens material (cont’d) Treatment:  Surgical intervention  Large amount of lens material  Inflammation not controlled by topical medication  2ndry hypotony / increased IOP from inflammation  PC intact:  Simple aspiration  PC ruptured: (Potential for lens-vitreous admixture)  Vitrectomy
  • 48. Vitreous disruption incarceration in the wound  Rupture of anterior vitreous face (ICCE/ECCE)  Anterior migration through pupil  Vitreous traction: - Retinal breaks and RD  Vitreous incarceration in the wound → chronic ocular inflammation with / without CME  Vitreous transparent, its presence datected by:  Touching / Manipulating the wound / iris with sponge or spatula:Adherent vitreous becomes apparent / cause movement of the pupil
  • 49. Vitreous disruption incarceration in the wound (cont’d)  Management  Cutting vitreous strands and removed by suction cutter / cellulose sponges  ND:YAG laser / anterior vitrecotmy  PPV: Chronic ocular inflammation with CME and vitreous incarcerated in the wound if cornea shows considerable compromise (to reduce surgical trauma)
  • 50. Suture induced astigmatism  Tight sutures:  post-operative astigmatism, Steepens the cornea in the direction of sutures  Removing sutures 6 – 8 wks postoperatively may alleviate astigmatism  Wound leak:  Significant against the rule astigmatism  Secondary intra-ocular infection:  Entry of organisms into the eye through suture tract
  • 51. Pupillary capture Causes  PS (Iris and PC Adhesions)  Improper placement of IOL haptics  Anterior displacement of PC IOL optic (non angulated IOL in ciliary sulcus)  Inadvertent flipping over of angulated IOL so it angles anteriorly  Positive vitreous pressure from behind the optic of IOL
  • 52. Pupillary capture (cont’d) Management  Asymptomatic:  Problem cosmetic – patient can be left untreated  Occasionally glare, photophobia, monocular diplopia  In bag placement has decreased the occurrence of pupillary capture  Symptomatic:  Pharmacological manipulation of pupil with mydriatics to free iris  Surgical intervention – free iris / break synechiae
  • 53. Implant displacement Decentration Optic capture • • May occur if one haptic is inserted Reposition may be necessary into sulcus and other into bag • Remove and replace if severe
  • 54. Complications of IOL implantation 1. Decentration and dislocation 2. Uveitis – glaucoma – hyphaema (UGH) syndrome 3. Corneal edema and pseudo-phakic bullous keratopathy 4. Wrong power IOL
  • 55. Complications of IOL implantation (cont’d) Decentration and dislocation Causes  Asymmetric hapitc placemnt:  One in bag and other in sulcus. IOL designed for bag fixation prone to decentration / dislocation   when one / both haptics are placed in sulcus Insufficient zonular support Irregular fibrosis of posterior capsule
  • 56. Complications of IOL implantation (cont’d) Decentration and dislocation (cont’d) Management  Rotation of IOL  Reposition IOL haptics  Replace capsule fixated IOL with PC sulcus fixated IOL  IOL exchange with AC IOL / Trans-sclerally sutured PC IOL (complete IOL dislocation)
  • 57. Complications of IOL implantation (cont’d) Uveitis-glaucoma-hyphaema (UGH) syndrome  UGH syndrome was first described in the context of rigid AC IOLs  Classic triad (UGH) or individual elements may occur Causative Factors: 1. Inappropriate IOL size 2. Contact between implant and vascular structures 3. Defects in implant manufacturing 4. Idiosyncretic reaction of patient to implant
  • 58. Complications of IOL implantation (cont’d) Uveitis-glaucoma-hyphaema (UGH) syndrome Treatment  Topical anti-inflammatory medications  Topical anti-glaucoma medications  IOL removal (symptoms not alleviated / threaten retinal or corneal function)
  • 59. Complications of IOL implantation (cont’d) Corneal edema and pseudo-phalic bullous keratopathy Causes 1. 2. 3. 4. 5. Surgical trauma IOL type: - Iris fixated / closed loop flexible AC IOL Vitreous contact with corneal edothelium Glaucoma Corneal endothelial dystrophy (Fuchs) – increased risk of developing postoperative corneal edema even after smooth, a traumatic surgery
  • 60. Complications of IOL implantation (cont’d) Corneal edema and pseudo-phalic bullous keratopathy Symptoms 1. 2. 3. 4. 5. Corneal edema → BK ↓ VA Irritation FB Sensation Epiphora 6. Infective keratitis (occasionally)
  • 61. Complications of IOL implantation (cont’d) Corneal edema and pseudo-phalic bullous keratopathy Management 1. Topical hyperosmotic agents 2. Topical steroids 3. Bandage (therapeutic) contact lens Early Stage 4. Penetrating keratoplasty (recurrent pain, infective keratitis, ↓ VA)
  • 62. Complications of IOL implantation (cont’d) Wrong power IOL A. 1. Miscalculation 2. Manufacturing defect B. If magnitude of implant error produce symptomatic anisometropia; replace IOL with appropriate power